stroke

Question 1

types of stroke

Answer 1

• Ischemic: compromised blood flow, usually atherosclerotic or clot
• Embolic: from dislodged thrombus
• Hemorrhagic: bleeding into surrounding tissue of brain from bursting of a defective cerebral artery
• TIA: episode of temporary (

Question 2

stroke risk factors

Answer 2

• modifiable: HTN, Cardiac disease (A.fib), TIAs, Diabetes, HLD, Cigarette smoking, obesity
• non-modifiable: Age, Gender (M>F), race, family hx, low birth weight

Question 3

ischemic stroke presentation

Answer 3

-unilateral or bilateral numbness/weakness, inability to speak, sudden onset of vision loss, vertigo, HA, facial droop

Question 4

ischemic stroke treatment

Answer 4

• Hypoglycemic (180mg/dL) untreated= worse outcomes

- t-PA: only drug FDA approved for ischemic stroke treatment

Question 5

t-PA for ischemic stroke

Answer 5

• Dosing: 0.9mg/kg IV (max of 90mg), with 10% as IV bolus (Example of 100kg patient = 9mg IV bolus + 81mg IV infusion over 60 minutes)
• AE: bleeding
• Monitoring: No anticoagulation/ antiplatelet for 24 hours following thrombolysis, keep BP under 180/105
• Criteria for use: SBP under 185 or DBP under 110, Onset of symptoms can be no longer than 3-4.5 hours before beginning treatment, No oral anticoagulation, or if taking, INR

Question 6

arterial HTN

Answer 6

• Aggressive BP decrease may worse neurological outcomes due to less profusion pressure to the ischemic areas of brain
• T-PA treatment? If BP over 185/110 = pretreatment with Labetalol 10-20 mg IV
• Patient not eligible for t-PA: goal is to lower BP by 15% over 24 hours: Treatment if SBP >220 or DBP >120, Labetalol, Nicardipine, Esmolol, Sodium Nitroprusside
• BP After 1st 24 hours: Previous HTN: restart home medication, Unknown: consider starting PO BP medication depending on BP

Question 7

anticoags and ischemic stroke

Answer 7

• Heparin = no benefit
• LMWH = did not lessen neurological risk
• DVT prophylaxis: UFH, LMWH, compression stockings, IVC

Question 8

antiplatelets and ischemic stroke

Answer 8

• Asprin 325mg within 24 hours of stroke

- Continue 1-2 weeks post stroke

Question 9

statins and ischemic stroke

Answer 9

• Reinitiate within 72 hours of stroke

- If not already on statin = consider adding during hospitalization

Question 10

hemorrhagic stroke presentation

Answer 10

-Altered mental status, N/V, headache, Seizures

Question 11

hemorrhagic stroke risk factors

Answer 11

HTN, AV malformation, ruptured neoplasm, intracranial neoplasm, coagulopathy

Question 12

hemorrhagic stroke treatment

Answer 12

• Surgical: craniotomy, clot evacuation, endoscopic evacuation
• Medical: slowly lower BP, correct coagulopathy, initiate anticonvulsants

Question 13

antiplatelet and hemorrhagic stroke secondary propylaxis

Answer 13

• daily dose of 50-325mg of aspirin
• Aggrenox: reserved for after clopidogrel d/t cost
• Clopidogrel: 75mg/day; greater efficacy than ASA alone for stroke prevention

Question 14

cardiogenics and hemorrhagic stroke secondary propylaxis

Answer 14

Cardiogenic (caused by A.fib or valvular heart disease or CHF)

• Warfarin to target INR range
• Direct thrombin and factor Xa inhibitors

Question 15

HTN and hemorrhagic stroke secondary propylaxis

Answer 15

• Monotherapy: ACE-inhibitors, CCBs, thiazide diuretics

- Combination: ACE + CCB or thiazide

Question 16

DM and hemorrhagic stroke secondary propylaxis

Answer 16

avoid hypoglycemia (symptoms mimic stroke)

Question 17

statins and hemorrhagic stroke secondary propylaxis

Answer 17

high intensity statin

Question 18

stroke-related seizures

Answer 18

• generally with 24-48 hours post-stroke -> 2 weeks post-stroke
• If seizure was associated with ischemic stroke, then give treatment, Otherwise no treatment
• Anticonvulsant: lamotrigine and gabapentin first

Question 19

depression and hemorrhagic stroke secondary prophylaxis

Answer 19

• may affect up to 50% of stroke patients and significantly impairs recovery
• Improvements in executive functioning found with anti-depressant therapy
• Treatment: sertraline, fluoxetine, escitalopram, citalopram all studied: Avoid TCAs

Question 20

tPA inclusion and exclusion criteria

Answer 20

inclusion: ischemic stroke confirmed by imaging, symptoms 0-3 hours, over 18 YO
exclusion: evidence of active internal bleed, hx of previous intracranial hemorrhage, previous stroke or head trauma in past 3 months, GI or genitourinary hemorrhage in past 21 days, major surgery in past 14 days, MI in past 3 months, BP over 185/110 at time of administration, BG under 50 mg/dL, platelets under 100,000, current anticoagulant use with INR over 1.7 or aPTT over 45 seconds, CI with NOAC

Question 21

extended alteplase window

Answer 21

can be used up to 4.5 hours after symptom onset
-must meet all inclusion and exclusion criteria PLUS: under 80 YO, no hx of previous stroke or DM, no recent use of ANY anticoag, and NIHSS under 25