stroke pathophysiology & treatment

Secondary Prevention-Atrial Fibrillation

CHADS-2 score >2 ( 2 pt for stoke )- First line: Anticoagulation Alternative: Aspirin + clopidogrel** Or aspirin monotherapy

Hemorrhagic Stroke -Non-pharmacologic interventions

Surgery

Define "mini stroke." Or TIA?

• A temporary obstruction of blood to the brain • symptoms resolve within 24 hours of onset (typically <30 minutes). Symptoms come and go.

Define stroke or CVA?

• Neurologic deficits ( due to rupture of vessel/ bleeding or clot ) that result from interruption of oxygen/blood to the brain. • 3rd leading cause of death • Brain cells become necrotic and die. "brain attack" or cerebrovascular accident (CVA)

Pathophysiology

"Core ischemic area" Primary area of damage; usually unviable tissue Decline in oxygen and glucose delivery resulting in necrosis of neurons "Ischemic pneumbra" Secondary area of damage; tissue usually still viable Area between normal perfused brain tissue and the main area of infarction Partially supplied areas due to collateral blood vessels Necrosis will occur if blood flow is not re-established within several hours of onset Pharmacologic interventions provide the greatest impact on this area "Normally perfused tissue" Brain tissue not affected by occlusion

Acute Ischemic Stroke -Pharmacologic treatment:

*Fibrinolytic's Recombinant tissue plasminogen activator (rt-PA) (Alteplase/Activase®) *Antiplatelets Aspirin Aspirin/extended-release dipyridamole (Aggrenox®) Clopidogrel (Plavix®) *Anticoagulants Warfarin (Coumadin®) Dabigatran (Pradaxa ®) Rivaroxaban (Xarelto®) Apixaban (Eliquis®)

What is CHADS2 criteria

- Congestive heart failure - Hypertension even if undercontrol with RX - Age > 75 yrs - Diabetes - Stroke or TIA (2pts) • CHADS-2 score to determine risk of stroke and tx in AF, if they choose not to cardiovert Total points 6 points

In acute ischemic stroke what is the goal blood pressure for: I. A patient not receiving alteplase? II. A candidate for alteplase prior to initiation? III. A patient receiving alteplase?

1. 220/120 2. 185/110 3. 180/105

Per guideline what are the Additional Exclusion Criteria ( not in the package insert ) for fibrinolytic therapy in pt wit in 3-4.5 hr window?

1. Age > 80, 2. NIHSS screening score >25 (severe) 3. on anticoagulants regardless of INR, 4. hx of stroke and diabetes, 5. ischemic involvement of >1/3 of the MCA ( middle cerebral artery)

Treatment overview of acute stroke ( general)

1. Diagnostic test to find out if there is a haemorrhage. If there is one, no fibrinolytics , do surgery, BP managememt, mannitol,antiepiletics. 2. If ischemic,< 4.5 hrs since symptom onset, fibrinolytics, then find out if cardioembolic or noncardioembolic stroke before starting antiplatelet/anticoagulant. a. If non- cardio start Antiplatelet > 24 hrs after fibrinolytic b. If cardio embolic start anticoagulants >48h after fibrinolytic 3. If ischemic, >4.5 hrs since symptom onset, no fibrinolytics, start antiplatelet within 48 hours. Try non pharmacologic methods, start on antiplatelet/ anticoagulants based on type of ischemia. a. If non cardioembolic continue antiplatelet b. If cardioembolic d/c and begin anticoagulant.

Primary Prevention & Secondary Prevention of Ischemic Stroke- goal/

1. Focus of 1o prevention is risk factor/lifestyle modification to prevent an initial stroke. add Aspirin if patient has 10-yr risk of CV events of ≥6% in Framingham Stroke Risk Profile. ( Differ in ACS) 2. Focus of 2 o Prevention is risk factor/lifestyle modification + continuation of indefinite antiplatelet therapy (Noncardioembolic) or anticoagulation (Cardioembolic) to prevent a recurrent stroke thus Long-term management of stroke.

Primary & Secondary Prevention- Modifiable Modifiable risk factors

1. HTN, 2. AF, 3. carotid artery stenosis, 4. lipid, 5. DM, 6. Smoking

Describe the complications of stroke?

1. Hemiparesis -Weakness of the arm and/or leg 2. Hemiplegia -Paralysis of the arm and/or leg 3. Aphasia -Difficulty speaking, writing, and understanding speech 4. Dysarthria -Knowing the appropriate words but trouble producing words 5. Dysphagia -Difficulty swallowing; Increases the risk of aspiration 6. Diplopia -Double vision 7. Ataxia -Uncoordinated and unsteady on feet 8. Impaired memory and learning

Primary Prevention only- Modifiable Modifiable risk factors

1. Patent foramen ovale 2. Sickle cell disease - high chance for sticking together. 3. OCP >50 mcg of estrogen 4. Hyperhomocysteinemia - give B complex 5. Elevated lipoprotein A - give niacin Elevated lipoprotein A & hyperhomocysteinmia potentially decrease the risk of stroke but no strong evidence.

Primary Prevention Atrial Fibrillation in patients *with CAD*. Tx

1. Stable CAD (no ACS with in 1 yr) - First line: Anticoagulation 2. Unstable CAD (ACS within 1 yr)- was stent placed? i. Aspirin + clopidogrel ii. Warfarin + 1 antiplatelet iii. Warfarin + aspirin + clopidogrel

Acute Stroke Timeline

10 min of hospital arrival -Immediate general assessment of patient 25 min -Neurologic assessment performed and CT scan or MRI obtained 45 min -CT scan/MRI is interpreted 60 min -Initiation of fibrinolytic therapy in appropriate patients

Patient -3 is a 55 yo F Sx: Sudden headache, loss of balance and confusion beginning 7 hours ago CT scan show white areas indicating hemorrhage Labs: INR = 1.5 Vitals BP 180/95 How many contraindications of alteplase does this patient have?

2. 1 for time, 1 for hemorrhage

Case [S]: Our patient is a 62 yo M with a history of HTN, DM, and AF He does not smoke, drinks 3 alcoholic beverages daily and does not exercise [O]: BP 123/77 mmHg, Pulse = 70 bpm, BMI = 24 How many modifiable stroke risk factors does this patient have? What is this patient's CHADS2 score? And what are appropriate therapies for primary stroke prevention based off of the score?

5 risk- HTN, AF,DM, alcohol, lack of activity. Chad score 2 due to dm and HTN. No CAD, anticoagulation for score of 2.

Fibrinolytics- ADR, monitoring

ADR - bleeding, hypotension. Monitoring- a. Neurologic assessment for bleeding- every 15 minutes during infusion and then every 30 minutes x 6 hours followed by hourly checks until 24 hours after treatment b. BP- every 15 minutes x 2 hours; every 30 minutes x 6 hours followed by hourly checks until 24 hours past alteplase initiation c. Sign of converting to a haemorragic stroke- signs of N/V. discontinue therapy and obtain CT scan d. CT scan - obtain follow-up prior to initiating antiplatelets or anticoagulants

Within what time period from onset of stroke symptoms can fibrinolytics be given? Acceptable time range? Ideal time range?

Acceptable -4.5 hr Ideal -3 hrs.

Goal blood pressure depends on if the patient is receiving fibrinolytic therapy or not

Acute ischemic stroke - not receiving fibrinolytics: ≤220/120 mmHg Acute ischemic stroke - receiving fibrinolytics: Monitor BP q 15 min x 2 hrs, then every 30 min x 6 hrs, then every hour x 16 hrs after tpa. High BP at the time of altiplase is CI. But BP controlled at the time of administration of tpa is ok. do not treat aggressively before tap. If bp remains high not a good candidate for fibrinolytics Prior to fibrinolytic initiation:≤185/110 mmHg Following fibrinolytic treatment:<180/105 mmHg. When treating BP in acute stroke reduce blood pressure by 15-25% over first 24 hrs.

Which antiplatelets can be used following an acute stroke?

Aspirin, aggrenox or Plavix.

Understand blood pressure management in acute stroke and agents that can be used in treatment

BP is allowed to run higher than normal for 24-48 hrs after aute stroke, to increases the chances of maintaining perfusion to the penumbra (collateral flow need BP). if pt is at goal just treat other symptoms that cause problems to pts like BP, seizure, hypoxia,N/V, headache. IV LABETALOL,Nicardepine, nitroprusside or nitropaste.

Hemorrhagic Stroke-Blood pressure goal and management

Blood pressure more tightly controlled in hemorrhagic stroke compared to ischemic stroke Goal - <180/105 TX. SBP 180-230 OR DBP 105-140 on 2 consecutive readings- Inititate IV labetalol, esmolol, enalaprilat SBP >230 OR DBP >140 on 2 consecutive readings- nitroprusside

Secondary Prevention-Hypertension, goals and TX recomendation

Blood pressure reduction generally begins ≥ 24-48 hrs after stroke Goal BP uncertain-keep BP moderate for 6-12months to have enough perfusion. Then normal ok medication regimen unclear-Diuretics w/o ACEI

Primary Prevention Atrial Fibrillation in patients with NO CAD. Tx

CHADS-2 score to determine risk of stroke and tx in AF. • Low risk for stroke patient,0 point: No therapy or ASA 75- 325 mg/d • Intermediate risk patient,1 point: I. anticoagulation (CHEST guideline recommend dabigatran) II. For patients unsuitable for anticoagulation, dual therapy with ASA and clopidogrel ,75mg • High risk patient≥ 2 points: prefer oral anticoagulation. (CHEST guideline recommend dabigatran). Warf INR goal- 2-3

What are two diagnostic tests that can distinguish between ischemic and hemorrhagic stroke?

CT Scan/MRI Used to determine presence and location of stroke Can differentiate between ischemic and hemorrhagic stroke

Dabigatran - Pradaxa® class, MOA, Indication ,ADR, monitoring, CI

Class- direct thrombin inhibitor. MOA- Inhibits free and fibrin-bound thrombin resulting in inhibition of thrombin-induced platelet aggregation and activation of factors V, VIII, XI, XIII. Indication- Stroke prophylaxis in non-valvular atrial fibrillation ADR- bleeding (more GI bleeding than warf, less intracranial bleeding. So recomented by guideline over warf) , GI upset , dyspepsia monitoring- ECT ( not available yet); aPTT can be used but not monitored regularly, tell u if rx is in the blood or not.; PT/INR not used CI - bleeding, CrCl ≤ 30 mL/min = 75 mg twice daily; CrCL < 15 mL/min Perals - no antidot. Recomented by guidelines over warfarin. Reanl adjustment - CrCl ≤ 30 mL/min = 75 mg twice daily; CrCL < 15 mL/min = CI

Apixaban - Eliquis® class, MOA, Indication ,ADR, monitoring, CI

Class- factor Xa inhibitor MOA - Direct, selective, and reversible inhibition of free and clot-bound factor Xa results in inhibition of platelet aggregation and fibrin clot formation Indication- Stroke prophylaxis in non-valvular atrial fibrillation Dosing - 5 mg twice daily Reduce the dose to 2.5 mg twice daily if the patient has 2 or more of the following: age 80 yo or greater, weight 60 kg or less, or a serum creatinine of 1.5 mg/dL or greater ADR- Bleeding, bruising, edema, headache Monitoring- Antifactor Xa activity can be used to detect presence Peals - No antidote; Take with food.ROCKET-AF Study : Non-inferior to warfarin in terms of efficacy; similar overall bleeding; increased GI bleeding with rivaroxaban. Renal adjustment - CrCl 15-50 mL/min = 15 mg daily; CrCL < 15 mL/min = Avoid.

Rivaroxaban - Xarelto® class, MOA, Indication ,ADR, monitoring, CI

Class- factor Xa inhibitor MOA- Direct, selective, and reversible inhibition of factor Xa in both the extrinsic and intrinsic pathways results in inhibition of platelet aggregation and fibrin clot formation Indication- Stroke prophylaxis in non-valvular atrial fibrillation ADR- Bleeding, bruising, edema, headache monitoring,- Antifactor Xa activity can be used to detect presence peals- No antidote; Take with food (requirement not optional per package insert -40% BA. No food not adequate levels.).ROCKET-AF Study : Non-inferior to warfarin in terms of efficacy; similar overall bleeding; increased GI bleeding with rivaroxaban. Renal adjustment - CrCl 15-50 mL/min = 15 mg daily; CrCL < 15 mL/min = Avoid

Warfarin - Coumadin®, class, MOA, indication, dosing,ADR, monitoring, CI & adv over others

Class- vitamin K antagoist MOA, Reduces synthesis of clotting factors II, VII, IX, and X and proteins C and S by competitively inhibiting vitamin K epoxide reductase complex 1 (VKORC1). Indication -Cardioembolic ischemic stroke prevention Dosing-Dosed to appropriate INR - usually 2-3 ADR- bleeding , bruising Monitoring - INR, signs of bleeding, consistent intake of vitamin K containing foods, alcohol consumption, addition/deletion of medications CI - Active bleeding, pregnancy, recent CNS surgery, recent epidural, severe uncontrolled hypertension Advantage - we do have an antidot if u have a high bleeding risk pt. No problem with RF. QD dose good adherence. INR level tell u whats the level. If you miss a dose more foregiving than newer agent. New agents get subtherapeutic and thromboembolism if you miss a dose.

Absolut CI for fibrinoytic therapy

Current Evidence/ History of intracranial hemorrhage Previous stroke, head trauma, intracranial or intraspinal surgery w/in 3 months Active internal bleeding Increase risk of bleeding Platelets <100,000/mm3 Heparin administration w/in 48 hrs causing an elevated aPTT On anticoagulation causing an INR ≥1.7 or PT >15 or stoped anticoagulation still elevated INR. It is ok to give after tpa. Known arteriovenous malformation, aneurysm, or neoplasm (cause of haemorragic stroke) Arterial puncture at a noncompressible site w/in 7 days Uncontrolled hypertension>185/110 mmHg - one of risk for haemorragic stroke. Rx cause low BP. As long as BP controlled at the time of infusion, it is ok to give. So its not an absolute CI.

Define Ischemic Stroke? Incidence and mortality

Damage to the brain due to an obstruction of blood flow in an artery which supplies blood to the brain. Incidence 87% , Mortality rate ~10% This obstruction can be due to atherosclerosis (plaque formation) with in the brian leading to narrowing of the blood vessels the formation of blood clots (can cause somewhere else in the body &travel to the brain) resulting in blockage of the blood vessels. • Symptoms last longer than 24 hours.

define Ischemic Stroke Sub-classification -Noncardioembolic?

Diseased cerebral vessels become blocked by plaque/ blood clots. Clot formed with in the brain.

Identify other tests to find out the cause of stroke ?

EKG- AF Echocardiogram- thrombi or valve problem Carotid Ultrasound Provides images of the carotid vessels to determine the presence of clots/narrowing of the vessels supplying blood to the brain

General inpatient Hospital Management of aute ischemic stroke

Early mobilization and/or DVT prophylaxis Cookie swallow (barium swallow) to test for dysphagia prior to eating/drinking to make sure pt is not going to aspirate. PT/OT/Speech Therapy Treat pneumonia and/or UTI with appropriate antibiotics Manage co-morbid disease states

Compare screening tools used in assessing stroke patients ?

FAST ( face movement- smile, arm movement, speak, time of onset of symptoms) Screen basiline, 24h after stroke, 1 week and 3 months of therapy to watch improvements. 1. Cincinnati Prehospital Stroke Scale (CPSS)- FAST. 50 sec 2. Los Angeles Prehospital Stroke Screen (LAPSS)- short 3. National Institutes of Health Stroke Scale (NIHSS)- 15 mins, score upto 42 points.

Primary Prevention Atrial Fibrillation in patients with mitral stenosis. Tx

First line: Anticoagulation (warfarin recommended) Alternative: Aspirin + clopidogrel

Define Ischemic Stroke Sub-classification -Cardioembolic ?

Formation of a blood clot somewhere in the body other than the brain (most commonly the heart - clot formed due to pooling of blood due to ineffective contraction, AF ) which travels from its location of origin and becomes lodged in a vessel supplying blood/oxygen to the brain

Primary Prevention-Oral contraceptives goal and tx

Goal:Eliminate use TX -use alternative contraceptive methods Avoid use especially in females >35 years of age, smokers, history of migraines and/or history of thromboembolic event

Primary and secondary Prevention Diabetes goals and TX recomentaion

Goals -FBS 70-130 mg/dL PPBS <180 mg/Dl HgbA1C <7% TX- diet, oral hypoglycemics and/or insulin as necessary ACEI or ARB for patients with diabetes and hypertension Include a statin in medication regimen

Primary Prevention-Sickle cell disease goal and tx

Goals: Reduce hemoglobin S from >90% to <30% Tx - Screen children with sickle cell via trancranial doppler ultrasound beginning at age 2 transfusion therapy for patients at high risk of stroke Alternative therapies include: hydroxyurea or bone marrow transplant

Primary and secondary Prevention -Smoking goal and tx

Goals: quit smoking Recommendations: Provide counseling, nicotine replacement, and pharmacologic interventions as necessary

Describe the clinical presentation Symptoms?

Good outcome if you identify it early. 1. Numbness of face and/or extremities usually on one side of the body 2. Partial or full paralysis of face and/or extremities 3. Difficulty speaking 4. Difficulty understanding speech/confused 5. Impaired vision or double vision 6. Loss of balance/trouble walking 7. Sudden headache ( hemorrhagic stroke)

In which type of stroke is blood pressure more tightly controlled?

Hemorrhagic

Primary & secondary Prevention-Lifestyle modifications:

I. Physical activity -Engage in ≥30 minutes of moderate-intense activity daily II. Diet-Consume ≥5 servings of fruits and vegetables daily Reduce sodium intake III. Alcohol-Men ≤2 drinks/day Women ≤1 drink/day IV. Obesity -Goal BMI = 18.5 - 24.9

Hemorrhagic Stroke- pharmacologic interventions

I. Seizure prophylaxis II. Reduction in cerebral edema-Mannitol III. Blood pressure management IV. Anticoagulation reversal-Vitamin K,Fresh frozen plasma V. Vasospasm prophylaxis In subarachnoid hemorrhage there is a high incidence of a delayed vasospasm resulting in ischemia Give nimodipine 60 mg

Ischemic Stroke - Non-pharmacologic treatment:

If CI to fibrinolytic therapy, did not work or >4.5 hrs use one of the following. i. Merci® Clot Retriever- catheter through femoral artery. ii. Solitaire Flow Restoration Device iii. Trevo Retriever iv. Pneumbral System- break the clot and vacuum. v. Cerebral Stenting

Secondary Prevention-Carotid artery stenosis goals and tx

If stenosis is severe = 70-99% Carotid endarterectomy is recommended If stenosis is moderate = 50-69% Carotid endarterectomy may be considered If stenosis mild = <50% Carotid endarterectomy not recommended Endarterectomy can occur 2-6 weeks after stroke

Primary Prevention Asymptomatic carotid stenosis goals and tx

If stenosis ≥70% via ultrasound I. May consider carotid endarterectomy II. Give in combination with aspirin III. Alternative: Carotid artery stenting

Clopidogrel - Plavix® MOA, indication, ADR, monitoring, CI

MOA - Active metabolite blocks the P2Y12 surface component of the ADP receptor on the platelet which prevents the activation of the glycoprotein IIb/IIIa receptor resulting in reduced platelet aggregation. Effects last for remainder of platelets lifespan (7-10 days). Indication- Can be used first line for secondary stroke prevention. Also, used when aspirin allergy present. ADR- Bleeding, GI upset, dizziness, headache, flu-like symptoms, rarely neutropenia or thrombotic thrombocytopenic purpura Monitoring- Hemoglobin/Hematocrit CI - Active bleeding, intracranial hemorrhage

Aspirin- MOA, indication, ADR, CI

MOA -Irreversibly inhibits cyclooxygenase-1 and 2 enzymes resulting in decreased conversion of arachadonic acid to thromboxane A2 resulting in inhibition of platelet aggregation. Indication -Initiate within 48 hours of acute ischemic stroke if not a candidate for alteplase and at least 24 hours after completion of alteplase, if given. Can be used first line for secondary stroke prevention. ADR -Bleeding, GI upset, bronchospasm CI - Use in children with viral illnesses, inherited bleeding disorders. Use caution in patients with asthma.

Aspirin/extended-release dipyridamole - Aggrenox®- MOA, indication, ADR, monitoring, CI

MOA- Dipyridamole = Inhibits activity of phosphodiesterase and adenosine deaminase resulting in accumulation of cAMP and other mediators which inhibit platelet aggregation. Indication- Can be used first line for secondary stroke prevention. More effective than aspirin alone. ADR- Headache, dizziness, flushing, bleeding, GI upset Monitoring - Hemoglobin, hematocrit, blood pressure CI - Use in children with viral illnesses, inherited bleeding disorders. Use caution in patients with asthma.

Fibrinolytics- MOA, indication, dosing

MOA- tpa binds to fibrin and Converts plasminogen ( seen inside the fibrin) to plasmin stimulating fibrinolysis of clot. Focus is to reperfuse ischemic penumbra. Indication - ischemic stroke. when symptom onset within 4.5 hours; Best results when used within 3 hours. Not for TIA ( <30 min, clear fast )or haemorrhagic stroke. Dosing.- 0.9 mg/kg (max-90 mg). 10% of total dose given as iv push over 1 min. followed by the rest (90%) admintered over 90 min.

Patient -4 is a 49 yo M Sx: Left sided weakness and difficulty speaking beginning 100 minutes ago. CT Scan indicates no hemorrhage BP 200/115 Is the patient a candidate for alteplase?

May be after you control bp. At this specific point no.

Patient -1 is a 67 yo WF Sx: Right sided paralysis, slurred speech and confusion beginning 2 hrs ago CT scan shows ischemia; no hemorrhage present Hx: A fib treated with warfarin; most recent INR = 2.2 Candidate for alteplase?

NO. due INR level

What 3 things do we monitor closely in patients receiving alteplase?

Neurologic assesmnet, BP, signs of converting to hemorrhage

What if a patient has a 2nd stroke?If a patient has a stroke while already receiving therapy for stroke prophylaxis?

No clear guidelines . If already receiving aspirin - switching to clopidogrel If already receiving clopidogrel -switching to anticoagulation May consider resistance testing to know Platelet/aspirin response or resistence

Patient -2 is a 83 yo WM Sx: Seizure followed by left sided facial droop and numbness with difficultly seeing beginning 45 minutes ago. PMH of HTN, DM, and CVA. Patient is diagnosed with an ischemic stroke via CT scan. Coagulation labs within normal limits. Platets 92x103 Candidate for alteplase?

No due to low patelet. Seizure is only a relative CI it is ok.

So, which antiplatelet to choose for acute ischemic stroke in cardio/ noncardioembolic stroke?

Noncardioembolic: monotherapy Cardioembolic Anticoagulation should be used unless contraindicated If antiplatelet needed, use dual therapy with aspirin + clopidogrel

Select patients who are candidates for fibrinolytic therapy? (Prior to use, complete a fibrinolytic checklist to assess)

Patient must have: 1. Diagnosis of ischemic stroke ( TIA or hemorrhagic kind CI) 2. Symptom onset ≤ 270* minutes 3. Age ≥ 18 Checklist also have absolute and relative CI if using with in 3 hours. If pt is between 3- 4.5 hours make sure pt don't have any additional exclusion criteria. Otherwise there is an increased risk of bleeding and mortality.

Secondary Prevention-Hyperlipidemia

Patients with atherosclerotic ischemic stroke or TIA without known CHD Target a reduction of at least 50% in LDL or a level of 70 mg/dL

Acute Stroke -Goals

Restore perfusion Prevent ongoing infarction Prevent long-term disability Prevent hemorrhagic conversion Decrease mortality Reduce incidence of recurrence.

Primary Prevention-Hypertension, goals ( based on co morbid dz state) and TX recomentaion

Risk for both ischemia and haemorrage. Goal BP = 1. <150/90 in pt >60yr. (JNC-8), <140/90 in pt <60, DM,CKD (JNC 8) 2. <140/80 in pts with DM (ADA) 3. <140/90 in CKD without protein urea (KDIGO) <130/80 with proteinurea (KDIGO) 4. <140/90 in general people (AHA) <130/80 in pts with DM,CAD or CKD (AHA), <120/80 in pts with LVD (AHA) TX - follow htn Guidelines keeping in mind patients co-morbid dz states

BP Treatment if not in goal :<180/105 mmHg& after Fibrinolytics

SBP 180-230 OR DBP 105-120 - IV LABETALOL SBP >230 OR DBP 121-140 - IV LABETALOL OR NICARDIPINE. DBP>140- iv nitroprusside

BP Treatment if not in goal :≤185/110 mmHg and prior to Fibrinolytics

SBP >185 OR DBP > 110 - IV LABETALOL OR nitropaste. do not treat aggressively. If bp remains high, not a good candidate for fibrinolytics.

BP Treatment if not in goal ≤220/120 mmHg & No fibrinolytics

SBP >220 OR DBP 121-140 - tx IV - IV LABETALOL OR NICARDIPINE. DBP>140- iv nitroprusside .

What two characteristics of the stroke must be identified prior to choosing therapy?

Step 1: Determine time since symptom onset- ideal <3 hrs , accepatable <4.5hrs for thrombolysis. ( ACS cut off 12 hrs for thrombolysis). All the time Throbolytics should be administered with in 1hr of hospital arrival .(ACS needle time is 30 min, PCI time is 90 min) last time patient was functioning normally- went to sleep at 8pm & woke up 6 am due to symptom. Symptom onset is 8 pm since that the time pt found function normally. Step 2: Identify the type of stroke Ischemic versus hemorrhagic Obtain a CT scan and/or MRI of the brain

Primary Prevention -Hyperlipidemia, goals and TX recomentaion

Treat LDL with statin and lifestyle modifications per the NCEP guidelines Fibric acid if high triglycerides and niacin if when HDL low or lipoprotein A elevated - not been shown to prevent strokes

Ischemic Stroke - Treatment with Antiplatelets, place in therapy

Used in all patients experiencing noncardioembolic ischemic stroke Initiation = 24 hours after completion of fibrinolytic therapy OR Within 48 hours (with in several hours of onset ) of stroke onset if patient is not a candidate for fibrinolytic therapy. Agents: Aspirin- 75-325 mg daily. Cheapest but highest bleeding. Aspirin 25/dipyridamole 200 (Aggrenox®) 1 BID- more effective than aspirin alone without increased bleeding. But less tolerated. Adeherence problem BID. Clopidogrel (Plavix®)- 75 mg QD.

Ischemic Stroke - Treatment with Anticoagulants, when do they receive therapy?

Used in patients suffering from a cardioembolic ( AF) ischemic stroke Initiation = Wait 48 hours after completion of fibrinolytics OR If not receiving fibrinolytics, as soon as hemorrhage ruled out For patients with stroke and atrial fibrillation- use anticoagulation If you cannot receive anticoagulation -use dual platelet aspirin + clopidogrel

How long do we usually wait after administering alteplase before initiating antiplatelets in a noncardioembolic stroke? Anticoagulants in a cardioembolic stroke?

Wait 24 hr and 48 hrs respectively

Ischemic Stroke - Anticoagulants agents?

Warfarin (Coumadin®)- INR 2-3 Dabigatran (Pradaxa®) 150 mg BID-recomented by guidelines over warf. Rivaroxaban (Xarelto®) 20 QD Apixaban (Eliquis®) - 5 mg twice daily.Reduce the dose to 2.5 mg twice daily if the patient has 2 or more of the following: age 80 yo or greater, weight 60 kg or less, or a serum creatinine of 1.5 mg/dL or greater IV anticoagualnet (Heparin/LMWH )-No evidence for use in treating acute stroke.Only place in stroke therapy is for "bridging" to warfarin until INR is therapeutic 2-3.

Classification or 3 types of stroke?

a. Ischemic i. Cardioembolic ii. Noncardioembolic b. Hemorrhagic i. Intracerebral ii. Subarachnoid iii. Subdural hematoma c. Transient Ischemic Attack (TIA) Therapy depends on on time & type of stroke.

Identify risk factors associated with stroke occurrence?

a. Non modifiable risk factors 1) Age >55 2) Gender- M 3) Race- Caucasian's has least risk 4) Family history 5) Low birth weight<250 gm b. Modifiable risk factors /life style 1. Smoking 2. Alcohol 3. Obesity 4. Inactivity 5. Hyperlipidemia 6. Elevated lipoprotein A 7. Hypertension - chance for ischemic or hemorrhagic stroke 8. AFib - CHADS score and give warfarin. 9. Patent foramen ovale ( opening between atria & ventricle not closed at birth) 10. Asymptomatic carotid stenosis 11. DM 12. Sickle cell disease - high chance for sticking together. 13. Hyperhomosteinemia 14. OCP >50 mcg of estrogen

What is an emboli

it is a broken piece of thrombus that can travel through the blood stream and lodges in blood vessel to block it.

Define Hemorrhagic Stroke and causes , incidence and mortality rate ?

• Damage to the brain due to rupture of a blood vessel and bleeding into or on the brain. • Symptoms last longer than 24 hours. • Incidence 13% , Mortality rate ~50% . TX is surgery. • Causes 1. Aneurysms ( weekened blood vessels) 2. arteriovenous malformations (AVM)(clustering of artery, capillary & veins) 3. trauma

Hemorrhagic Stroke Sub-classification ?

• Within the brain o Intracerebral hemorrhage - Rupture of a blood vessel within the brain • Surface of brain o Subarachnoid hemorrhage -Collection of blood within the subarachnoid space. Increase intracranial pressure and inflammation & swelling. o Subdural hematoma -Collection of blood below the dura

Relative Contraindications for rt-PA - Alteplase/Activase®

MI w/in past 3 months Witnessed seizure at symptom onset