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Pharmacology II > Stroke > Flashcards

Stroke Flashcards

1
Q

What is one of the leading causes of serious long-term disability in the U.S?

A

Stroke

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2
Q

What type of stroke is characterized by too much blood within the closed cranial cavity?

A

Hemorrhagic (13%)
Intracerebral (ICH) or bleeding into the brain tissue (10%)
Subarachnoid (SAH) or bleeding into the CSF (3%)

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3
Q

What type of stroke is characterized by inadequate supply of oxygen and nutrients to an area of the brain?

A

Ischmia (87%)
Thrombosis (in-situ obstruction of the artery)
Embolism (Debris from elsewhere)
Systemic hypoperfusion (general circulatory problem)

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4
Q

What is the clinical presentation of a stroke?

A 
ALTERATION IN CONSCIOUSNESS
HEADACHE
APHASIA
FACIAL WEAKNESS OR ASYMMETRY
INCOORDINATION, WEAKNESS, PARALYSIS, OR SENSORY LOSS OF ONE OR MORE LIMBS
ATAXIA
VISUAL LOSS
INTENSIVE VERTIGO, DOUBLE VISION, UNILATERAL HEARING LOSS, NAUSEA, VOMITING, PHOTOPHOBIA, OR PHONOPHOBIA
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5
Q

What are the characteristics of alteration in consciousness for stroke?

A

Stupor or Coma
Confusion or agitation/memory loss
Seizures
Delirium

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6
Q

What are the characteristics of headache for stroke?

A
  • Intense or unusually severe
  • Associated with decreased level of consciousness/neurological deficit
  • Unusual/severe neck or facial pain
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7
Q

What are the characteristics of facial weakness or asymmetry for stroke?

A
  • Paralysis of facial muscles (e.g., when patients speaks or smiles)
  • May be on same side (ipsilateral) or opposite side contralateral to limb paralysis
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8
Q

What are the characteristics of Incoordination, weakness, paralysis, or sensory loss of one or more limbs of stroke?

A

Usually one half of the body

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9
Q

What are the characteristics of ataxia for stroke?

A

poor balance, clumsiness, or difficulty walking

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10
Q

What are the characteristics of visual loss for stroke?

A
  • Monocular or binocular

- May be partial loss of the field

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11
Q

What are the stroke warnings?

A
  • pSudden numbness or weakness of the face, arm or leg, especially on one side of the body
  • Sudden confusion, trouble speaking or understanding
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Sudden, severe headache with no known cause
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12
Q

What should you do if you experience stroke warnings or if a patient does?

A

Call 9-1-1 immediately

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13
Q

What are the differential diagnosis for stroke sx?

A
  • Ischemic stroke
  • Hemorrhagic stroke
  • Craniocerebral / cervical trauma
  • Meningitis/encephalitis
  • Intracranial mass: Tumor, Subdural hematoma
  • Seizure with persistent neurological signs
  • Migraine with persistent neurological signs
  • Metabolic-Hyperglycemia (nonketotic hyperosmolar coma), Hypoglycemia, Post-cardiac arrest ischemia, Drug/narcotic overdose
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14
Q

What should be obtained for stroke assessment?

A

-History
-Neurologic examination
-CT of the brain without contrast
-Electrocardiogram
-Laboratory
Hematologic studies (CBC, platelet count, prothrombin time, partial thromboplastin time)
Serum electrolytes/renal function
Blood glucose
Cardiac enzymes
-National Institutes of Health Scale (NIHSS) score

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15
Q

What are the risk factors for stroke?

A
  • Hypertension (huge risk factor)
  • Age
  • Gender (men > women)
  • Race ( African American > whites)
  • Previous stroke/TIA
  • Hypertension (huge risk factor)
  • Age
  • Gender (men > women)
  • Race ( African American > whites)
  • Previous stroke/TIA
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16
Q

What are the major causes of hemorrhagic stroke?

A
  • Rupture of an arterial aneurysm (huge cause)

- Bleeding from vascular malformations

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17
Q

What are the types of hemorrhagic strokes?

A

Intracerebral Hemorrhage (ICH)
Bleeding directly into the brain → Localized hematoma
Grows until surrounding pressure limits growth
Destroys brain tissue with increasing size
Up to 44% 30 day mortality rate

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18
Q

What are the most common causes of hemorrhagic stroke ICH?

A

HYPERTENSION
Trauma
Illicit drug use (amphetamines and cocaine)
Vascular malformations

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19
Q

What is the clinical presentation of an ICH hemorrhagic stroke?

A
  • Neurological symptoms increase gradually (over minutes – hours)
  • Headache, N/V, and decreased level of consciousness
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20
Q

What is the goal of treatment for ICH hemorrhagic stroke?

A

-Contain and limit bleeding
-Removal of blood
-Manage complications
Increased intracranial pressure (ICP)
Decreased cerebral perfusion
-Control of causative factor (i.e.: Hypertension)

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21
Q

What drugs are contraindicated for hemorrhagic strokes?

A

THROMBOLYTICS
ANTICOAGULANTS- Heparin/LMWH
Warfarin
ANTIPLATELET DRUGS- ASA,Clopidogrel, Gp IIb/IIIa inhibitors

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22
Q

How do you treat hemorrhagic stroke ICH?

A
  • Admit to intensive care unit
  • Treat seizures when necessary
  • If febrile, assess and treat source and treat fever with antipyretics
  • Encourage early mobilization and rehab
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23
Q

What can be done to treat hemorrhagic stroke ICH?

A
  • Elevated ICP (Class IIa, Level of Evidence B)
  • Elevation of the head of bed
  • Analgesia and sedation
  • Osmotic diuretics
  • Drainage of CSF fluid via catheter
  • Neuromuscular blockade
  • Hyperventilation
  • Treat hyperglycemia (Class IIa, Level of Evidence C)
  • Brief prophylactic antiepileptic therapy (Class IIb, Level of Evidence C)
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24
Q

What should be done for blood pressure if SBP is 200mmHg or MAP is 150mmHg?

A

If SBP is 200 mm Hg or MAP is 150 mmHg, then consider aggressive reduction of blood pressure with continuous IV infusion, with frequent BP monitoring every 5 minutes.

25
Q

What should be done for blood pressure if SBP is 180mmHg or MAP is 130 mmHg and there is evidence or suspicion of elevated ICP?

A

If SBP is 180 mm Hg or MAP is 130 mm Hg and there is evidence of or suspicion of elevated ICP, then consider monitoring ICP and reducing BP using intermittent or continuous IV meds to keep cerebral perfusion pressure 60 to 80 mm Hg.

26
Q

What should be done for blood pressure if SBP is 180mmHg or MAP is 130mmHg and there is not evidence of or suspicion of elevated ICP?

A

If SBP is 180 mm Hg or MAP is 130 mm Hg and there is not evidence of or suspicion of elevated ICP, then consider a modest reduction of BP (eg, MAP of 110 mm Hg or target blood pressure of 160/90 mmHg) using intermittent or continuous IV meds to control BP, and clinically reexamine the patient every 15 minutes.

27
Q

What should be done for prevention of VTE in stroke patients?

A
  • Patients with acute primary ICH and hemiparesis/hemiplegia should have intermittent pneumatic compression (IPC) for prevention of VTE (Class I, Level of Evidence B).
  • After documentation of cessation of bleeding, low dose SQ LMWH or UFH may be considered in patients with hemiplegia after 3 to 4 days from onset (Class IIb, Level of Evidence B).
  • Patients with an ICH who develop an acute proximal venous thrombosis, particularly those with clinical or subclinical pulmonary emboli, should be considered for acute placement of a vena cava filter (Class IIb, Level of Evidence C).
28
Q

What is involved with subarachnoid (SAH) hemorrhage?

A

Bleeding into the CSF → rapidly increased intracranial pressure (ICP)
Bleeding usually only lasts seconds, but rebleeds are common
Continued bleeding can result in coma or death
Causes brain damage secondary to delayed ischemia

29
Q

What is the clinical presentation of SAH?

A
  • Abrupt onset
  • Loss of function
  • Sentinal headache (severe and widespread)
  • N/V
30
Q

What is the goal of treatment for SAH?

A
  • Quickly identify cause and prevent re-bleeding

- Prevent brain damage

31
Q

What is the treatment of SAH?

A

-Surgical clipping or endovascular coiling should be performed to reduce the rate of rebleeding after aneurysmal SAH (Class I, Level of Evidence B).

-Treatment/Prevention of Cerebral Vasospasm
Occurs 3-5 days after hemorrhage; max narrowing at 5-14 days.
Responsible for 50% of deaths in patients surviving initial bleed

32
Q

Nimodipine

A

ASA Recommendation (Class I, Level of Evidence A)

  • calcium channel blocker
  • A dihydropyridine Calcium channel blocker
  • Should be started within 96 hours of SAH onset continue x 21 days (decrease chance of ischemic deficits)
  • Reduces the incidence and severity of ischemic deficits
  • Metabolized by CYP450 3A4 enzymes
  • Caution when administered with inhbitors or inducers of CYP450 3A4.
  • Reduce dose in patients with significant hypotension
33
Q

What is an ischemic stroke?

A

Inadequate supply of oxygen and nutrients to an area of the brain

  • Thrombosis (in-situ obstruction of an artery)
  • Embolism (Debris from elsewhere)
  • Systemic hypoperfusion (general circulatory problem)
34
Q

What is the clinical presentation of ischemic stroke?

A

Very similar to hemorrhagic stroke

35
Q

What is very important for treatment decisions for ischemic stroke?

A

Time of symptom onset

36
Q

What MUST BE RULED OUT prior to treatment of an ischemic stroke?

A

Hemorrhagic stroke

37
Q

What diagnostics are used for ischemic stroke?

A

CT, MRI, PET Scan

ECG to evaluate heart rhythm- Atrial fibrillation / Atrial flutter

38
Q

What is an in situ obstruction of the arteries (large and small) that supply the brain (atherosclerosis and dyslipidemia) usually caused by atherosclerosis?

A

Thrombosis

39
Q

What is a blood clot coming from elsewhere in the CV system?

A

Embolism

40
Q

What are the cardiac sources of embolism?

A

Left atrial appendage
Left ventricular thrombus
Aorta

41
Q

What are other sources of embolism?

A

Cardiac sources
Arterial source
Idiopathic/cryptogenic

42
Q

What are the general treatment measures for ischemic stroke?

A

-Airway support and ventilatory assistance are recommended for the treatment of patients who have decreased consciousness (Class I, Level of Evidence C).
-Hypoxic patients should receive supplemental oxygen (Class I, Level of Evidence C).
-Fever should be treated and antipyretic medications given to lower temperature in febrile patients (Class I, Level of Evidence C).
-Cardiac monitoring should be performed during the first 24 hours after onset of ischemic stroke (Class I, Level of Evidence B).
-A cautious approach to the treatment of arterial hypertension should be recommended (Class I, Level of Evidence C).
See Blood pressure management
-Hypovolemia should be corrected with normal saline, and cardiac arrhythmias that might be reducing cardiac output should be corrected (Class I, Level of Evidence C).

43
Q

What is the treatment for ischemic stroke?

A

–Thrombolytic therapy (clot busters)
Administration of these medications is highly regulated
–Recombinant tissue plasminogen activator (rtPA, alteplase, Activase®)
Only FDA approved therapy for treatment of acute ischemic stroke
Therefore have to pick alterplase, activase and not another one
–NINDS Trial Results
Patients treated with rtPA had better outcomes (in terms of disability) at 3 months
–DVT PROPHYLAXIS SHOULD NOT BE STARTED WITHIN 24 HOURS OF rtPA THERAPY

44
Q

What are the indications for thrombolytics?

A
  • ICH ruled out by CT
  • Clinical diagnosis of stroke
  • Time: onset of symptoms to administration of drug must be < 3 hours
  • Age > 18 years
  • Consent by patient or surrogate
45
Q

What are the contraindications for thrombolytics?

A
  • PRIOR ICH- ever at anytime in their life.
  • Sustained BP > 185/110
  • Platelets < 100,000
  • HCT < 25
  • Glucose < 50 or > 400
  • Major surgery in previous 14 days
  • GI bleed within 21 days
  • Myocardial infarction in past 3 months
  • Stroke or head trauma within prior 3 months
  • Coma
46
Q

What is done for blood pressure control for ischemic stroke patients?

A

–For patients eligible for rtPA and with SBP > 185 mmHg or DBP > 110 mmHg
Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat 1;
Nitropaste 1 to 2 inches;
Nicardipine infusion, 5 mg/h, titrate up by 0.25 mg/h at 5- to 15-minute intervals, maximum dose 15 mg/h; when desired blood pressure attained, reduce to 3 mg/h

– If blood pressure does not decline and remains > 185/110 mm Hg, do not administer rtPA

–BP should be stabilized at the lower level before treating with rtPA and maintained < 180/105 mm Hg for at least 24 hours after rtPA treatment.

47
Q

What thrombolytic should you NEVER use for ischemic stroke?

A

Streptokinase- due to increase morbidity and mortality to intra-cranial hemorrhage
Use of other thrombolytics outside of a clinical trial is not recommended (Class III recommendation)

48
Q

What are the goals of therapy for ischemic stroke?

A

-Goals of therapy
-Reduce stroke progression
-Reduce the risk of recurrent thromboembolism
-Prevention of venous system thromboembolism
Deep vein thrombosis (DVT)
Pulmonary embolism (PE)

49
Q

Aspirin

A
  • Only antiplatelet agent evaluated for the treatment of acute ischemic stroke
  • Dose: 325mg (Class IA)
  • Should be started within 48 hours of stroke onset
  • May be used in combination with Low dose SQ heparin for DVT prophylaxis (Class 1A)
50
Q

What blood pressure management should be used for ischemic stroke?

A
  • Medications should be withheld unless the SBP > 220 mmHg or the MAP> 120mmHg (Class I, Level of Evidence C).
  • In such patients a reasonable goal would be to lower BP by 15% during the first 24 hours after onset of stroke.
51
Q

What is the DVT/PE prophylaxis for acute ischemic stroke?

A

Restricted mobility
Prophylactic low-dose SQ heparin or LMWH
Contraindications to anticoagulants
Intermittent pneumatic compression devices or elastic stockings

52
Q

What is the DVT/PE prophylaxis for intracerebral hemorrhage, acute ICH?

A
  • Initial use of intermittent pneumatic compression

- In stable patients, low dose SQ heparin may be initiated as soon as the 2nd day after onset of hemorrhage

53
Q

What antiplatelet therapy is used for secondary stroke prevention?

A
  • Inhibition of platelet aggregation prevents strokes
  • For patients with noncardioembolic ischemic stroke or TIA, antiplatelet agents rather than oral anticoagulation are recommended to reduce the risk of recurrent stroke and other CV events (Class I, Level of Evidence A).
54
Q

What are acceptable options for initial therapy in secondary stroke prevention?

A

ASA (50 to 325 mg/d) monotherapy, the combination of ASA+ER-DP, and clopidogrel monotherapy are all acceptable options for initial therapy (Class I, Level of Evidence A).

55
Q

Aggrenox®- used for secondary stroke prevention

A
  • ER-Dipyridamole + ASA (Aggrenox®)
  • MOA dipyridamole: inhibition of PDE mediated platelet aggregation
  • The combination of ASA and ER-DP is recommended over ASA alone (Class I, Level of Evidence B).
56
Q

Clopidrogel- used for secondary stroke prevention

A
  • Clopidogrel may be considered over ASA alone on the basis of direct-comparison trials (Class IIb, Level of Evidence B).
  • For patients allergic to ASA, clopidogrel is reasonable (Class IIa, Level of Evidence B).
  • Clopidogrel+Aspirin not recommended for ischemic stroke (Class III)
57
Q

What is key to primary and secondary prevention of stoke?

A

Control of high blood pressure

58
Q

What is the JNC-7 goal blood pressure?

A

<140/90

59
Q

What drug classes are used for recurrent stroke prevention?

A

Thiazides

ACEI

Pharmacology II (23 decks)

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