Stroke

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Questions and Answers

What is a primary cause of cerebral infarction?

Hemorrhage

Trauma

Ischemia (correct)

Neurodegeneration

Which of the following conditions is NOT classified as a type of stroke?

Ischemic stroke

Transient ischemic attack (TIA)

Subdural hematoma (correct)

Hemorrhagic stroke

Which of the following is a non-modifiable risk factor for stroke?

Obesity

Age (correct)

Smoking

High cholesterol

What is the typical duration for symptoms to persist to diagnose cerebral infarction?

24 hours Signup and view all the answers

What is a possible consequence of a hemorrhagic stroke?

Compression on brain tissue Signup and view all the answers

Which of the following best describes the term 'Central nervous system infarction'?

Injury due to a lack of oxygen Signup and view all the answers

What is a common symptom associated with an ischemic stroke?

Focal neurological deficit Signup and view all the answers

Which type of stroke includes subarachnoid hemorrhage?

Hemorrhagic stroke Signup and view all the answers

What percentage of strokes are categorized as hemorrhagic?

10% to 20% Signup and view all the answers

Which of the following is NOT a warning sign of a stroke?

Sudden loss of appetite Signup and view all the answers

What should be recommended for patients with a CHA2DS2-VASc score of 0 in men?

No therapy is necessary Signup and view all the answers

Which anticoagulant is considered a direct thrombin inhibitor?

Dabigatran Signup and view all the answers

What is the recommended dose of apixaban for atrial fibrillation management?

5 mg BID Signup and view all the answers

In the case of high bleeding risk, which anticoagulant can be considered?

Apixaban Signup and view all the answers

What is a common management strategy for patients with acute intracerebral hemorrhage?

Blood pressure management Signup and view all the answers

Which ethnic group is listed as a risk factor for atrial fibrillation?

African American Signup and view all the answers

What complication is most commonly associated with ischemic strokes?

Residual deficits Signup and view all the answers

Which of the following is NOT considered a risk factor for atrial fibrillation?

High physical activity Signup and view all the answers

What typical symptom is associated with a hemorrhagic stroke?

A sudden severe headache Signup and view all the answers

Which of the following explains a transient ischemic attack (TIA)?

Transient episode of neurological dysfunction Signup and view all the answers

Which of the following is a characteristic symptom of an ischemic stroke?

Falling without reason Signup and view all the answers

What factor contributes to both atrial fibrillation and ischemic stroke?

Cigarette smoking Signup and view all the answers

Which of the following is a common cause of adult disability?

Ischemic stroke Signup and view all the answers

Which of the following risks is associated with higher estrogen oral contraceptive use?

Cerebral hemorrhage Signup and view all the answers

Which symptom is defined by weakness on one side of the body and inability to speak?

Ischemic stroke Signup and view all the answers

Which symptom is indicative of a potential intracranial hemorrhage (ICH)?

Severe headache Signup and view all the answers

What is the recommended action if a patient's SBP is greater than 185 mmHg before treatment?

Provide labetalol IV Signup and view all the answers

What complication can arise from ischemic stroke due to endothelial dysfunction?

Systemic bleeding Signup and view all the answers

What is a critical determinant for treatment initiation in stroke patients?

The time of symptom onset Signup and view all the answers

Which blood glucose level indicates a contraindication for the administration of alteplase?

50 mg/dL Signup and view all the answers

Which of the following actions is recommended for immobile stroke patients?

Use intermittent pneumatic compression Signup and view all the answers

What is the target blood pressure during or after alteplase infusion?

Below 180/105 mmHg Signup and view all the answers

What intervention is NOT recommended for patients who have had a seizure after a stroke?

Administer prophylactic antiseizure medication Signup and view all the answers

Which imaging modality is ideally performed within 20 minutes for stroke evaluation?

CT scan Signup and view all the answers

What should be monitored every 15 minutes during intravenous alteplase infusion?

Blood pressure and neurological assessments Signup and view all the answers

What is the appropriate dual antiplatelet therapy for patients presenting with minor stroke?

Aspirin and clopidogrel Signup and view all the answers

What should be given to patients who are not eligible for rt-PA within 48 hours of stroke onset?

Aspirin 160- to 325-mg Signup and view all the answers

What is one primary goal of primary stroke prevention?

Initiating statin therapy Signup and view all the answers

Which treatment is specifically indicated for secondary stroke prevention?

Antiplatelet therapy Signup and view all the answers

Which of the following is NOT a focus of secondary stroke prevention?

Patient education on warning signs Signup and view all the answers

What drug combination should be avoided for patients after a minor stroke?

Aspirin and ticagrelor Signup and view all the answers

Which condition is generally controlled in both primary and secondary stroke prevention?

Hyperlipidemia Signup and view all the answers

What lifestyle change is consistently recommended in both types of stroke prevention?

Smoking cessation Signup and view all the answers

For patients with atrial fibrillation, what assessment tool is utilized for stroke prevention?

CHA2DS2-VASc score Signup and view all the answers

Why is patient education concerning stroke warning signs important?

It encourages timely emergency care. Signup and view all the answers

Study Notes

Stroke (Cerebrovascular Accident-CVA) Definition

A reduced blood supply to the brain reduces oxygen supply, potentially causing brain death ("central nervous system infarction").
Cerebral infarction: Brain, spinal cord, or retina cell death due to ischemia (lack of blood flow). Neurological evidence of permanent injury for at least 24 hours confirms diagnosis, excluding other causes.

Etiology & Pathophysiology Overview

Ischemic Stroke: (3rd or 4th leading cause of death in developed countries). Occurs from thrombotic or embolic occlusion of cerebral arteries. Causes sudden focal neurological deficits.
Hemorrhagic Stroke: Bleeding into brain tissue or other CNS spaces. Includes subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and subdural hematomas. Bleeding causes compression on brain tissue.

Risk Factors

Non-Modifiable:*
Age (males > females, >55 years)
Race/ethnicity (American Indian, Alaska Natives, African American, Asian/Pacific Islander, Hispanic)
Genetic predisposition/family history
Low birth weight
Modifiable:*
Hypertension
Cardiovascular diseases (e.g., atrial fibrillation, CHD)
Diabetes
Dyslipidemia
Oral contraceptive use (estrogen content >50 mcg)
Cigarette smoking
Alcohol use
Obesity
Physical inactivity
Drug abuse (cocaine, amphetamines, heroin)

Classification

Transient Ischemic Attack (TIA): Transient neurological dysfunction from focal brain, spinal cord, or retinal ischemia, without acute infarction. No deficit remains after the attack.
Ischemic Stroke: Neurological symptoms lasting 24 hours or more. Most common cause of adult disability. Tissue injury and infarction result.
Hemorrhagic event: Sudden, severe headache, nausea, and vomiting

Clinical Presentation

Ischemic Stroke:*
Weakness on one side of the body. Inability to speak, loss of vision, vertigo, headache, or falling.
Hemiparesis (facial droop, weakness on one side of the body)
Hemisensory deficit (loss of sensation on one side of the body)
Vertigo and double vision
Slurred speech
Altered level of consciousness
Hemorrhagic Stroke:*
Sudden severe headache.
Nausea and vomiting.
"Worst headache of my life"
Photophobia
Nuchal rigidity

Diagnosis

No specific laboratory tests for stroke exist.
CT scan (ideally within 20 minutes of symptom onset)
MRI
Carotid Doppler
ECG
Transthoracic echocardiogram (TTE)

Ischemic Stroke- Complication

Cerebral edema (due to endothelial dysfunction)
Increased intracranial pressure (ICP)
Seizures
Hemorrhagic conversion (ischemic stroke converted to hemorrhagic stroke)

Ischemic Stroke- Management

Identification of stroke onset time and manner is critical for treatment.
NIHSS score assessment.
Supplementary oxygen (saturation >94%)
Correct volume status and electrolytes.
Check blood glucose; treat hypoglycemia and maintain blood glucose ≤180 mg/dL.
Blood pressure (BP) check; Alteplase must be below 185/110 mmHg before use.
Fibrinolytic therapy (Alteplase/rt-PA) in appropriate cases.

Ischemic Stroke- Fibrinolytic Therapy

Alteplase (rt-PA) is the only FDA-approved agent for acute ischemic stroke. Administered within 3 hours (or up to 4.5 hours) after symptom onset.
Timing is critical: Treatment should begin as soon as possible.
Therapy benefit is time-dependent.

Ischemic Stroke- Fibrinolytic Therapy - Mechanism of Action

activates plasminogen to plasmin, which degrades fibrin
results in thrombus breakdown

Ischemic Stroke- Fibrinolytic Therapy - Administration

Only after a brain imaging is completed
Assess blood glucose levels
Aim for door-to-needle time of 60 minutes. Dosing: 0.9 mg/kg (maximum 90 mg).
First 10% as an IV bolus, rest infused over 1 hour

Inclusion and Exclusion Criteria for Alteplase (rt-PA)

Inclusion:*
Age 18 years or older.
Clinical diagnosis of ischemic stroke, measurable neurological deficit.
Onset time within 4.5 hrs of treatment.
Exclusion:*
Active internal bleeding
Current anticoagulation therapy.
LMWH within past 24 hours.
NOAC within 48 hours.
INR > 1.7.
Platelets < 100 000/mm3.
aPTT > 40 seconds.
Blood glucose < 50 mg/dL (2.8 mmol/L)
Previous stroke within 3 months
History of subarachnoid or intracranial hemorrhage
SBP > 185 mmHg or DBP > 110 mmHg at treatment time

Major Adverse Effects of Fibrinolytic Therapy (rt-PA)

Bleeding, including ICH and systemic bleeding.
Intracranial hemorrhage (ICH) may result in mental status changes and severe headaches.
Angioedema.
Systemic bleeding includes hematemesis, guaiac-positive stools, black tarry stools, hematoma formation, hematuria, gingival bleeding, and nosebleeds

Blood Pressure (BP) Recommendations for Ischemic Stroke (Alteplase-Eligible)

Before treatment: If SBP > 185 or DBP > 110, administer labetalol (10-20 mg IV over 1-2 minutes, repeat every 10 minutes) or nicardipine infusion (5 mg/hour) to reduce BP to ≤185/110 mm Hg.
During/After Treatment: Reduce SBP and DBP to <180/105:
- If SBP > 180 or DBP > 105: labetalol (10–20 mg IV over 1–2 min followed by infusion 2-8 mg/min) or nicardipine 5 mg/hour.
- If uncontrolled or DBP > 140, nitroprusside 0.3-0.5 mcg/kg/min IV.
Measure BP and neurological assessments
every 15 min, 2hr duration of alteplase IV, then every 30 min for 6hrs, then hourly to 24hrs

Blood Pressure (BP) Recommendations for Ischemic Stroke (Not Alteplase-Eligible)

SBP ≤ 220, DBP < 120: Observe for 2-3 days in absence of comorbidities; labetalol (10–20 mg IV over 1-2 minutes) or nicardipine 5mg/hour for 2-3 days
SBP ≥ 220 or DBP ≥120 or comorbid conditions: use labetalol for at least 10 -20 minutes, and repeat every 10 minutes.
If BP not controlled or DBP ≥ 140: use nitroprusside at 0.3-0.5 mcg/kg/min.
Goal reduce BP by 15% within 24 hours.

Ischemic Stroke- Management (general)

Fever control: Identify and treat fever source.
Cardiac monitoring: Monitor for 24 hours for atrial fibrillation.
Immobile Stroke Patients: use Intermittent pneumatic compression (IPC).
Enteral diet introduction: Start within 7 days of hospitalization.
Seizure treatment: Treat according to patient characteristics.
Rehabilitation: Well-organized rehabilitation program for stroke patients.

Surgical Management

Mechanical thrombectomy: In selected patients, within 24 hours of symptom onset.
Carotid endarterectomy (CEA): Removal of a thrombus from the carotid artery.

Antiplatelet Agents

Aspirin: Administered within 24–48 hours post-onset and continued indefinitely.
Glycoprotein IIb/IIIa receptor inhibitors (GPIIb/IIIa): Not recommended.
Minor Stroke: Patients with minor stroke often benefit from dual antiplatelet therapy (aspirin and clopidogrel) for up to 90 days post-symptom onset. (Avoid ticagrelor or prasugrel)
Non-rt-PA Eligible Patients: Initiate aspirin (160-325 mg initial dose and 50-100 mg maintenance dose) within 48 hours.

Stroke Outlines

Stroke definition/CVA.
Stroke etiology, pathophysiology, and risk factors.
Stroke classification and clinical presentation.
Ischemic stroke definition and diagnosis.
Ischemic stroke complications.
Ischemic stroke management.
Ischemic stroke prevention.
Acute hemorrhagic stroke definition and treatment.
Outcome evaluation.

Ischemic Stroke- Prevention

Primary prevention:* Treatment of individuals with no history of stroke.
Reduce all modifiable risk factors: Diabetes, hypertension, hyperlipidemia,smoking, weight reduction.
Medications like statins and antiplatelets in eligible patients.
Educate patients about stroke warning signs.
Secondary prevention:* Treatment of individuals with history of stroke or TIA.
Reduce all modifiable risk factors, including diabetes, hypertension, smoking cessation, and body weight reduction.
Statin (high-intensity) use

Ischemic Stroke- Atrial Fib Treatment Intervention (CHA2DS2-VASc)

If total score = 0 in men or 1 in women →no treatment.
If total score ≥ 1 in men or ≥ 2 in women→ Give oral anticoagulant.

Anticoagulant and Stroke Prevention (atrial fibrillation treatment)

Current guidelines recommend newer oral anticoagulants (NOACs) over Warfarin.
HAS-BLED score to evaluate bleeding risk for patients with high risk.

Treatment of Acute Hemorrhagic Stroke

Supportive Measures:
- No proven treatment for ICH.
- Manage increased ICP, seizures, glucose, infections, bleed prevention.
- Manage BP to <180/140 mm Hg.
- Prevention of hemorrhage extension.
Deep vein thrombosis prophylaxis: Use of intermittent compression stockings and use of UH or LMWH, once stabilized.
Calcium antagonists: Oral nimodipine for aneurysmal SAH to prevent delayed cerebral ischemia within 96 hours.

Potential Medication for Hemorrhagic Stroke

Recombinant factor VIIa (rFVIIa) phase III trial for hemorrhagic stroke treatment remains inconclusive regarding efficacy.

Treatment of Acute Hemorrhagic Stroke - Blood Pressure Management

Elevated SBP: Lower SBP to ≤ 220 mmHg (using nicardipine or labetalol).
Gradually reduce to target range of 140–160 mmHg once the patient is clinically stable.

Treatment of Acute Hemorrhagic Stroke - Control of Intracranial Pressure (ICP)

In patients with GCS 3–8, place an ICP monitor.
Maintain ICP < 20 mmHg and cerebral perfusion pressure (CPP) at 50–70 mm Hg.
Treatment options include ventricular drainage and 20% mannitol (osmotic diuretic). Hypertonic saline (3%, 7.5%, or 23.5% NS) may be used.

Discontinue anticoagulation immediately for IC patients to reverse.
Rapid anticoagulant reversal with appropriate measures (Factor PCC or Vitamin K).

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