Chapter 33: Stroke

Question 1

How is acute ischemic stroke (aka, a non-cardioembolic stroke) caused

Answer 1

By a thrombus that forms during a cerebral atherosclerotic infarction

Question 2

How does a cardioembolic stroke occur

Answer 2

when an embolus forms in the heart and travels to the brain

Question 3

A common cause of cardioembolic stroke

Answer 3

AFib

Question 4

Risk factors for stroke

Answer 4

HTN (most important)
AFib
Gender (F > M)
Ethnicity (↑risk in AA)
Age > 55 years
Atherosclerosis
Diabetes
Prior stroke or TIA
Smoking
Dyslipidemia
Patent Foramen Ovale (PFO)
Sickle Cell Disease

Question 5

What is a TIA

Answer 5

caused by a temporary clot, or block of blood flow, in the brain. Symptoms are the same as stroke, but disappear on their own within minutes to a few hrs; there is NO permanent damage
-Seek immediate medical attention: TIAs are often a warning for a future full stroke

Question 6

Signs and symptoms of stroke

Answer 6

• remember: act F.A.S.T*
• Face: ask the person to smile. Does one side of the face droop or is it numb? Is the smile uneven?
• Arms: ask the person to raise both arms. Does one arm drift downward?
• Speech: ask the person to repeat a simple sentence. Are the words slurred? Is the sentence repeated correctly?
• Time: if the person shows any of these sx, even if they go away, call 911 immediately

Question 7

What is performed in stroke patients within 20 min of arrival to ED

Answer 7

Brain imaging, using CT

Question 8

Immediate goal for ischemic stroke

Answer 8

Restore blood flow to the ischemic area of the brain to obtain complete neurological recovery

Question 9

MOA of alteplase

Answer 9

recombinant tissue plasminogen activator (tPA) that binds to fibrin in a thrombus and converts plasminogen to plasmin, resulting in fibrinolysis

Question 10

What is the ONLY fibrinolytic drug that is used in acute ischemic stroke

Answer 10

Alteplase

Question 11

Patients are candidates for alteplase if a clot is confirmed on brain imaging and the following criteria for timing are met:

Answer 11

• Can be administered within 3 hours of symptom onset
• It can be administered within 4.5 hours of symptom onset in select patients (not FDA-approved)
• It can be administered within 60 min of hospital arrival (door-to-needle time)

Question 12

Alteplase CI

Answer 12

• Active bleed (e.g., internal bleed, ICH)
• Conditions or labs that increase risk of bleed (e.g., severe HTN, INR > 1.7)
• Drug interactions with bleeding risk (e.g., anticoagulants)
• Severe, uncontrolled HTN (BP > 185/110 mmHg)
• History of recent stroke

Question 13

Alteplase brand name

Answer 13

Activase

Question 14

Max dose of alteplase in ischemic stroke

Answer 14

90 mg

Question 15

What must be excluded before using alteplase

Answer 15

intracranial hemorrhage

Question 16

Alteplase SE

Answer 16

Major bleeding (e.g., ICH)

Question 17

ASA __-__ mg PO within __-__ hrs after stroke onset is recommended to prevent early recurrent stroke

Answer 17

162 – 325

24-48

Question 18

Which antihypertensive drug classes have the best evidence for stroke risk reduction

Answer 18

ACEi and thiazide diuretics

Question 19

What is the goal BP for ischemic stroke

Answer 19

< 130/80 mmHg

Question 20

What statin intensity should be used in secondary prevention of stroke

Answer 20

High-intensity

Question 21

For patients with non-cardioembolic ischemic stroke or TIA, what drug is recommended to reduce the risk of recurrent stroke

Answer 21

ASA (or clopidogrel if ASA is CI)

Question 22

Combo of ASA and clopidogrel can be initiated within 24 hrs of a minor ischemic stroke & continued for 21 days. This combination should not be used long-term for secondary prevention of stroke or TIA as it increases the risk of ____

Answer 22

hemorrhage (NOTE: this is different for ACS - in ACS, DAPT is used for 12 months & can be continued if the pt is tolerating and are not high risk for bleeding following stent placement)

Question 23

T/F: In patients who have an ischemic stroke or TIA while taking ASA, there is an added benefit to increase the ASA dose

Answer 23

False - there is no added benefit

Question 24

What is the MOA of dipyridamole

Answer 24

inhibits the uptake of adenosine into platelets and increases cAMP levels, which inhibits platelet aggregation

Question 25

Aspirin dosing in stroke

Answer 25

50-325 mg daily

Question 26

Aspirin ER capsule brand name

Answer 26

Durlaza

Question 27

Aspirin DR tablet brand name

Answer 27

Yosprala

Question 28

ER dipyridamole/aspirin brand name

Answer 28

Aggrenox

Question 29

ER dipyridamole/aspirin warnings

Answer 29

hypotension

Question 30

ER dipyridamole/aspirin SE

Answer 30

headache

Question 31

Clopidogrel dosing in stroke

Answer 31

75 mg daily

Question 32

Clopidogrel should be stopped __ days prior to elective surgery

Answer 32

5

Question 33

Clopidogrel should be avoided with which 2 drugs

Answer 33

omeprazole and esomeprazole

Question 34

What should be done in patients with intracranial hemorrhage who are anticoagulated

Answer 34

reversal of the anticoagulant should be considered

Question 35

What should be done in ICH if there is clinical evidence of seizures

Answer 35

They should be treated but ppx anticonvulsant meds should not be used

Question 36

How is ICH treated

Answer 36

elevate the head by 30 degrees and use mannitol or hypertonic saline

Question 37

MOA of mannitol

Answer 37

Produces osmotic diuresis. Reduces ICP by withdrawing water from the brain

Question 38

Mannitol formulation

Answer 38

injection

Question 39

Mannitol CI

Answer 39

severe renal disease

Question 40

How does acute subarachnoid hemorrhage present

Answer 40

Severe headache

Question 41

Cerebral artery vasospasm can occur __=__ days after the bleed in SAH, causing delayed cerebral ischemia

Answer 41

3-21

Question 42

Which drug & route is used to prevent vasospasm in SAH

Answer 42

oral nimodipine

Question 43

Nimodipine MOA

Answer 43

DHP CCB that is more selective for cerebral arteries d/t increased lipophilicity

Question 44

Nimodipine BW

Answer 44

Do not administer IV or by any other parenteral routes; death and serious life-threatening AE have occurred when contents of the capsules have been injected parenterally

Question 45

Nimodipine SE

Answer 45

Hypotension

Question 46

If nimodipine capsules cannot be swallowed, what can be done

Answer 46

contents can be withdrawn with a parenteral syringe, then transferred to an oral syringe that cannot accept a needle; label oral syringes “For Oral Use Only” or “Not for IV Use”