Stroke (Cerebrovascular Accident) - W8.Stroke Modified PDF

¡ A condition of a reduced blood supply to the brain which reduce the oxygen supplement and cause brain death “Central nervous system infarction” Brain th Dea Blood supply ain Br...

¡ A condition of a reduced blood supply to the brain which reduce the oxygen supplement and cause brain death “Central nervous system infarction” Brain th Dea Blood supply ain Br ¡ Cerebral infarction: brain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/ or clinical evidence of permanent injury, given symptoms persisting for 24 hours or more until death or other etiologies excluded  es Ischemic Stroke (3rd or 4th most most common death in all developed countries) Thrombotic or embolic occlusion of the cerebral artery Abrupt development of a focal neurological deficit - Sigis Hemorrhagic Stroke Compression on brain tissue "5 %1. - Bleeding into the brain and other spaces within the central nervous system (CNS) and includes subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and subdural hematomas https://www.youtube.com/watch?v=bp1HRfpOUo0  Non-Modifiable Modifiable (well-documented) Age (> 55 years) Hypertension Gender (males > females) Cardiovascular diseases (e.g. Atrial fibrillation, CHD) Race and ethnicity (American Indian/ Diabetes Alaska Natives, African American, Dyslipidemia Asian/ Pacific Islander, Hispanic) Oral contraceptive use (with estrogen content greater than 50 mcg) Genetic predisposition/family history Cigarette smoking Low birth weight Alcohol use Sig Obesity and Physical inactivity S Drug abuse (cocaine, amphetamines and heroin)  Cerebral Ischemic Attack Hemorrhagic event Transient ischemic attack (TIA) Ischemic stroke Transient episode of neurological Symptoms lasting 24 hours or A sudden severe headache, nausea, dysfunction caused by focal brain, spinal greater vomiting cord, or retinal ischemia without acute infarction No deficit remains after the attack Most common cause of adult disability: Tissue injury and infarction are present, and in many patients, residual deficits remain after the event  Ischemic stroke Hemorrhagic stroke Symptoms Weakness on one side of the body, inability to A sudden severe headache, nausea, speak, loss of vision, vertigo, headache, or falling vomiting. “the worst headache of my life” Signs Hemiparesis: Weakness on one side of the body Photophobia (facial drop) Nuchal rigidity Hemisensory deficit: Loss of sensation on one side of the body Vertigo and double vision Slurred speech Altered level of consciousness ¡ There are no specific laboratory tests for stroke ¡ CT- scan (ideally within 20 minutes) ¡ MRI ¡ Carotid Doppler ¡ ECG ¡ Transthoracic echocardiogram (TTE) ¡ Acute complications of ischemic stroke include: – Bc of endothelial dysfunction – – –  Identification of the time and manner of stroke onset is an important determinant in treatment [The last time patient was known normal (last known well) is used as the time of stroke onset] q NIHSS score has to be evaluated q Supplemental oxygen should be provided to maintain oxygen q Volume status and electrolytes saturation >94% should be corrected q BP should be checked (Alteplase q Blood glucose should be checked since can not be given unless BP is hypoglycemia and hyperglycemia may 1.7, platelets 40 s Blood glucose concentration ≤ 50 mg/ dL (2.8 mmol/ L) - Time of symptom onset well established Previous stroke within 3 months to be less than 4.5 hours before treatment History of subarachnoid or intracranial hemorrhage or would begin SBP >185 mmHg /DBP >110 mmHg at time of treatment  Bleeding, including intracranial hemorrhage (ICH) and serious systemic bleeding ICH Systemic bleeding Mental status changes and a severe headache may - Angioedema indicate ICH Signs of systemic bleeding include inside The Hematemesis Brains Guaiac-positive stools Black, tarry stool - - Hematoma formation Hematuria Bleeding gums Nosebleeds  BP Management Before treatment: if SBP >185 or DBP >110 Labetalol 10-20 mg IV over 1-2 min (repeat every 10 min) OR (9) suj449x Nicardipine infusion 5mg/hour & = yog(d) Jj9* During or after treatment to maintain BP ≤ 180/105: & 1) If SBP >180 or DBP >105 Labetalol 10-20 mg IV over 1-2 min followed by infusion 2-8 mg/min OR Nicardipine infusion 5mg/hour\ 2) If BP is not controlled or DBP >140 Nitroprusside 0.3-0.5 mcg/kg/min IV ✵ Measure BP and perform neurological assessments everyO O 15 min during and after IV alteplase infusion for 2 h, then every 30 min > - C for 6 h, then hourly until 24 h after IV alteplase treatment 1gm som In the 24h  1837183 BP Management 8or DBP < 120 SBP 140 Nitroprusside 0.3-0.5 mcg/kg/min ✵ Starting or restarting antihypertensive therapy during hospitalization in patients with BP >140/90 mm Hg who are neurologically stable is safe and is reasonable to improve long-term BP control unless contraindicated ¡ Control fever (source of fever should be identified and treated) ¡ Cardiac monitoring continued for the first 24h to screen for atrial fibrillation (AF) - side ¡ In immobile stroke patients, intermittent pneumatic compression (IPC) is recommended for DVT prophylaxis (benefit of prophylactic anticoagulants in immobile patients with acute => ischemic stroke [AIS] is not well established) ¡ Enteral diet should be started within 7 days of admission after an acute stroke = ¡ If seizure occurred, it should be treated based upon patient characteristics (prophylactic antiseizure is not recommended) ¡ Stroke patient should receive a well-organized rehabilitation program ¡ Surgical: – – ¡ Administration of aspirin is recommended within 24 to 48 hours after onset and to be continued indefinitely ¡ Glycoprotein IIb/ IIIa receptor inhibitors (e.g. abciximab, eptifibatide & tirofiban) are NOT recommended ¡ In patients presenting with minor stroke: Dual antiplatelet therapy (aspirin and clopidogrel) should be begun within 24 hours can be beneficial for early secondary stroke prevention for a period of up to 90 days from symptom onset (avoid ticagrelor or prasugrel) 3tM loading Jose ¡ In patients not eligible for rt-PA: Initiate aspirin (160- to 325-mg initial dose with a 50- to 100-mg maintenance dose) within 48 hours of stroke onset  Outlines § Definition of stroke/CVA § Etiology, pathophysiology and risk factors of stroke § Classification and clinical presentation of stroke § Definition and diagnosis of ischemic stroke § Complication of ischemic stroke § Management of ischemic stroke § Ischemic stroke prevention § Definition and treatment of acute hemorrhagic stroke § Outcome evaluation o Primary stroke prevention refers to treatment of individuals with no history of stroke o Secondary stroke prevention refers to the treatment of individuals who have already had a stroke or transient ischemic attack (TIA) Primary Secondary Reduction of all modifiable risk factors (control Reduction of all modifiable risk factors (control diabetes, hypertension & hyperlipidemia, smoking diabetes, hypertension & hyperlipidemia, cessation, body weight reduction) smoking cessation, body weight reduction) Antiplatelets in eligible patient Antiplatelet therapy Statin Statin (high-intensity) A Fib treatment (CHA2DS2-VASc) A Fib treatment Patient education regarding stroke warning signs Carotid endarterectomy (CEA) Carotid angioplasty with stenting (https://www.youtube.com/watch?v=I6mgmXGrn2U) ¡ Patients should be educated about stroke warning signs and instructed to seek emergency care if they have any of them. Warning signs: - Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body - Sudden confusion, dizziness, loss of balance or coordination - Trouble speaking or understanding - Sudden trouble seeing in one or both eyes - Sudden trouble walking - Sudden, severe headache with no known cause Atrial Fib treatment ¡ CHA2DS2-VASc intervention: If total score = 0 in men or 1 in women If total score ≥ 1 in men or ≥ 2 in women Give no therapy Give oral anticoagulant Atrial Fib treatment o Current guideline suggest new oral anticoagulants (NOAC) over Warfarin o HAS-BLED score to evaluate bleeding risk o For patient at high risk of bleeding: apixaban, edoxaban, or dabigatran 110 mg Warfarin Dabigatran Rivaroxiban Apixaban Edoxaban MOA Vit K antagonist Direct thrombin Direct factor Xa Direct factor Xa Direct factor inhibitor inhibitor inhibitor Xa inhibitor Dose Varied (INR= 2-3) 150 mg BID, 110 20 mg /day 5 mg BID 60 mg/day mg BID evening Atrial Fib treatment à To assess the one year risk of bleeding Modifiable risk ¡ Supportive Measures – – => hemorrhage extension and – – – Anth · ant, iggle Anticoagulrose 55 o Supportive Measures - Deep vein thrombosis prophylaxis with intermittent compression stockings should be implemented early after admission - UH or LMWH prophylactic dose can be started after bleeding stops (after 4 days) => Conce stabilized o Calcium antagonist – Nimodipine & &  - Yest Coed Potential Medication for Hemorrhagic Stroke - Recombinant Factor VIIa (rFVIIa) for Hemorrhagic Stroke Trial (FASTEST) is phase 3 trial  Treatment of Acute Hemorrhagic Stroke o Blood Pressure Management Elevated blood pressure is common in patients with acute intracerebral hemorrhage (ICH). Patients may develop elevated blood pressure due to an increase in intracranial pressure (ICP) and pain from the mass effect of the hemorrhage. Additionally, many patients with acute ICH have high blood pressure due to comorbid baseline hypertension. Uncontrolled elevations in blood pressure and blood pressure variability are risk factors for hemorrhagic expansion and poor outcome - - - For patients with acute ICH who present with SBP >220 mmHgà Lower SBP to