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NAPLEX 2024 > 33. Stroke > Flashcards

33. Stroke Flashcards

1
Q

Acute ischemic stroke can be caused by ___ or ____

A

thrombus (i.e. localized clot) that forms during a cerebral atherosclerotic infarction (similar to MI but in the brain); referred to as non-cardioembolic stroke (origin is in brain, not heart)
Embolus (i.e. a clot) that forms in the heart and travels to the brain. Referred to as cardioembolic stroke, common cause is Afib

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2
Q

A common cause of cardioembolic stroke is ___

A

Afib

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3
Q

What are the 2 types of strokes

A

Acute ischemic stroke (caused by thrombus or embolus)
Hemorrhagic stroke (bleeding in brain, often intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH)

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4
Q

____ is sometimes called a “mini-stroke”
It is caused by a temporary clot and blockage of blood flow in the brain, resolves within minutes to a few hrs with no permanent damage (often a warning sign for acute ischemic stroke and should be medically managed with the same risk reduction strategies)

A

Transient ichemic attack 9TIA)

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5
Q

What type of stroke is more common: ischemic or hemorrhagic?

A

Ischemic

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6
Q

Stroke risk factors

A

Modifiable:
HTN - most important
Afib
Dyslipidemia
DM
Physical inactivity
smoking

Non-modifiable risk factors:
Prior stroke or TIA
Advanced age (e.g. ≥80yo)
Race (higher risk in African American pts)
Genetic diseases (e.g. sickle cell)

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7
Q

S/sx of stroke (ACT F.A.S.T)

A

Face drooping
Arm weakness
Speech difficulty
Time to call 911 (immediately)

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8
Q

Brain imaging using ___ is ideally performed within 20 min of arrival to the ED to quickly identify whether stroke symptoms are d/t hemorrhage

A

computed tomography (CT) scan

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9
Q

In addition to cardiac and respiratory support, the immediate goal of treatment of ischemic stroke is to _____

A

restore blood flow to the ischemic area of the brain to obtain complete neurologic recovery

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10
Q

Restoring blood flow may require mechanical removal (e.g. with stent retrievers) or the clot can be dissolved with IV ____ if the pt arrives at the hospital in a timely manner after ischemic stroke symptom onset

A

fibrinolytic therapy

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11
Q

MOA alteplase

A

recombinant tissue plasminogen activator (tPA or rtPA)
Binds to fibrin in a clot and converts plasminogen to plasmin&raquo_space; fibrinolysis

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12
Q

___ is the ONLY fibrinolytic drug FDA-approved to treat acute ischemic stroke

A

Alteplase

Note: Tenectplase, another fibrinolytic is occasionally used off-label

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13
Q

Pts are candidates for alteplase if no bleeding seen on CT scan, stroke symptom onset is ≤ _____, and alteplase can be administered within ___ of hospital arrival (door-to-needle time) + no contraindications

A

Symptom onset ≤ 4.5 hrs
Can be administered within 60min of hospital arrival

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14
Q

Contraindications to alteplase

A

Active internal bleed (e.g. ICH)
Risk of internal bleed d/t:
- severe HTN (BP >185/110) - lower with IV meds (e.g. labetalol, nicardipine) before proceeding with alteplase admin
- Other conditions (e.g. head trauma, hx of recent stroke (within 3 months))
- Labs (e.g. INR >1.7, platelet count <100,000, BG<50)
- DDIs (e.g. anticoag use - LMWH within previous 24 hrs, DOAC within 48hrs, warfarin with INR > 1.7)

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15
Q

Alteplase (Activase) dosing

A

0.9mg/kg
(max dose 90mg)

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16
Q

T/F: Alteplase contraindications and dosing differ when used for ACS vs stroke

A

True

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17
Q

Initiation of aspirin ___ PO daily is recommended within ___ after stroke onset to prevent early recurrent stroke.
Aspirin should NOT be given within ___ of fibrinolytic therapy

A

81-325mg
48 hrs
24 hrs

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18
Q

If alteplase is not administered, IV antihypertensives (e.g. labetalol, nicardipine) may not be required unless BP is severely elevated (≥____). In this case, a __% reduction in BP during the first 24 hrs after stroke onset is considered safe.

A

≥ 220/120
15%

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19
Q

After ischemic stroke, maintain BG levels in the range of ____ and closely monitor to prevent hypoglycemia (which can mimic stroke symptoms)

A

140-180

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20
Q

Which antihypertensives have best evidence for stroke risk reduction for secondary prevention? What is the BP goal for most pts?

A

Thiazides diuretics
ACEi/ARBs
<130/80

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21
Q

Weight reduction recommendation for treatment of modifiable risk factors (secondary ischemic stroke prevention)

A

BMI 18.5-24.9
Waist circumference <35 inches for women and <40 inches for men

22
Q

for pts with non-cardioembolic ischemic stroke of TIA, antiplatelet therapy with ____ is recommended to reduce risk of recurrent stroke, MI, or death.
___ is contraindicated in anyone with hx of TIA or stroke d/t increased risk of intracranial bleed

A

aspirin, aspirin/ER dipyridamole, clopidogrel

Prasugrel contraindicated

23
Q

Combination of clopidogrel and low-dose aspirin can be initiated within ___ of minor ischemic stroke (i.e. NIHSS score ≤3, did not receive alteplase) and continued for ___ days.

A

24 hrs
21-90 days

Note: Should NOT be used long-term for secondary prevention of stroke or TIA d/t increase risk of hemorrhage). Use short-term DAPT and then antiplatelet monotherapy indefinitely - diff recs than DAPT in heart disease (

24
Q

T/F: if pt is already taking aspirin, increasing aspirin dose will provide additional antiplatelet benefit for ischemic stroke or TIA

A

False - no added benefit to increasing aspirin dose in pts already taking aspirin who have an ischemic stroke or TIA

25
Q

Aspirin MOA in secondary ischemic stroke prevention

A

Irreversibly inhibits COX-1 and 2, resulting in decreased prostaglandin and TXA2 production (potent vasoconstrictor and inducer of platelet aggregation)

26
Q

Dipyridamole MOA

A

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

27
Q

Clopidogrel MOA

A

prodrug that irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation

28
Q

Which formulations of aspirin are Rx?

A

ER capsule (Durlaza)
DR tablet (Yosprala)

29
Q

Contraindications of aspirin (Bayer, Bufferin, Ecotrin)

A

NSAID or salicylate allergy, children and teenagers with viral infection d/t risk of Reye’s syndrome

30
Q

Warnings with aspirin (Bayer, Bufferin, Ecotrin)

A

bleeding
Tinnitus (salicylate overdose)

31
Q

Side effects of aspirin (Bayer, Bufferin, Ecotrin)

A

Dyspepsia, heartburn, bleeding, nausea

32
Q

Warnings with ER dipyridamole/aspirin (Aggrenox)

A

hypotension and chest pain (in pts iwth coronary artery disease) can occur d/t vasodilatory effects of dipyridamole

33
Q

Side effects of ER dipyridamole/aspirin (Aggrenox)

A

Headache (From vasodilatory effects of dipyridamole)

34
Q

T/F: ER dipyridamole/aspirin (Aggrenox) can be replaced wtih dipyridamole and aspirin separately

A

False - not interchangeable

35
Q

Clopdiogrel (Plavix) dose

A

75mg daily

36
Q

Clopdiogrel is a prodrug and requires conversion to active metabolite by ____

A

CYP2C19
Poor metabolizers exhibit higher CV events than normal CYP2C19 function
Test CYP2C19 genotype

37
Q

Contraindications of clopidogrel (Plavix)

A

Active serious bleeding

38
Q

Warnings clopidogrel (Plavix)

A

Bleeding risk: Stop 5 days prior to elective surgery, do not use with omeprazole or esomeprazole
Premature d/c (increased risk of thrombosis), thrombotic thrombocytopenic purpura (TTP)

39
Q

____ is drug of choice in stroke/TIA if contraindication or allergy to aspirin

A

Clopidogrel (Plavix)

40
Q

Avoid concurrent use of clopidogrel and PPIs __ and __ (other PPIs interact less) and use caution with other CYP2C19 inhibitors

A

Omeprazole, esomeprazole

41
Q

For intracerebral hemorrhage (ICH), ___ should be d/c and reversal agents should be administered (if appropriate). If there is clinical evidence of seizures, they should be treated but ____ should NOT be used

A

anticoagulants d/c
ppx antiepileptic drugs should NOT be used

42
Q

Increased intracranial pressure (ICP) is a medical emergency that can lead to brain death. What can be done to lower ICP?

A

Elevating head by at least 30 degrees
Administering IV osmotic therapy with either hypertonic saline (NaCl 3%, NaCl 23.4%) or mannitol&raquo_space; draws water out of brain and into intravascular space where it can be renally excreted

43
Q

Contraindications of mannitol (Osmitrol) injection

A

Severe renal disease (anuria)
Others: severe hypovolemia, pulmonary edema or congestion, active intracranial bleed (except during craniotomy)

44
Q

Before administering mannitol(Osmitrol), what should be done?

A

inspect for crystals - if crystals present, warm the solution to redissolve

45
Q

Use a filter for administration with mannitol conc ≥___%

A

≥20%

46
Q

Subarachnoid hemorrhage (SAH) usually results from ___and results in a ___

A

cerebral aneurysm rupture
severe headache (usually described as “worst HA ever experienced”)

47
Q

Cerebral artery vasospasm can occur ___ days after bleed, causing delayed cerebral ischemia; ____ has been show to improve outcomes a/w vasospasm-induced ischmia and should be initiated in pts with SAH

A

3-21 days
oral nimodipine (Nymalize)

48
Q

Nimodipine MOA

A

DHP CCB that is more selective for cerebral arteries d/t increase lipophilicity
Only indicated for SAH and not used for HTN

49
Q

Boxed warning for nimodipine (Nymalize)

A

Do not administer nimodipine IV or by other parenteral routes; death and serious life-threatening ADEs have occured when the contents of nimodipine caps have been inadvertently injected parenterally

50
Q

Side effects of nimodipine (Nymalize)

A

hypotension

51
Q

If nimodipine (Nymalize) capsules cannot be swallowed and oral solution is not available, what do you recommend?

A

Capsule contents may be withdrawn with parenteral syringe and then transferred to oral syringe that cannot accept a needle and only administer PO or via NG tube

52
Q

What auxillary labels should be placed on nimodipine (Nymalize) oral syringes

A

“For Oral Use Only”
“Not for IV Use”

NAPLEX 2024 (74 decks)

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