ES Stroke

Ischemic stroke

inadequate blood supply to an area of the brain

Embolic ischemic stroke

piece of thrombus from anywhere in body breaks loose and travels to brain artery

Hemorrhagic stroke

bleeding into the brain and other spaces in CNS

Subarachnoid hemorrhage

bleeding into space between inner and middle layer of meninges (trauma or aneurysm rupture)

Intracerebral hemorrhage

bleeding directly into brain parenchyma (uncontrolled hypertension)

Subdural hematoma

bleeding under dura overing the brain (head trauma)

Transient ischemic attack (TIA)

transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia w/o infarction

Characteristics of TIA

rapid onset, shorter duration, no deficit after attack, risk for acute ischemic stroke

Ischemic stroke characteristics vs TIA

tissue injury and infarction present, residual effects after event

Non-modifiable risk factors: ischemic stroke

age >55, gender, race/ethnicity, genetic predisposition, low birth weight

Modifiable risk factors: ischemic stroke

Afib, valvular heart disease, LA enlargement, MI, TIAs or prior stroke, diabetes, dyslipidemia, oral contraceptive use, smoking, obesity, etc

Risk factors: hemorrhagic stroke

hypertension, trauma, smoking, cocaine use, heavy alcohol use, anticoagulant use, cerebral aneurysm

Is aspirin recommended for primary prevention of stroke

in people w/ 10 year cardiovascular risk >10%

What is the most important initial diagnostic test in patients w/ suspected stroke?

noncontrast brain CT or MRI to differentiate ischemic stroke from hemorrhagic stroke

Symptoms: ischemic stroke

weakness on one side of body, facial droop, aphasia, loss of vision, vertigo, headache, falling

Signs: ischemic stroke

multiple signs of neurological dysfunction, hemiparesis or mono paresis, aphasia, dyarthia, altered levels of consciousness

NIHSS use

evaluation can be done quickly and by many different types of health care professionals --> quantifies level of neurological deficit

Components of NIHSS

level of consciousness, orientation questions, response to commands, gaze, visual fields, facial movement, motor function (arm and leg), limb ataxia, sensory, language, articulation, extinction or inattention

Short term goals: stroke

reducing secondary brain damage by reestablishing and maintaining perfusion

Long term goals: stroke

prevent recurrent strokes through reduction and modification of risk factors

Why is hypertension not normally treated within the acute period of a stroke?

may cause decreased blood flow in ischemic areas, which can increase area of damage

When should we treat hypertension in patients w/ stroke

w/ severe hypertension or patients w/ endovascular disorder

Alteplase inclusion criteria

18 or older, clinical diagnosis of ischemic stroke causing neurological defect, time of symptom onset <4.5 onset

Alteplase exclusion criteria

- non disabling mild stroke

- clinical presentation suggestive of SAH even w/ normal head CT or intracranial hemorrhage

- active internal bleeding

- current oral anticoagulant

- current use of direct thrombin inhibitors or direct factor Xa inhibitors

- previous intracranial hemorrhage

- SBP >185 mmHg or DBP >100 mmHg at time of treatment or patient requires aggressive treatment to reduce BP w/in these limits

When should alteplase be administered?

w/in 3-4.5 hours of S/S onset

How is efficacy determined after treatment w/ alteplase?

elimination of existing neurological deficits and long term improvement in neurological status

What are the major adverse effects of fibrinolytic therapy?

bleeding (ICH and systemic bleeding) --> easy bruising, hematemesis, black tarry stools, hematoma, hematuria, bleeding gums

How long after starting IV infusion of alteplase do we need a CT scan?

24 hours

What are recommendations for anti platelet therapy in patients w/ minor noncardioembolic ischemic stroke who did not receive alteplase?

dual anti platelet therapy started w/in 24 hours after symptom onset and continued for 21 days

What anti platelet agents are recommended for secondary prevention of ischemic stroke?

aspirin 50-325 mg, clopidogrel 75 mg daily, ER dipyridamole + aspirin

When should anticoagulants be used for the secondary prevention of ischemic stroke?

patients w/o AF or carotid stenosis

What additional conditions should be appropriately managed with a stroke?

hypertension, diabetes, dyslipidemia

S/S hemorrhagic stroke

sudden severe headache, N/V, photophobia, neck pain and stiffness

Short term goals: hemorrhagic stroke

-maintain adequate oxygenation, breathing, circulation

-management of increased ICP and BP

Long term goals: hemorrhagic stroke

prevention of complications and recurrent bleeds, prevent long term disability and death

Recommendations for BP control in hemorrhagic stroke

want SBP between 130-150, labetalol

What medication is recommended after a subarachnoid hemorrhage?

nimodipine, delays cerebral ischemia