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CVA TIA+IS
cerebrovascular accidents: TIA and ischemic stroke
| Question | Answer |
|---|---|
| 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
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