cerebrovascular accidents: TIA and ischemic stroke
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| types of CVA | hemorrhagic and ischemic
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| types of ischemic attacks | transient ischemic attack and stroke
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| ischemic stroke | clot blocks blood flow to an area of the brain
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| hemorrhagic stroke | bleeding occurs inside or around the brain tissue
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| thrombi | artheromas in major cerebral arteries in areas of turbulent flow
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| emboli lodged in cerebral artery because of: | A fib, post-MI, vegitations as in endocardidtis, prosthetic heart valves
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| subarachnoid hemorrhage (SAH) | bleeding in space between brain and skull
caused by aneurism
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| symptoms of SAH | worst headache, N, V, loss of conciousness, coma
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| SAH physical exam findings | nuchal regidity, paralysis
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| Tx goal of SAH | prevent complications, delay ischemia, allow HTN to redirect bloodflow to ischemic areas
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| Tx choice for SAH | nimodipine 60mg IV q4h
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| Tx of seisures due to SAH | phenytoin
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| Tx of rebleeding | surgical clipping
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| Tx of hydrocephalus | drain and/or shunt
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| 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
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| 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
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| primary stroke prevention | treat modifiable risk factors
aspirin use recomended in women >65y/o with high stroke risk
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| 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
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| Neurologic exam (NIHSS) | identifies location of ischemia
guides theraputic decisions
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| NIHSS score <20 | mild to moderate stroke
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| NIHSS score >22 | very poor prognosis
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| transient ischemic attack (TIA) | "mini stroke" transient focal neurologic lesion = decrease in O2 supply
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| course of TIA | rapid symptom onset
Sx resolves w/i 24h usually in 15mins
no residual neurologic deficit
warning sign of impending stroke
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| Stroke | permanent focal neurologic lesion (cell death has occured)
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| course of stroke | rapid symptom onset
Sx last >24 hours
residual neurologic deficit present
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| symptoms of TIA and stroke | hemiparesis, aphasia, ataxia, parestesia, blindness, vertigo, headache
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| F.A.S.T. | face, arm, speech, time (to call 911)
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| 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
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| TIA goals for therapy | modify risk factors for future stroke (secondary prevention)
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| acute Tx of ischemic stroke | ASA 325mg po qd (immediately)
(clopidigrel 75mg po qd if allergic to ASA)
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| benefits of ASA | slight reduction in early stroke recurrence
no benefits in neurological deficit
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| acute Tx of ischemic stroke | Alteplase (tPA) MUST ADMINISTER WITHIN 3 HOURS OF SYMPTOM ONSET (based on efficacy and safety)
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| 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)
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| acute Tx of ischemic stroke goals | prevent complications
reduce long standing neurological deficits
physical therapy/occupational therapy
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| additional Tx for ischemic stroke | BP goal s<185 d<110
antithrombotic therapy
secondary prevention measures
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| acute ischemic stroke BP drugs | labetalol IV, nitropaste 1-2 inches, nicardipine IV
follow JNC7 bp goals after discharged
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| antithrombotic therapy in acute ischemic stroke | warfarin indicated if A fib and is initiated 24 hours after tPA dose
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| secondary stroke prevention general principles | long term antiplatelet therapy after TIA or stroke
manage risk factors
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| 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
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| ASA vs. aggrenox vs. plavix | aggrenox or plavix monotherapies are more recommended than ASA alone
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| clopidigrel vs. aggrenox | clopidigrel more prefered by neurologists due to less adverse reactions
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| aggrenox ADEs | HA, GI, dizziness, fainting, more bleeding
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| ASA + clopidigrel | increase risk of hemorrhage
ONLY use combination with specific indication: coronary stent or ACS
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| ASA + aggrenox | may not provide adequate Tx for cardiac indications
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| statins in stroke therapy | use them they are good for you decrease risk of stroke by 18% with or without CHD
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