Term
age > 55
gender
race
family history of stroke
low birth weight |
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Definition
| nonmodifiable risk factors of stroke |
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Term
HTN ***the single most important risk factor of ischemic stroke***
Afib ***increases risk of stroke 6 times***
other cardiac causes (CAD, CHF, LVH)
atherogenic states (diabetes, dyslipidemia, cigarette smoking)
alcohol abuse |
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Definition
| modifiable risk factors of stroke |
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Term
oral contraceptives
migraine
high levels of homocysteine
sleep apnea/snoring
drug abues (cocaine, amphetamines, heroin) |
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Definition
| potentially modifiable/unproven risk factors for stroke |
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Term
control of HTN: HTN - 70% of strokes, BP control can decrease the risk of stroke by 35-40%
smoking cessation
control of DM
cholesterol reduction
treatment of atrial fibrillation: CHADS2 score |
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Definition
| what can be done for primary prevention of a stroke? |
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Term
seek immediate medical attention for sudden: numbness or weakness of the face, arm/leg (especially on one side of the body), confusion, trouble speaking or understanding, trouble seeing in one or both eyes, trouble walking, dizziness, loss of balance or coordination, severe headache with no known cause
Act FAST: face, arm, speech, time |
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Definition
| patient education on stroke |
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Term
normal cerebral blood flow (CBF) is 50mL/100g/min
cerebral autoregulation: cerebral blood vessels dilate and constrict in response to BP changes to maintain cerebral blood flow despite BP fluctuation. Cerebral autoregulation can be impaired by artherosclerosis and injury.
ischemia: local cerebral blood flow decreased to less than 20mL/100g/min
infarction (irreversible brain tissue damage): local cerebral blood flow persistently less than 12mL/100g/min.
ischemic tissue surrounding an infracted area is called the ischemic penumbra and can potentially be saved
carotid artherosclerosis or cardiac issues can cause ischemic stroke |
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Definition
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Term
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Definition
| mechanism of stroke via carotid atherosclerosis pathway and cardiac flow issue pathway (AFib, vavlular, etc) |
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Term
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Definition
abrupt onset focal neurologic deficit
at least 24 hours
presumed vascular origin |
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Term
| transient ischemic attake (TIA) |
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Definition
abrupt onset focal neurologic deficit
less than 24 hours (usually 30 minutes) |
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Term
symptoms: unilateral weakness, inability to speak, loss of vision, vertigo/feeling of falling, headache (more severe with hemorrhagic stroke)
signs (dependent upon area affected): neurological dysfunction, hemi- or monoparesis (weak or paralyzed on one or both sides of the body), aphasia (can't speak), dysarthria (difficulty speaking, slurred speak), visual field defects, altered level of consciousness |
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Definition
| signs and symptoms of stroke |
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Term
PE, history, and clinical presentation
testing:
CT scan of head: may take 24 hours to reveal area of infarction, preferred method of diagnosis, ischemic areas will be dark, hemorrhage will appear white
MRI of head: reveal areas of ischemia with higher resolution and sooner than CT
carotid doppler: determine if high degree of stenosis in carotid arteries supplying blood to the brain
ECG: determine presence of AFib
TTE: evaluate for valve abnormalities or wall-motion abnormalities as embolic sources to the brain
TEE: more sensitive test for thrombus in left atrium |
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Definition
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Term
National Institutes of Health Stroke Scale (NIHSS)
scored based on level of consciousness, motor function, sensory function, and language ability
possible scores range from 0 to 42
scores less than 3-4 have excellent chance for complete recovery, scores greater than 20 predict poor outcomes |
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Definition
| what scale determines the prognosis of a patient who has had a stroke? |
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Term
| anticoagulation or thrombolytic therapy |
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Definition
| risk factors that a stroke will develop into a hemorrhagic stroke |
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Term
reduce ongoing neurologic injury and decrease mortality/long term disability
prevent complications from immobility and neurologic dysfunction
prevent stroke recurrence |
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Definition
| goals of therapy for stroke |
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Term
| tissue plasminogen activator (t-PA) |
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Definition
thrombolytic therapy to restore or improve perfusion to the penumbra
binds to fibrin in a thrombus and converts bound plasminogen to plasmin
plasmin is responsible for clot dissolution and initiates local fibrinolysis
adverse reactions and monitoring: bleeding - monitor Hgb/Hct, signs/symptoms of bleeding, monitor for mental status changes
outcomes: 3 month outcomes significantly improved, intracerebral hemorrhage increased but no increase in mortality or disability |
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Term
0.9 mg/kg IV total dose
max 90mg
10% as bolus
remainder as infusion over 1 hour |
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Definition
| what is the dose for t-PA? |
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Term
age 18 years or older
clinical diagnosis of ischemic stroke causing a measurable neurologic deficit
time to symptom onset is well established to be less than 3-4.5 hours before treatment would begin |
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Definition
| inclusion criteria for t-PA use in acute ischemic stroke |
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Term
intracranial or subarachnoid bleeding (or history)
other active/recent internal bleeding
recent intracranial surgery, head trauma, stroke
BP > 185/110 mmHg at the time of treatment
seizure at stroke onset
intracranial neoplasm, arteriovenous malformation, aneurysm
active treatment with warfarin, heparin, platelets < 100,000 or INR > 1.7
current pregnancy or lactation |
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Definition
| exclusion criteria for t-PA use in acute ischemic stroke |
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Term
age > 80
oral anticoagulant use
basline NIHSS score > 25
history of stroke and DM |
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Definition
| additional exclusions for t-PA use in acute ischemic stroke within 4.5 hours of event. |
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Term
reducing the formation of brain edema
lessening the risk of hemorrhagic transformation or the infarction
preventing further vascular damage
forestalling early recurrent stroke
aggressive BP lowering could worsen hypoperfusion |
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Definition
| benefits of BP control in stroke patients |
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Term
NOT eligible: treat SBP > 220 or DBP > 140, goal of lowering BP 10-15% from baseline
eligible: treat SBP > 185 or DBP > 110, goal of maintaining BP < 185/110
use short acting agents such as labetolol or nicardipine (CCB) with strong cerebral and coronary vasodilatory activity |
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Definition
| BP recommendations for patient not eligible for thrombolytics and patients eligible for thrombolytics |
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Term
aspirin: 325 mg da withing 24-48 hours of onset, wait 24 hours if patient given t-PA
venous thromboembolism prophylaxis: low dose subq heparin or LMWH, hold therapy for 24 hours if patient received t-PA |
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Definition
| acute therapy for ischemic stroke |
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Term
swallow evaluation - appropriate feeding based on ability to swallow
speech therapy
physical therapy
occupational therapy
social support
palliative care when appropriate |
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Definition
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Term
consider carotid endarterectomy depending on stenosis and other factors
reduce risk factors: control BP and lipids
antiplatelet therapy recommended for non-cardioembolic ischemic stroke: aspirin - 50-325 mg da, if patient has additional stroke while taking aspirin, no evidence that increasing aspirin dose will provide additional benefit, 27-30% risk reduction of stoke. clopidogrel - 75 mg po da, 8.7% risk reduction compared to ASA, not studied in acute ischemic stroke. ER dipyridamole/IR aspirin (aggrenox) - 37% risk reduction of stroke, not studied in acute ischemic stroke
antihypertensive therapy with ACEi and diuretic: caution lowering within first 7 days of stroke (potential for decreased cerebral blood flow)
lipid lowering therapy: stroke/TIA are coronary equivalents, LDL goal < 100 or < 70, statin therapy should be considered regardless of baseline cholesterol levels
patients with cardioembolic stroke: warfarin with INR goal 2-3 if the patient has AFib, pts with certain heart valves may require higher INR goals |
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Definition
| secondary prevention of ischemic stroke |
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Term
| intracerebral hemorrhage (ICH) |
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Definition
bleeding into the brain with formation of hematoma
greater morbidity/mortality than ischemic stroke
risk factors: male, age > 60 years, HTN, excessive alcohol intake, thrombolytic or anticoagulation therapy
an artery suddenly bursts
blood released within brain tissue: damage the brain tissues, cause a stroke, sudden increase in the pressure inside the skull
blood in brain damages surrounding tissues (mechanical effect, neurotoxicity of blood components and degradation products)
30% continue to enlarge over first 24 hours
clot volume = most important predictor or outcome
signs/symptoms: headache, focal neurologic deficits, decreased level of consciousness |
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Term
| subarachnoid hemorrhage (SAH) |
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Definition
bleeding occurs withing the subarachnoid space
caused by trauma or spontaneous
risk factors: age > 40 years, female, cigarette smoking, HTN, excessive alcohol use
cerebral aneurysm: abnormal outpouching of an artery, rupture, release of blood into the subarachnoid space (between the skull and brain), sudden increase in pressure inside the skull
signs/symptoms: sudden and unusually severe headache, N/V, decreased or loss of consciousness, difficulty speaking, visual defects, hemiparesis |
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Term
general supportive care, typically in ICU
management of BP if SPB > 200 or MAP > 150
often surgical intervention: place a metal clip at the base of aneursym, remove abnormal vessels comprising an arteriovenous malformation, endovasular procedures (less invasive) - catheter introduced through a major artery in leg or arm, guided to the aneurysm or AVM, deposits a mechanical agent such as a coil to prevent rupture |
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Definition
| treatment of hemorrhagic stroke |
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Term
control of HTN
smoking cessation
avoidance of heavy alcohol intake
avoidance of cocaine use |
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Definition
| secondary prevention of hemorrhagic stroke |
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