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67 Cards in this Set

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Modifiable risk factors for stroke:
HTN
Cardiac Dx
TIA
HPL
Two types of stroke & their incidences?
Ischemic- 88%
Hemorrhagic - 12%
Define stroke
Abrubt onset neurologic deficit &
lasts at least 24 hours &
vascular origin
Another name for ischemic stroke?
Cerebral infarction
The mortality rates for Ischemic stroke vs. Hemorraghic stroke?
Ischemic mortality= 12%
Hemorrhagic mortality = 38%
The 3 types of hemorrhagic stroke?
Subarachnoid: Due to Trauma, aneurysm, or AVmalform rupture

Intracerebral: blood vessel ruptures w/in brain parenchyma resulting in hematoma

Subdural: refers to collections of blood below the dura-> often due to trauma
What is a TIA?
transient episode of neuro deficit w/ rapid onset & resolution w/in 24 hours (us 1 hr)
How long do most TIAs persist?
<30 minutes
What % of TIA pts end up experiencing A cerebral infarction?
33%
What % of pts if untreated have stroke w/in 5 years?
35%
What is primary tx goal for TIAs?
Prevent stroke
How is TIA treated
Similar to stroke!
What are the 5 main causes of ischemic stroke?
1. Atherosclerotic/ CV disease
2. Penetrating Artery Disease
3. Cardiogenic Embolism: AFib, Valve Dx, Vent Thrombosis, Many others
4. Cryptogenic Stroke
5. Other, Unusual Causes: Prothrombotic states, Dissections, Arteritis, Migraines, vasospasm, Drug abuse, & more
Risk factors for strokes per Kanaan:
Modifiable?
Nonmodifiable?
Modifiable:
HTN
Cardiac dx
Smoking/illicit DU, EtoH
Hypercholesterolemia
Obesity/Physical inactivity
Carotid stenosis

Nonmodifiable:
Age (risk doubles ea decade after 55)
Gender (>male, but mortality worse for females)
Ethnicity (AAs, APIs, Hispanics)
Heredity
Which Cardiac disease poses the highest risk for stroke? What is the incidence?
Afib, 5-20% of incidence of stroke
Which risk factor is the most important?
HTN
Stroke is also increased by which 5 multiple risk factors (re Framingham profile)?
1. increased systolic
2. increased cholesterol
3. glucose intolerance
4. smoking
5. left ventricular hypertrophy
TIA will preced an ischemic stroke in ?% of cases?
60%
When do the majority of strokes occur? %?
At rest (sleeping or rising) - 60%
Signs of stroke:
Vertigo/double vision: posterior circulation involvement
Aphasia: Anterior Circ involved
Aphasia, Rt hemiparesis & visual field deficit, dysarthria: diff w/ calcs, read, write-->left dominant hemisphere
What are the 7 diagnostic tests used re stroke cases?
What will each show?
CT scan: dark area(hypointesity)=infarction; White everywhere-> hemorrhagic stroke; may take 24 hrs to reveal, used to r/o hemorrhagic stroke
MRI: shows areas of ischemia
Carotid doppler: shows if high degrees of stenosis in carotid arteried
ECG: shows if AFib present
TTE: transthoracic echo shows if valve or motion wall abnormalities are source of brain emboli
TEE: transesoph echo shows if thrombus is in left atrium
TCD: transcranial doppler: shows if intracranial sclerosis is present
What are the 3 goals of stroke therapy?
1. Reduce ongoing jeuro injury & decrease mortality & long term disability
2. Prevent complications 2ndary to immobility and neurologic dysfnxn
3. Prevent stroke recurrence
General Approach To Stroke Tx:
a. Stable cardiac/resp
b. Determine stroke type via CT scan
c. Pts w/ high BP should NOT be txd UNLESS: BP>220/120, aortic dissection, acute MI, pulm edema, or HTN encephalopathy
d. Supportive care: e'lytes (hyponatr), glycemic control, DVT prophylaxis
General Approach To Stroke Tx:
a. Stable cardiac/resp
b. Determine stroke type via CT scan
c. Pts w/ high BP should NOT be txd UNLESS: BP>220/120, aortic dissection, acute MI, pulm edema, or HTN encephalopathy
d. Supportive care: e'lytes (hyponatr), glycemic control, DVT prophylaxis
Which 3 meds can be given (alone) for management of BP (>220/120) with stroke?
Which of these NOT ideal in pts w/ renal dysfxn?
Labetolol
Nicordipine
Nitroprusside


Nitroprusside
General Pharmacological ACUTE tx for stroke (doesn't include post-stroke meds)?
a. Thrombolytic (us tPA)
b. Antiplatelet (us ASA) if can't use tPA (otherwise would give 24-48 hrs after conclusion of tPA)
Non-pharm tx for stroke?
a. For acute ishcemic stroke, ltd to:
Craniectomy when a large infarct present to release pressure
Surgical decompression can save life if signif swelling present
b. Early rehab
What is the timeframe for administration of thrombolytic?
What s/b ruled out prior to administering lytic?
S/b given w.in 3 hours of onset of sx for reperfusion therapy.
Always R/O hemorrhagic stroke
Preferred thrombolytic therapy in stroke tx?
Dose schedule?
Max dose?
Alteplase (tPA)
0.9 mg/kg over 60 min w/ 10% of dose give as an initial bolus over 1 min
Max dose of 90 mg
When Alteplase (thrombolytic) given for ischemic stroke tx, how do beneifits outweigh risk?
Beneficial effects outweigh the 10x increase in risk of intracerebral hemorrhage
What must be withheld for at least 24 hours after thrombolytic therapy?
ALL antiplatelet & anticoagulant therapy m/b withheld for at least 34 hours post thrombolytic (Alteplase) therapy
What trial supports the use of Alteplase in stroke pts?
NINDS rtPA Stroke Trial
Why might a stroke pt NOT be a candidate for a thrombolytic?
If >3 hours past sx onset
??other reasons?
If a pt is NOT a candidate for thrombolytic, what type of pharm therapy should be used?
Antiplatelet s/b used if pt not a candidate for thrombolytic therapy
If a pt is not a candidate for thromboltics, and as such is given ASA, when should it be given in order to decrease M&M?
**ASA w/in 48 hrs of sx shown to decrease M&M by IST study (300mg), and CAST study (160mg)
So, dose 162-325mg/day
HOW is UFH/LMWH used in stroke tx?
Trials do NOT SUPPORT use for management of ischemic stroke, however, can be used for VTE prophylaxis
What are the doses of BPmanagement meds used for stroke tx?
Labetolol:
If got tPA & BP180-230/105-120 or
If NO tPA & BP>220/121-140
(10-20mg, doubled q10min to max of 300mg) or2-8mg/min infus
Nicordipine:
If got tPA & BP 180-230/105-120, or
if NO tPA & BP>220/121-140:
5mg/hr infus, max 15mg/hr
Nitroprusside:
If DBP>140 w/ or w/o tPA
0.5mcg/kg/min IV infus for
What is the 2ndary prevention tx for stroke pts?
In non-cardiioembolic stroke pts, antiplatelet therapy s/b started
In cardioembolic pts, warfarin therapy s/b initiated w/ INR goal of 203. BP s/b controlled but not during the acute phase (1st 7 days)
What drugs can be used for 2ndary prevention of stroke?
1. Antiplatelets
2. Anticoagulants
3. BP-lowering agents
4. Statins
**For 2ndary prevention of stroke, what did the studies show re meds?
CAPRIE: (in pts w/ MI, stroke, PVD): Plavix 75mg better than ASA325mg, both similar bleeding incidences

ESPS-2: supports use of ERdipyridamole & ASA combo (200/25mg) po BID

MATCH: Patients (with prior stroke or TIA) plus additional risk factors were allocated to clopidogrel 75mg or clopidogrel 75 mg + ASA 325 mg. There was no significant benefit of combination therapy and increased bleeding risk was observed. Use of clopidogrel+ASA supported in stroke ptsw/ acute ACS
What are the anticoags that can be used for 2ndry prev of stroke & their roles?
Warfarin:
Most effective tx for pts w/ AFib
INR goal is 2-3 w/ target of 2.5

UFH : For DVT prophylaxis

Enoxiparin: For DVT prophylaxis

Fondaparinux: For DVT prophylaxis
What BP lowering has shown a benefit in 2ndry prevention of stroke?
Average reduction as low as 10/5mm Hg
What did the PROGRESS study show?
PROGRESS study supports the use of an ACEI (ramipril) + diuretic (thiazide) in pts w/ strokes/TIA for BP control.
What did the LIFE study show?
LIFE study supports the use of ARBs in pts that are intolerant to ACEI
What role do statins play in the 2ndary prevention of stroke?
"Heart Protection Study" supports the use of statins in high risk pts even w/ LDL <116mg/dL

LDL goal is <100mg/dL or <70mg/dL depending on pt; <70 preferred for ACS pts
Tx of Hemorrhagic Stroke?
If subarachnoid hemorrhage 2ndary to ruptured aneurysm,=surgical to clip/ablate vasc abnorm reduces mortality.

If primary intracerebral hemorrhage, insertion of EVD & monitoring of ICP

If subarachnoid hemorrhage: Nimodipine: CCB at a dose of 60mgq4h fx21d to prevent delayed cerebral ischemia.
Irregular rhythym + absent p-wave=
AFib
NTK Osmolality cal for NA & GLUC:
When correcting Na, don't exceed (?). What is supp rate & max?
What do S3 sounds indicate?
S4sounds?
How does this affect case?
S3=CHF
S4=uncontrolled HTN
S4->single monst important risk factor for stroke
What is dysarthria?
Trouble speaking
What causes ischemic strokes?
Either:
local thrombus formation, or
Emboli that occlude a cerebral artery
What % of embolic stroke arise from the heart?
20%
What is cardiogenic embolism?
An embolism caused by blood stasis in heart which leads to clots which then dislodge & go to cerebral circulation!
What is most of early mortality in hemorrhagic stroke caused by?
The abrupt increase in ICP-> compression leads to secondary ischemia
Inclusion criteria for Alteplase use in acute ischemic stroke?
1. 18yrs +
2. Clinical dx of ischemic stroke causing a measurable neurological deficit
3. Time of sx onset well established to be <3 hours b4 treatment would begin.
Exclusion criteria for Alteplase use in ischemic stroke?
Any of below-> CI for Alteplase:
1. Evidence of intracranial hemorrhage on CT
2. Only minor or rapidly improving stroke sx
3. High clinical suspicion of subarachnoid hemorrage even w/ normal CT
4. Active internal bleeding w/in 21 days
5. Heparin w/in 48hrs & had elevated aPTT
6. Recent use of anticoag (warfarin) & PT>15seconds
7. Intracranial surgery, serious head trauma, or prev stroke w/in 3 mos
8. Major surgery or serious trauma w/in 14days
9. Lumbar puct w/in 7 days
Hx of intracranial hemorrage, av malform, or aneurysm
10. Seizure at onset of stroke
11. Recent MI
12. SBP>185 or DBP>110 at time of tx
Antiplatelets used for secondary prevention of stroke:
Doses of each, when used?
Roles of each in therapy?
ASA (162-325mg): 1st line
Clopidegrel(75mgpoQD)/Ticlodipine (150mgpoBID): For pts intolerant of ASA
Dipyridamole(75-400mg divided tid/qid): Not effective in preventing recurrent ischemic stroke in pts w/ TIA
What does MRI of the head reveal?
Ischemia
What does a Carotid Doppler determine?
if high degree of stenosis in carotid arteries (this helps to determine which meds to d/c pts on)
What will an ECG determine?
If Afib is present
What does a transthoracic echo (TTE) determine?
if valve or motion wall abnormalities are the source of emboli to the brain.
What does a TEE (transesophageal echo) determine?
If thrombus is present in the left atrium
What does a transcranial Doppler determine?
If intracranial sclerosis is present
What agents are used for the complete management of stroke?
What stage is each used for?
Dose of each?
tPA: acute: 0.9mg/kg IV over 1 hour; 10% given as bolus over 1 min; max 90mg
ASA: acute only if tPA is CI, otherwise for 2ndry prevention: 162-350mg w/in 24-48hrs after tpa completed
UFH/LMWH/Fondaparinux - for DVT prophylaxis only if pt has thrombus: UFH=5000U BID or q8h; LMWH=40mg q24h; Fond=2.5mg SQ q24h
Clopidegrel- for 2nd prevention: 75mgqd
ACEI: 2ndry prevention (us w/ HTN pts, in combo w/ a THIAZIDE)
Statin: 2ndry prevention
ARB: alternative to ACEI in 2ndry prevention
If a patient has a stroke and was already on ASA, what is appropriate re the use of ASA/clopidogrel in the secondary prevention of stroke?
If pt was already on ASA & has a stroke, it is appropriate to increase the ASA level or add clopidegrel.
Physical activity recommendations for stroke pts- long term:
Resistance training 2d/week
Aerobic activity 30-60min min 5d/wk
Diet recommendations for stroke pts
Sat fat <7% of calories
< 200mg dietary cholesterol
Omega-3: 1g/d
Sodium reduction
Alcohol moderation
Increase consumption of fresh fruit, vegetables, & low-fat daily products