Stroke

Why is it important to determine if a patient's stroke is cardioembolic vs non-cardioembolic?

-It determines appropriate secondary prevention treatment with antithrombotics

-it determines WHEN secondary prevention treatment with antithrombotics can be initiated

What are examples of Atherosclerotic Cardiovascular Disease (ASCVD)?

Stroke

Transient ischemic attack

Stable or unstable angina

Acute coronary syndromes

History of MI

Arterial revascularization

Peripheral arterial disease

What are examples of nonmodifiable risk factors for stroke?

Age

Race

Sex

Low birth weight

Genetic factor

What are examples of modifiable risk factors for stroke?

Hypertension

Cigarette smoking

Diabetes

Dyslipidemia

Atrial fibrillation

Poor diet

Obesity

Physical inactivity

Asymptomatic carotid stenosis

Sickle cell disease

Other CV disease

What agent is used for the primary prevention of stroke?

Low dose aspirin (81 mg)

What is the USPS Task Force recommendation for the primary prevention of stroke in 40-59 year olds with a >10 year CVD risk?

81 mg aspirin for those who are NOT at an increased risk for bleeding

Consider stopping at age 75

What is the USPS Task Force recommendation for the primary prevention of stroke in >60 years with a >10 year CVD risk?

Recommends against initiating low dose aspirin

What is the clinical presentation of a stroke?

Weakness on one side of the body

Inability to speak

Visual impairment

NIHSS score interpretation of 1-5?

Minor stroke

NIHSS score interpretation of 6-15?

Moderate stroke

NIHSS score interpretation of 16-20?

Moderate-severe stroke

NIHSS score interpretation of 21-42?

Severe stroke

What is the reccomended thrombolytic therapy if patient meets criteria?

Alteplase

Tenecteplase

What is the MOA of tPA?

Initiates local fibrinolysis by binding to fibrin in a thrombus and converting entrapped plasminogen to plasmin

What is the dose of alteplase?

0.9 mg/day (max 90 mg) with 10% of the dose given as a bolus over 1 minute

Remainder of the dose is given over 1 hour

What is the dose of tenecteplase?

0.25 mg/kg (max 25 mg) single rapid IV bolus

Why does tPA have extensive exclusion and inclusion criteria?

Increases risk for major bleeding

Are thrombolytics indicated in mild non-disabling strokes presenting within 4.5 hours of symptom onset?

No -

Not superior in improving functional outcomes compared to double

antiplatelet treatment (DAPT)

What is the criteria for tPA?

Clinical diagnosis of tPA

Noncontrast CT scan reading

Time frame within 4.5 hours

Blood glucose before initiation

CI in INR >1.7, aPTT >40s, platelets < 100,000

Past medical history CI

Current medications CI

BP <185/110 mmHg

Why is there a tPA criteria for a clinical diagnosis and CT or MRI brain imaging?

To rule out a cerebral hemorrhage

Why is there a tPA criteria for a timeframe of 4.5 hours of symptom onset?

Faster treatment improves functional outcomes

Treatment should be initiated as quickly as possible

Why is there a tPA criteria for a blood glucose reading before intiation?

To rule out hypoglycemia as it could present as similar symptoms

Why is there a tPA criteria for specific coagulopathie labs?

To prevent bleeding

What are the past medical history contraindications in tPA?

Traumatic brain injury <14 days

Neurosurgery <14 days

Spinal cord injury within 3 months

Infective endocarditis

Severe coagulopathy

Aortic arch dissection

Intracranial neoplasm

What are the current medications contraindication in tPA?

LMWH (if full treatment dose received within 24 hours)

DOAC (relative contraindication if received within 48 hours)

What is the BP threshold to initiate tPA?

Lower BP to <185/110 mmHg before initiating to prevent converting to a intracranial hemorrrhage

What agents can be used to lower BP to <185/110 mmHg?

IV Labetalol

IV Nicardipine

IV Clevidipine

What is the BP monitoring required during tPA administration?

Every 15 min during & after IVT for 2 hours

Every 30 minutes for 6 hours

Every hour for 16 hours

What is the follow-up CT requirement for tPA administration?

Follow up CT or MRI 24 hours after IVT

Obtain before starting anticoagulants or antiplatelet agents

When is aspirin indicated for acute stroke treatment?

When a patient is ineligble for tPA

If a patient receives tPA (generally) withhold aspirin for at least _____ to reduce the risk of hemorrhage?

24 hours

When is aspirin + clopidogrel (DAPT) indicated?

Minor noncardioembolic ischemic stroke (NIHSS ≤3) or TIA

When should DAPT be initiated in a minor noncardioembolic stroke?

Initiate within 24 hours of symptom onset

How long should DAPT be continued in a noncardioembolic stroke?

Continued for 21 days followed by single anti-platelet therapy

Can DAPT be given in patients who received IV thrombolysis?

No

What is the acute BP management for non-tPA candidates?

If BP > 220/110 mm Hg, lower BP by 15% during the first 24 hours

What is the supportive care oxygen requirement?

Supplemental oxygen to maintain oxygen saturation >94%

What is the supportive care hyperthermia requirement?

Temperature >100.4°F should be treated with antipyretic medications

What is the supportive care hyperglycemia requirement?

Treat blood glucose to achieve 140-180 mg/dL

What are the VTE prophylaxis options for stroke patients?

Unfractionated heparin (UFH) 5000 units SC BID or TID

Enoxaparin (LMWH) 40 units SC daily

Fondaparinux 2.5 mg SC daily

Rivaroxaban 10 mg PO daily

What VTE prophylaxis agent should be used if impaired mobility?

UFH or LMWH

Should compression socks be used for VTE prophylaxis in stroke patients?

No - they cause harm!

What is secondary prevention for non-cardioembolic stroke patients?

Lifelong antiplatete therapy

What are antiplatelet options for a noncardioembolic stroke?

Aspirin 50 - 325 mg PO daily

Dipyridamole ER 200 mg + aspirin 25 mg PO BID

Clopidogrel 75 mg PO daily

Antiplatelet monotherapy after 21 days of ASA + clopidogrel

Can DAPT be used for >90 days?

No!

Continuous use of DAPT for >90 days or the use of triple antiplatelet therapy is associated with excess risk of hemorrhage.

What is the antiplatelet therapy for a intracranial large artery atherosclerosis with 50-99% stenosis?

Aspirin 325 mg daily is preferred to warfarin

Clioztisol 200 mg daily might be considered in addition to aspirin

What is the antiplatelet therapy for a intracranial large artery atherosclerosis with 70-99% stenosis?

90 days of ASA + clopidogrel is reasonable

What is the MOA of ciloztisol

Inhibitors of phosphodiesterase III to increase cyclic AMP

Reversible inhibition of platelet aggregation

Vasodilation

Inhibition of vascular smooth muscle cell proliferation.

If you have a stroke when you already taking aspirin should you increase the aspirin dose?

Effectiveness of increasing the dose of aspirin not well established

What MUST you obtain before starting antiplatelet or anticoagulant?

A follow-up CT or MRI scan at 24 hours after IV tPA

When can home BP medications be resumed post stroke?

After neurologic stability- 48-72 hours

What is the BP goal to reduce the risk of a recurrent stroke and vascular event?

<130/80 mmHg

What are the lipid goals for a very high risk patient?

>50% reduction in LDL-C

Target LDL-C <55 mg/dL

What are the criteria for a very high risk patient?

At least 2 major ASCVD events or 1 major ASCVD event and at least 2 high-risk conditions

What are major ASCVD events?

ACS within past 12 months

History of MI

History of ischemic stroke

Symptomatic PAD

What are high-risk conditions?

Age >65

Coronary bypass or percutaneous intervention (PCI)

Current smoker

Diabetes

Hx of congestive HF

Hypertension

LDL-C >100 mg/dL despite maximally tolerated statin + ezetimibe

What are the lipid goals for a patient not at very high risk?

>50% reduction in LDL-C

Target LDL-C <70 mg/dL

What is a cardioembolic stroke?

Blood stagnates in dysfunctional

atrium

Thrombus forms in left atrium

Thrombus then has potential to leave left atrium and cause embolic CVA

What is used to evaluate the annual stroke risk in atrial fibrillation patients?

CHA2DS2-VASc

What does "C" mean and how many points is it?

C = Congestive Heart Failure/Left Ventricular Dysfunction (1 point)

What does "H" mean and how many points is it?

H = Hypertension (1 point)

What does "A" mean and how many points is it?

A = Age > 75 (2 points)

What does "D" mean and how many points is it?

D = Diabetes mellitus (1 point)

What does "S" mean and how many points is it?

S = Stroke/TIA/thromboembolism (2 points)

What does "V" mean and how many points is it?

V = Vascular disease (prior MI, PAD, or aortic plaque) (1 point)

What does "A" mean and how many points is it?

A = Age 65-74 (1 point)

What does "Sc" mean and how many points is it?

Sc = Sex category (female) (1 point)

CHA2DS2-VASC score of >2 male or >3 female

Anticoagulation

CHA2DS2-VASC score of 1 male or 2 female

Anticoagulation is reasonable

What is secondary prevention in cardioembolic strokes?

DOACs (Apixaban, Dabigatran, Edoxaban, Rivaroxaban)

Warfarin

What secondary prevention in cardioembolic stroke is perferred?

DOACs

When should anticoagulation be initiated in cardioembolic stroke?

2-14 days after stroke to prevent bleeding