Stroke

Question 1

define stroke

Answer 1

abrupt onset focal neurologic deficit that lasts >24 hours and is of presumed vascular origin

Question 2

what causes ischemic stroke

Answer 2

interruption of blood flow to the brain due to a clot

occlusion of a cerebral artery

Question 3

what causes hemorrahgic stroke

Answer 3

uncontrolled bleeding in the brain

Question 4

what is an embolic ischemic stroke

Answer 4

emboli from intra (another cerebral artery) or extracranial (from somewhere else) arteries

Question 5

describe carotid stenosis

Answer 5

atherosclerotic plaque rupture — thrombus formation — local occlusion or dislodge as emboli and causes downstream cerebral vessel occlusion

Question 6

describe cardiogenic embolism

Answer 6

secondary to valvular heart disease

atrial blood stasis — emboli — occlusion of cerebral circulation

Question 7

describe a transient ischemic attack

Answer 7

temporary docal neurologic deficit lasting less than 24 hr as a result of dimished or absent blood flood
no residual neurologic deficit
absence of acute infarction or recurrent tia

Question 8

when is the highest risk for infarction or recurrent tia

Answer 8

90 days after definite tia

Question 9

cause of neurologic effects in hemorrhagic stroke

Answer 9

initial neurologic edficit due to direct irritant effects of blood in contact with brain tissue
also due to atoxia

Question 10

causes of cerebral hemorrhage

Answer 10

cerebral artery aneurysm
hypertensive hemorrhage
trauma
drugs

Question 11

whats the prognosis fo rhemorrhagic stroke

Answer 11

poor

worsened outcomes

Question 12

modifiable risk factors for stroke

Answer 12

hypertension 
smoking 
dyslipidemai 
diabetes
heart disorders- atrial fibrillation 
hypercoagulability 
diet, exercise, obesity 
psycosocial stress
intracranial aneurysm
alcohol use

Question 13

non modifiable risk factors

Answer 13

age 
male
family history 
prior stroke
race

Question 14

clinical presentation of a stroke

Answer 14

one sided weakness 
trouble speaking 
vision problems
headache - sudden severe unusual
dizziness
altered level of consciousness

Question 15

what does face stand for

Answer 15

face -drooping?
arms - raise?
speech - slurred?
time - call 911

Question 16

time is what in stroke

Answer 16

brain cells

Question 17

how long is the acute phase

Answer 17

0-7 days

Question 18

how long is the hyperacute phase

Answer 18

0-24 hours

Question 19

goals of theapy

Answer 19

stabilization 
reperfusion
supportive measures 
prevent complications
prevent stroke recurrence

Question 20

four things to treat in the acute phase

Answer 20

blood pressure
fluid,electrolytes, temperature
glucose management
neurological assessment

Question 21

hypertension is common and transient in acute phase stroke, when do you treat it

Answer 21

only if >220/120
evidence of aortic dissection 
acute MI 
pulmonary edema
hypertensive encephalopathy 
reduce 15-25%

Question 22

what should be the target bp for patients eligible to recieve thrombolytics

Answer 22

<185/<110

Question 23

gold standard for early reperfusion

Answer 23

thrombolysis with r-tPA (recombinant tissue plasminogen activator)

Question 24

inclusion criteria for r-tpa

Answer 24

over 18
ischemic stroke causing measurable neurologic deficit
given within 4.5 hrs before symptom onset

Question 25

exclusion criteria for r-tpa

Answer 25

only minor or rapidly improving stroke symptoms condition that could increase risk of major hemorrhage active hemorrhage recent major surgery SBP >185 or DBP>110 refractory to antihypertensives

Question 26

dosing for r-tpa

Answer 26

0.9mg/kg max 90mg over 1 hour 10% iv bolus over 1min

Question 27

r-tpa monitoring

Answer 27

bp neurologic response signs of bleeding/hemorrhage avoid anticoagulants or antiplatelets for 24 hr

Question 28

describe endovascular therapy

Answer 28

catherter up femoral artery to cerebrovasculature | stent to retrieve the clot but doesnt leave it in there

Question 29

what is there evidence for in endovascular therapy

Answer 29

benefit of recanalization rate, early neurologic improvement, functional independence at 90 days

Question 30

criteria for EVT in addition to r-tpa

Answer 30

over 18 functionally disabling stroke infarct in major cerebral artery must be done by experienced neurointerventionalist within 6 hr of stroke onset

Question 31

when and what dose of asa

Answer 31

160-325 mg daily within 24-48 hours of stroke onset

Question 32

how does asa benefit post stroke

Answer 32

reduces recurrence within first couple weeks but no difference in long term death

Question 33

one study showed clopidogrel anda asa reduced the risk of recurrent stroke without increased hemorrhagic stroke but what were the limitations

Answer 33

chinese demographic given within 12 hours of symptom onset baseline risks not reported asa not or the whole time

Question 34

is asa/clopidogrel combo recomended

Answer 34

no concern of increased bleeding or hemorrhagic transformation

Question 35

should combo antiplatelet therapy be used

Answer 35

not beyond 90 days for stroke prevention due to lack of benefit in long term secondary prevention and an increased blleding risk

Question 36

DVT prophylaxis what when adn for who

Answer 36

LMWH or UFH for hospitalized patients with limited mobility | initiate within 24-48 hours

Question 37

complications of ischemic stroke

Answer 37

infections | dvt/pe

Question 38

acute phase monitoring

Answer 38

``` neurologic symptoms - speech, facial symmetry blood pressure electrolytes complications (calf, chest pain) signs of bleeding - inr, hgb, plt ```

Question 39

when is carotid endarterectomy for secondary prevention of ischemic stroke recommended

Answer 39

carotid artery stenosis of >70% on the side of neurologic deficit

Question 40

who is carotid artery angioplasty and stenting restricted to

Answer 40

patients refractory to medical therapy and notsurgical candiates higher 30 day stroke rate vs carotid endarterectomy

Question 41

what is recommended for patients with noncardioembolic ischemic stroke or tia to reduce risk of recurrent stroke

Answer 41

antiplatelet agents rath than oral anticoagulation asa 50-325 clopidogrel if asa CI

Question 42

most common ae of asa

Answer 42

upper gi discomfort | bleeding

Question 43

is asa + extended release dipyridamole better for secondary prevention

Answer 43

most costly and inconvenient, increased risk of bleeding but shown to be superior in secondary stroke prevention

Question 44

dosing of assa + erdp

Answer 44

asa 25 | erdp 200 bid

Question 45

SE of ERDP

Answer 45

headache decreases after several days dyspepsia nausea diarrhea

Question 46

ae of clopidogrel

Answer 46

diarrhea rash less gi bleed than asa

Question 47

when would you use clopidogrel

Answer 47

cant tolerate asa or had a recurrent stroke on asa

Question 48

is warfarin recommended in noncardioembolic ischemic stroke

Answer 48

not superior to asa | increased bleeding risk

Question 49

recommendations for secondary prevention in cardioembolic stroke

Answer 49

wafarin apixaban dabigatran if unable to take anticoagulants asa is recommended addition of clopidogrel may be reasonable

Question 50

how do you initiate warfarin after cardioembolic stroke

Answer 50

start within 1-2 weeks use asa until inr target 2.5

Question 51

cautions with direct oral anticoagulants

Answer 51

new to market less real world experience no measure of anticoagulation state no reversible agent if cases severe not approved for patients with valvular AF safety post thrombolytic unknown

Question 52

other secondary prevention measures

Answer 52

``` blood pressure lowering statin therapy - recommended for most patients diabetes management lifestyle changes depression screening ```

Question 53

lifestyle changes

Answer 53

``` smoking cessation avoid alcohol consumption increase physical activity weight loss diet less saturated fat ```