Chapter 33: Stroke Flashcards

1
Q

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

A

By a thrombus that forms during a cerebral atherosclerotic infarction

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2
Q

How does a cardioembolic stroke occur

A

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

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3
Q

A common cause of cardioembolic stroke

A

AFib

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4
Q

Risk factors for stroke

A
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
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5
Q

What is a TIA

A

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

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6
Q

Signs and symptoms of stroke

A
  • 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
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7
Q

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

A

Brain imaging, using CT

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8
Q

Immediate goal for ischemic stroke

A

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

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9
Q

MOA of alteplase

A

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

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10
Q

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

A

Alteplase

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11
Q

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

A
  • 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)
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12
Q

Alteplase CI

A
  • 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
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13
Q

Alteplase brand name

A

Activase

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14
Q

Max dose of alteplase in ischemic stroke

A

90 mg

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15
Q

What must be excluded before using alteplase

A

intracranial hemorrhage

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16
Q

Alteplase SE

A

Major bleeding (e.g., ICH)

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17
Q

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

A

162 – 325

24-48

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18
Q

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

A

ACEi and thiazide diuretics

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19
Q

What is the goal BP for ischemic stroke

A

< 130/80 mmHg

20
Q

What statin intensity should be used in secondary prevention of stroke

A

High-intensity

21
Q

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

A

ASA (or clopidogrel if ASA is CI)

22
Q

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 ____

A

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)

23
Q

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

A

False - there is no added benefit

24
Q

What is the MOA of dipyridamole

A

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

25
Aspirin dosing in stroke
50-325 mg daily
26
Aspirin ER capsule brand name
Durlaza
27
Aspirin DR tablet brand name
Yosprala
28
ER dipyridamole/aspirin brand name
Aggrenox
29
ER dipyridamole/aspirin warnings
hypotension
30
ER dipyridamole/aspirin SE
headache
31
Clopidogrel dosing in stroke
75 mg daily
32
Clopidogrel should be stopped __ days prior to elective surgery
5
33
Clopidogrel should be avoided with which 2 drugs
omeprazole and esomeprazole
34
What should be done in patients with intracranial hemorrhage who are anticoagulated
reversal of the anticoagulant should be considered
35
What should be done in ICH if there is clinical evidence of seizures
They should be treated but ppx anticonvulsant meds should not be used
36
How is ICH treated
elevate the head by 30 degrees and use mannitol or hypertonic saline
37
MOA of mannitol
Produces osmotic diuresis. Reduces ICP by withdrawing water from the brain
38
Mannitol formulation
injection
39
Mannitol CI
severe renal disease
40
How does acute subarachnoid hemorrhage present
Severe headache
41
Cerebral artery vasospasm can occur __=__ days after the bleed in SAH, causing delayed cerebral ischemia
3-21
42
Which drug & route is used to prevent vasospasm in SAH
oral nimodipine
43
Nimodipine MOA
DHP CCB that is more selective for cerebral arteries d/t increased lipophilicity
44
Nimodipine BW
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
45
Nimodipine SE
Hypotension
46
If nimodipine capsules cannot be swallowed, what can be done
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”