36 - Acute Stroke

Question 1

Stroke can either be caused by a block/clot or a bleed. List the 3 types of strokes that can happen

Answer 1

1-cerebral infarction (ischemic stroke) = block
2-intracerebral hemorrhage = bleed
3-subarachnoid hemorrhage = bleed

Question 2

What type of stroke is most common

Answer 2

1-cerebral infarction (ischemic stroke) = block

85% of strokes are this type

Question 3

Warning signs for stroke?

Answer 3

FAST

Face - is it dropping?
Arms - can you lift both of them?
Speech - is it slurred?
Time - time to call 911

Question 4

Non-pharms?

Answer 4

• Endovascular thrombectomy - within 6 hours of onset. May be performed after initiating tx with IV alteplase (TPA) or in patients in whom TPA is CI (after recent surgery, patients on warfarin with INR > 1.7, or on a DOAC)
• Neurosurgical Intervention
• Supportive care (treat fever and hyperglycemia. use oxygen if SaO2 < 95%)
• Swallowing and Nutrition
• Venous Thromboembolism (early mobilization is key, pneumatic compression stockings are recommended as they decrease risk of DVT but graduated compression stockings are NOT recommended)

Question 5

Pharmacologic Tx for Ischemic Stroke: (Clot)

When should thrombolytics (ex. alteplase) be administered?

Answer 5

administer IV ASAP after stroke onset

Question 6

Pharmacologic Tx for Ischemic Stroke: (Clot)

After what amount of time is alteplase of no benefit?

Answer 6

> 4.5 hours after symptom onset

Question 7

Pharmacologic Tx for Ischemic Stroke: (Clot)

Who should get VTE prevention?

Answer 7

Those who had ischemic stroke who cannot move one or both lower limbs or mobilize independently

Question 8

Pharmacologic Tx for Ischemic Stroke: (Clot)

What should they receive as VTE prevention?

Answer 8

in the absence of CIs, use LMWHs or UFH in prophylactic doses

can use ASA

Question 9

Pharmacologic Tx for Ischemic Stroke: (Clot)

If intracranial hemorrhage has been excluded but alteplase is not indicated, what can you give?

Answer 9

ASA 160 mg immediately

follow with ASA 80-325 mg daily

Question 10

Pharmacologic Tx for Ischemic Stroke: (Clot)

If Alteplase is used, what until ___ _____ is excluded 24 hours post-Tx until giving ASA

Answer 10

intracranial hemorrhage

Question 11

Pharmacologic Tx for Ischemic Stroke: (Clot)

If patient was taking ASA prior to their stroke, what agents should you consider?

Answer 11

clopidgrel 75 mg once daily or dipyridamole/ASA 200/25mg BID

Question 12

Pharmacologic Tx for Ischemic Stroke: (Clot)

Should you combine ASA and clopidogrel post stroke?

Answer 12

Combining them in the 1st month after a non-disabling stroke or TIA decreases the risk of major stroke at 3 months w/o increases risk of serious bleeding

This combo is not recommended long-term

Question 13

Pharmacologic Tx for Ischemic Stroke: (Clot)

Options for anticoagulation?

Answer 13

-apixaban, dabigatran, endoxaban, rivaroxaban

If can’t be anticoagulated, use ASA

Question 14

Pharmacologic Tx for Ischemic Stroke: (Clot)

Which anticoagulants are CI if CrCl < 30?

Answer 14

dabigatran, endoxaban, rivaroxaban

Question 15

Pharmacologic Tx for Ischemic Stroke: (Clot)

Which anticoagulants are CI if CrCl < 15?

Answer 15

apixaban

Question 16

Pharmacologic Tx for Ischemic Stroke: (Clot)
Need to lower BP: using _____ ______ within 6 hours in those who had SBP = 140-220 showed improvement in functional outcomes

Answer 16

transdermal nitroglycerin

Question 17

Pharmacologic Tx for Ischemic Stroke: (Clot)

When should oral BP-lowering agents be started?

Answer 17

prior to discharge from hospital who have BP > 140/90 (or 130/80 in DM)

Question 18

Pharmacologic Tx for Intracranial Hemorrhage Stroke: (Bleed)

If they have established coagulopathy or hx of warfarin, what options do we have to reverse coagulopathy?

Answer 18

• prothrombin complex concentrate (PCC)
• vitamin K
• fresh frozen plasma (FFP)

*recombinant factor 7a prevents hematoma growth but not used routinely

Question 19

Pharmacologic Tx for Subarachnoid Hemorrhage Stroke: (Bleed)

What do we use for this?

Answer 19

Nimodipine x 3 weeks decreases risk of secondary vasospam and cerebral infarction