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cerebrovascular accidents: TIA and ischemic stroke

types of CVA hemorrhagic and ischemic
types of ischemic attacks transient ischemic attack and stroke
ischemic stroke clot blocks blood flow to an area of the brain
hemorrhagic stroke bleeding occurs inside or around the brain tissue
thrombi artheromas in major cerebral arteries in areas of turbulent flow
emboli lodged in cerebral artery because of: A fib, post-MI, vegitations as in endocardidtis, prosthetic heart valves
subarachnoid hemorrhage (SAH) bleeding in space between brain and skull caused by aneurism
symptoms of SAH worst headache, N, V, loss of conciousness, coma
SAH physical exam findings nuchal regidity, paralysis
Tx goal of SAH prevent complications, delay ischemia, allow HTN to redirect bloodflow to ischemic areas
Tx choice for SAH nimodipine 60mg IV q4h
Tx of seisures due to SAH phenytoin
Tx of rebleeding surgical clipping
Tx of hydrocephalus drain and/or shunt
non-modifiable risk factors for stroke age (risk doubled every decade after 55) gender M>F low birth weight race black>hispanic>white genetics - paternal history
modifiable risk factors for stroke HTN, smoking, alcohol, diabetes, A fib, dyslipidemia, CHD, sickle cell, post menopausal therapy, obesity, diet, body fat distribution, physical inactivity
primary stroke prevention treat modifiable risk factors aspirin use recomended in women >65y/o with high stroke risk
assessment of TIA and ischemic stroke non-IV CT scan to rule out hemorrhage rule out modifiable risk factors PMH - A fib, MI neurologic exam
Neurologic exam (NIHSS) identifies location of ischemia guides theraputic decisions
NIHSS score <20 mild to moderate stroke
NIHSS score >22 very poor prognosis
transient ischemic attack (TIA) "mini stroke" transient focal neurologic lesion = decrease in O2 supply
course of TIA rapid symptom onset Sx resolves w/i 24h usually in 15mins no residual neurologic deficit warning sign of impending stroke
Stroke permanent focal neurologic lesion (cell death has occured)
course of stroke rapid symptom onset Sx last >24 hours residual neurologic deficit present
symptoms of TIA and stroke hemiparesis, aphasia, ataxia, parestesia, blindness, vertigo, headache
F.A.S.T. face, arm, speech, time (to call 911)
acute Tx of TIA 325mg po ASA qd immediately (clopidigrel 75mg if allergy to ASA) initiate adjust secondary prevention meds non-pharmacologic management: carotid endarterectomy
TIA goals for therapy modify risk factors for future stroke (secondary prevention)
acute Tx of ischemic stroke ASA 325mg po qd (immediately) (clopidigrel 75mg po qd if allergic to ASA)
benefits of ASA slight reduction in early stroke recurrence no benefits in neurological deficit
acute Tx of ischemic stroke Alteplase (tPA) MUST ADMINISTER WITHIN 3 HOURS OF SYMPTOM ONSET (based on efficacy and safety)
Alteplase (tPA) (tissue plasminogen activator) dosing infuse 0.9mg/kg IV over 60 minutes within 10% of the dose given as a bolus over 1 minute (max bolus dose 90mg)
acute Tx of ischemic stroke goals prevent complications reduce long standing neurological deficits physical therapy/occupational therapy
additional Tx for ischemic stroke BP goal s<185 d<110 antithrombotic therapy secondary prevention measures
acute ischemic stroke BP drugs labetalol IV, nitropaste 1-2 inches, nicardipine IV follow JNC7 bp goals after discharged
antithrombotic therapy in acute ischemic stroke warfarin indicated if A fib and is initiated 24 hours after tPA dose
secondary stroke prevention general principles long term antiplatelet therapy after TIA or stroke manage risk factors
acceptable options for initial secondary stroke prevention therapy ASA 50-325mg monotherapy OR dipyridamole 200mg ER + ASA 25mg (aggrenox) BID OR clopidigrel 75mg po qd monotherapy
ASA vs. aggrenox vs. plavix aggrenox or plavix monotherapies are more recommended than ASA alone
clopidigrel vs. aggrenox clopidigrel more prefered by neurologists due to less adverse reactions
aggrenox ADEs HA, GI, dizziness, fainting, more bleeding
ASA + clopidigrel increase risk of hemorrhage ONLY use combination with specific indication: coronary stent or ACS
ASA + aggrenox may not provide adequate Tx for cardiac indications
statins in stroke therapy use them they are good for you decrease risk of stroke by 18% with or without CHD
Created by: lex86