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Therapeutics I > Stroke > Flashcards

Stroke Flashcards

1
Q

What are the types of stroke?

A
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2
Q

What is a cryptogenic stroke?

A

ischemic stroke of undetermined etiology

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3
Q

What are the causes of ischemic stroke?

A
  1. Lack of oxygen → decreased ATP → Increased lactate → increased Na+ and water → cytotoxic edema → cell lysis
  2. Increased Ca2+ → lipases and protease → protein degradation and FFA release
  3. Excitatory AA → neuronal damage and production of damaging immune cells
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4
Q

What is the difference between SAH and ICH?

A

SAH: blood enters the subarachnoid space (trauma and aneurysm)

ICH: bleeding in the brain parenchyma itself with the formation of a hematoma within the brain (cocaine and methamphetamine)

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5
Q

What are the nonmodiifable risk factors?

A
  1. Low birth weight
  2. Genetic factors
  3. Age, race, sex
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6
Q

What are modifiable risk factors for ischemic stroke?

A
  1. Cigarette smoking
  2. HTN
  3. Diabetes
  4. A fib
  5. Sickle cell disease
  6. Migraine
  7. Metabolic syndrome
  8. Drug and alcohol abuse
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7
Q

When would the risk for ischemic stroke increased?

A

Risk score doubles for each decade older than 55 years

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8
Q

What is a stroke?

A

An episode of neuorlogic dysfunction (focal cerebral, spinal, and retinal infarction)

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9
Q

What is transient ischemic attack?

A

Syndrome of arterial ischemia with transient symptoms (<24 hr)

No evidence of infarction

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10
Q

What are the signs and symptoms of ischemic stroke?

A

Balance, eyes (trouble seeing), face, arm, speech, time to call 911

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11
Q

What is the left side stroke?

A
  1. Paralysis on right side
  2. Speech, language problems
  3. Slow behavior changes
  4. Memory loss
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12
Q

What is the right side stroke?

A
  1. Vision problems
  2. Quick, inquisitive behavioral changes
  3. Memory loss
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13
Q

How do you test for acute stroke?

A
  1. Neurologic exam
  2. Blood glucose, platelet count, coagulation parameters
  3. CT/MTI
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14
Q

How do you test for deeper workup stroke?

A
  1. Hypercoagulable states
  2. ECG, TTE, dopplers
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15
Q

What is the difference between TTE and TEE?

A

TTE: less invasive
TEE: more invasive (48 hrs before cardioversion)

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16
Q

What does the glasgow coma scale evaluate? What is considered severe?

A
  1. Eye opening response
  2. Verbal response
  3. Motor response

Severe: <8
Moderate: 9-12
Mild: 13-15

GCS score ≤ 8 requires tx

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17
Q

Identify

A

Area of hyperdensity (white)→ Hemorrhagic

Area of hypodense (dark) → Ischemic

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18
Q

What are the goals of stroke treatment?

A
  1. Reduce the ongoing neurologic injury in acute setting
  2. Prevent complications
  3. Prevent stroke recurrence
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19
Q

What are vitals we need to assess when it comes to stroke?

A
  1. Temperature elevation
  2. Hypoglycemia
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20
Q

How would you score TIA? and what is the treatment?

A

Low-risk TIA → ABCD2score <4: Start ASA 162 to 325 mg/daily

High-risk TIA → ABCD2score of ≥4: Dual antiplatelet therapy (DAPT) for the first 21 days

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21
Q

What are non pharm treatment of ischemic stroke?

A
  1. Endovascular intervention and thrombectomy with retrievable stents (6-24 hr of symptom onset)
  2. Decompressive hemicraniectomy
  3. Carotid endarterectomy
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22
Q

What are the pharm treatments for ischemic stroke?

A
  1. Thrombolytic
  2. Aspirin
  3. BP reduction
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23
Q

What is the inclusion criteria for thromolytics in ischemic stroke?

A
  1. Age ≥18 yr
  2. Ischemic stroke with neurologic deficit
  3. Symptom onset <4.5 hrs
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24
Q

How are CI for thrombolytics for ischemic stroke?

A
  1. Hemorrhagic stroke
  2. Infective endocarditis
  3. Neoplasm
  4. Aortic arch dissection
  5. Coagulopathy
  6. DTI and factor Xa inhibitors (anticoags)
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25
Q

How are warnings for thrombolytics for ischemic stroke?

A
  1. Intracranial hemorrhage
  2. Ischemic stroke within prior 3 months
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26
Q

What do you do before you treat ischemic stroke with thrombolytics?

A

Treat BP while maintaining permissive HTN

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27
Q

What are HTN drugs used for ischemic stroke?

A
  1. Nicardipine and clevidipine
  2. Labetalol
    3., Hydralazine, enalaprilat, nitroprusside IV infusion
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28
Q

BP management Ischemic Stroke with Thrombolytic Treatment?

A

Pre-thrombolytic: lower BP to SBP <185 mm Hg and DBP <110 mm Hg

Post-thrombolytic: maintain SBP <180 mm Hg and DBP <105 mm Hg for 24 hours

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29
Q

BP management Ischemic Stroke without Thrombolytic Treatment?

A
  1. Treatment benefit uncertain/not recommended unless BP >220/120 mm Hg
  2. Lowering BP by 15% is probably safe when required by comorbid conditions
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30
Q

What is the alteplase dosing for ischemic stroke?

A

0.9 mg/kg total dose (max: 90mg) → 10% as a bolus over 1 minute → Remaining 90% over 1 hr

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31
Q

What is the tenecteplase dosing for ischemic stroke?

A

Off-label indication

0.25 mg/kg (max 25 mg) IV push

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32
Q

What is the cascade of ischemic treatment with thrombolytic?

A
  1. Stroke team activation
  2. CT scan to rule out hemorrhage
  3. Treatment as early as possible within 4.5 hours of symptom onset
  4. Alteplase inclusion and exclusion criteria
  5. Administration of thrombolytic
  6. Avoidance of antithrombotic therapy (anticoagulant or antiplatelet) for 24 hours after thrombolytic
  7. Close patient monitoring for elevated blood pressure, neurologic status, and hemorrhage
33
Q

How should you monitor thrombolytics?

A
34
Q

When should you administer aspirin for ischemic stroke?

A
  1. 325mg at the first signs/symptoms
  2. Thrombolytic therapy used → initiate ASA 24 hours after
35
Q

What is the secondary prevention for ischemic stroke?

A
  1. Anti platelet/anticoag
  2. HTN management
  3. Statin
  4. Non pharm
36
Q

What is most routinely used lifelong therapy drug?

A

Aspirin

37
Q

What can you use instead of aspirin?

A

ER dipyridamole/aspirin or clopidogrel

38
Q

What are the types of anitplatelets for ischemic stroke secondary prevention?

A
  1. Aspirin
  2. Clopidogrel
  3. Dipyridamole
  4. DAPT
39
Q

Metabolism of clopidogrel? DDI?

A

CYP2C19 → pharmacogenic testing

DDI: omeprazole and esomeprazole

40
Q

MOA of dipyridamole?

A

Inhibits PDE → Increased camp and cGMP intracellular → decreased platelet activation

Enhances antithrombin potential of the vascular wall

41
Q

What is a common ADR of dipyridamole?

A

HA

42
Q

How should DAPT be coursed for ischemic stroke?

A

21-90 days

43
Q

What are the anticoags for a fib and ischemic stroke?

A
  1. Warfarin
  2. Dabigatran
  3. Rivaroxaban 20mg daily w/evening meal
  4. Apixaban 5mg BID
  5. Edoxaban 60mg daily
44
Q

Dabigatran reduction?

A

Dose reduce to 75 mg twice daily for CrCl of 15-30 mL/min

45
Q

Rivaroxaban reduction?

A

Dose reduce to 15 mg daily for CrCl of ≤50 mL/min (0.83 mL/s

46
Q

Apixaban reduction?

A
  1. Age greater than or equal to 80 years
  2. body weight less than or equal to 60 kg
  3. serum creatinine greater than or equal to 1.5 mg/dL

2.5 mg twice daily

47
Q

Edoxaban reduction?

A

Dose reduce to 30 mg daily for CrCl of 15-50 mL/min

Do not use if CrCl >95mL/min

48
Q

What is the low risk of hemorrhagic conversion? High?

A

Begin 2 to 14 days after the stroke

Waiting at least 14 days is recommended

49
Q

Non pharms of ischemic stroke

A
  1. Diet mod
  2. Excersise
  3. Smoking cessatin
  4. Avoid tobacco smoke
  5. Reduce alcohol consumption
  6. Avoid stimulant (cocaine and amphetatime)
50
Q

BP goals of ICH?

A

SBP 150-220 mmHg w/o contraindication lower SBP to a goal of 140.

SBP >220 mm Hg, aggressively reduce BP with a continuous IV infusion w/ frequent monitoring of BP to a goal SBP 140.

51
Q

What is BP

A
52
Q

Type of hemorrhagic stroke?

A
  1. SAH
  2. ICH
53
Q

Non pharm of SAH?

A

Surgical clipping or end-vascular coiling of the vascular anomaly

54
Q

Non pharm of ICH?

A
  1. Surgical intervention and hematoma removal
  2. Ventricular drainage with an extra ventricular drain (EVD)
55
Q

BP goals of SAH?

A

If patient is alert, dial SBP is <160

56
Q

How do you treat thrombolytic induced hemorrhagic stroke?

A
  1. Stop thrombolytic
  2. Cryoprecipitate (includes factor VIII): 10 U infused over 10-30 min (onset in 1 h, peaks in 12 h); administer additional dose for fibrinogen level of <150 mg/dL
  3. +/- Tranexamic acid
57
Q

Treatment with ICH on anticoagulation?

A
58
Q

Meds for those on anti-platelet therapy?

A

Platelets and desmopressin

59
Q

Treatment for seizure prophylaxis?

A
  1. Not recommended for ICH
  2. If given, 7 day duration
  3. SAH guidelines do not mention use
60
Q

Seizure management therapies?

A
  1. Active seizures
  2. Levetiracetam and phenytoin
61
Q

Why is nimodipine used for subarachnoid hemorrhage?

A

DHP CCB is more selective for cerebral arteries (increased lipophilicity)

Prevention of vasospasm in cerebral

62
Q

Dosing of nimodipine? Hepatic?

A

60 mg by mouth every 4 hours for 21 days + maintenance of intravascular volume with vasopressor therapy.

30 mg every 4 hours for 21 days.

Start within 96 hrs of SAH onset

63
Q

CI of nimodipine?

A

Increase the risk of hypotension in combination with strong CYP 3A4 inhibitors & inducers

64
Q

ADRs of nimodipine? Monitoring

A

Hypotension, bradycardia, HA, nausea, edema

ICP, BP, HR, neurologic checks

65
Q

CYP3A4 inhibitors?

A

Grapefruit
Protease inhibitors
Azole antifunguls
Cyclosporine
Macrolides
Amiodarone and dronedarone
Non-DHP CCB

66
Q

CYP3A4 inducers?

A

Phenytoin
Smoking
Phenobarbital
Oxcarbazepine
Rifampin
Carbamazepine
St Johns wort

67
Q

Characteristics of metabolic inhibitors?

A

INhibitors = Increase serum Concentrations → increased SE/levels/ADRs/Toxicities

Decreases the metabolism

68
Q

Characteristics of metabolic inducers?

A

InDucers = Decreases serum concentration → decreasing clinical effects

Increases metabolism

69
Q

What is ICP and its presentations?

A

Pressure within the craniospinal compartment

HA, Confusion, Drowsiness, coma

70
Q

Monitoring parameters of ICP?

A

Extraventricular Drain (EVD) or Intraventricular Catheter

ICP >22 requires treatment

71
Q

What is CPP? Goal?

A

Net pressure gradient that drives oxygen delivery to cerebral tissue

CPP=MAP-ICP
Goal CPP: 60-80 mm hg
CPP <50 requires tx

72
Q

Non pharm for ICP?

A

Decompressive craniotomies (removal of the skull bone to allow space)

73
Q

Pham treatment for ICP?

A

Mannitol (Osmitrol) → taper due to mannitol drawing fluid into CNS → rebound cerebral edema and ICP

Hypertonic saline (central venous only): 23.4% 15-60 mL over 2-20 minutes

74
Q

Mannitol monitoring?

A
  1. ICP, CPP
  2. Mannitol induced diuresis
  3. Serum osmolarity goal <300-320
  4. Hypovolemia, hyperosmolarity, renal failure
75
Q

Storage of mannitol?

A

Heated environment and use filter for admin

76
Q

Initial monitoring for stroke?

A
  1. Development of neurologic worsening
  2. Complications
  3. ADRs with pharm and non-pharm
77
Q

What are the reasons for deterioration in stroke patients?

A
  1. Lesion
  2. Cerebral edema and ICP
  3. Hemorrhagic conversion
  4. HTN emergency
  5. Infection
  6. Venous thromboembolism
  7. Electrolyte abnormalities (K+ first)
78
Q

Care team considerations for stroke?

A
  1. Rehabilitation
  2. Nutrition
  3. Screening for depression
  4. DVT prophylaxis
  5. Smoking cessation
79
Q
A

Therapeutics I (32 decks)

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