Cardiology Test 5- Montepara Stroke

2 types of stroke?

ischemic, hemorrhagic

ischemic stroke

-occlusion within a cerebral artery due to ___ or a traveling clot from the heart (___), resulting in the sudden death of brain cells due to inadequate blood flow

atherosclerosis, cardioembolism

2 types of hemorrhagic stroke

1) ___ hemorrhage (SAH)

2) ___ hemorrhage (ICH)

subarachnoid, intracerebral

subarachnoid hemorrhage

-bleeding occurs in subarachnoid space

-causes are ___, rupture of intracerebral ____, or rupture of arteriovenous ___ (AVM)

trauma, aneurysm, malformation

intracerebral hemorrhage

-bleeding occurs in the brain parenchyma, leading to the formation of a hematoma within the brain

-causes are uncontrolled ___ and __ therapy

HTN, antithrombotic

Hemorrhagic stroke has a significantly higher ____ than ischemic stroke !

mortality

Transient ischemic attack (TIA)

-mini stroke

-occurs when a cerebral artery is __ blocked, decreasing blood flow to the brain

temporarily

Stroke non-modifiable risk factors

1) age (≥ __ years)

2) race (higher risk with __ ___ )

3) sex (higher risk with ___)

4) low birth rate

5) genetics

6) prior stroke/TIA

55, african americans, females

Stroke modifiable risk factors

1) ___ smoking

2) HTN

3) DM

4) Dyslipidemia

5) Other atherosclerotic CV disease (CAD, PAD)

6) atrial fibrillation

7) ___ cell disease

8) poor diet

9) obesity

10) physical inactivity

cigarette, sickle

ACT FAST acronym

Face, Arms, Speech, Time

Stroke Diagnosis-brain imaging!!

-(____ ideally performed within __ min of arrival to ED)

-MRI is less common

CT, 20

Stroke Diagnosis-identification of cause

-ECG

-ECHO

-___ ultrasound

-___ ultrasound

carotid, transcranial

Acute Tx of Ischemic Stroke

-first administer fibrinolytic therapy with ___ (tPA)

alteplase

fibrinolytic therapy with alteplase

-administer within __ hours of symptom onset

-administer within __ hours of symptom onset in select patients

-goal door-to-needle time is __ min upon hospital arrival

3, 4.5, 60

fibrinolytic therapy with alteplase

dosing is ___mg/kg, give ___% of dose as a bolus over 1 min, then infuse the remainder over 60 min

0.9, 10

fibrinolytic therapy with alteplase

max dose?

90 mg

Acute Tx of Ischemic Stroke

-give ____ 165mg-325mg po within ___-__ hours of stroke onset

aspirin, 24-48

Acute Tx of Ischemic Stroke

-aspirin should not be given within __ hours of fibrinolytic therapy

24

Alteplase criteria for use

-age over 18

-clinical diagnosis of ischemic stroke with neurological deficit

-time of symptom onset well established to be < __ hours from treatment initiation

4.5

Alteplase Contraindications

-if symptoms/imaging are consistent with subarachnoid/intracerebral ____

-concurrent use of direct __ inhibitors of direct ___ __ inhibitors in prior 48 hours

hemorrhage, thrombin, factor Xa

Alteplase Contraindications

-use of low molecular weight __ in last 24 hours

-active internal bleeding or coagulopathy (INR >___)

heparin, 1.7

Blood pressure management with alteplase

BP goal is <__/___ mmHg pre-alteplase

BP goal < ___/___ mmHg for at least the first 24 hours post-alteplase

185/110, 180/105

If ischemic stroke was non-cardioembolic (ie due to atherosclerosis):

use ___ therapy for secondary prevention

antiplatelet

non-cardioembolic ischemic stroke secondary prevention

- ___ 50-325mg daily

aspirin

non-cardioembolic ischemic stroke secondary prevention

-___25mg + ER ____ (Aggrenox) 200mg BID

aspirin, dipyridamole

non-cardioembolic ischemic stroke secondary prevention

-___75 mg daily if contraindicated to aspirin

clopidogrel

non-cardioembolic ischemic stroke secondary prevention

-___ + ___ within 24 hours of a minor ischemic stroke and continued for 21 days

make sure to use __ therapy if the stroke was due to atherosclerosis (remember these patients are in benefit group 1)

statin

If ischemic stroke was cardioembolic (ie from clot in heart):

use ___ therapy for secondary prevention

anticoagulant

cardioembolic ischemic stroke secondary prevention

-__

-____ (dabigatran, rivaroxaban, apixaban, edoxaban)

warfarin, DOACs

after acute phase of ischemic stroke, the BP goal is <130/80; first line agents are __ __ and __/__

thiazide diuretic, ACE-I/ARB

Hemorrhagic Stroke Treatment-Intracerebral Hemorrhage (ICH)

-high risk for rapid ___ deterioration in the early hours of ICH due to ongoing bleeding and hematoma enlargement

neurological

Hemorrhagic Stroke Treatment-ICH

-if on anticoagulation with ICH, ___ should be considered !! (bc it is just making the bleeding worse)

reversal

Hemorrhagic Stroke Treatment-ICH

-if seizures occur, they should be treated, but ___ anticonvulsants should NOT be used

prophylactic

Hemorrhagic Stroke Treatment-ICH

-if increased intracranial pressure, reduce by elevating the head of the bed by __ degrees and using ___ or __ ___

30, mannitol, hypertonic saline

Hemorrhagic Stroke Treatment-ICH

-___ surgery to remove blood may be required

decompressive

Hemorrhagic Stroke Treatment-Acute Subarachnoid Hemorrhage (SAH)

-usually results from the rupture of a cerebral ___ and presents with a severe ___

aneurysm, headache

Hemorrhagic Stroke Treatment-SAH

-surgical __ or endovascular __ to completely remove the aneurysm is performed when feasible to prevent rebleeding

clipping, coiling

Hemorrhagic Stroke Treatment-SAH

-cerebral artery ___ can occur 3-21 days after the bleed, causing delayed cerebral ischemia

vasospasm

Hemorrhagic Stroke Treatment-SAH

-oral ___ is used to prevent vasospasms; it is started within 96 hours of SAH onset

nimodipine

Hemorrhagic Stroke Treatment-SAH

-use of ___ anticonvulsants may be considered for seizures, but long-term use is not recommended

prophylactic