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Flashcards in Stroke (Hon) Deck (29):
1

List facts about stroke (cause of death, incidence, etc)

3rd leading cause of death in US
Leading cause of long-term disability in US
Annual health care cost>$40 billion
Annually, 90,000 women & 60,000 men die, 2/3 within 90 days of stroke
Among survivors, majority will have residual impairment and disability
Approximately 25% of survivors will have another stroke
Important cause of death and disability in women, including both pregnancy and postpartum period
Under age 45 yr, more women die from stroke than from myocardial infarction

2

What are the subtypes of stroke?

Hemorrhagic stroke (20% of cases)
Intracerebral hemorrhage (cortical vs subcortical)
Subarachnoid hemorrhage

Ischemic stroke (80%)
Large artery atherosclerosis with thromboembolism
Small vessel (lacunar) disease
Cardioembolism
Nonartherosclerotic vasculopathies
Hypercoagulable States

3

What are the risk factors for stroke?

Increasing age
Previous TIA or stroke
atherosclerosis
Cardiac disorders
Drug abuse (IVDA, cocaine, amphetamines)
Oral contraceptives
Pregnancy/postpartum period
Fibromuscular dysplasia
Hypercoagulable states
Inflammatory disorders
Migraine

4

Describe atherosclerosis risk factors for stroke

HTN
Smoking
Diabetes mellitus
Hyperlipidemia

5

Describe cardiac disorder risk factors for stroke

Valvular heart disease (dysfunctional or prosthetic valve)
Cardiac dysrhythmia (atrial fibrillation)
Mural thrombus
Endocarditis
Atrial myxoma
Interatrial septal abnormalities

6

Describe hypercoaguable states risk factors for stroke

Thrombocytosis
Polycythemia
Sickle cell disease
Leukocytosis
Protein C, protein S deficiency
Homocysteine
Anticardiolipin/antiphospholipid antibodies

7

Describe inflammatory disorders risk factors for stroke

Giant cell arteritis
SLE
Polyarteritis nodosa
Granulomatous angiitis
Syphilitic arteritis
AIDS

8

What are the symptoms of stroke in left hemisphere?

Aphasia
Right-sided sensory symptoms
Right-sided motor symptoms
Right visual field cut

9

What are the symptoms of stroke in right hemisphere?

Left hemineglect
Left-sided sensory symptoms
Left-sided motor symptoms
Left visual field cut

10

What are symptoms of stroke in cerebellar region?

Ipsilateral ataxia
Vertigo
Nystagmus

11

What are symptoms of stroke in brainstem?

Cranial nerve finding with contrallateral hemisensory or hemimotor symptoms
Vertigo

12

Describe general management of stroke

Primary prevention
Management of acute stroke itself (major area of change)
Prevention or control of medical complications (complications accoutn for 50% of deaths attributable to stroke: pneumonia, DVT, PE, UTI, decubitus ulcers)
Rehabilitation
Prevention of recurrent stroke

13

Describe emergent diagnosis and treatment of stroke

ABC's: airway, breathing, and circulation

BP, pulse, cardiac monitor, EKG, O2 saturation
-acute HTN is common in acute ischemic stroke and in most cases should NOT be treated
-area of infarction may have lost autoregulatory function, so that "normal" BP may be relatively hypotensive in braine

IV access
-all stroke pts need this
-IVF's should NOT include glucose as hyperglycemia is associated with worse neurologic outcomes
-If tPA is a consideration, 2 IV access sites will be needed to eliminate venipuncture after infusion

Neurologic examination and rapid transport to CT scan

Labs (CBC c diff, PT/PTT, full chemistry panel & fingerstick glucose, UA, CXR)

14

Describe NIH stroke scale

Important if tPA or intra-arterial intervention is a consideration
Score ranges from 0 (normal) to 42 (coma) and can be used to predict hemorrhagic conversion
-score20 = 17% risk of hemorrhage

15

Describe summary of evaluation and treatment of acute stroke

Maintain airway, breathing, circulation
Elevate HOB to 30 degrees
O2 @ 2 liters per NC
Obtain vital signs and establish IV with NS
EKG
Obtain pt weight
Try to identify cause and treat fever if present
Obtain history

16

What history should you obtain for evaluation and treatment of acute stroke?

When was last time pt known to be without symptoms?
Did head trauma or seizure occur at onset of symptoms?
Is pt on warfarin/heparin?
Does pt have symptoms suggestive of MI?
Does pt have symptoms suggestive of intracranial hemorrhage?

17

Describe actions if CT findings show cerebral infarction or is normal

Cerebral infarction
If pt meets all tPA criteria, consider administering tPA if absolutely sure of time deficits began

Normal
Consider another cause: seizure, migraine, hypoglycemia
If history not consistent with ischemia, consider tPA or other therapies (ASA, Aggrenox, Ticlid, Plavix)

18

Describe IV thrombolytic therapy: tPA

Results of parts 1 and 2 of NINDS rt-PA stroke study support use of tPA for treatment of acute ischemic stroke in patients who meet eligibility requirements if treatment is initiated within 3 hours of onset of symptoms (maybe better if within 1.5 hr)

Of pts treated with tPA, 31-50% had complete or near-complete recovery at 3 months as compared with 20-38% of pts given placebo

19

Describe eligibility criteria for IV tPA

Age>= 18 yr
Diagnosis of ischemic stroke with clinically apparent neurological deficits
No stroke or head trauma in preceding 3 mo
No major surgery in preceding 14 days
No h/o intracranial hemorrhage
No rapidly resolving symptoms of only minor symptoms of stroke
No symptoms suggestive of SAH
No GI or GU hemorrhage in preceding 21 days
No arterial puncture at non-compressible site in preceding 7 days
No seizure at onset of symptoms
PT=100,000 mm3
Blood glucose > 50 mg/dl
SBP

20

Describe treatment of acute ischemic stroke with IV tPA

Infuse tPA at dose of 0.9 mg/kg (max 90 mg) over 60 min period with first 10% of dose given as bolus over 1 min period

Perform neuro assessments and check BP q15min during infusion, q30min for 6 hr after, and then q60min for next 16hr (in ICU/stroke unit)

If severe HA, acute HTN, or N/V occur, stop infusion and obtain emergent CT head

If SBP>180 or DBP>105 mm Hg, check BP more frequently and give anti-HTN drugs as needed to maintain BP at below these levels

21

Describe anticoagulation with heparin for stroke

Sometimes used in effort to
-prevent or limit progression in pts with acute atherothrombotic infarction
-or to prevent recurrent embolism in pts with cardioembolic stroke

But no consensus of indications, optimum level, duration, or loading bolus

AHA guidelines for acute ischemic stroke:
-strongly recommends prophylactic administration of heparin or low-molecular-weight heparin or heparinoids to prevent DVT in immobilized pts with acute stroke when there is no contraindications to antithrombotic drugs

22

What agents can be used for stroke?

Aspirin
Aggrenox
Ticlid
Plavix
Persantine
Warfarin
Low molecular wt heparin
Dagibatran etxilate (Pradaxa)
Riveroxaban (Xarelto)
Apixaban (Eliquis)

23

Describe aspirin (ASA) use for stroke

Antiplatelet agent
50-325 mg seems to decrease risk of stroke by approximately 25%
Increasing doses of ASA do not seem to increase efficacy, but do increase side effects
Recent data suggests that ACE inhibitors may interact with ASA, resulting in poor HTN control

24

Describe aggrenox for stroke

Antiplatelet agent
ASA 25 mg / 200 mg extended-release dipyridamole
ESPS2 study: Reduced risk of stroke by 37% compared to placebo and by 22% compared to ASA 50mg/day
Common ADR: headache (39.2%)

25

Describe plavix for stroke

Antiplatelet agent
Similar to ASA for prevention of stroke
Caprie trial: decreased risk of stroke by 9% over ASA
TASS trial: decreased risk of stroke by 12% over ASA
NEJM article - link to TTP: 10/11 cases developed within 2 weeks after starting plavix

26

In what clinical situations is warfarin generally indicated?

Atrial fibrillation
Prosthetic valve
MI
Atrial septal defect
Hypercoagulable state
Large vessel disease (carotid or vertebral dissection or large artery intracranial stenosis)
Aortic arch disease

27

Describe early diagnostic testing for stroke

In addition to emergent CT scanning of brain, other studies may include CT perfusion studies, MRI, MRA, diffusion weighted and perfusion weighted MRI, transcranial doppler ultrasonography, CT angiography, xenon-enhanced CT, single-photon-emission CT, and cerebral angiography

Above tests would be selected to establish anatomical regions and structures involved and cause of infarct, thereby choosing appropriate interventions

28

Describe carotid angioplasty with stent placement

Early data shows lower risk of complications than CEA
Consideration when pt at high risk for surgery
-severe CAD or valvular heart disease, distal carotid disease, or bilateral severe carotid disease

29

Describe endovascular therapy (intra-arterial thrombolysis with clot retrieval)

Early studies showed no difference in outcome when compared to later trials, but this was likely due to poor devices
As devices have improved, now several good, solid studies showing significant improvement in pt outcomes when compared to standard therapy