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Flashcards in Stroke Deck (42)
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1

Stroke

Sudden onset of focal neuronal deficit lasting longer than 24 hours

2

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

Blacks > whites

3

Two main types of stroke

Hemorrhagic
Ischemic

4

Ischemic stroke

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

5

Cardiogenic embolism is presumed when the pt has...

Afib
Valvular heart disease

6

Risk factors of ischemic stroke

Nonmodifiable
Modifiable
Potentially modifiable

7

Nonmodifiable risk factors of ischemic stroke

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

8

Modifiable risk factors of ischemic stroke

HTN
Smoking
Diabetes
Afib
High cholesterol

9

Hemorrhagic stroke

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

10

Two types of hemorrhagic strokes

Intracerebral hemorrhage
Subarachnoid hemorrhage

11

Intracerebral hemorrhage

Most common type of hemorrhagic stroke
Artery in the brain bursts, flooding the surrounding tissue with blood

12

Subarachnoid hemorrhage

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

13

Transient ischemic attack (TIA)

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

14

Clinical presentation of stroke

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

15

CT scan in stroke

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)

16

MRI in stroke

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

17

Modified Rankin Scale

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

18

Other diagnostic tests for stroke

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

19

BP management on alteplase

SBP < 180 and DBP < 105

20

BP management no alteplase

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

21

TPA based on BP alone

TP <180/105
No TPA <220/120

22

1st line agents for BP management

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

23

Labetalol or nicardipine BP numbers to treat

185-230/110-120

24

BP numbers in order to treat with nitroprusside

Diastolic > 120

25

Labetalol IV dosing

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

26

Nicardipine IV dosing

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

27

Nitroprusside IV dosing

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

28

ASA parameters with tPA

No ASA for 24 hrs after tPA

29

Inclusion criteria for tPA

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

30

Exclusion criteria for tPA

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)