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67 Cards in this Set
- Front
- Back
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What are the non-modifiable stroke risk factors?
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-Age (doubling each 10 yrs over 55)
-gender (men > women) -race (blacks > hispanics > whites) -FH of stroke (parental > maternal) -low birth weight (<2.5kg) |
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What are the modifiable stroke risk factors?
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HTN, a fib, other cardiac disease, diabetes, dyslipidemia, smoking, sickle cell disease, asymptomatic carotid stenosis, postmenopausal hormone therapy, lifestyle factors (obesity, physical inactivity, diet)
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What are the potentially modifiable risk factors in stroke?
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metabolic syndrome, alcohol abuse (>=5 drinks/day), hyperhomocysteinemia, drug abuse, hypercoagulability, oral contraceptive use, inflammatory process, acute infection, migraine HA, sleep-disordered breathing
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What are the types of hemorrhagic strokes?
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subarachnoid, intrecerebral, subdural hematomas (all more lethal than ischemic stroke)
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What is the etiology of subarachnoid hemorrhage?
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occurs when blood enters subarachnoid space; trauma, rupture of intracranial aneurysm,rupture of arteripvenous malformation (AVM)
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What is the etiology of intracerebral hemorrhage?
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occurs when blood vessels ruptures withinn brain parenchyma, resulting in formation of hematoma
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What is the etiology of subdural hematomas?
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collections of blood below dura
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What classifies an ischemic stroke as cardiogenic embolism?
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in pts with a fib, valve disease, or ventricular thrombi
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Pathophys of carotid atherosclerosis?
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progressive accumulation of lipids and inflammatory cells, hypertrophy of arterial smooth muscle cells, results in plaque formation
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Pathophys of cardiogenic embolism?
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stasis of blood in atria or ventricles of heart leads to formation of local clots that can dislodge and travel to cerebral circulation
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What is the normal cerebral blood flow in ml/100g/min?
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50ml/100g/min
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What value is ischemia in cerebral blood flow in ml/100g/min?
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<20ml/100g/min
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What value is infarction (irreversible brain damage) in cerebral blood flow in ml/100g/min?
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<12ml/100g/min
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What is an ischemic penumbra?
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potentially salvageable ischemic tissue
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What is the clinical presentation of stroke symptoms?
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-weakness on one side of body
-inability to speak -loss of vision -vertigo or falling -HA (severe with hemorrhagic strokes) |
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What are the stroke signs?
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-hemi or monoparesis
-vertigo or double vision -aphasia -dysarthria, visual field defects, and altered level of consciousness |
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What is a transient ischemic attack (TIA)?
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transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction (leads to an increased risk of ischemic stroke after TIA - highest first few days after)
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What are conditions that can mimic acute ischemia?
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seizures, syncope, migraine, hypoglycemia
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What labs should be take on admission for ischemic stroke?
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-CBC with platelets
-cardiac enzymes and troponins -electrolytes, BUN, scr -serum glucose -PT and INR -PTT -02 stat -lipid profile -selected pts: LFTs, tox screen, BAC, preg test, arterial blood gas |
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What diagnostic test should be done on an ischemic stroke pt?
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-CT scan of head (gold standar)
-mri -ecg -carotid doppler -TTE -TEE -trancranial doppler (TCD) -selected pts: lumbar puncture, electroencephalogram |
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What are the desired outcomes of tx in stroke?
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-reduce ongoing neurologic injury and decrease mortality and long-term disability
-prevent complications secondary to immobility and neurologic dysfunction -PREVENT STROKE RECURRENCE |
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What is the tx in subarachnoid hemorrhagic stroke?
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immediate assessment of whether pt has berry or saccular aneurysm should be made with possibly following with endovascular coiling or clipping via craniotomy to prevent rebleeding
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What is the tx in intracerebral hemorrhage?
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may require external ventricular drainage (EVD) if there is intraventricular blood and evloving hydrocephalus (no standard drug regimes)
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In hemorrhagic stroke, what affect does hemostatic agents lead to?
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reduce hematoma growth, but no improvement in outcomes
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What drug tx for subarachnoid hemorrhage (SAH)?
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Nimodipine 60 mg po q4h x 21 days
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What is the NINDS trial?
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-National Institutes of neurologic disorders and stroke recombinant Tissue Type Plasminogen Activator Stroke Trial
-rt-PA vs placebo within 3h -better outcomes with rt-PA |
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What kind of drug is Alteplase?
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recombinant tissue-type plasminogen activator or TPA
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In what time period should t-PA be given in ischemic stroke?
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within 3h
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What is the dosing in ischemic stroke for Alteplase?
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0.9mg/kg over 1h - max 90mg (10% as initial bolus over 1 min)
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What is the inclusion criteria for alteplase?
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- >=18yoa
-diag of ischemic stroke causing measurable neurologic deficit -within 3 hours of symptom onset |
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What are alteplase exclusion criteria?
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-evidence of intracranial hemorrhage on noncontrast head CT
-CT shows multilobar infarction (>1/3 cerebral hemisphere) -only minor or rapidly improving stroke symptoms -high clinical suspicion of subarachnoid hemorrhage even with normal CT -Active internal bleeding (ex GI within 21 days) -known bleeding diathesis, including but not limited to platelet count <100,000 -pts receieved heparin within 48h and had elevated aPTT -recent use of anticoag and elevated PT (>15sec)/INR (>1.7) -intracranial surgery,serious head trauma, or previous stroke within 3 months -major surgery or serious trauma within 14 days -recent (7 days) arterial puncture at noncompressible site -lumbar puncture within 7 days, hx of intracranial hemorrhage, av malformation, or aneurysm -witnessed seizure at stroke onset -blood glucose <50mg/dL -recent (3months) acute MI -SBP >185 or DBP >110 at time of treatment |
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What is the ECASS 3 trial?
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-European Cooperative Acute Stroke Study
-Acute Ischemic stroke -Alteplase vs placebo admin 3-4.5 after stroke onset -Alteplase better -expanded guidelines to 4.5h |
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What are the 3-4.5h ischemic stroke exclusions?
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> 80 yoa, NIH stroke scale >25, combination of previous stroke and diabetes, those on anticoags regardless of INR
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What is PROACT II trial?
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-Prolyse in Acute Cerebral Thromboembolism
-benefit for intraarterial pro-urokinase in occulsion to 6 h (not approved in US) |
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What is MERCI trial?
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-Mechanical Embolus Removal in cerebral ischemia
-fda approved for within 8h of onset of symptoms -alternative for pts unable to receive thrombolytics or have had failed therapy |
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Aspirin dose in acute ischemic stroke?
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160-325mg daily within 48 h (but not within 24 h of tPA)
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Dose of heparin in ischemic stroke?
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generally not recommended
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What BP should not be treated acutely in ischemic stroke?
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SBP <220mgHg or DBP <120mmHg unless pt has evidence of aortic dissection acute MI, pulmonary edema, hypertensive encephalopathy
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What drugs for htn should be used in acute ischemic stroke?
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labetolol, nicardipine, nitroprusside
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What dose of labetolol should be used in acute ischemic stroke htn tx?
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labetolol IV 10-20 mg, doubled q 10-20 min to max 300mg; can also use infusion of 2-8mg/min
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What dose of nicardipine should be used in acute ischemic stroke htn tx?
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5mg/h up to 15mg/h
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What dose of nitroprusside should be used in acute ischemic stroke htn tx
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If diastolic >140, infuse at 0.5mcg/h with continous arterial blood pressure monitoring
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How much should BP be lowered in the first 24h after stroke onset?
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15%
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If a patient receives tPA, what should their BP be treated to?
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< 185/110
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What is the dose of ASA for secondary stroke prevention?
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50-325 mg/day
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If patient needs ibuprofen, how do you dose with ASA?
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admin ASA 2 h before or 4 h after ibuprofen
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ss for ASA toxicity?
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GI bleeding, major bleeding, intracranial bleeding
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What dose of ASA is associated with lower risk of bleeding?
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<100mg/d. Keep dose at 50-100mg/d for secondary stroke prevention
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What is the dose of clopidogrel for secondary stroke prevention?
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75mg po daily
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What is the CAPRIE trial?
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-Clopidogrel vs ASA in pts with ischemic event risk
-clopidogrel better, best in PAD |
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Clopidogrel SEs?
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rash, diarrhea, gi bleed, gi upset
-low incidence of neutropenia -rare thrombotic thrombocytopenic purpura |
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Clopidogrel polymorphisms?
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1A2, 3A4, 2C19 (2c19 issue with PPI)
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What is the moa of dipyridamole?
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impairs platelet function by inhibiting phosphodiesterase which causes accumulation of cAMP and cGMP
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What is the dosing for secondary prevention of stroke with aggrenox?
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extended release 200mg/25mgASA BID
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What is the esprit trial?
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-aggrenox vs asa in minor stroke or tia pts
-aggrenox had better composite primary |
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SEs of dipyridamole?
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HA, increase LFTs, GI upset, diarrhea, less Gi bleed and overall bleed than ASA
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WHat is Profess trial?
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-aggrenox vs plavix in stroke pts
-no difference |
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Match and charisma trial conclusion?
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ASA + plavix = higher risk of bleed and no increase in benefit
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MOA of ticlopidine?
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similar to plavix
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Dosing of ticlopidine in secondary stroke prevention?
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250mg po bid with food
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SEs with ticlopidine?
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nausea, increased cholesterol and TGs, neutropenia, rash, diarrhea; monitor CBC q2 wks x 3 months and periodically thereafter; not first line
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When is warfarin indicated in stroke patients?
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secondary prevention of cardioembolic stroke
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What is the target INR on warfarin for A fib patients in secondary stroke prevention?
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2.5 (2-3)
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What is the target INR on warfarin for mechanical prosthetic heart valves patients in secondary stroke prevention?
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3 (2.5-3)
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AHA/ASA recommendation on BP lowering in stroke pts?
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bp reduction recommended beyond first 24 h regardless of hx of HTN, optimal drug therapy uncertain but available data points to diuretics + ACEi
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LDL goals in secondary prevention of stroke?
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50% reduction in LDL or <70mg/dL; statin therapy recommended to those with evidence of atherosclerosis, without CHD, and LDL > 100mg/dl
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When is carotid endarterectomy indicated?
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-ischemic stroke or TIA pts with severe (70-99%) stenosis of ipsilateral carotid artery
-moderate stenosis (50-69%) depending on age, sex, comorbidities -NOT recommended in stenosis <50% |
