Term
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Definition
| abrupt development of focal neurologic deficit that occurs due to inadequate blood supply to an area of the brain; most often due to thrombotic or embolic arterial occlusion leading to cerebral infarction; |
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Term
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Definition
| result of bleeding into brain & other spaces within CNS & includes subarachnoid hemorrhage, intracerebral hemorrhage, & subdural hemorrhage; |
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Term
| Major Goal in Long-term Treatment of Ischemic Stroke |
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Definition
| prevention of a recurrent stroke through reduction and modification of risk factors |
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Term
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Definition
| diagnostic tests used to differentiate between an ischemic stroke and a hemorrhagic stroke --> MUST rule out hemorrhagic stroke in order to treat with thrombolytic (fibrinolytic) therapy |
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Term
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Definition
in carefully selected pts, effective in limiting infarct size & protecting brain tissue from ischemia & cell death by restoring blood flow;
give tx within 3 hrs & not more than 4.5 hrs after symptom onset;
earlier tx preferred due to improved outcomes; |
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Term
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Definition
| early initial dose of this drug is recommended in most pts w/ acute ischemic stroke within 48 hrs after stroke onset; |
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Term
| clopidogrel (Plavix) or ER-dipyridamole + IR aspirin (Aggrenox) |
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Definition
| preferred antiplatelet agents for secondary prevention of ischemic strokes |
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Term
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Definition
| recommended in subarachnoid hemorrhage to prevent delayed cerebral ischemia |
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Term
| Transient Ischemic Attacks (TIAs) |
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Definition
episodes of temporary reduction in perfusion causing a short-lived disturbance of function;
Pt experiences temporary focal neurological deficit (slurred speech, aphasia, monocular blindness, weakness of limb);
Onset: rapid, <5 min;
Duration: 2-15 min, can last up to 24 hrs;
No neurological deficit remains after attack |
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Term
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Definition
| permanent neurological disorder, pt presents with fixed deficits; |
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Term
| Non-Modifiable Risk Factors |
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Definition
age (>55 yrs old);
gender (males > females);
race & ethnicity (African-American, Hispanic, Asian/Pacific);
heredity;
low birth weight; |
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Term
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Definition
HTN;
Atrial fibrillation; MI;
TIAs or prior stroke;
DM; Dyslipidemia;
Cigarette smoking; Excessive EtOH intake; Physical Activity; Obesity; Diet; |
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Term
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Definition
1) Reduce secondary brain damage - re-establish & maintain adequate perfusion to ischemic areas of brain;
2) Prevention of a recurrent stroke - reduce & modify risk factors using appropriate therapy;
3) Prevent long-term complications & death; |
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Term
| General Management of Acute Ischemic Stroke |
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Definition
1) Accurate diagnosis is KEY!
2) CT scan --> rule out hemorrhagic stroke before initiating tx;
3) Assessment of Pts: level of consciousness (most are not impaired), history (documentation of stroke presentation), Clinical Presentation & Diagnosis;
4) Supportive Care (ABCs, BP, volume state, fever, hypo/hyperglycemia, VTE prophylaxis);
5) Pharmacologic Therapy: t-PA, aspirin; |
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Term
| Symptoms of Acute Ischemic Stroke |
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Definition
weakness on one side of body;
inability to speak;
loss of vision, vertigo, or falling;
complaints of HA (Severe = hemorrhagic) |
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Term
| Signs of Acute Ischemic Attack |
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Definition
multiple signs of neurological deficit (depends on area of brain involved);
hemiparesis or monoparesis;
vertigo, double vision;
aphasia;
dysarthria, visual field defects, altered levels of consciousness; |
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Term
| ABCs of Supportive Care for pts w/ Acute Ischemic Stroke |
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Definition
maintain adequate tissue oxygenation (airway support, ventilatory assistance if needed) --> maintain O2 sat >92%;
Check for possible aspiration pneumonia; |
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Term
| Blood Pressure Control during Acute Ischemic Stroke |
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Definition
many pts come in with this elevated, DO NOT lower this acutely;
- rapid lowering of this may decrease blood flow in ischemic areas potentially increasing infarct size;
For pts that have this SEVERELY ELEVATED (>220 mmHG systolic, >120 diastolic) and are NOT receiving alteplase SHOULD receive ANTIHYPERTENSIVEs to immediately lower this --> aim for 10-15% reduction;
AVOID using SL CCBs --> may lower too rapidly; |
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Term
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Definition
| correct for hypovolemia & maintain electrolytes in normal range |
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Term
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Definition
treat and look for source of elevated body temperature;
if pt is febrile, tx w/ APAP;
associated w/ brain ischemia & increased morbidity & mortality after stroke; |
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Term
| hypoglycemia/hyperglycemia |
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Definition
these conditions may WORSEN ischemic injury;
when LOW, bolus with 50% dextrose;
if ELEVATED, lower to <200 mg/dL using SC insulin; |
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Term
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Definition
required in stroke pts because they have a high risk for venous thromboembolism;
Tx w/:
- Low-dose UFH 5,000 IU SC q8-12 hrs;
- LMWH SC: enoxaparin 30 mg q12 hrs;
Early ambulation is important to prevent this from occurring;
Delay for 24 hrs in pts who are given alteplase to avoid bleeding complications; |
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Term
| recombinant Tissue Plasminogen Activator - (t-PA, Alteplase) |
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Definition
IV thrombolytic for treatment of acute stroke;
Only FDA-approved acute treatment for ischemic stroke --> early diagnosis & tx of appropriate pts;
rapid diagnosis & immediate administration increases its efficacy & may limit potential for hemorrhagic conversion of ischemic stroke;
ADRs:
- bleeding (intracerebral hemorrhage), mental status changes, severe HA, angioedema; |
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Term
| streptokinase, tenecteplase, reteplase, desmoteplase, urokinase |
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Definition
| thrombolytics that are NOT indicated for use in acute ischemic stroke |
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Term
| Intra-arterial Thrombolytics (prourokinase - r-Pro UK) |
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Definition
may improve outcomes in select pts w/ acute ischemic stroke due to large-vessel occlusion;
- no difference in mortality was found;
NOT FDA-approved, NOT available for clinical use in US;
- may be an option for pts who have C/I's to IV alteplase |
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Term
| Unfractionated Heparin (UFH) |
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Definition
current acute ischemic stroke tx guidelines DO NOT RECOMMEND routine, urgent, or full-dose anticoagulation with these drugs due to lack of a proven benefit in improving neurologic function & risk of intracranial bleeding;
- may prevent early recurrent stroke in pts w/ large-vessel atherothrombosis or those thought to be at high risk of recurrent stroke;
Major Adverse Events:
- ischemic stroke forms into hemorrhagic stroke, bleeding, thrombocytopenia; |
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Term
| Low-Molecular Weight Heparins (enoxaparin [Lovenox], dalteparin [Fragmin]) |
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Definition
| full dose drugs are NOT RECOMMENDED in tx of acute ischemic stroke |
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Term
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Definition
early therapy IS recommended in most pts w/ acute ischemic stroke within 48 hrs after stroke onset;
Initial dose: 50-325 mg PO within 48 hrs of stroke onset, reduce to 50-100 mg daily to reduce bleeding complications;
Administer 24 hrs AFTER pt receives alteplase;
Do NOT use in combo with clopidogrel (NOT RECOMMENDED) |
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Term
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Definition
| DO NOT use alone or in combo with aspirin in acute ischemic stroke; |
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Term
| Primary Prevention of Cerebrovascular Dx |
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Definition
1) aspirin;
2) statins;
3) BP management;
4) smoking cessation;
5) other risk factors: atrial fibrillation, DM, carotid stenosis, cardiac dx, obesity, physical inactivity; |
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Term
| Secondary Prevention of Cerebrovascular Dxs |
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Definition
1) Eliminate or control risk factors;
2) Patient education;
3) Medical Intervention: aspirin, ticlopidine [Ticlid], clopidogrel [Plavix], ER-dipyridamole + IR-asprin [Aggrenox], statin, anticoagulation (warfarin)
4) Surgical interventions: Carotid Endaerterectomy (CEA), Carotid Angioplasty |
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Term
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Definition
used for Primary Prevention of stroke and 2ndary Prevention of recurrent stroke;
Primary Prevention:
- reduced incidence of nonfatal MI but NOT stroke;
- slight increase of hemorrhagic stroke, bleeding risk;
- RECOMMEND use in older women at high-risk for stroke, DO NOT RECOMMEND in men;
Secondary Prevention:
- MoA: inhibits plt aggregation, decreases release of vasoactive substances from plts, IRREVERSIBLE inhibitor of platelet COX;
- clinically significant reductions in recurrent stroke risk & death;
- Doses: 50-325 mg PO daily, recommend 50-100 mg PO daily;
ADRs: GI intolerance, GI bleeding, hypersensitivity rxns |
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Term
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Definition
Used in Primary Prevention of first stroke;
Primary Prevention:
- relationship exists b/w total cholesterol & stroke risk;
- may decrease incidence of first stroke in high risk pts even if they do NOT have elevated lipids;
- benefits pts w/ hx of MI, CAD, DM, & increased lipid levels |
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Term
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Definition
Primary Prevention;
- lowering this decreases risk of both ischemic & hemorrhagic stroke by 35-44%; |
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Term
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Definition
| stroke risk declines over time after stopping this --> Primary Prevention of stroke |
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Term
| Carotid Endarterectomy (CEA) |
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Definition
surgical removal of atheromatous plaque in carotid arteries;
reserved for pts w/ ulcerated lesion or clot that occludes 70% or > of blood flow in carotid artery; |
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Term
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Definition
small deflated balloon is placed in stenosed vessel & then inflated to press plaque against vessel wall;
stent may be inserted at same time;
restricted to pts who are refractory to medical therapy & are not surgical candidates |
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Term
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Definition
MoA:
- inhibits ADP-induced plt aggregation;
- prolongs bleeding time;
- minimal effect on COX;
Efficacy:
- reduces incidence of stroke by 21% in pts who have experienced a previous TIA or stroke;
- slightly more effective than aspirin w/ less GI SEs;
- Dosing: 500 mg/day, 250 mg PO BID;
- more costly than aspirin;
ADRs:
- diarrhea, rash, increased total cholesterol, bone marrow suppression;
Monitor CBC;
Drug is generally AVOIDED clinically. |
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Term
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Definition
MoA:
- irreversible inhibitor of ADP-binding, blocking activation of plts;
- interferes w/ ADP-dependent activation of GpIIb/IIIa complex;
- inhibits ADP-induced plt aggregation;
Efficacy:
- compared to aspirin, showed relative-risk reduction of 7.3% in stroke prevention;
- Dosing: 75 mg PO daily;
- more costly than aspirin;
ADRs: less rash & diarrhea than ticlopidine, less incidence of neutropenia (NO CBC required);
Place in Therapy:
- monotherapy for stroke prevention;
- option for initial therapy & is considered 1st line in pts w/ peripheral arterial disease (PAD); |
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Term
| extended release (ER) dipyridamole + immediate release (IR) aspirin [Aggrenox] |
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Definition
MoA of D:
- weak inhibitor of platelet aggregation;
- inhibits plt phosphodiesterase;
Efficacy:
- combination to be additive with highly significant benefits (37% risk reduction);
Place in Therapy:
- option for initial therapy but NOT appropriate in pts intolerant to ASA |
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Term
| aspirin, clopidogrel, or Aggrenox (dipyridamole + ASA) |
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Definition
| current stroke guidelines recommend these as initial antiplatelet therapy for 2ndary prevention of stroke |
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Term
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Definition
anticoagulant;
MoA: Vit. K inhibition of clotting factor formation;
Use in 2ndary prevention in pts with atrial fibrillation or carotid stenosis; In pts w/o these problems, antiplatelet therapy is recommended;
INR: 2.0-3.0 |
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Term
| Dose of t-PA (Alteplase) for Acute Treatment of Ischemic Stroke |
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Definition
| 0.9 mg/kg IV (max of 90 mg) over 1 hr in selected pts w/in 3 hrs of onset; |
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Term
| Dose of aspirin in Acute Treatment of Ischemic Stroke |
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Definition
| 150-325 mg PO started within 48 hrs of onset (wait 24 hrs from start of alteplase if pt is given alteplase), may reduce to 50-100 mg daily; |
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Term
| 2ndary Prevention Dose of Aspirin |
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Definition
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Term
| 2ndary Prevention Dose of Clopidogrel |
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Definition
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Term
| 2ndary Prevention Dose of Aggrenox (dipyridamole + aspirin) |
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Definition
| 25 mg ASA + 200 mg dipyridamole BID |
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