Stroke

Question 1

Stroke

Answer 1

Sudden onset of focal neuronal deficit lasting longer than 24 hours

Question 2

What population is 2x as likely to have a stroke?

Answer 2

Blacks > whites

Question 3

Two main types of stroke

Answer 3

Hemorrhagic

Ischemic

Question 4

Ischemic stroke

Answer 4

87% of all strokes
Blood flow to the brain is blocked
-Local thrombus or embolic phenomena occluding cerebral arteries
-Atherosclerosis of cerebral vascular is primary cause

Question 5

Cardiogenic embolism is presumed when the pt has…

Answer 5

Afib

Valvular heart disease

Question 6

Risk factors of ischemic stroke

Answer 6

Nonmodifiable
Modifiable
Potentially modifiable

Question 7

Nonmodifiable risk factors of ischemic stroke

Answer 7

Risk doubles every 10 yrs after age 55
Men > women (more likely to die)
Low birth weight
AA, Asian-Pacific, Hispanics
FHx

Question 8

Modifiable risk factors of ischemic stroke

Answer 8

HTN
Smoking
Diabetes
Afib
High cholesterol

Question 9

Hemorrhagic stroke

Answer 9

Much less common but more lethal
Herniation and death
50% of 30 day mortality attributed to abrupt increase in ICP

Question 10

Two types of hemorrhagic strokes

Answer 10

Intracerebral hemorrhage

Subarachnoid hemorrhage

Question 11

Intracerebral hemorrhage

Answer 11

Most common type of hemorrhagic stroke

Artery in the brain bursts, flooding the surrounding tissue with blood

Question 12

Subarachnoid hemorrhage

Answer 12

Less common

Bleeding in the area between the brain and the thin tissues that cover it

Question 13

Transient ischemic attack (TIA)

Answer 13

Short blockage-usually no more than five mins
Warning sign of a future stroke
Blood clots often cause TIAs
More than a third of ppl who have a TIA and don’t get tx have a major stroke within 1 yr

Question 14

Clinical presentation of stroke

Answer 14

Hx typically comes from a witness
Unilateral body weakness
Loss of speech and/or vision
Vertigo
HA
-Ischemic: mild
-Hemorrhagic- severe

Question 15

CT scan in stroke

Answer 15

W/o contrast to r/o hemorrhage and determine size, location, vascular distribution of infarct
Neurological deficits determined with National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS)

Question 16

MRI in stroke

Answer 16

Higher resolution
Reveals damage earlier than CT
Get CT first then f/u with MRI if needed

Question 17

Modified Rankin Scale

Answer 17

0- No sx
1-No significant disability, despite sx; able to perform all usual duties and activities
2- Slight disability; unable to perform all previous activities but able to look after own affairs without assistance
3- Moderate disability; requires some help, but able to walk without assistance
4-Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
5- Severe disability; bedridden, incontinent, and requires constant nursing care and attention
6-Death

Question 18

Other diagnostic tests for stroke

Answer 18

Carotid Doppler
-Carotid artery stenosis
ECG
-Afib
Transthoracic echocardiography
-Structural abnormalities
Transesophageal echocardiography
-Thrombus in the LA
Transcranial Doppler
-Intracranial stenosis

Question 19

BP management on alteplase

Answer 19

SBP < 180 and DBP < 105

Question 20

BP management no alteplase

Answer 20

Avoid aggressive BP lowering which can decrease cerebral blood flow and perfusion pressure

Question 21

TPA based on BP alone

Answer 21

TP <180/105

No TPA <220/120

Question 22

1st line agents for BP management

Answer 22

Nicardipine: rapidly titratable and baseline BP returns on discontinuation
Labetalol: low cost, beta-blockade beneficial in Afib pts
Nitroprusside: for diastolic management

Question 23

Labetalol or nicardipine BP numbers to treat

Answer 23

185-230/110-120

Question 24

BP numbers in order to treat with nitroprusside

Answer 24

Diastolic > 120

Question 25

Labetalol IV dosing

Answer 25

10 mg, followed by an infusion of 2-8 mg/min

Question 26

Nicardipine IV dosing

Answer 26

Infusion starting at 5mg/h up to 15 mg/h

Question 27

Nitroprusside IV dosing

Answer 27

Infusion starting at 0.5 mcg/kg/min, with continuous arterial blood pressure monitoring

Question 28

ASA parameters with tPA

Answer 28

No ASA for 24 hrs after tPA

Question 29

Inclusion criteria for tPA

Answer 29

Age 18 years or older Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit Time of symptom onset well establish to be <4.5 hrs before tx would begin

Question 30

Exclusion criteria for tPA

Answer 30

Hx of previous intracranial hemorrhage Active internal bleeding Platelet count <100,000/mm cubed Pt has received heparin within 48 hrs, resulting in an elevated APTT Recent anticoagulant use and elevated INR (>1.7) or pT (>15 seconds) Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (aPTT, INR, platelet count, or appropriate Xa activity assays) Significant head trauma or previous stroke within 3 mos Arterial puncture at noncompressible site within 7 days Intracranial neoplasm, arteriovenous malformation, or aneurysm SBP >185 mm Hg or DBP >110 mm Hg Blood glucose < 50 mg/dL (2.7 mmol/L) CT demonstrates multilobar infarction (hypodensity .1/3 cerebral hemisphere)

Question 31

Acute tPA tx

Answer 31

Less than 3 hrs from onset 0. 9 mg/kg over 1 hours - 10% given as bolus over 1 min

Question 32

Between 3 and 4.5 hrs exclusions tPA

Answer 32

Age >80 OA regardless of INR Score >25 on Stroke scale Hx of diabetes and stroke

Question 33

Contraindications of tPA

Answer 33

``` Bleeding Recent stroke BP <185/110 Platelets <100,000 Anticoagulation therapy within 24 hrs ```

Question 34

Endovascular thrombectomy

Answer 34

Done with stent retriever within 6 hrs of tPA

Question 35

Treatment/prevention of stroke

Answer 35

Carotid endarterectomy should be performed in ischemic stroke pts with 70% to 99% stenosis of the carotid artery Done in an experienced center Pts younger than 70 yrs

Question 36

ASA in stroke

Answer 36

Irreversibly inhibiting cylooxygenase, which, in platelets, prevents conversion of arachidonic acid to thromboxane A2, which is a powerful vasoconstrictor and stimulator of platelet aggregation Platelets remain impaired for their lifespan (5-7 days) after exposure to ASA ASA also inhibits prostacyclin (PGI2) activity in the smooth muscle of vascular walls. PGI2 inhibits platelet aggregation, and the vascular endothelium can synthesize PGI2 such that the platelet antiaggregating effect is maintained.

Question 37

ASA dosage

Answer 37

325 mg within 48 hrs | Do not give within 24 hrs of tPA use

Question 38

Secondary prevention of stroke

Answer 38

``` BP control <140/90 LDL <100 HgA1c <7 DASH diet -2000 calorie-a-day diet -Low in saturated and trans fats -Rich in K, Ca, Mg, fiber, and protens -Lower in sodium < 2300 mg ```

Question 39

Antiplatelet ASA

Answer 39

50-325 mg/daily Ibuprofen taken with daily ASA dose inhibits the ASA from binding irreversibly to the cylooxygenase and can decrease its antiplatelet effect ASA at least 2 hrs before ibuprofen or to wait at least 4 hrs after ibuprofen dose

Question 40

Another antiplatelet option

Answer 40

ER dipyridamole (ERDP) + ASA - ASA 25 mg + ERDP 200 mg BID - Take on empty stomach 1 hr before or 2 hrs after meals - -If stomach hurts, take with small snack or milk - Discontinuation due to HA 6x higher

Question 41

Clopidogrel

Answer 41

Antiplatelet tx- secondary prevention 75 mg daily Antiplatelet effects diminished in pts with reduced-fxn CyP2C19 or in those receiving agents that inhibit hepatic metabolism Contraindicated with proton pump inhibitor use

Question 42

Oral anticoagulants

Answer 42

``` Warfarin -INR 2.5 Dabigatran (Pradaxa) -150 mg BID Rivaroxaban (Xarelto) -20 mg/daily Apixaban (Eliquis) -5 mg BID ```