Stroke Meded

Pathogenesis

brain attack, infarct

• Ischemic- Embolic: thrombus somewhere else

  • coronary artery: blockage, clot, fall off

  • Dissection clot

  • Afib, bad valve (endocarditis, prosthetic)

• Ischemic- Thrombotic: thrombus in brain artery, similar to heart attack

  • atherosclerosis, HTN, diabetes, CAD, PVD)

• Hemorrhagic: blood is irritant. Brain bleed = lose brain parenchymal. Either subarachnoid or intraparenchymal

Demographics and Symptoms

1. HTN, DM, smoker, old, bad cholesterol

2. afib, prosthetic valves

3. young woman, neck pain, FND

4. thunderclap headache (worst headache of life)

Locations of Stroke

• ACA: feet leg

• MCA: arms, hands, face, speech

• PCA: vision changes, cortical blindness

• Basilar: locked in syndrome

• Vertebrobasilar: syncope

• Cerebellum: ataxia, cerebellar signs

Management

Pt walks in with FND:

• non-contrast CT: is this brain bleed

  • if bleed: hemorrhagic, drop BP, call neuro, clip/coil/craniotomy, FFP to reverse bleeding if on blood thinner

  • no blood: ischemic. Do I give tPA?

• If better in 24 hrs = TIA. Otherwise stroke

• Next day:

  • EKG: if afib, anticoagulation

  • echo: look for thrombus, anticoagulation (heparin/warfarin bridge)

  • carotid US: >80% asymptomatic or >70% symptomatic, intervene via carotid endarterectomy or stent. Surgery better than stent (wait 2 weeks). If <70%/asymptomatic, medical treatment

  • MRI: no evidence for TIA. Optional

  • CT Angiogram or MR Angiogram for more info. Optional

	Acute	Chronic
tPA	< 3 hrs (<4.5 if not DM) from symptoms onset or last seen normal (when they went to sleep), BP <180/105, no previous bleed/surgery/anticoagulation	no
Heparin	No	no
Warfarin	No	if afib, CHADS
Anti platelet	ASA 325	ASA 81. If stroke on ASA, combine ASA and dipyramidal, clopidogrel if no ASA tolerance
BP	Permissive HTN up to 220/120 for good perfusion	<140/90
DM	<140	A1C < 7
Statin	Start high potency	high potency