Therapeutics II > Stroke (Exam 2) > Flashcards

Stroke (Exam 2) Flashcards

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1
Q

types of stroke

A

acute ischemic stroke
hemorrhagic stroke
transient ischemic attack

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2
Q

what puts someone at an increased risk for stroke

A

HTN
HLD
smoking
obesity
diabetes

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3
Q

which type of stroke is more common?

more fatal?

A

ischemic stroke

hemorrhagic

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4
Q

what is the most potent risk factor for stroke?

A

atrial fibrillation

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5
Q

acute ischemic stroke

A

complete or partial vessel occlusion leads to reduced cerebral blood flow
reduction in CBF causes cell death

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6
Q

decreased tissue perfusion leads to

A

neuronal damage and loss of function

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7
Q

every minute untreated, how many neurons die?

A

about 1.9 million

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8
Q

time is ____________

faster treatment leads to

A

brain

lower disability and better functional outcomes

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9
Q

types of ischemic stroke

A

thrombotic (forms in brain)
embolic (travels to brain)

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10
Q

penumbra

A

tissue that is ischemic but maintains membrane integrity

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11
Q

apoptotic cell death in the penumbra occurs

A

over days to weeks after stroke

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12
Q

hemorrhagic stroke

A

weakened blood vessels rupture and blood accumulates, compression surrounding tissue
rapid neurological dysfunction

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13
Q

types of hemorrhagic ruptures

A

aneurysm (ballooning of weakened BV)
arterovenous malformation (cluster of abnormally formed BVs)

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14
Q

types of hemorrhagic strokes

A

intracerebral hemorrhage
subarachnoid hemorrhage

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15
Q

intracerebral hemorrhage

A

release of blood in brain tissue
increased ICP

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16
Q

subarachnoid hemorrhage

A

release of blood into space between brain and skull

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17
Q

signs and symptoms of stroke

A

BEFAST
Balance loss
Eyes (vision change)
Face (unilateral drooping)
Arms (numbness/weakness)
Speech (difficulty speaking/slurring)
Terrible headache

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18
Q

what are atypical signs and symptoms of stroke that women experience

A

hiccups
NV
palpatations

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19
Q

severe headache is more specific to which type of stroke

A

hemorrhagic

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20
Q

a bleed in the left brain leads to

A

right side paralysis
speech/language problems
slow, cautious behavior
memory loss

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21
Q

a bleed in the right brain leads to

A

left side paralysis
vision problems
quick, inquisitive behavior
memory loss

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22
Q

a bleed in the brain stem leads to

A

locked in syndrome

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23
Q

stroke

A

abrupt onset focal neurological defect
lasts over 24 hours
vascular in origin

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24
Q

transient ischemic attack (TIA)

A

symptoms last under an hour

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25
TIA requires
urgent intervention without reperfusion therapy
26
_________ risk is elevated in the first few days after TIA
stroke
27
stroke chain of survival
detection dispatch delivery door decision drug disposition
28
in the initial evaluation, what is the most important piece of information?
patient history = time of onset or last know well time (LKWT)
29
only the assessment of ______________ must precede the initiation of IV thrombolytics in all patients
blood glucose
30
why should glucose testing occur first?
hypoglycemia (under 70) can be a common stroke mimic may present with aphasia and hemiplegia
31
if patient is hypoglycemic, administration of _____________ should rapidly resolve symptoms whereas they would persist in stroke
dextrose
32
anticoagulation tests
warfarin (INR) heparins (aPTT, PT, factor Xa) DOACs (PT/INR and aPTT)
33
what happens if the stroke patients has taken a DOAC within 48 hours?
they are ruled out for being a thrombolytic candidate
34
in order to assess for stroke, what needs to be ruled out
stroke mimics
35
examples of stroke mimics
seizure hypoglycemia migraine with aura wernicke's encephalopathy CNS abscess CNS tumor drug toxicity Bell's palsy
36
what drugs can lead to stroke mimics?
lithium phenytoin carbamazepine
37
how to differentiate bells palsy from stroke?
bells palsy - whole face droops and speech still intact stroke - one side droops, speech not intact
38
NIH Stroke Scale (NIHSS)
measures neurological function
39
NIHSS of 0
normal
40
NIHSS of under 5
minor stroke likely to have good outcome
41
NIHSS of 6-15
moderate stroke
42
NIHSS of 16-20
moderate to severe stroke
43
NIHSS of 21-42
severe stroke
44
more severe strokes are correlated with
worse outcomes
45
what is the purpose of NIHSS
identifies stroke severity to help identify patients who quality for thrombolytic or mechanical intervention
46
Before any medications are given, what imaging test should be done? Why?
non constrast CT rules out ICH
47
when should a non contrast CT be performed?
less than 20 minutes upon arrival
48
DWI
diffusion weighted imaging on MRI identifies infarcted brain tissue
49
FLAIR
fluid-attenuated inversion recovery on MRI detects subacute infarction
50
DWI-FLAIR mismatch
DWI +, FLAIR -
51
what is DWI-FLAIR mismatch used for?
selects patients with wake-up or unknown onset strokes who may still benefit from IV alteplase if treated less than 4.5 hrs from symptom recognition
52
what is the first step of approach to treatment for stroke
determine if its ischemic of hemorrhagic
53
what type of stroke is reperfusion used for
acute ischemic stroke
54
pharmacological options for reperfusion in AIS
tenectaplase (TNK) alteplase (tPA)
55
non-pharmacologic options for perferfusion in AIS
mechanical thrombectomy
56
when should a mechanical thrombectomy be carried out
within 6-24 hours of symptom onset
57
should patients getting a mechanical thrombectomy be on an IV thrombolytic?
they should receive an IV thrombolytic FIRST
58
MOA of thrombolytic
binds to fibrin in thrombus convert plasminogen to plasmin plasmin degrades fibrin meshwork and fibrinogen clot dissolutes and cerebral blood flow restored
59
In order to be on a thrombolytic, what should be ruled out first?
hemorrhagic stroke
60
when should an IV thrombolytic be administered
within 3 hours from symptom onset window can be extended to 4.5 HOURS
61
when should the window to receive and IV thrombolytic not be extended?
age over 80 AC use NIHSS score over 25 history of both stroke and diabetes
62
door to needle time for iv thrombolytic
within 60 minutes
63
what if it has been over 4.5 hours, should the patient still receive an IV thrombolytic?
no unless selected for thrombectomy
64
TNK dose
0.25mg/kg IV bolus (max 25mg)
65
TNK is resistant to
PAI-1
66
TNK and tPA are
fibrin specific
67
tPA dose
0.9 mg/kg (max 90MG) 10% - IV bolus over 1 min 90% - continuous infusion over 60 min
68
thrombolytic absolute contraindications stroke type
mild, nondisabiling stroke (0-5)
69
thrombolytic absolute contraindications imaging findings
extensive hypo attenuation on CT ICH or subarachnoid hemorrhage
70
thrombolytic absolute contraindications recent events/surgery
Ischemic stroke, severe head trauma, intracranial or spinal surgery within 3 months
71
thrombolytic absolute contraindications PMH
prior ICH, intra-axial IC neoplasm, aortic arch dissection ineffective endocarditis
72
thrombolytic absolute contraindications bleeding risk/labs
platelets under 100,000 INR over 1.7 aPTT over 40s PT over 15s full dose LMWH within 24hr DOAC within 48 hr GI malignancy or GI bleed within 21 days
73
thrombolytic absolute contraindications concomitant medications
abciximab
74
what happens if there is clinical signs of worsening?
dc thrombolytic
75
what should be checked regularly if a person is being treated for stroke
neurological assessments BP
76
when should a follow up CT be done after starting an IV thrombolytic
at 24 hours before starting anticoagulants or anti platelets
77
patients who are at a higher risk of hemorrhagic conversion
age over 80 large infarct size severe stroke (NIHSS > 25) uncontrolled HTN DM and/or severe hyperglycemia prior antiplatelet/anticoagulant therapy
78
what reversal agents can be given to help with hemorrhagic conversion?
cryoprecipitate: 10 U over 10-30min (additional dose if fibrinogen over 150) tranexamic acid 1000mg IV over 10min e-aminocaproic acid 4-5g over 1h, then 1g IV until bleeding controlled
79
angioedema management
stop infusion (if tPA) Hold ACEi IV medrol 125mg diphenhydramine 50mg famotidine 20mg IV consider epinephrine
80
Blood pressure ______________ in the days after stroke
spontaneously decreases
81
what should BP management be done for candidates for thombolytic therapy or endovascular therapy with elevated BP
lower BP to less than 185/110 before IV thrombolysis initiated maintain less than 180/105 during/after infusion/injection for 24 hrs
82
what should BP management be for NONcandidates for thrombolytic therapy with BP over 220/120
permissive HTN bring down to 220/120 lower BP by 15% within 24hrs of stroke onset
83
examples of IV antihypertensive agents
labetolol nicardipine clevidipine hydralazine enalaprilat
84
clevidipine
fast onset and titration contraindicated in those with soy/egg allergy or defective lipid metabolism
85
secondary prevention for stroke
aspirin 81-325mg high intensity statin OAC lifestyle modifactions
86
high intensity statin is recommended for all
ischemic stroke patients
87
OAC is recommended for
cardioembolic strokes
88
administer antiplatelet agents (aspirin) within
24-48 hours of AIS onset
89
when to start antiplatelet agents in AIS?
only after imaging rules out hemorrhage
90
antithrombotic therapies for secondary prevention of stroke
aspirin 81mg/day clopidogrel 75mg/day Aggrenox 200mg/25mg BID
91
should clopidogrel be used in combination with aspirin for long term stroke prevention?
NO!
92
what is the preferred choice for antithrombotic therapies for secondary prevention of stroke
aspirin 81mg
93
who benefits from DAPT?
minor non-cardioembolic stroke (score under 3) high risk TIA NO IV thrombolytics administered
94
DAPT window and duration for stroke
window: start within 24 hours of symptom onset duration: 21-90 days
95
DAPT options for stroke
Aspirin and clopidogrel aspirin and ticagrelor aspirin and dipyridamole
96
what is preferred in cardioembolic stroke?
ACs over APs
97
when are anti platelets in combo with Acs considered?
patients with a history of CCD
98
CHADSVASc score
risk stratification for stroke prevention in a-fib
99
initial management of hemorrhagic stroke
dc all anti platelets and ACs obtain CT/MRI to confirm consult neurology maintain airway, oxygen, glucose treat seizures only if present
100
reversal agent for warfarin
vitamin K and 4-factor PCC (KCentra)
101
reversal agent for UFH/LMWH
protamine sulfate
102
reversal agent for dabigatran
Praxbind (idarucizumab)
103
reversal agent for apixaban/rivaroxabam
andexanent alfa (Andexxa) or 4F-PCC
104
reversal agent for antiplatelets
desmopressin (DDVAP) 0.3mcg/kg IV
105
High BP after ICH increases
risk of hematoma growth and poor outcomes
106
recommendations for SBP 150-220
lover to under 140 within 1 hour
107
recommendations for SBP over 220
initiate aggressive IV antihypertensive therapy target 140-160
108
in BP management, avoid _______________ that may reduce cerebral perfusion
sudden drops in BP
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