Stroke

Question 1

Hemorrhagic stroke

Answer 1

subarachnoid hemorrhage, intercerebral bleed

Question 2

Ischemic stroke

Answer 2

lacunar, thromboembolic (most common), embolic

Question 3

CHADS2-VASc Score

Answer 3

C - CHF - 1
H - HTN - 1
A - Age > 75 - 2
D - DM - 1
S2 - Prior TIA/stroke - 2
V - Vascular disease - 1
A - Age 65-74 - 1
Sc - Sex (fem) - 1

Question 4

TIA

Answer 4

cerebral ischemic event lasting less than 24 hrs, usually minutes w/ no neurologic deficit

Question 5

Complete stroke

Answer 5

cerebral ischemic acute event w deficit that persists

Question 6

Hemispheric infarct

Answer 6

whole hemisphere - paralysis, can’t speak

Question 7

Lacunar infarct

Answer 7

small stroke (white matter)

Question 8

Treatable risk factors

Answer 8

HTN, hypercholesterolemia, heart disease (A. fib), DM, smoking, excessive alc use, lack of exercise, obesity, carotid bruit

Question 9

untreatable risk factors

Answer 9

age, sex, race, prior stroke, heredity

Question 10

Stroke patho

Answer 10

-Thrombus formation: asymp atherosclerotic plaque, platelet deposition, occlusive thrombus formation, plaque fissure-red thrombus-embolism)
-cardiogenic embolus-blood stasis-thrombus-ejected to brain

Question 11

Carotid territory (most common presentation)

Answer 11

unilateral weakness, unilateral sensory symptoms, aphasia-difficulty understanding speech or speaking, or both, monocular visual loss, and transient global amnesia

Question 12

Vertebrobasilar territory presentation

Answer 12

-bilateral weakness, sensory, &/or visual complaints
-diplopia, vertigo, ataxia w/o weakness, dysphagia (diff swallowing)

Question 13

Phases of stroke

Answer 13

-Primary prevention (mod. risk factors/non mod. risk factors)
-Acute management
-secondary prevention

Question 14

Types of stokes prevented by anti platelet therapy

Answer 14

-small vessel lacunar
-large vessel embolic
-large vessel thrombotic

Question 15

types of strokes prevented by warfarin

Answer 15

Cardioembolic

Question 16

Ticlopidine/Plavix/Prasugrel MOA

Answer 16

block ADP receptors

Question 17

ASA MOA

Answer 17

inhibits cyclooxygenase and thromboxane to inhibit platelet aggregation and activation

Question 18

Dipyridamole MOA

Answer 18

inc plasma adenosine and inhibits platelet phosphodiesterase

Question 19

Secondary stroke prophylaxis

Answer 19

anti platelet drugs (ASA, ticlopidine, plavix, prasugrel, ticagrelor, ASA/ER Diprydamole

Question 20

Prasugrel and Ticagrelor

Answer 20

FDA approved for CAD
-use when ASA and Plavix or Aggrenox don’t work

Question 21

ASA

Answer 21

-avoid if they have an allergy or bleeding risk
-if pt needs rapid effect 81 mg doesn’t get to full effect until 7-10 days so use 325 and then taper down to 81

Question 22

Plavix

Answer 22

don’t use if they are on CCB

Question 23

Aggrenox

Answer 23

Causes HA and GI effects

Question 24

ASA + Plavix

Answer 24

inc risk of bleeding

Question 25

Dual anti platelet therapy

Answer 25

-coronary artery stents and new cerebral ischemia
-cerebral ischemia within 90 days
-A. fib not able to take warfarin

Question 26

ASA resistance

Answer 26

-compliance: urinary salicylates
-NSAIDs other than Celebrex comprise ASA
-EC to chewable or alka seltzer
-change dose where appropriate

Question 27

Plavix resistance

Answer 27

-minimize 3A4 & 2C19 drugs (inhib)
-CCB to ACE & PPI to H2
-Add med that induces CYP

Question 28

Common meds that influence Plavix metabolism

Answer 28

-Statins other than rosuvastatin
-change CCB to ACE as long as its not for rate control
-Ambien, eszopiclone (zaleplon less likely)
-Gliburide, not glypizide or metformin
-Enablex, Ditropan, not Detrol or Sanctura
-PPIs

Question 29

Patient resistant to ASA and Plavix

Answer 29

-Ticagrelor (not FDA approved)
-max ASA dose 100 mg daily w/ Ticagrelor
-Prasugrel (pro drug dependent on 3A4)