Neuro/Psych Exam 4 Part 3: Peds Psychosis and Depression, Autism Spectrum Disorder

Peds Psychosis and Depression

Dr. Johnson

Signs/Symptoms of Depression in Adolescents

- Depressed most of the day ===> _________/_________, preoccupation with song lyrics that suggest lift is meaningless

- Decreased interest/enjoyment in once-favorable activities ===> Loss of interest in ________, video games, _______ with ________

- Significant weight loss/gain ===> Failure to gain weight, eating disorders, complaints of physical illness or __________

- Insomnia or Hypersomnia ===> Excessive late night TV, _______ _____ __________ for school in the morning

- Psychomotor Agitation/retardation ===> Talk of ________ _________ or efforts to do so

- Fatigue or loss of energy ===> ________ _______

- Low self-esteem/guilt ===> Oppositional/________ _______

- Decreased Concentration ===> _______ _______ _________, truancy issues

- irritable/cranky

- sports, activities with friends

- pain

- refusal to wake up

- running away

- persistent boredom

- negative behavior

- poor school performance

What SSRI(s) have the FDA label for depression in pediatrics??

fluoxetine and escitalopram

True/False

AVOID sertraline in pediatric depression due to increased agitation and hostility

False ; paroxetine

Miscellaneous Antidepressants: SNRIs

Venlafaxine was studied in ________ yr

- ADE: somnolence, headache, _________ ________

Duloxetine was studies in _______ yr

- ________ _______, headache, nausea, xerostomia

12-18 yr

- diastolic hypertension

7-17 yr

- weight loss

Miscellaneous Antidepressants: Bupropion

- Class = __________ reuptake inhibitor

- Ages = _________ yr

ADE:

- Exacerbate ______ _________

- Confusion/agitation

- Altered ________ _________

- _________ _________

- Hypertension

- dopamine

- 12-17 yr

- tic disorders

- seizure threshold

- orthostatic hypotension

Miscellaneous Antidepressants: Mirtazapine

- Class = __________ __________ (increases _______ and _______)

- Ages = _________ yr

ADE:

- Increased ________

- _______ _______

- Somnolence

- tetracyclic antidepressant (NE and serotonin)

- 12-18 yr

- appetite

- weight gain

SSRIs are considered first-line for Pregnancy (except __________), but there is a potential risks of birth defects with SSRIs and SNRIs:

1. _________ _________ ____________

2. Neural (__________ and ___________) and Gastrointestinal (____________) birth defects

3. Persistent __________ __________ of the newborn

4. ___________ __________ ___________

paroxetine

1. Congenital heart abnormalities

2. craniosynostosis and anencephaly ; omphalocele

3. Pulmonary hypertension

4. Neonatal withdrawal syndrome

Weight Categories for Children:

- Underweight = __________ BMI for age

- Normal Weight = _________ BMI for age

- Overweight = ___________ BMI for age

- Obesity = __________ BMI for age or BMI ___________ in adolescents if above threshold

- <5th percentile

- 5-84th percentile

- 84-94th percentile

-≥95th percentile ; ≥30 kg/m2

Weight Categories for Adults:

- Underweight = BMI __________ kg/m2

- Normal Weight = BMI __________ kg/m2

- Overweight = BMI __________ kg/m2

- Obese = BMI __________ kg/m2

Obesity Classifications:

- Class 1 = BMI __________ kg/m2

- Class 2 = BMI __________ kg/m2

- Class 3 = BMI __________ kg/m2

- <18.5

- 18.5 to <25

- 25 to <30

- >30

- 30 to <35

- 35 to <40

- >40

What antipsychotic has the highest rate of Dyslipidemia?

review slide 39

Olanzapine (Zyprexa)

Monitoring for Dyslipidemia: Antipsychotics

- _________ _________ _________ at baseline, at 3 months, then every 6 months

- More frequent monitoring when _______ _______ or significant ________ ________ identified

- At minimum, panel should include _______, _______, _______

- fasting serum lipids

- abnormal levels ; weight gain

- TC, HDL, TG

What antipsychotic has the highest rate of Insulin Resistance?

review slide 42

Olanzapine (Zyprexa)

Monitoring for Insulin Resistance: Antipsychotics

- _________ ________ _________ at baseline, at 3 months, then every 6 months

- High risk patients (e.g. _______ BMI percentile, ______ ______) may require more frequent assessments

- Patients should be asked at every visit about ________ ______ ______, _________, ________

- fasting blood glucose

- ≥95 ; weight gain

- unintended weight loss, polyuria, polydipsia

What antipsychotic has the highest rate of Weight Gain?

Olanzapine > risperidone ≥ quetiapine > aripiprazole

Monitoring for Weight/Body Composition: Antipsychotics

- _______, _______, ________, and ________ at baseline and at each visit

- _______ and ________ ________ for age at baseline, at 3 months after onset of med and then every 6 months

- height, weight, BMI %, z-score

- weight and BMI percentile

What antipsychotic has the highest rate of extrapyramidal ADEs?

Risperidone and Aripiprazole

Monitoring for EPS and Akathisia: Antipsychotics

Akathisia

- Difficult to recognize in childhood

- Mostly seen as worsening of _________ ________ or _________ __________ related to primary disorder (psychosis, mania, anxiety)

- Observed in around 12-23% of patients depending on agent

Monitoring

- __________, __________ for first 2 weeks after initiation or dose increase, then periodically

- psychomotor agitation or sleeping difficulties

- baseline ; weekly

What antipsychotic has the highest rate of Sedation? Lowest risk?

highest = risperidone

lowest = aripiprazole

Monitoring for Sedation: Antipsychotics

- Lifestyle behaviors such as _______ _______, diet, exercise, _________, _______ _______

- Evaluate at baseline and at every visit

- sleep hygiene, smoking and substance use

Which of the following 2nd generation antipsychotics is associated with the highest degree of insulin resistance?

A. Aripiprazole

B. Olanzapine

C. Quetiapine

D. Risperidone

B. Olanzapine

Which of the following is the definition of overweight in a pediatric patient 3

years of age?

A. BMI 26 kg/m2

B. BMI 33 kg/m2

C. 89% BMI percentile for age

D. 96% BMI percentile for age

C. 89% BMI percentile for age

Autism Spectrum Disorder

Dr. Johnson

What are the 4 red flag indicators developed by the AAP and Child Neurology Society for ASD symptoms in infants?

1. No babbling, pointing or other gesture by 12 months

2. No single words by 16 months

3. No two-word spontaneous phrases by 24 months

4. Loss of language or social skills at ANY age

There are 3 core domains of ASDs: _________ _______, __________ and stereotypic or __________ _________. DSM-V Criteria for ASD includes:

- ______ symptoms in the impairment in social interaction

- ________ symptom in communication impairment

- _________ symptoms in restricted, repetitive, and stereotyped patterns of behavior

- _______ symptom in the delays in normal function ≤3 years

social interaction, communication ; repetitive disorders

- 2

- 1

- 1

- 1

NEED 5 TOTAL

DSM-V Criteria: Impairment in Social Interaction symptoms

- Impairment in multiple __________ behaviors such as eye-to-eye gaze, ________ _______, postures, and gestures related to social interaction

- Failure to develop ________ ___________ appropriate to developmental level

- Lack of spontaneous seeking to share ________, _________ or __________ with other people

- Lack of ________ or ________ reciprocity

- non-verbal ; facial expressions

- peer relationships

- enjoyment, interests or achievements

- social or emotional

DSM-V Criteria: Communication Impairment symptoms

- Delay or lack of development of _______ ________(not accompanied by attempt to ________ through other ways of communication)

- Marked impairment in _______ to speak or ______ ________ in those able to speak

- Stereotyped and ___________ use of language or ________ language

- Lack of varied, spontaneous __________ _______ or social imitative play appropriate to developmental level

- spoken language ; compensate

- ability ; sustained conversation

- repetitive ; idiosyncratic

- make-believe play

DSM-V Criteria: Restricted, Repetitive and Stereotyped Patterns of Behavior symptoms

- Encompassing preoccupation with ________ or more stereotyped and restricted patterns of interest that is abnormal either in _______ or ________

- Apparently __________ __________ to specific, nonfunctional routines or rituals

- Stereotypes and repetitive _________ __________

- Persistent preoccupation with ______________

- ≥1 or more ; intensity or focus

- inflexible adherence

- motor mannerisms

- parts of objects

DSM-V Criteria: Delays in Abnormal Function ≤3 years

- ________ _________

- _________ used in social communication

- _________ or __________ play

- social interaction

- language

- symbolic or imaginative

ASD Diagnosis with 1) Disruptive behavior, 2) Comorbid Conditions and 3) Unresponsive to non-pharmacologic interventions: Symptoms of Aggression or Irritability

- 1st line ===> _________, __________

- 2nd line ====> __________, _________ (whichever was not used in first line)

- 3rd line ====> ___________ or __________ or ___________/____________

- risperidone, aripiprazole

- risperidone, aripiprazole

- haloperidol or olanzapine or clonidine/guanfacine

ASD Diagnosis with 1) Disruptive behavior, 2) Comorbid Conditions and 3) Unresponsive to non-pharmacologic interventions: Symptoms of ADHD

- 1st line ====> __________

- 2nd line ====> ___________ , __________

- psychostimulants

- clonidine, guanfacine

ASD Diagnosis with 1) Disruptive behavior, 2) Comorbid Conditions and 3) Unresponsive to non-pharmacologic interventions: Symptoms of Stereotyped or Repetitive Behaviors

- 1st line ====> _________, _________

- 2nd line ====> ____________

- 3rd line ===> _________ ________, __________, _________, or __________

- risperidone, aripiprazole

- fluoxetine

- alternate SSRI (escitalopram, sertraline and fluvoxamine) ; haloperidol ; divalproex ; naltrexone

ASD Diagnosis with 1) Disruptive behavior, 2) Comorbid Conditions and 3) Unresponsive to non-pharmacologic interventions: Symptoms of Depression or Anxiety

- 1st line ====> ____________, ____________

- 2nd line ====> __________ _________ or _________

- SSRIs , antidepressants

- alternative SSRIs, TCAs

ASD Diagnosis with 1) Disruptive behavior, 2) Comorbid Conditions and 3) Unresponsive to non-pharmacologic interventions: Symptoms of Self-Injury Behavior

- 1st line ====> ________, __________

- 2nd line ====> __________, ___________

- 3rd line ===> _________, _________ (whichever not used in the 2nd line)

- risperidone, aripiprazole

- fluoxetine, naltrexone

- fluoxetine, naltrexone

What 2 antipsychotics have FDA labeled indication for ASD?

What 2 SSRIs?

- risperidone and aripiprazole

- fluoxetine and escitalopram

True/False

AVOID paroxetine in ASD due to increased agitation and hostility and avoid clomipramine due to increased anticholinergic effects, CNS depression and long term weight loss/growth changes

true

Bipolar Disorders

Dr. Lambert

True or False

Obesity is a mental disorder

False; is NOT a mental disorder but cna be a symptom of one

What are the 3 most common types of eating disorders?

- Anorexia nervosa (nervous absence of appetite)

- Bulimia nervosa (nervous ravenous hunger)

- Binge-eating disorder

True or False

The most common purging method is induced vomiting and the second is laxatives.

True

Typical Caloric Intake for Patient with ED:

- AN: ______ to _______ calories per day

- BN: _____________ calories per day

- BED: ______________ to ______________ per BINGE

This is compared to the daily recommended intake of 1,600 to 2,500 calories per day.

- 600-900

- 1,200

- 5,000-20,000

Diagnostic Criteria - Anorexia Nervosa (AN)

- Calorie restriction => significant _____ body weight

- ___________ or ______ about eating and gaining weight

- ___________ body image

- Can be __________ or binge/purge type

Severity: based on current BMI

- Mild: BMI __________ kg/m2

- Moderate: BMI ______________ kg/m2

- Severe: BMI _____________ kg/m2

- Extreme: BMI __________ kg/m2

- low

- obsessions or fears

- distorted

restricting

- ≥17

- 16-16.99

- 15-15.99

- <15

Anorexia Nervosa Clinical Presentation:

- ___________ and delayed sexual development

- Lethargy and weakness

- _________, vomiting, and restricted food intake

- Delayed _______ ________ and ___________

- _________-cardia and ____________

- Lanugo, brittle hair, dry skin

- Osteopenia or Osteoporosis

- Complaints of feeling _______ after a small amount of food

- Denial of symptoms, fail to see low body weight

- ________ self-esteem

- Electrolyte imbalances

- ______ ________ and _______ _______

- Anemia

- Elevated _____________

- amenorrhea

- cachexia

- gastric emptying and constipation

- bradycardia and hypotension

- full

- low

- EKG changes and heart attacks

- cholesterol

Other Considerations: Anorexia Nervosa

Risk Factors:

- Psych disorders like ________, OCD, _______ ________

- 1st degree relative with ______, _________, or ________

- Certain occupations like female gymnast, ballet, dancers, etc.

Functional Consequences:

- Some patients maintain normal social, education, and occupational engagement, while others engage in __________ behaviors, are unable to complete ________ ______, or hold a _______.

review slide 13 for medical complications

- anxiety ; personality disorder

- ED, bipolar or MDD

- isolation ; education goals ; job

Diagnostic Criteria - Bulimia Nervosa

- Recurrent episodes of _____ ______ that is for a specific amount of time and lack of control of ________ ________, followed by __________ _______ to prevent weight gain.

- Self-esteem is determined by __________.

- For most patients, these episodes occur ______.

- Behaviors occur ______ per week for ___________.

Severity: Based on frequency of episodes of behaviors/week

- Mild: average ____ to _____

- Moderate: average _____ to ______

- Severe: average _____ to ______

- Extreme: average _______

- binge eating ; over eating ; compensatory behaviors

- weight

- daily

- 1/week x 3 months

- 1-3

- 4-7

- 8-13

- ≥14

Bulimia Nervosa Clinical Presentations:

- Purging behaviors such as induced vomiting, ________,________ and _________

- Misusing medications such as taking extra ______, ______, or ________ and skipping _______

- Excessive _________

- Concerned about _____ ______ and ______, but lacks drive of AN

- Does not eat regular meals

- Does not feel full after eating

- Weight fluctuations

- Purging leads to extreme _______, ________ and _______ _______

- laxatives, diuretics and enemas

- thyroid, stimulants or caffeine ; insulin

- exercise

- body image and weight

- guilt, depression and social isolation

Consequences of ED: Bulimia Nervosa

Medical Complications:

- Low ________

- __________ _________

- Elevated serum _________

- Dental ____________

- ___________ __________

- _________ _______ __________

- potassium

- metabolic acidosis

- amylase

- erosions

- Russell's signs

- salivary gland inflammation

Other Considerations: Bulimia Nervosa

Risk Factors:

- Psycho disorders like anxiety, ______, _______ anxiety disorder, and _________ disorders

- _______ self-esteem

- Childhood ________ and _________ abuse

- Early onset _________

- Family member with eating disorder

Functional Consequences:

- Limited close social relationships due _______ and _______, and not as impaired as with AN.

- Patients in recovery are often triggered by _______.

- ___________ ____________ is common.

- MMDD, social anxiety and personality

- low

- sexual and physical abuse

- puberty

- shame and guilt

- stress

- substance abuse

What most common signs/symptoms do BN and AN have in COMMON?

review slide 20

- perioral dermatitis

- gastroparesis

Diagnostic Criteria - Binge-Eating Disorder

- Recurrent episodes of binging

- Episodes have _______ characteristics which include eating:

===> ________ than normal

===> Until __________________

===> A lot of food, but not feeling _________

===> _________ out of embarassment due to feelings of disgust or guilt

- Significant ________ from binging

- Lack of ____________

- Episodes average _____ per week x ___________

- No _______ _______ behaviors

Severity: based on frequency of binge episodes/week

- Mild: average _____ to _____

- Moderate: average _____ to _____

- Severe: average ______ to ______

- Extreme: average _______

- ≥3

==> faster

==> uncomfortable

==> hungry

==> alone

- distress

- self-control

- 1/week x 3 months

- no compensatory purging

- 1-3

- 4-7

- 8-13

- ≥14

Binge Eating Disorder Clinical Presentation:

- Patients report _______ _______ during binges

- Weight can be normal, over, or obese; but usually on __________ of weight

- Are concerned about body image, but urge to binge is too great

- BED can lead to ________ _________

- dissociative feelings

- upper end

- extreme dieting

Consequences of ED: Binge-Eating Disorder

Medical Complications:

- Expected health concerns associated with being ______ or ______

- ________ or ________

- _______, HTN, and chronic ________

- _________

- Elevated _______, ________, and _________

- Electrolyte disturbances

- overweight or obese

- MDD or anxiety

- GERD ; pain

- Asthma

- lipids, glucose, HgbA1C

Other Considerations: Binge-eating Disorder

Risk Factors:

- Psych disorders like anxiety, ______, _______, and _______ ________ disorder

- Family member with BED

Functional Consequences:

- Impaired _______ ______ for similar reasons as BN

- Health problems such as increase ________, ________, and ________ ________

- Quality of life

- MDD, bipolar and borderline personality

- social relationships

- morbidity, mortality and healthcare utilization

Non-pharmacologic Treatment for Eating Disorder:

- ___________________ includes dialectical behavioral therapy

- __________ management

- ____________ __________

- ____________ therapy

- Nutritional counseling such as ______ _______ for anorexia and ________ _________ for bulimia

- Stress managements including mindfulness for ________ and _______, and exercise/yoga for _______.

Specifically, for BED: ________________ + _____________

Psychotherapy should be used for _________________ to prevent relapse.

- CBT

- behavioral

- interpersonal psychotherapy

- family therapy

- oral refeeding ; scheduled meals

- BN and BED ; BN

weight loss + CBT

6 months to 1 year

Pharmacological Treatment for Anorexia Nervosa:

Acute Anorexia:

- _______________ have NO role due to low ________. Only should be considered if patients has _______ and weight is close to normal.

Chronic Management of Anorexia:

- First line is _________ for ________________

- _____________ ( ___________ ) starting at 20 mg/day and increased to a daily maximum of 60 mg/day.

- Other antidepressants (TCAs, MAOis) are recommended only as 2nd or 3rd line or if first line is not tolerated, due to _____ ________ being a concern.

- antidepressants ; 5HT ; MDD

- SSRI for 9-12 months

- Fluoxetine (Prozac)

- CV effects

Pharmacological Treatment for Anorexia Nervosa Continued:

Antipsychotics:

- No evidence to support use and ADE not worth benefit

- ONLY if other psych issues are present

- ________, _________, and ________ have been studied

- olanzapine, quetiapine, risperidone

Pharmacological Treatment for Anorexia Nervosa Continued:

Metoclopramide:

- Good for _____ ________ and increased feelings of ______________

- No impact on _______

- Monitor for ____________ effects

- GI disturbances ; satiety

- weight

- anticholinergic

Pharmacological Treatment for Anorexia Nervosa Continued:

Benzos:

- ONLY with __________ ________ around meals / eating

- Usually only used for __________ settings

- Low dose, short-acting, scheduled

- extreme anxiety

- inpatients

Pharmacological Treatment for Anorexia Nervosa Continued:

Estrogen:

- Used to restore _______

- ___________ has greater benefit

- menses

- refeeding

Pharmacological Treatment for Anorexia Nervosa Continued:

Calcium Supplements:

- May be too late to prevent ______ _______

- bone loss

Pharmacological Treatment for Anorexia Nervosa Continued:

_________ Supplements:

- Have been studied

Zinc supplements

Pharmacological Treatment for Bulimia Nervosa:

- First Line: ___________ therapy and preferred agent is ______________ in combination with CBT

- Failed preferred therapy than switch to ____________

- Failed both preferred and secondary agent, consider other _______ or _________

- Failed antidepressant therapy than consider ______________

Co-morbid Psychiatric Diagnosis Present:

- Bipolar: ____________, ______________, _____________, or _____________

- Schizophrenia: _____________, _____________, or _____________

- Depression: ____________ or __________

- ADHD: ________________

AVOID: _______________ due to seizures and _________ or ______________ due to impulsivity

Review Slides 30 - 32 for Specifics of BN Pharmacological Treatment

- antidepressant ; fluoxetine

- sertraline

- SSRI or SNRI

- topiramate

- divalproex, olanzapine, quetiapine, risperidone

- olanzapine, quetiapine, risperidone

- fluoxetine or sertraline

- methylphenidate

bupropion ; MAOI and TCAs

Pharmacological Treatment for Binge-Eating Disorder:

First Line: ___________________

- Monotherapy or with CBT

- Decrease binge eating episode frequency and obsessions

- _________ are preferred at _______ doses, specifically citalopram, escitalopram, fluvoxamine, fluoxetine, sertraline

- Second choices include ____________ or ______________

Second Line: Other Agents

- ________________ ( Strattera )

- ________________ ( Zonegran )

- ________________ ( Topamax )

Third Line: _________________ ( ______________ )

- ONLY FDA approved drug

- Used for moderate to severe BED which is _______ episodes/week

- Decreases binging episodes or obsessions

- STILL NOT 1st line treatment due to abuse potential and CV effects

- Start at _______ QAM and titrate weekly to a target dose of 50-70 mg daily

- _________ if binge behavior does NOT improve.

Antidepressants

- SSRIs ; MDD

- venlafaxine, duloxetine

- Atomoxetine

- Zonisamide

- Topiramate

Lisdexamfetamine (Vyvanse)

- ≥4

- 30 mg

- stop

Stroke Pharmacotherapy

Dr. Splinter

_________________________: a brief impairment of neurological function secondary to an interruption of regional cerebral blood flow, which may last only several seconds or up to 24 hours in duration.

_____________ or _________________________: indicates an irreversible neurological injury caused by interruption of cerebral blood flow (87%) or hemorrhage (15%).

Transient Ischemic Attack (TIA)

Stroke or Cerebrovascular Accident

Ischemic Stroke Risk Factors:

Unmodifiable Risk Factors:

- Age: doubling risk for each decade ______ YO

- Sex: ______ at higher risk at younger ages

- Race: ______, ______-_______ ________, ___________

- __________ factors

- ________ birth weight ( _______ kg)

- _____________, premature _______ _______ ( _____ YO), early onset ____________ ( ______ YO)

- >55

- males

- AA, asian-pacific islanders, hispanics

- genetic

- low (<2.5 kg)

- endometriosis ; ovarian failure (<40 yr) ; menopause (<45 yr)

Ischemic Stroke Risk Factors:

Modifiable Risk Factors:

- Hypertension: BP ≥ _____________ mm Hg during pregnancy

- Diabetes: Use of ___________________ recommended in patients with diabetes and high CV risk or established CV risk

- __________ ___________

- __________

- _________________

- Asymptomatic ________ ___________

- _________ ______ disease

- Other cardiac diseases (CAD, HF, PAD)

- Drugs: oral ___________ and _________ _______ therapy (including transgender women taking estrogens for gender affirmation)

- Lifestyle: diet, smoking, drugs of abuse, excessive alcohol consumption, physical activity

- ≥160/110 mmHg

- GLP-1 RA

- Atrial fibrillation

- Obesity

- Dyslipidemia

- carotid stenosis

- sickle cell

- oral contraceptives and hormone replacement

Ischemic Stroke Risk Factors:

Potentially Modifiable:

- __________

- Sleep-disordered _________

- ___________ syndrome

- _______________ and ____________

- _________________

- Patent foramen ovale (PFO)

- Elevated ______________

- migraine

- breathing

- metabolic

- inflammation and infection

- homocysteinemia

- lipoprotein A

Etiology/Characteristics of Different Types of Ischemic Stroke: Lacunar (Small Vessel)

- ____________ occlusion of small intracranial vessels

- Risk factors: _______ _______ and __________ __________

- Leads to _________ ___________

- thrombotic

- chronic HTN and DM

- vascular dementia

Etiology/Characteristics of Different Types of Ischemic Stroke: Cardioembolic (35% of non-lacunar IS)

- Major causes include _______ _______ (50% of cardioembolic strokes), mural thrombus, acute MI, prosthetic valves, rheumatic heart disease, and patent foramen ovale (PFO)

- atrial fibrillation

Etiology/Characteristics of Different Types of Ischemic Stroke: Large Vessel Atherosclerosis (17% of non-lacunar IS)

1.) ______ _________: flow reducing plaque

2.) _________-_________ _________: caused by atherosclerotic plaque on aortic arch, carotid bifurcation, or intracranial vessel that symbolizes. Embolism travels until it includes a distal vessel and prevents distal cerebral blood flow.

1. carotid stenosis

2. artery-artery embolism

Etiology/Characteristics of Different Types of Ischemic Stroke: Other Non-Lacunar IS

- _________ ___________

- ____________ (protein C or S deficiencies, Factor Leiden V, methylene tetrahydrofolate reductase (MTHFR) mutations)

- ______________: hypotension and poor cerebral perfusion ( ____________ or ________ ________)

- Intracranial atherosclerosis

- Coagulopathy

- Hypoxia ; watershed, border zone

Subarachnoid Hemorrhagic Stroke

Causes:

- Trauma or rupture of a _________ _________ or an __________ ________ __________

- Bleeding quickly disseminated throughout the subarachnoid space and can lead to a sudden increase in ______ _______

Symptoms:

- ___________

- Vomiting

- _______ _______ _________

Treatment:

- Target an SBP < ______ mmHg from symptom onset to ___________ _________

- cerebral aneurysm ; arterial venous malformation (AM)

- intracranial pressure

- headache

- mental status changes

- <160 mmHg ; aneurysm obliteration

Intracerebral Hemorrhagic Stroke

Causes:

- Uncontrolled _________

- _____________

- _____________

- ______________

- _______________

Treatment:

- Treat if SBP > _______ mmHg

- Acute lowering of SBP < ______ mmHg is safe and may improve functional outcomes.

- HTN

- thrombolytics

- anticoagulants

- cocaine

- methamphetamine

- >220

- <140

Clinical Presentation: Anterior

Stroke occurs in Internal carotid arteries (ICA) which further divides into an Anterior cerebral artery (ACA) and Middle cerebral artery (MCA).

Clinical Syndromes of Ischemia:

- _________ _________

- Loss of ____________

- ___________ / ____________

- ___________ blindness

- Infarction may result in ___________ _____________

- motor weakness

- sensation

- dysphagia/aphasia

- monocular

- contralateral hemiplegia

Clinical Presentation: Posterior

Stroke occurs in Vertebral arteries (VA) which fuse into a basilar artery, which then divides into a pair of Posterior cerebral arteries (PCA).

Clinical Syndromes of Ischemia:

- _____________

- Diplopia

- ______________

- ____________

- Dysarthria

- ____________

- Cranial nerve (CN) _______________

- Infarction may result in _______ _________.

- vertigo

- ataxia

- amnesia

- dysphagia

- palsies-ipsilateral

- crossed paralysis

Appropriate Candidates to Receive Thrombolytic Therapy Following an Ischemic Stroke

- Age ≥ ___________

- Time of symptom onset ≤ ___________

- Clinically important ________ present

- ________________ rules out ICH, SAH, and tumor

- Serum glucose > _______ and < ________

- NO Excessive Bleeding Risk Factors:

===> Uncontrolled HTN > _____/_____ mmHg

===> Current _________ _________ (INR >1.7 for warfarin, DTI or Factor Xa inhibitor < 48 hrs)

===> _______________

===> Recent severe _______ ________ within 3 months

- ≥18 yr

- ≤4.5 hours

- deficit

- head CT

- >50 and <400

===> >185/110

===> anticoagulant therapy

===> coagulopathy

===> head trauma

Acute Treatment of Ischemic Stroke: Thrombolysis

_______________ (Activase)

- _________-______ form of tPA (tissue plasminogen activator)

- FDA approved for ischemic stroke

- Efficacy is highly dependent on ______ of dose

Clinical Outcomes:

- When given within 4.5 hours of stroke onset, this drug improves clinical outcomes, ________ ________ and ________ __________

- Follow-up at ______ and ______ months

- No proven benefit on _________ outcomes

Alteplase

- recombinant-DNA

- timing

- neurological function

- functional disabilities

- 3 and 12 months

- mortality

Dosing of Alteplase (Activase):

___________ mg/kg (max ______ mg)

- _____% of total dose given as IV bolus and remainder given as IV continuous infusion over ___________

- BP must be ___________________ prior to administration

- 0.9 mg/kg (90 mg)

- 10% ; 1 hour

- <185/110

Monitoring for Alteplase Therapy:

Blood Pressure

Frequent monitoring required:

- Q 15 minutes X ____ hours after starting infusion

- Q 30 minutes for ____ hours

- Q one hour for ____ hours

Maintain SBP < ______ mmHg or DBP < _____ mmHg

- ___________ infusion 5 mg/hr

- ___________ 10 mg IV over 1-2 minutes, may repeat q 10-20 minutes

- ___________ 1-2 mg/hour IV, titrate up to 21 mg/hour.

Bleeding Complications:

- Avoid antiplatelet or anticoagulant for ________, unless _______ treatment benefit outfights risk in presence of concomitant condition.

Monitor:

- Hemoglobin

- _________

- _________ guaiac

- UA for __________

- 2 hours

- 6 hours

- 16 hours

<180 or <105

- IV nicardipine

- labetalol

- clevidipine

- 24 hours ; ASA

- hematocrit

- stool

- blood

Acute Treatment of Ischemic Stroke: Thrombolysis

_______________ (TNKase)

- ______________ __________ of tPA. More _______ specific and more resistant to _________ by endogenous PA inhibitor-1.

Half-life:

- Initial: 20-40 minutes

- Terminal: ______ minutes

Preparation:

- ______________; 1 minutes

Dosing:

- ____________ mg/kg IV __________

- Max dosing = _______ mg

Tenecteplase

- bioengineered variant ; fibrin ; degradation

- 90-130 min

- Simple

- 0.25 mg/kg IV bolus

- 25 mg

Acute Treatment of Ischemic Stroke: Non-tPA Eligible Patients

Aspirin ______________ mg

- Reduction in recurrent stroke AND mortality benefit when given within ____________.

Permissive BP Control

- < 220/120 mmHg: reinitiating treatment of hypertension within first _______________ = no benefit

- ≥ 220/120 mmHg: benefit of treatment uncertain. Reasonable to lower BP by ____% during first ____________ after onset of stroke

- 160-325 mg

- 48 hours

- 48-72 hr

- 15% ; 24 hours

Managing Acute Complications of Ischemic Stroke: Arterial Hypertension

- Increased pressure may be beneficial to maintain _______ _______

Treatment:

________________ or _________________

- High vascular selectivity

- Strong cerebral and coronary vasodilatory activity

- Linear, dose-related BP response

- Does not increase ICP and preserves cerebral autoregulation

__________________

- Fast onset of action (within 5 minutes)

- Duration of action 3-6 hours, difficult to titrate as a continuous infusion

- Does not adversely affect cerebral blood flow or autoregulation in healthy volunteers and patients with ICH

- cerebral perfusion

Nicardipine or Clevidipine

Labetalol

Managing Acute Complications of Ischemic Stroke:

Cardiac Arrhythmias

- ECG x ____________ minimum post-stroke

- ________ ___________ is most commone

- Treat on _________ basis

- 24 hours

- atrial fibrillation

- PRN

Managing Acute Complications of Ischemic Stroke:

Seizures

- Occur ___________ in 2-23% or _________ in 3-67%

- Treat __________

- early (within 24 hr) or late

- PRN

Managing Acute Complications of Ischemic Stroke: Venous Thromboembolic Events

- Common in patients with decreased mobility

Modes of Prophylaxis:

- Mechanical: _______ _______ ________, but DO NOT use ______ _________ ___________

- Anticoagulants should NOT be used during the first __________ post tPA. The benefit of these are not well established due to decreased risk of _________ ______ and increased risk of ____________ intracranial and extracranial ____________.

===> Recommended agents ______________________ or ________________________________

- intermittent pneumatic compression ; elastic compression stockings

- 24 hours ; asymptomatic PE ; symptomatic ; hemorrhages

===> SQ LMWH or SQ UFH 5000 U TID

Managing Acute Complications of Ischemic Stroke: Glycemic Control

Hypoglycemia:

- Mimics ischemic stroke and can lead to _______ _________

Hyperglycemia:

- _______ of patients on admission with stroke

- Effects include:

===> Tissue acidosis secondary to anaerobic glycolysis, lactic acidosis and free radicals

===> Affects BBB leading to _______ _______

===> ____________ ____________

===> Predictor of poorer outcomes

- GOAL: ____________ mg/dL and maintain >60 mg/dL

- brain injury

- 1/3

===> brain edema

===> hemorrhagic transformation

- 140-180

Secondary Prevention of Noncardioembolic Stroke: Antiplatelet Agents

- Antiplatelet therapy reduced the odds of a second stroke by 16% to 41% in patients with previous stroke.

Aspirin: ______ ________

- Dose: ____________ mg daily

- __________ for non-fatal stroke 23% over 3 years

Clopidogrel (Plavix): __________ _________ _________ __________

- Dose: ________ mg daily

Ticagrelor (Brilinta): __________________ __________ ________ _________ ___________

ER Dipyridamole /Aspirin (Aggrenox): _________________ _____________

- ER Dipyridamole ______ mg / Aspirin _____ mg BID

COX inhibitor

- 75-325 mg

- RRR

ADP P2Y12 receptor inhibitors

- 75 mg daily

Non-thienopyridine reversible ADP P2Y12 inhibitor

phosphodiesterase inhibitor

- 200 mg / 25 mg BID

Review Slides 50-53 for Combination Antiplatelets for Intracranial Large Artery Atherosclerosis and TIA or Mild Stroke

slides 50-553

True or False

No trials have shown warfarin benefit over aspirin for non-cardioembolic stroke and it is NOT recommended for preventing non-cardioembolic stroke.

True

Secondary Prevention of Non-Cardioembolic Stroke: Antihypertensives

Goal:

- SBP: < __________ mmHg

- DBP: < __________ mmHg

Use: ___________ +/- __________ or _____________

- <130

- <80

diuretics +/- ACEi or ARB

Secondary Prevention of Noncardioembolic Stroke: Prevention by Controlling Dyslipidemia

Multiple mechanisms by which statins decrease stroke risk:

- Could be the result of lipoprotein alterations

- Improved endothelial function

- Plaque stabilization

- Antithrombotic effect

- Anti-inflammatory effect

- Neuroprotective properties

Recommendations:

- Statin ( _______________________ ) for LDL > _______ mg/dL

- Statin + Ezetimibe, if needed, to goal LDL < _______ mg/dL

- Statin + PCSK9 inhibitor if ______ ______ ______

- Atorvastatin 80 mg ; >100

- <70

- very high risk

Secondary Prevention of Non-Cardioembolic Stroke: Prevention with Smoking Cessation

- Decreasing the number of cigarettes per day is ____________________ in reducing risk of stroke, BUT_________ __________ should be stressed.

- Framingham Heart Study found stroke risk to be at the level of non-smokers at ________ from cessation.

- ___________ _________ also increases risk.

- ___________ ________ ________ _________ may increase risk

- NOT effective ; complete cessation

- 5 years

- secondhand smoke

- Electronic nicotine delivery systems

Non-pharmacologic Therapy for Secondary Prevention of Noncardioembolic stroke

- Mediterranean and _______ diet

- ______ ______ for those that are overweight or obese (esp. abdominal obesity)

- Physical activity

- ________ ______ therapy

- _______ ______ _______ evaluation

- low-salt

- weight loss

- substance use

- obstructive sleep apnea