treatment in acute stroke Flashcards
what do every single stroke patient receive in terms of care and the benefits of this?
Admissions to a stroke unit benefit every patient who has experienced a stroke, regardless of whether it was a hemorrhagic stroke or an ischemic infarct. These specialised units are designed to enhance patient outcomes by providing immediate rehabilitation starting from day one, which is crucial for recovery. Additionally, patients receive early treatment for any complications that may arise, ensuring a comprehensive approach to care. The dedicated medical and nursing staff in stroke units are specifically trained to address the unique needs of stroke patients, further improving their chances of survival and recovery. This ensures that the patient’s condition is managed promptly, effectively reducing the mortality of stroke patients.
what condition can predispose to small vessel disease?
Hyaline atherosclerosis: thickening of arterial blood vessel wall via hyaline deposits, plaques of fatty material, and cholesterol
what is are the two thrombolytic treatments for acute ischemic stroke that end in ase
both are type of fibrolytic drug which is a form of thrombolytic therapy
alteplase:
recombinant tissue plasminogen activator that is licensed for use in ischemic stroke, with a small half life thus bolus dose is required (10% initially given over 5 mins then a 90% second bolus is given as infusion over 1 hr)
tenecteplase:
newer drug, not yet licensed, but is proven to be more effective with a greater half life therefore only require one single bolus given intravenously. its also shown to be safer than alteplase as it is more fibrin-specific
when should the thrombolytic be given according to the stroke onset? what ages can you not give thrombolytic for a certain range of time and the name of trial for one of the thrombolytics
stroke onset is around 4.5 hours
thus, thrombolytic medication should be given before 4.5 hours
cannot give this to ages over 80 years between 3-4.5 hours of stroke onset
ECASS-3 -> showed that alteplase can be given up to 4.5 hours, but benefit drops. Did not include those above 80 – cannot be given after 3 hours.
what is the metric used to determine suitability of acute stroke treatments and the criteria
NIHSS: National Institutes of Health Stroke Scale.
quantifies stroke severity based on findings.
select patients for acute stroke treatments goes from 0-42
Lower Scores: Patients with very mild strokes (e.g., NIHSS score 0-4) might be carefully evaluated to ensure that the benefits of treatment (especially thrombolytics)
Moderate to High Scores: Some patients with more severe problems (NIHSS scores 5 and above) might be better candidates for thrombolytic therapy if they meet other requirements. This is because improving blood flow can be very helpful.
Very High Scores: When someone has a severe stroke (NIHSS score of 20 or more), it is harder to decide whether to go ahead with acute interventions like thrombolytic therapy or mechanical thrombectomy because there is a higher risk of complications, such as hemorrhagic transformation. Yet, high scores do not automatically exclude patients from treatment, especially if mechanical thrombectomy is considered viable.
what technique is used that allowed to move away from time to tissue window
perfusion imaging, guiding
intravenous thrombolytic treatment all the way up to 9 hours after the onset of stroke
after the perfusion imaging, areas of greater risk of damage (green) are selected for this intravenous thrombolytic therapy that’s extended to 9 hours.
what is the surgical procedure known as that involves removal of thrombus and how does it work and what size of a clot does it have to be to undergo this procedure large or small?
mechanical thrombectomy
Initially, a specialist will assess the severity and suitability of the patient for this surgery, making sure the benefits outweigh the risks. Then, it involves mechanically passing a wire/tube called a catheter up the arteries in the groin via imaging guidance and into the blocked blood vessel (in the brain). Once the catheter reaches the clot, it can remove it using a suction device, This restores blood flow and restores the affected brain part, immediately relieving symptoms of stroke.
tackles those patients with largest stroke due to larger clots whereby intravenous thrombolysis is least likely to work or prove effective.
what is the dual medication given that works as an antiplatelet therapy for ischemic stroke and its mechanism of action and what’s the complication of using them in combination?
aspirin and clopidogrel
Aspirin blocks an enzyme called cyclooxygenase, which is crucial for the formation of thromboxane A2, which is involved in platelet aggregation and clumping. By reducing the formation of thromboxane A2, you reduce the aggregation of platelets, making it harder for clots to form.
clopidogrel is an antiplatelet also reducing platelet aggregation and formation.
its not an immediate treatment but is given to help reduce clot formation reducing subsequent strokes risk.
this dual usage increase risk of bleeding in long term so use in timely manner and with adequate dosage.
What two surgeries are implicated for two types of ischemic stroke and describe them?
For malignant MCA (middle cerebral artery) syndrome a decompressive hemicraniectomy is performed to relieve pressure on the brain, involving removal of large bone flap on the side of the stroke- considered a life saving operation therefore may need to stay in hospital due to increased risk from removal of bone). the malignant MCA syndrome involves an infarct within MCA (extends from internal carotid artery) region affecting parietal and frontal lobes, characterised by increased swelling in those regions, leading to increased pressure within the skull.
For large cerebellar infarction a posterior fossa decompression is done to relieve pressure due to increased swelling in posterior regions of brain. Large cerebellar infarction is a stroke within the cerebellum (Posterior cranial fossa), thus leads to impaired perfusion of blood, causing reduction of oxygen delivery and subsequent motor and balance deficits- can result in cell necrosis and oedema. Therefore this surgery involves drilling a hole in the back of the brain to relieve pressure on posterior regions and on brainstem.
What stroke is associated with the highest mortality? What is the management of acute primary intracerebral haemorrhage, including which medications can cause PICH? Quickly state what intracerebral haemorrhage is and how it differs from subarachnoid haemorrhage. What is another term for pool of blood in brain, what can expand this and what can mitigate this?
PICH is associated with highest mortality of all strokes.
IC is when the blood vessel suddenly bursts, causing a bleed within the brain and causing further damage to the brain (can arise due to hypertension, injury, blood vessel abnormalities). the main issue is that the increase bleeding within brain leads to increased pressure and damage brain cells.
whereas SH, is a bleed within the subarachnoid space, which is the space between the thin protective layer (meningitis) and the brain itself (often arises due to aneurysms, bulging sacs of blood vessels caused by vessel abnormalities, hypertension). The main issue here is that the bleed within this space increases pressure within the skull and can damage brain tissue. symptoms such as severe headaches.
With the management of PICH, there are fewer things to be done; however, urgent and immediate brain imaging is required to determine the severity of brain damage and those at-risk brain areas, as well as confirm bleeds in the brain. Send them to stroke unit admissions to reduce the risk of mortality.
Hematoma (a pool of blood in the brain), increased oedema or swelling, and pressure within the skull. Severe hypertension can cause hematoma expansion. But blood pressure lowering can help prevent haemorrhage from expanding. But it has its associated risks so guidelines recommend this only if the hypertension persists and is really high.
provide reversal of anticoagulants in relevant patients to stop bleeding, as some medications such as warfarin or direct oral anticoagulants (DOAC). can give prothrombin complex concentrate (PCC) which reverses the effect of anticoagulants- type of haemostatic therapy.
tranexamic acid inhibits plasmin and fibrinolysis
Posterior fossa decompression can relieve pressure by creating a defect in the back of the skull.
what is hydrocephalus and treatment?
It is a conditions where there is an abnormal buildup of CSF in the ventricles of the brain, causing ventricles to widen an increased pressure within skull that can damage brain cells or tissue.
can be managed by inserting a intravascular drain to remove excess CSF
