NEUROLOGY-STROKE AND CVD LEARNING OBJECTIVES
1) To Learn the Cause, DX, and Management of the following
a. Subarachnoid He...
Carotid Doppler and
TCD (MRA neck, and
angiogram)
Risk factor assessment
TIA Reversible, Focal
Dysfunction.
Usually lasts ...
Atria Fibrillation: Heparin, Coumadin, Heparinoids
High Cholesterol and CAD- Lifestyle Modification and certain drugs (sta...
 Should be used in SYMPTOMATIC, SEVERE carotid stenosis
 In interventional studies it is important to look at the number...
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Stroke.doc.doc.doc

  1. 1. NEUROLOGY-STROKE AND CVD LEARNING OBJECTIVES 1) To Learn the Cause, DX, and Management of the following a. Subarachnoid Hemorrhage b. Cerebral Hemorrhage c. Cerebral Infarction d. TIA What Cause/Etiology Diagnosis Management Subarachnoid Hemorrhage Extravasations of blood within the leptomeninges Monitored bed setting (look for paroxysmal a.fib.) Brain imaging (CT, MRI/MRA  identifies stroke subtype) Echocardiogram (TTE, TEE) Carotid Doppler and TCD (MRA neck, and angiogram) Risk factor assessment 1st Stabilizing Patient Finding the source of the bleed Reducing ICP Cerebral Hemorrhage Extravasations of blood within the brain. 80% of the cases and most occur in Basal Ganglia Monitored bed setting (look for paroxysmal a.fib.) Brain imaging (CT, MRI/MRA  identifies stroke subtype) Echocardiogram (TTE, TEE) Carotid Doppler and TCD (MRA neck, and angiogram) Risk factor assessment 1st Stabilizing Patient Finding the source of the bleed Reducing ICP Cerebral Infarction a) Thrombosis- Atherosclerotic in Nature b) Emboli- Cardiac Origin Monitored bed setting (look for paroxysmal a.fib.) Brain imaging (CT, MRI/MRA  identifies stroke subtype) Echocardiogram (TTE, TEE) See below
  2. 2. Carotid Doppler and TCD (MRA neck, and angiogram) Risk factor assessment TIA Reversible, Focal Dysfunction. Usually lasts minutes Reverses in 24 hours Stroke warning signs: TIA TIA is a focal deficit in the vascular territory of the brain. It has the clinical characteristics of an ischemic event, but resolves within 24 hours Monitored bed setting (look for paroxysmal a.fib.) Brain imaging (CT, MRI/MRA  identifies stroke subtype) Echocardiogram (TTE, TEE) Carotid Doppler and TCD (MRA neck, and angiogram) Risk factor assessment See below 2) To Learn the Methods of Stroke Prevention for Patients Who: a. Have Never Had A Stroke b. Have Already Had a Stroke As a Whole Stroke Risk Factors are as follows: -Age - HTN and DM - Atria Fibrillation - High Cholesterol - Smoking - Coronary Artery Disease Therefore, if A person has never had a stroke, but has one of the following risk factors present, it is appropriate to target and modify these. These can also apply to someone who has had a stroke Age- Really cannot modify that? =-) Smoking: Try to get the person to quit HTN- • Lifestyle Modification- Diet and Exercise • Uncomplicated HTN- Diuretics and/or Thiazides • Complicated HTN- ACE-inhibitors, ARBs, in combination with above Diabetes Mellitus • Lifestyle Modification- Diet and Exercise. Build Muscle Mass and Lose Fat • Oral Medications- Glyberide • If not able to control with lifestyle modifications and oral medications, then it might be time to place patient on Insulin
  3. 3. Atria Fibrillation: Heparin, Coumadin, Heparinoids High Cholesterol and CAD- Lifestyle Modification and certain drugs (statins, resins, etc) Methods of Stoke Prevention in someone who has already had a stroke: Treating to Prevent Treatment Modalities o There is no proven right or wrong answer on how to treat stroke patients. o Anti-platelet drugs (aspirin, ticlid, plavix, aggrenox)  Ticlid is slightly more effective than aspirin in preventing strokes. But, the cost is higher and side effects are worse and include leukopenia and diarrhea.  Plavix is slightly better than ASA for all events and stroke and has minimal side effects  Aggrenox (ASA+dipyrimadole) is slightly more effective than ASA but has GI side effects and headaches o Anticoagulants (heparin, coumadin, heparinoids)  Heparin keeps clots from propagating and breaking off but does not dissolve the clot or make the platelets “unsticky”. • It is used especially with chronic atrial fibrillation because of increased risk of stroke. Heparin therapy is monitored using PTT levels. • Risk of hemorrhage, HIT, or “white clot syndrome”- clot is treated with heparin and causes hemorrhagic stroke • Give heparin with small emboli and high risk. Do not give to patients with large emboli.  Coumadin should be used if the embolus is large. Wait 7-10 days and repeat the CT. IF there is no blood, give patient coumadin. • Coumadin has proven efficacy for atrial fibrillation, but there is a small risk of brain hemorrhage. • Patients are split into 7 groups based on their age, risk, and history. Coumadin is used in patients in groups 4-7 (older than 60 and with risk factors including diabetes, CAD, thyrotoxicosis, low left ventricular ejection fraction, diabetes, prior thromboembolus, or prosthetic heart valve)  Heparinoids used as an alternative to heparin, but there is not much data on the use of these drugs o Thrombolysins (t-PA, urokinase, streptokinase)- only t-PA is FDA approved  T-pa must be used within 3 hours of onset of the symptoms  Must check for bleeding using a CT, and do not use a thrombolytic if evidence of bleeding is found  Everyone must act very quickly and efficiently in treating stroke patients to maximize positive results  Inclusion criteria – 1) in most cases, should be 18 y.o. or older, 2) must have had an acute ischemic stroke with a defined focal deficit, 3)stroke must have occurred within the last 3 hrs., 4) measureable neuro deficit must exist , 5)CT must show no evidence of intracranial hemorrhage  Exclusion criteria – 1)stroke or head trauma in last 3 months, 2)major surgery in the last 14 days, 3)hx of ICH, 4)BP >185/110, 5)GI bleed or urinary tract hemorrhage within 21 days prior, 6)arterial puncture at a non-compressible site within 7 days (this does not include cardiac cath) 7)use of heparin within 48 hours and elevated ptt, 8)others o Surgery: Carotid endartarectomy
  4. 4.  Should be used in SYMPTOMATIC, SEVERE carotid stenosis  In interventional studies it is important to look at the number needed to treat. In this case, doing surgery on 4-5 people protects 1 patient with severe symptomatic carotid stenosis  If the patient is symptomatic with moderate carotid stenosis, it is up to the patients/physicians discretion whether the procedure should be done  In < 50% stenosis or if the patient is asymptomatic, there is NO BENEFIT to doing a carotid endarterectomy  So, do this procedure if the patient is symptomatic, has major stenosis, and the surgeon is good o Interventional angiography  Basilar artery clots have much better prognoses when intra-arterial t-PA is given  Angioplasty and stenting are other options

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