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Stroke Cheat Sheet (DRAFT) by

stroke stroke stroke

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Stroke Overview

A stroke, or cerebr­ova­scular accident (CVA), occurs when blood flow to an area of the brain is interr­upted.
There are two main types of stroke: ischemic stroke, which is caused by a blockage in a blood vessel in the brain, and hemorr­hagic stroke, which is caused by bleeding in the brain or surrou­nding area.
Strokes can cause long-l­asting disability or even death; however, early treatment and preventive measures can reduce the brain damage that occurs because of stroke.
In both ischemic and hemorr­hagic stroke, one or more areas of the brain can be damaged.
Depending upon the area affected, a person may lose the ability to move one side of the body, the ability to speak, or a number of other functions.
The damage from a stroke may be temporary or permanent.
A person's long-term outcome depends upon how much of the brain is damaged, how quickly treatment begins, and several other factors.

Types of Stroke

Ischemic stroke
Ischemic strokes are caused by a blockage (clog) in one of the blood vessels that supply oxygen and other important nutrients to the brain.
 
There are two main subtypes of ischemic stroke, thrombotic and embolic.
 
 
Thrombotic stroke
A thrombotic stroke results from a problem within an artery (blood vessel) that supplies blood to the brain.
   
This is most likely to occur in arteries that are clogged with fatty deposits, called plaques.
   
Plaques partially block the artery, and can rupture and bleed, forming a blood clot.
   
This blood clot ("th­rom­bus­") can further clog or completely block the artery, which then slows or prevents blood flow to the area of brain fed by that artery.
   
Blood clotting disorders can also cause clots to form within arteries in some people.
 
Embolic stroke
An embolic stroke occurs when a blood clot or other particle breaks loose from another part of the body, often the heart or a large artery in the neck, and travels through the bloods­tream to the brain where it lodges in a smaller blood vessel.
   
The blood clot or particle, called an "­emb­olu­s," then blocks blood flow to that area of the brain, reducing the amount of oxygen and nutrients that reach that area.
   
One of the most common causes of embolic strokes is an irregular heart rhythm called "­atrial fibril­lat­ion."
   
Emboli can also originate in the aorta and in the arteries within the neck and head and travel further along within arteries within the brain.
 
Transient ischemic attack (TIA)
Transient ischemic attacks are episodes in which a person has signs or symptoms of a stroke (eg, weakness; inability to speak) that last for a short time, but without any sign of stroke on brain scans such as MRI or CT.
   
Symptoms of a TIA usually last between a few minutes and a few hours.
   
A person may have one or many TIAs.
   
People recover completely from the symptoms of a TIA.
 
Hemorr­hagic stroke
Hemorr­hagic strokes occur when blood vessels in the brain leak or rupture (break), causing bleeding in or around the brain.
 
There are two main subtypes of hemorr­hagic stroke, intrac­erebral and subara­chnoid.
 
 
Intrac­erebral hemorrhage
In an intrac­erebral hemorrhage (ICH), bleeding occurs within the brain.
   
This damages the brain as blood collects and puts pressure on the surrou­nding tissue.
   
Causes of ICH:
   
• High blood pressure
   
• Injury
   
• Bleeding disorders
   
• Deform­ities in blood vessels, such as an aneurysm (a weakening in the lining of the blood vessel)
 
Subara­chnoid hemorrhage
Subara­chnoid hemorrhage occurs when a blood vessel on the surface of the brain ruptures.
   
The blood builds up and causes pressure in the "­sub­ara­chn­oid­" space, which is between two layers of the tissue covering the brain.
   
The most common early symptom of a subara­chnoid hemorrhage is a severe headache called "­thu­nde­rclap headac­he,­" which many patients describe as the worst headache of their life.

Stroke Risk Factors

Ischemic stroke risk factors
Hypert­ension
Diabetes
Atrial fibril­lation
Prior stroke or TIA
Sex (females > males)
Physical inactivity
Ethnicity (highest risk in African Americans)
Smoking
Age > 55 years
Dyslip­idemia
Athero­scl­erosis
Patent foramen ovale (PFO)
Sickle cell disease
Illegal drug use
Obesity
 
Hemorr­hagic stroke risk factors
High blood pressure
Use of warfarin or other blood thinning medicines
Smoking
Illegal drug use (espec­ially cocaine and "­crystal meth"

Stroke Symptoms

Signs and symptoms of stroke often develop suddenly and then may tempor­arily improve or slowly worsen, depending upon the type of stroke and area of the brain affected.
 
Classic symptoms
Classic stroke symptoms can be recalled with the acronym FAST
F
Face
Sudden weakness or droopiness of the face, or problems with vision
Ask the person to smile. Does one side droop?
A
Arm
Sudden weakness or numbness of one or both arms
Ask the person to raise both arms. it through lifestyle changes and medicine are critical to reducing stroke risks. There are several steps you can take to reduce your risk for stroke: Does one arm drift downward?
S
Speech
Difficulty speaking, slurred speech, or garbled speech
Ask the person to repeat a simple sentence. Are the words slurred?
T
Time
Time is very important in stroke treatment. The sooner treatment begins, the better the chances are for recovery.
If the person shows any of these signs, call 9-1-1 immedi­ately. Stroke treatment can begin in the ambulance.
 
Other common signs of stroke
Sudden dizziness, trouble walking, or loss of balance or coordi­nation
Sudden trouble seeing in one or both eyes
Sudden severe headache with no known cause
Sudden numbness of the face, arm, or leg
Sudden confusion or trouble unders­tanding others

Stroke Diagnosis

Brain and blood vessel imaging
After doing a quick physical exam, the doctor or nurse usually sends the patient right away for an imaging test of the brain (eg, CT scan or MRI scan) and an imaging test of the blood vessels in the neck and head (eg, CT angiog­raphy or MR angiog­raphy) that supply the brain with blood.
 
The imaging allows the doctor or nurse to see the area of the brain affected by the stroke, as well as to confirm the type of stroke (ischemic or hemorr­hagic).
 
Occasi­onally, a catheter must be inserted through a blood vessel in the groin and threaded up to the blood vessels of the neck, where dye is injected to highlight any areas of blockage.
 
Heart testing
An electr­oca­rdi­ogram (ECG) is performed in most people who are thought to be having a stroke.
 
Because many people with ischemic strokes also have coronary artery disease, there may be a lack of blood flow (called "­isc­hem­ia") in the heart during the stroke.
 
Other heart testing may also be recomm­ended, such as an echoca­rdi­ogram.
 
This test uses sound waves to examine the heart and the aorta (the main artery that supplies the whole body).
 
In some people with embolic strokes, the heart or the aorta is the source of the blood clot that led to the stroke.

Treatment

Ensure adequate respir­atory and cardiac support and determine quickly from CT scan whether the lesion is ischemic or hemorr­hagic.
Evaluate ischemic stroke patients presenting within hours of symptom onset for reperf­usion therapy.
Elevated blood pressure (BP) should remain untreated in the acute period (first 7 days) after ischemic stroke to avoid decreasing cerebral blood flow and worsening symptoms.
BP should be lowered if it exceeds 220/120 mm Hg or there is evidence of aortic dissec­tion, acute myocardial infarction (MI), pulmonary edema, or hypert­ensive enceph­alo­pathy.
If BP is treated in the acute phase, short-­acting parenteral agents (eg, labetalol, nicard­ipine, nitrop­rus­side) are preferred.
Assess patients with hemorr­hagic stroke to determine whether they are candidates for surgical interv­ention.
After the hyperacute phase, focus on preventing progre­ssive deficits, minimizing compli­cat­ions, and instit­uting secondary prevention strate­gies.

Nonpha­rma­cologic Therapy

Acute ischemic stroke
Surgical decomp­ression is sometimes necessary to reduce intrac­ranial pressure.
 
An interp­rof­ess­ional team approach that includes early rehabi­lit­ation can reduce long-term disabi­lity.
 
In secondary preven­tion, carotid endart­ere­ctomy and stenting may be effective in reducing stroke incidence and recurrence in approp­riate patients.
 
Hemorr­hagic stroke
In SAH, surgical interv­ention to clip or ablate the vascular abnorm­ality reduces mortality from reblee­ding.
 
After primary intrac­erebral hemorr­hage, surgical evacuation may be beneficial in some situat­ions.
 
Insertion of an external ventri­cular drain with monitoring of intrac­ranial pressure is commonly performed in these patients.

Pharma­cologic Therapy of Ischemic Stroke

Alteplase
(t-PA, tissue plasmi­nogen activator) initiated within 4.5 hours of symptom onset reduces disability from ischemic stroke.
 
Adherence to a strict protocol is essential to achieving positive outcomes:
 
(1) activate the stroke team;
 
(2) treat as early as possible within 4.5 hours of onset;
 
(3) obtain CT scan to rule out hemorr­hage;
 
(4) meet all inclusion and no exclusion criteria;
 
(5) administer alteplase 0.9 mg/kg (maximum 90 mg) infused IV over 1 hour, with 10% given as initial bolus over 1 minute;
 
(6) avoid antico­agulant and antipl­atelet therapy for 24 hours;
 
(7) monitor the patient closely for elevated BP, response, and hemorr­hage.
Aspirin
160 to 325 mg/day started between 24 and 48 hours after completion of alteplase also reduces long-term death and disabi­lity.

Drugs Used For Ischemic Stroke

Drug
Alteplase (Activase) Injection
 
Cathflo Activase (singl­e-use 2 mg vial) used to restore function of potent­ially clotted central lines and devices
Dosing
0.9 mg/kg (maximum dose 90 mg); give 10% of the dose as a bolus over 1 minute then infuse the remainder over 60 minutes
 
Must rule out an intrac­ranial hemorrhage before use
Contra­ind­ica­tions
Active internal bleeding or bleeding diathesis (predi­spo­sition)
 
History of recent stroke (within the past 3 months)
 
Severe uncont­rolled hypert­ension (BP > 185/110 mmHg)
 
Any prior intrac­ranial hemorrhage (ICH)
 
Other conditions that increase bleeding risk: recent intrac­ranial or intras­pinal surgery, trauma (within the past 3 months), intrac­ranial neoplasm, arteri­ovenous malfor­mation or aneurysm
 
Labs that increase bleeding risk: INR > 1.7, aPTT > 40 seconds, platelet count < 100,000/mm3
 
Treatment dose of LMWH (within the previous 24 hours), use of a direct thrombin inhibitor or direct factor Xa inhibitor (within the previous 48 hours)
 
Blood glucose < 50 mg/dL
Side Effects
Major bleeding (i.e., ICH)
Monitoring
Hgb, Hct, s/sx of bleeding
 
Neurol­ogical assess­ments and BP
 
Head CT 24 hrs after treatment, before starting antico­agu­lants or antipl­atelet drugs
Notes
Contra­ind­ica­tions and dosing differ when used for ACS and pulmonary embolism, due to a higher risk of hemorr­hagic conversion (i.e., brain bleed) in stroke
 
If severe headache, acute hypert­ension, nausea, vomiting or worsening neurol­ogical function occurs, discon­tinue the infusion and obtain an emergent head CT
 
The abbrev­iation "­tPa­" is prone to errors; not recomm­ended by ISMP, but used commonly

Secondary Prevention of Ischemic Stroke

Antipl­atelets
Use antipl­atelet therapy in noncar­dio­embolic stroke.
 
Aspirin, clopid­ogrel, and extend­ed-­release dipyri­damole plus aspirin are all first-line agents
 
Cilostazol is also a first-line agent, but its use has been limited by lack of data.
 
Limit the combin­ation of clopid­ogrel and ASA to select patients with a recent MI history or intrac­ranial stenosis and only with ultra–­low­-dose ASA to minimize bleeding risk.
Antico­agu­lants
Oral antico­agu­lation is recomm­ended for atrial fibril­lation and a presumed cardiac source of embolism.
 
A vitamin K antagonist (warfarin) is first line, but other oral antico­agu­lants (eg, dabiga­tran) may be recomm­ended for some patients.
Antihy­per­ten­sives
Treatment of elevated BP after ischemic stroke reduces risk of stroke recurr­ence.
 
Treatment guidelines recommend BP reduction in patients with stroke or TIA after the acute period (first 7 days).
Statins
Reduce risk of stroke by approx­imately 30% in patients with coronary artery disease and elevated plasma lipids.
 
Treat ischemic stroke patients, regardless of baseline choles­terol, with high-i­nte­nsity statin therapy to achieve a reduction of at least 50% in LDL for secondary stroke preven­tion.
Low-mo­lec­ula­r-w­eight heparin or low-dose subcut­aneous unfrac­tio­nated heparin
(5000 units three times daily) is recomm­ended for prevention of deep vein thrombosis in hospit­alized patients with decreased mobility due to stroke and should be used in all but the most minor strokes.

Antipl­atelet Drugs

Drug
Aspirin (Bayer, Buffferin, Ecotrin, Ascriptin, Durlaza, others)
 
+ omeprazole (Yosprala)
 
OTC: tablet, chewable tablet, enteric coated tablet, suppos­itory
 
Rx: ER capsule (Durlaza), delaye­d-r­elease tablet (Yosprala)
Dosing
50-325 mg daily
 
Yosprala: 81 mg/40mg or 325 mg/40 mg daily
 
Do not crush enteri­c-c­oated, delaye­d-r­elease or ER products
Contra­ind­ica­tions
NSAID or salicylate allergy; children and teenagers with viral infection due to risk of Reye's syndrome (symptoms include somnol­ence, N/V, confus­ion); rhinitis, nasal polyps or asthma (due to risk of urticaria, angioedema or bronch­ospasm)
Warnings
Bleeding [including GI bleed/­ulc­era­tion, increase risk with heavy alcohol use or other drugs with bleeding risk (i.e., NSAIDs, antico­agu­lants, other antipl­ate­lets)], tinnitus (salic­ylate overdose)
Side Effects
Dyspepsia, heartburn, bleeding, nausea
Monitoring
Symptoms of bleeding, bruising
Notes
To decrease nausea, use EC or buffered product or take with food
 
PPIs may be used to protect the gut with chronic NSAID use; consider the risks from chronic PPI use (decrease bone density, increase infection risk)
 
Yosprala is indicated for those at risk of developing aspiri­n-a­sso­ciated gastric ulcers
 
Drug
Extend­ed-­release dipyri­dam­ole­/as­pirin (Aggrenox)
 
Capsule
Dosing
200 mg/25 mg BID
 
If intole­rable headache: 200 mg/25 mg QHS (+ low-dose aspirin daily in the morning), then resume BID dosing within 1 week
Contra­ind­ica­tions
As above for aspirin component plus:
Warnings
Hypote­nsion and chest pain (in patients with coronary artery disease) can occur due to the vasodi­latory effects of dipyri­damole
Side Effects
Headache
Notes
Not interc­han­geable with the individual components of aspirin and dipyri­damole
 
Amount of aspirin provided is not adequate for prevention of cardiac events (i.e., MI)
 
Drug
Clopid­rogel (Plavix)
 
Tablet
 
Indicated for ACS, recent MI, stroke and PAD
Dosing
75 mg daily
Boxed Warnings
Clopid­ogrel is a prodrug. Effect­iveness depends on the conversion to an active metabolite, mainly by CYP450 2C19. Poor metabo­lizers of CYP2C19 exhibit higher cardio­vas­cular events than patients with normal CYP2C19 function. Tests to check CYP2C19 genotype can be used as an aid in determ­ining a therap­eutic strategy. Consider altern­ative treatments in patients identified as CYP2C19 poor metabo­lizers.
Contra­ind­ica­tions
Active serious bleeding (i.e., GI bleed, intrac­ranial hemorr­hage)
Warnings
Bleeding risk: stop 5 days prior to elective surgery, do not use with omeprazole or esomep­razole, premature discon­tin­uation (increase risk of thromb­osis), thrombotic thromb­ocy­topenic purpura (TTP)
Side Effects
Generally well tolerated, unless bleeding occurs
Monitoring
Symptoms of bleeding, Hgb/Hct as necessary
Notes
Drug of choice in stroke/TIA if a contra­ind­ication or allergy to aspirin; do not use ini combin­ation with aspirin long-term for stroke prevention

Treatment of Modifiable Risk Factors

Hypert­ension
Blood pressure lowering treatment is often initiated after the first several days following a stroke.
 
Thiazide diuretics, ACE inhibitors and ARBs have the best evidence for stroke risk reduction.
 
A goal BP < 130/80 mmHg is recomm­ended for most patients.
 
Lifestyle modifi­cations are an important part of hypert­ension manage­ment.
Dyslip­idemia
Treat with a high-i­nte­nsity statin, with atorva­statin 80 mg/day being preferred.
 
In patients at higher risk, consider adding ezetimibe or a PCSK9 inhibitor to achieve an LDL < 70 mg/dL.
Diabetes
Patients with no establ­ished history should be screened for diabetesin the post-s­troke period; an A1C is the preferred test.
 
Treat diabetes according to the most recent ADA guidel­ines.
Atrial Fibril­lation
Cardio­embolic stroke due to atrial fibril­lation requires antico­agu­lation to prevent future strokes.
Lifestyle Modifi­cations
Patients should be screened for obesity and counseled on lifestyle modifi­cations for hypert­ension and cardio­vas­cular risk reduction (i.e., smoking cessation, diet, exercise, weight loss).
 
Nutrition
Sodium restri­ction to < 2.4 grams/day, or < 1.5 grams/day for greater blood pressure reduction and a Medite­rra­nea­n-type diet (empha­sizing vegeta­bles, fruits, whole grains, fish, poultry, legumes, nuts and olive oil) is recomm­ended.
 
Physical activity
If capable, patients should engage in modera­te-­int­ensity exercise (at least 10 minutes four days per week) and avoid long periods of sitting.
 
Weight reduction
Maintain a BMI 18.5 - 24.9 kg/m2 and a waist circum­ference < 35 inches for women and < 40 inches for men.
 
Alcohol intake
Limit to < 2 drinks/day for males and < 1 drink/day for females.

Pharma­cologic Therapy of Hemorr­hagic Stroke

There are no standard pharma­cologic strategies for treating intrac­erebral hemorr­hage.
Follow medical guidelines for managing BP, increased intrac­ranial pressure, and other medical compli­cations in acutely ill patients in neuroi­nte­nsive care units.
SAH due to aneurysm rupture is often associated with delayed cerebral ischemia in the 2 weeks after the bleeding episode.
Vasospasm of the cerebral vascul­ature is thought to be respon­sible for the delayed ischemia and occurs between 3 and 21 days after the bleed.
The calcium channel blocker nimodipine 60 mg every 4 hours for 21 days, along with mainte­nance of intrav­ascular volume with pressor therapy, is recomm­ended to reduce the incidence and severity of neurologic deficits resulting from delayed ischemia.

Drugs Used For Hemorr­hagic Stroke

Drug
Mannitol (Osmitrol, Resectisol)
 
Injection
Dosing
5%, 10%, 15%, 20%, 25%
 
Mannitol 20%: 0.25-1 g/kg/dose IV Q6-8H PRN
Contra­ind­ica­tions
Severe renal disease (anuria), severe hypovo­lemia, pulmonary edema or conges­tion, active intrac­ranial bleed (except during cranio­tomy)
Warnings
CNS toxicity (can accumulate in the brain, causing rebound increases in ICP, if used for long periods of time as a continuous infusion; interm­ittent boluses prefer­red), extrav­asation (vesic­ant), nephro­tox­icity, fluid and electr­olyte imbalances (i.e., dehydr­ation, hypero­smo­lar­-in­duced hyperk­alemia, acidosis, increase osmolar gap)
Side Effects
Dehydr­ation, headache, lethargy, increase or decrease BP
Monitoring
Renal function, daily fluid intake and output, serum electr­olytes, serum and urine osmola­lity, ICP, CPP
Notes
Maintain serum omlolality < 300-320 mOsm/kg
 
Inspect for crystals before admini­ste­ring; if crystals are present, warm the solution to redissolve
 
Use a filter for admini­str­ation
 
Drug
Nimodipine (Nymalize)
 
Capsule, oral solution
Dosing
60 mg PO Q4H for 21 days
 
Start within 96 hours of SAH onset
 
Swallow capsules whole; administer on an empty stomach, at least 1 hour before or 2 hours after meals
 
Cirrhosis: 30 mg PO Q4H for 21 days (closely monitor)
Boxed Warnings
Do not administer nimodipine IV or by other parenteral routes; death and serious life-t­hre­atening adverse events have occurred (including cardiac arrest, cardio­vas­cular collapse, hypote­nsion and bradyc­ardia) when the contents of nimodipine capsules have been inadve­rtently injected parent­erally
Contra­ind­ica­tions
Increase risk of signif­icant hypote­nsion when used in combin­ation with strong inhibitors of CYP3A4
Side Effects
Hypote­nsion
Monitoring
CPP, ICP, BP, HR, neurol­ogical checks
Notes
If capsules cannot be swallowed, contents may be withdrawn with a parenteral syringe, then transf­erred to an oral syringe that cannot accept a needle and that can only administer medication orally or via nasoga­stric tube; **label oral syringes "For Oral Use Only" or "Not for IV Use"; the medication should be drawn up in the pharmacy to reduce medication errors