General
Define ischemic stroke and what is MAP usually maintained at?
blockage in cerebral artery caused by thromboembolic formation, 50mmHg
TIA vs ischemic stroke
TIA: abrupt onset lasting less than 1 hour and without evidence of infarction on imaging, risk factor for developing stroke
stroke: lasts more than 1 hour and with evidence
Diagnosis based on imaging and not time
Hemorrhagic stroke treatment
No true treatment, can use Nimodipine 60 mg PO q4hrs for 21 days
Alteplase inclusion criteria
>18 yrs old, diagnosis of ischemic stroke, time of onset <4.5 hours from treatment
How soon do you start ASA after stroke onset?
Within 48 hours
Define hemorrhagic stroke
when blood enters the subarachnoid space, higher mortality than ischemic but less common
Types of imaging used to diagnose stroke and labs
What is the NIH stroke scale?
CT: may take 24 hours to detect ischemia, but reveals hemorrhages immediately
MRI: reveals areas of infarct quicker
glucose, BP, electrolytes, Scr, BUN, CBC, LFTs, baseline INR
NIH scale: severity of symptoms (1-4 is minor stroke)
What is recommended for BP for a stroke with vs without alteplase? For hemorrhagic stroke?
without: BP decrease not recommended unless BP >220/120
with: pre alteplase lower to <185/110, post maintain at <180/105
lowering SBP to 140 is safe
Alteplase exclusion criteria
Evidence of hemorrhage on CT, pt received heparin within 48 hrs and high apTT, current use of anticoag (INR>1.7 or PT>15 sec), SBP>185, DBP>110, >80 yrs old, NIH scale >25, PMH stroke and DM
How many hours do you have to wait after TPA to give ASA?
24 hours
Stroke modifiable and non modifiable risk factors
non mod: risk x2 every decade after 55, AA>hispanic>white, female, genes
mod: smoking, HTN, diabetes, dyslipidemia, a-fib, diet, obesity, stasis, sickle cell, CV disease
How is ASA used for prevention
Used for asymptomatic carotid artery stenosis as primary prevention with statin, 10 year ASCVD >10%
81mg daily
Pharmacologic therapy for ischemic stroke
for first 7 days, admin alteplase within 4.5 hours of stroke onset, give ASA 24-48 hours after
Alteplase monitoring
S/Sx of ICH, BP, obtain CT in 24 hours before starting antiplatelet/coag (ASA)
Treatment with what has shown to not be beneficial?
anticoagulants
stroke presentation (what is FAST)
Inability to speak, 1 side of body is weak, loss or double vision, vertigo, falling, HA
FAST: face droop, difficulty raising arms, slurring words, time is important (call 911 immediately)
What is the initial treatment approach
Ensure adequate O2, BP, electrolytes, fluids
Give CT to determine if ischemic or hemorrhagic
Alteplase MOA
dissolves clot and restores blood flow
Secondary Prevention for cardioembolic
calculate CHA2DS2-VASc, 0-1 give antiplatelet/coag, greater than 2 give anticoag
Can we use DAPT? If so, what?
ASA and clopidogrel, may be considered in patients with minor stroke or TIA, not long term
Primary prevention
Cholesterol management, Bp, BG, diet, exercise, smoking cessation
Surgical: CEA (only >70% stenosis) or CAS (secondary prevention only)
What is permissive hypertension?
Allowing patient's BP to stay high to keep MAP high and adequate perfusion to brain
May need to decrease BP for pts eligible for alteplase or have compelling conditions
Alteplase dose
0.9 mg/kg IV max 90 mg
10% given IV push over 1 min, 90% IV infusion over 1 hour
Secondary prevention for non cardioembolic
ASA, Aggrenox, Clopidogrel, high intensity statin (moderate if >75 yrs old), keep BP <140/90
How long should DAPT be given after CAS for secondary prevention?
30 days