Term
| What is the difference between stroke and TIA? |
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Definition
- Trans-ischemic attack - no cell death occurs - ischemia without acute infarct, lasts 1-2 hrs with resolution of symptoms
- Stroke - cell death occurs, lasts 24 hrs, vascular origin |
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Term
| What types of stroke exist? |
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Definition
- Non-cardioembolic ischemic stroke - clot occludes BV, did not come from heart
- Cardioembolic ischemic stroke - clot originates at heart, Afib #1 cause
- Lacunes ischemic stroke - small vessel thickens
- Hemorrhagic stroke - rupture and bleeding occurs |
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Term
| What is the etiology and RF for ischemic stroke? |
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Definition
- Plaque forms and ruptures, sending a clot to the brain, or stasis in the atria --> Ischemia post-occlusion (infarct)
- Non-modifiable - Age, gender, etc
- Modifiable - HTN, Afib, DM2, Lipids, Smoking, hormone therapy, lifestyle, alcohol |
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Term
| What is the etiology of hemorrhagic stroke? |
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Definition
- Intracerebral hemorrhage - blood vessel rupture in the brain due to HTN or thrombolytics, high INR
- Subarachnoid - trauma or malformation
- Subdural - trauma |
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Term
| What is the common clinical presentation of stroke? |
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Definition
F - Face droop
A - Arm strength
S - Slurred Speech
T - Time
Also may see vision abnormalities, sensory loss/consciousness loss |
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Term
| What diagnostics are performed for suspected stroke patients? |
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Definition
- History - need to know time of onset, RF, history
- Physical exam, neurological exam
- Non-contrast brain CT - see hemorrhage
- ECG - look for Afib --> Cardioembolic
- Carotid doppler - Occlusion > 50% |
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Term
| When should BP be acutely lowered in a stroke patient? |
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Definition
- Signs of target organ damage: encephalopathy, dissection, ARF, pulmonary edema, MI
- Lower 15-25% on day 1, then per JNC7 after 24h |
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Term
| How can a patient meet the hypertensive goals of rtPA therapy/what are those goals? |
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Definition
- BP must be less than 185/110 to qualify - reduce using Labetalol, nitropaste, CCB
- BP goal while on rtPA is less than 180/105, use labetalol --> nicardipine --> Nitroprusside |
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Term
| What is the BP goal of a patient not receiving rtPA? |
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Definition
Goal is <220/120
If above, treat w/ Labetalol --> Nicardipine --> Nitroprusside |
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Term
| How are thrombolytics used to manage ischemic stroke? |
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Definition
- Window of opportunity: 4.5 hrs
- Use Alteplase: 0.9mg/kg (max 90) over 60 min, with 10% given as a bolus.
- No hemorrhage, Age>18, do not use in TIA, Low PLT, Pregnancy category X, evidence of trauma/surgery, low or high glucose
- BP must be below 185/110
- If between 3-4.5 hrs - cannot use if prior stroke or DM2, use of anticoagulants, Age > 80. |
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Term
| What is the dose for alteplase? |
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Definition
0.9mg/kg (max 90) over 60 min, with 10% given as a bolus.
Assess Neurological and BP OFTEN - q15min during, q30min x6h, then q1h |
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Term
How is antiplatelet therapy managed in ischemic stroke?
VTE prevention? |
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Definition
- ASA 325 at least 48h after stroke - wait 24h after tPA. IMMEDIATELY if no tPA
- Heparin/LMWH not used for Tx
- 24h after tPA, give Heparin 5000 units q8h/Lovenox 40 mg q24h/Dalteparin 5000 q24h for VTE prevention |
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Term
| What is the difference in Long term management techniques for ischemic stroke? |
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Definition
- non-cardioembolic/TIA - use Aggrenox or Plavix or ASA - single therapy. Plavix/Aggrenox better than ASA. Do NOT combine ASA + Plavix
- NEVER use Effient in stroke patients
- Cardioembolic - likely originates in Afib - use warfarin or Pradaxa (non-valvular) within 1-2 weeks, bridge with ASA until INR at goal |
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Term
| What other goals are managed in stroke? |
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Definition
HTN according to JNC7
LDL < 100, if stenosis > 50% goal becomes < 70
Stop smoking, limit alchohol |
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Term
| What medication management is used for hemorrhagic stroke? |
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Definition
- control HTN
- Nimodipine for subarachnoid hemorrhage
- Seizure and DVT control
- Surgery to clip vessels |
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