Treatment of TIA/Stroke B&B

Question 1

what is the difference between TIA and stroke?

Answer 1

TIA = transient ischemic attack, symptoms resolve within 24 hours

stroke = symptoms resolve after 24 hours or persist

Question 2

what is the etiology of strokes? (2)

Answer 2

80% = ischemic (thrombosis, embolism, hypoperfusion) - symptom onset over hours

20% = hemorrhage (brain bleed) - sudden onset of symptoms

Question 3

what is the most accurate and best first test, respectively, for stroke patients?

Answer 3

most accurate = diffusion weighted MRI (time consuming)

best first test = non-contrast CT of the head

Question 4

what is the benefit of doing a non-contrast CT as the first test for stroke patients? in other words, how does this influence your treatment plan?

Answer 4

tells you if stroke is ischemic vs hemorrhagic

if ischemic - use thrombolytic drugs

if hemorrhagic - do NOT use thrombolytic drugs (CONTRAindicated); instead, reduce BP, reverse anti-coagulants, surgery

NO benefit to heparin, warfarin, anti-platelets during acute stroke (may be used later as prevention of recurrent stroke)

Question 5

how are ischemic (80%) vs hemorrhagic (20%) acute stroke treated?

Answer 5

first, non-contrast CT will differentiate the subtype

if ischemic - use thrombolytic drugs

if hemorrhagic - do NOT use thrombolytic drugs (CONTRAindicated); instead, reduce BP, reverse anti-coagulants, surgery

NO benefit to heparin, warfarin, anti-platelets during acute stroke (may be used later as prevention of recurrent stroke)

Question 6

what drug is used to treat ischemic stroke, and when can/should it be used? when should this drug NOT be used (9)?

Answer 6

3 hour window!! in which TPA (alteplase) is beneficial! must record when symptoms started!

contraindications: stroke/head trauma past 3 months, arterial puncture in non-compressible site past week (angioplasty), internal bleeding or trauma, ANY history of intracranial bleed, BP>185/110, INR>1.7, platelets <100k, elevated PTT, glucose <50mg/dL

[TPA = tissue plasminogen activator, strong clot-buster]

Question 7

describe post-stroke management (4)

Answer 7

1. aspirin for prophylaxis (clopidogrel if allergic) - anti-platelet, lower risk of 2ndary strokes
2. EKG to look for a-fib (may have silent runs post-stroke) - if stroke + a-fib, given warfarin or other anti-coagulant
3. echocardiogram to look for embolism in heart or PFO (patent foramen ovale) - risk of crossing into arterial system and causing stroke
4. carotid ultrasound - surgery considered if >70% stenosis

Question 8

explain the purpose of each of the following steps of post-stroke management:
1. aspirin OR clopidogrel
2. EKG
3. echocardiogram
4. carotid ultrasound

Answer 8

1. aspirin for prophylaxis (clopidogrel if allergic) - anti-platelet, lower risk of 2ndary strokes
2. EKG to look for a-fib (may have silent runs post-stroke) - if stroke + a-fib, given warfarin or other anti-coagulant
3. echocardiogram to look for embolism in heart or PFO (patent foramen ovale) - risk of crossing into arterial system and causing stroke
4. carotid ultrasound - surgery considered if >70% stenosis

Question 9

how is it decided which patients with atrial fibrillation should be given warfarin (or other anti-coagulants)?

Answer 9

CHAD score:
CHF = 1 point
HTN = 1 point
age >75 = 1 point
diabetes = 1 point
stroke = 2 points

score > 2 = warfarin or other AC
score 0-1 = aspirin

also newer CHAD VASC score: add 1 point for female, age 65-75 is 1 point, age >75 is 2 points, add 1 point for vascular disease

Question 10

what are the options of anticoagulation drugs for patients who qualify (via CHAD or CHAD VASC score)? (3)

Answer 10

1. warfarin: requires regular INR monitoring (goal 2-3), dose will have to be titrated per person

“Novel anticoagulants”: do not require INR monitoring, standard dose
2. rivaroXaban, apiXaban: factor X inhibitors
3. dabigatran: direct thrombin inhibitor