Stroke pre-lec 1

Question 1

Stroke epidemiology

Answer 1

-approx 800,000/y
-fifth leading cause of death in US
-freq cause of impairment in elderly

Question 2

Stroke

Answer 2

-acute focal injury due to lack of blood/oxygen to CNS
=neurological deficits
-ischemic (85%)
-hemorrhagic (15%)
-historically called cerebrovasc accident (CVA) but not an accident so moving away from this term

Question 3

Ischemic stroke

Answer 3

-infarction of brain tissue from compromised blood flow
-artherosclerotic ischemic stroke
-cardioembolic ischemic stroke

Question 4

Hemorrhagic stroke

Answer 4

-bleeding in brain due to cerebral artery rupture
-AKA intracranial hemorrhage (ICH

Question 5

Patho of artherosclerotic ischemic stroke

Answer 5

-plaque build up (platelets, lipids, inflammatory markers)
-blood clot blocks artery (coagulation cascade)
-normal sinus rhythym

Question 6

Patho of cardioembolic ischemic stroke

Answer 6

-AFib
-valv abnormalities
-still a blood clot block but no plaque?

Question 7

Stroke risk factors

Answer 7

-age
-fam hx
-females
-race
-low birth weight
-sickle cell disease
-CVD
-AFib
-DM
-HLD
-HTN
-drug/alc
-obesity
-cigs

Question 8

Stroke clinical presentation

Answer 8

-Facial droop
-Ataxia (muscle movement)
-dysphasia (difficulty speaking)
-uni or bilateral weakness
-vision changes (diplopia)
-HA (more common w hemorrhagic)

Question 9

NIH stroke scale (NIHSS)

Answer 9

-0-42 w high scores = poor prognosis

Question 10

Stroke assessment

Answer 10

-head CT or MRI
-BP
-O2
-BG (is it hypoglycemia?)
-BMP
-CBC
-INR, aPTT
-ECG (artherosclerotic or cardioembolic)
-echocardiogram

Question 11

Tx goals for acute stroke

Answer 11

-limit neurlogic injury and long-term disability
-dec mortality
-prevent future strokes

Question 12

Acute stroke management overview

Answer 12

-supportive care
-glycemic control
-med access
-anti-HTN
-thrombolytics
-antiplatelets
-anticoags

Question 13

Hypoglycemia

Answer 13

-neurological sx mimi stroke
-tx w carbs to maintain euglycemia

Question 14

Hyperglycemia

Answer 14

-BG >180 = worse mortality during stroke
-tx w subQ insulin to maintain BG < 180 while inpt
-only use insulin drip if pt in acidosis

Question 15

Med access

Answer 15

-pt may not be able to swallow (NPO)
-IV, topical, rectal, fedding tube

Question 16

argument for dec BP

Answer 16

-minimize long-term neuro defects
-dec cerebral edema and hemorrhagic transformation risk
-prevention of recurrent stroke

Question 17

Argument against dec BP

Answer 17

-permissive HTN
-dropping BP too quickly can limit brain perfusion which can worsen ischemia and neuro fx
-BP control requires BALANCE

Question 18

Acute BP goals

Answer 18

-check BP q15min x2h
-then q30min x6h
-then q1h for 16h
-BP goals in first 48h higher than normal to allow permissive HTN
-no tPA: <220/110
-tPA: <180/105
-after 48h, normal BP goal

Question 19

Acute HTN tx options

Answer 19

-don’t need to know agents/dose just know we’re giving parenteral anti-HTN
-labetolol
-nicardipine
-sodium nitroprusside

Question 20

HTN management after 48h

Answer 20

-if BP still elevated, re/start PO anti-HTN

Question 21

HTN management summary

Answer 21

-parenteral anti-HTN is BP above goal to dec risk of hemorrhagic stroke
-no tPA: <220/110
-tPA: <180/105
-if HTN after 48h start PO anti-HTN and reduce goal to >130/80 or >140/90

Question 22

Thrombolytics MOA + drugs

Answer 22

-tissue plasminogen activator (tPA)
=lyse blood clots

-alteplase
-tenecteplase

Question 23

Thrombolytic use

Answer 23

-ISCHEMIC stroke
-improves fx capabilities
-NO impact on mortality but can improve neuro fx
-ONLY IN PT MEETING ELIGIBILITY
-must meet ALL inclusion and NO exclusion criteria

Question 24

tPA inclusion criteria

Answer 24

-must meet all:
-ischemic (NOT hemorrhagic)
-sx onset ≤ 4.5h
-age ≥ 18

Question 25

tPA exclusion criteria

Answer 25

-BP>185/110 at time of admin -BG < 50mg/dL -lots of others regarding other hemorrhages/bleeding risks

Question 26

tPA agents + ADRs

Answer 26

-alteplase IV infusion over 1h -tenecteplase IV bolus (off-label) -bleeding risk (could cause hemorrhagic stroke) -keep BP < 180/105 to dec bleeding risk -cerebral edema -avoid ALL antiplatelets and anticoags for 24h after

Question 27

Thrombolytic summary

Answer 27

-pt must meet all inclusion criteria w no exclusion criteria -monitor bleeding, BP goal -avoid antiplatelets/coags for 24h

Question 28

Antiplatelet MOA

Answer 28

-P2Y12 inhibitor that blocks ADP receptor -ASA is COX-1 inhibitor =dec aggregation of platelets

Question 29

Antiplatelet acute ischemic stroke options

Answer 29

-ASA monotx -ASA + clopidogrel or ticagrelor -ticagrelor

Question 30

ASA MOA

Answer 30

-irreversible COX-1 inhibition =dec formation of thromboxane A2 =dec aggregation

Question 31

ASA utility

Answer 31

-first-line for acute ischemic stroke tx -ALL ischemic stroke pt unless CI for bleeding risk -immediate if no tPA -≥ 24h if tPA -dec in early recurrent stroke w high dose ASA (160-325mg qd) for 2-4 weeks

Question 32

Antiplatelets monitoring

Answer 32

-bleeding -stroke

Question 33

ASA + clopidogrel use

Answer 33

-2nd line for minor stroke -combo ONLY in minor stroke (NIHSS ≤ 4) -dec recurrent stroke but inc bleeding 81mg/75mg

Question 34

Ticagrelor +/- ASA use

Answer 34

-ONLY in minor strokes (NIHSS ≤ 5) -2nd line -likely use for true ASA allergy -180mg once then 90mg PO BID

Question 35

Anticoagulants

Answer 35

-lack of data -no improvement in neuro fx or prevention of stroke -just inc bleeding risk -use ASA instead -if pt is on this put them on ASA -do NOT use alteplase if pt comes in on anticoag -if cardioembolic stroke or other indication for anticoag, start 2-14 days after stroke and d/c ASA

Question 36

Acute ischemic stroke summary

Answer 36

-eval tPA need -BP and glycemic control minimize complications -antiplatelets recommended in acute management to prevent recurrent stroke -monitor BP, bleeding, stroke