What is the cause of stroke?
Cerebral infarction (ischemic stroke), or intracerebral hemorrhage
Goals of therapy
- minimize brain damage
- prevent complications (pneumonia, VTE)
- reduce risk of stroke recurrence
- restore function and minimize long-term disability
Endovascular thrombectomy
non-surgical, angiographic procedure, uses microcatheters to remove blood clots and re-establish arterial blood flow in the brain
-can be performed after initiating tPA or in patients who can not use tPA
What type of compression stockings should be used to prevent VTE?
pneumatic compression stockings (inflate and deflate to help blood flow) within 24 hours
What is the treatment criteria for Thrombolysis in Acute Ischemic Stroke?
- patient is 18+
- stroke onset is less than or equal to 4.5 hours before drug administration
TIA?
brief episode of neurological dysfunction < 1 hr upto 24 h, no evidence of infarction on imagine (cell death)
which stroke is more common?
ischemic = due to blockage of blood flow
Mechanisms of ischemic stroke?
- thrombosis (atherosclerosis, vasoconstriction)
- emboli that contains thrombi that travel thru the blood
- cerebral hypo-perfusion due to reduced cardiac output
Forms of thrombolysis for acute treatment of ischemic stroke
- tPA
- TNK (tenectaplase) - not appoved yet by HC
What are the absolute contraindications for tPA?
- active hemorrhage (or any condition that can increase risk of major bleeding after tPA)
- acute hemorrhage on intracranial imagine
What lab values suggest a relative contraindication to tPA ?
- Blood glucose < 2.7 or > 22 mmol/L
- INR > 1.7
- elevated aPTT (activated partial thromboplastin time)
- platelet count <100 *10^9/L
What clinical findings determine a relative contraindication to thrombolytic therapy (tPA)?
- subarachnoid hemorrhage
- stroke symptoms due to another nonischemic acute neurologic condition (ex. seizure with postictal Todd paralysis, severe hypo or hyperglycemia)
- hypertension refractory to therapy - target BP of < 185/110 mmHg can not be reached.
- patient is taking DOAC
What BP should be targeted for a patient prior to starting thrombolysis and during treatment?
BP < 180/105 mmHg
DOACs to avoid in relation to low CrCl?
CrCl < 30 : avoid dabigatran and rivaroxaban
CrCl < 15 : avoid apixaban and edoxaban
When is DAPT recommended in stroke? Is it recommended for secondary prevention?
ONLY in acute setting with ASA + clopidrogrel short-term use between 21 and 30 days.
Not recommended for long-term or for secondary prevention.
