Ch 1 - Stroke: Medical Treatment

Question 1

What should be done immediately to manage stroke?

Answer 1

ABC of critical care
IVF
Make NPO
CT head
Seizure management
Check blood sugar
Control ICP
Control fever

Question 2

Which IVF should be avoiding in stroke?

Answer 2

Hypotonic solutions or excessive fluid overloading can worsen brain edema

Question 3

What is the treatment of hypoglycemia in stroke?

Answer 3

Bolus 50% IV dextrose

Question 4

What is the treatment of hyperglycemia in stroke?

Answer 4

Insulin if blood sugar >300 mg/dL

Question 5

What are the favored antihypertensives for BP control in ischemic stroke?

Answer 5

IV labetalol and enalapril

Question 6

At what BP should antihypertensives be given in non-thrombolytic candidates?

Answer 6

SBP >220
DBP >120
MAP >120

Question 7

At what BP should antihypertensives be given in Thrombolytic candidates (before thombolytic given)?

Answer 7

SBP >185

DBP >110

Question 8

At what BP should antihypertensives be given in Hemorrhagic stroke?

Answer 8

SBP >180

DBP >105

Question 9

What is the antihypertensive of choice for hemorrhage stroke?

Answer 9

IV labetalol (does not cause cerebral vasodilation, which could worsen increased ICP)

Question 10

What are the 1st line agents for seizures (in stroke)?

Answer 10

IV lorazepam or diazepam

Question 11

If seizures do not respond to benzodiazepines, what should be given?

Answer 11

Long acting anticonvulsants
– Phenytoin
– Fosphenytoin
– Phenobarbital

Question 12

What is a normal ICP?

Answer 12

<15 mmHg

Question 13

What should ICP be kept under in stroke?

Answer 13

<20mmHg

Question 14

What can increase ICP and worsen cerebral edema?

Answer 14

Fever
Hyperglycemia
Hyponatremia
Seizures
Hypoxia
Hypovolemia
Acidosis
Hypercarbia

Question 15

What positioning should be avoiding in elevated ICP?

Answer 15

Flat/supine

Head/neck positions that compress jugular veins

Question 16

What is the most rapid way of lowering ICP?

Answer 16

Reducing PaCO2 through hyperventilation

Question 17

What can excessive hyperventilation lead to?

Answer 17

Hypoxia which worsens brain ischemia

Question 18

What medications can improve brain edema?

Answer 18

Mannitol
Furosemide
Acetazolamide

Question 19

What is FDA approved treatment for acute ischemic strokes?

Answer 19

Intravenous tissue plasminogen activator (tPA)

Question 20

When can tPA be safely given and improve outcomes in stroke?

Answer 20

3 to 4.5 hours after stroke onset

Question 21

What is the inclusion criteria for tPA?

Answer 21

Age >18 yo
Sx onset <4.5 hrs
Measurable stroke deficits
Head CT neg for blood
Informed consent

Question 22

What are clinical exclusion criteria for tPA use?

Answer 22

Minor stroke/TIA
CT head + blood
BP >185/100 despite tx
Acute MI
Seizure at onset of stroke
On anticoagulants
>80 yo
NIHSS score >25
Ischemic injury > 1/3 of MCA territory

Question 23

What are laboratory exclusion criteria for tPA use?

Answer 23

PT >15 sec
INR >1.7
Heparin in 24 hr with inc PTT
Platelets <100,000
Blood sugar <50 or >400

Question 24

What history components are exclusion criteria for tPA?

Answer 24

Stroke or head injury in 3 mo
ICH, AVM or aneurysm
GI or GU bleeding in 21 days
Pregnancy last 30 days
Major surgery in 14 days
History of stroke and DM

Question 25

When can Intra-arterial fibrinolysis be beneficial?

Answer 25

Major ischemic strokes <6 hours post-onset caused by occlusions of the MCA who are not otherwise candidates for intravenous tPA

Question 26

What is the best reason to anticoagulate a patient to decrease stroke risk?

Answer 26

Cardiac emboli: from nonvalvular Afib or mural thrombus from MI

Question 27

When is the largest risk of intracranial hemorrhage with starting anticoagulation after stroke?

Answer 27

First 24-36 hours after large infarcts

Question 28

What is the MOA of Warfarin (Coumadin)?

Answer 28

Inhibits vitamin K-dependent coagulation factors

Question 29

What is the MOA of Dabigatran (Pradaxa)?

Answer 29

Direct thrombin inhibitor

Question 30

What is the MOA of Rivaroxaban (Xarelto)?

Answer 30

Factor Xa inhibitor

Question 31

What is the MOA of Apixaban (Eliquis)?

Answer 31

Factor Xa inhibitor

Question 32

Which medications reduced the risk of recurrent stroke and other CV events in noncardioembolic ischemic stroke or TIA?

Answer 32

ASA 50-325 mg/day aspirin/ER dipyridamole (Aggrenox®) Clopidogrel (Plavix®)

Question 33

When should ASA 325 mg be given after ischemic stroke?

Answer 33

First 24-48 hrs

Question 34

When are Antiplatelet medications beneficial in stroke prevention?

Answer 34

Secondary stroke prevention of | presumed arterial origin

Question 35

When is Carotid endarterectomy (CEA) beneficial?

Answer 35

Symptomatic lesions 70% to 99% stenosis is effective in reducing the incidence of ipsilateral hemisphere stroke

Question 36

What are activity restrictions for patients after acute SAH?

Answer 36

Bedrest in dark, quiet room Cardiac monitoring Avoid all straining (give stool softeners/laxatives)

Question 37

What medication is used to control cerebral edema in SAH?

Answer 37

Mannitol

Question 38

What medications are used for headache in SAH?

Answer 38

Acetaminophen | Codeine

Question 39

What decreases cerebral vasospasms and improves outcomes after SAH?

Answer 39

Nimodipine (calcium channel blocker)

Question 40

What does early surgery with clipping or coiling of the aneurysm do?

Answer 40

Reduces risk of rebleeding but does not prevent vasospasm or cerebral ischemia

Question 41

What are treatments for AVMs?

Answer 41

Surgical excision Embolization Proton beam