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Clinical Pharmacy 2 > Stroke > Flashcards

Stroke Flashcards

1
Q

What is the pathophysiology of a stroke?

A
  • abrupt onset focal neurologic deficit that lasts >24 hours and is of presumed vascular origin
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2
Q

What is an ischemic stroke?

A

an interruption of blood flow to the brain due to a clot
- occlusion of the cerebral artery causing abrupt development of a focal neurological deficit due to inadequate blood supply to an area of the brain

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3
Q

What is a hemorrahgic stroke?

A

caused by uncontrolled bleeding in the brain

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4
Q

What are ischemic strokes sometimes caused by?

A

caused by a thrombus formation inside an artery in the brain (i.e. atherosclerosis of cerebral vasculature)

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5
Q

What are the kinds of embolisms that can cause an ischemic stroke?

A
  1. carotid stenosis: atherosclerotic plaque rupture -> thrombus formation -> local occlusion or dislodge as emboli and causes downstream cerebral vessel occlusion
  2. cardiogenic embolism:
    secondary to valvular heart disease, or nonvalvular atrial fibrillation
    atrial blood stasis ->emboli -> occlusion of cerebral circulation
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6
Q

Describe a TIA

A
  • temporary focal neurologic deficit lasting less than 24 hours (typically <30 minutes) as a result of diminished or absent blood flow
  • results from small clots breaking away from larger, distant blood clots
  • blood flow is reestablished as the emboli are dissolved by the fibrinolytic system
  • no residual neurological deficit
  • absence of acute infarction on imaging
  • at high risk for an infarction or recurrent TIA
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7
Q

Describe the pathophysiology go the hemorrhagic stroke?

A
  • escape of blood from cerebral vasculature into surrounding brain structure
  • initial neurologic deficit attributable to direct irritant effects of blood in contact with brain tissue
  • subsequent dysfunction due to anoxia (similar to ischemic stroke)
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8
Q

What are some causes of hemorrhagic stroke?

A
  • subarachnoid hemorrhage, intracranial hemorrhage
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9
Q

What are some of the main causes of cerebral hemorrhage?

A
  • cerebral artery aneurysm, hypertensive hemorrhage, trauma, drugs
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10
Q

What are some predictors for worsened outcomes with hemorrhagic stroke?

A
  • higher clot volume

- early and late edema

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11
Q

What are some of the main modifiable risk factors associated with a stroke?

A
  • hypertension
  • smoking
  • dyslipidemia
  • diabetes
  • heart disorders (atrial fibrillation, infective endocarditis)
  • hypercoagulability
  • obesity, physical inactivity
  • psychosocial stress
  • intracranial aneurysms
  • alcohol use, carotid stenosis
  • drugs
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12
Q

What are some go the main non-modifiable risk factors associated with a stroke?

A
  • age (risk doubles for each decade older than 55)
  • male sex
  • family history
  • prior stroke
  • race (african american, asian-pacific islanders, hispanics)
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13
Q

What are the main clinical presentations associated with stroke?

A
  1. one sided weakness (sudden loss of strength or suffer numbness)
  2. trouble speaking/confusion
  3. vision problems/photophobia
  4. headache
  5. dizziness/ N/V
  6. altered level of consciousness
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14
Q

What timeline is acute phase treatment?

A

0-7 days

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15
Q

What timeline is hyper acute phase treatment?

A

0-24 hours

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16
Q

What are the goals of therapy associated with stroke therapy?

A
  • stabilization
  • reperfusion
  • supportive measures
  • prevent complications
  • prevent stroke recurrence
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17
Q

What are the main acute phase treatments associated with ischemic strokes?

A
  1. ABCs
  2. BPs
    - HTN common and transient in acute phase post stroke
    - treat only is the SBP is >220/120 mmHg, have evidence of aortic dissection, acute MI, pulmonary edema or hypertensive encephalopathy
    - aim for a moderate reduction only (15-25%)
  3. fluid, electrolytes, temperature
  4. glucose management
  5. neurological assessment
18
Q

What is typically used as reperfusion strategy after a stroke?

A

r-tPA

19
Q

What is the inclusion criteria to use tPA?

A
  • age 18 years or older
  • ischemic stroke causing measurable neurologic deficit
  • r-tPA can be given within 4.5 hours before symptom onset
20
Q

What would exclude tPA from being used to treat a stroke?

A
  • only minot or rapidly improving stroke symptoms
  • any source of active hemorrhage or any condition that could increase risk of major hemorrhage after r-tPA
  • any hemorrhage on brain imaging
  • recent major surgery
  • SBP >185 or DBP >110 refractory to antihypertensives
21
Q

What should be avoided for 24 hours after r-tPA?

A
  • anticoagulants and antiplatelets
22
Q

What is the purpose of anti platelets after a stroke?

A
  • reduces the risk of early recurrent stroke
    ASA 160-325 mg po daily should be given within 24-48 hours of stroke onset
  • ASA should be given 24 hours AFTER tPA
23
Q

_________ combination reduces the risk of recurrent stroke without increasing the risk of hemorrhagic stroke

A

Clopridogrel/ASA

24
Q

Combination antiplatelets (ASA/Clopridogrel) combination is not indicated in most cases due to what?

A

due to a concern of increased bleeding risk/hemorrhagic transformation (especially not after the 90 days after a stroke- there is a lack of long term benefit)

25
Q

What is used for DVT prophylaxis?

A

LMWH and UFH

these are used for hospitalized patents with limited mobility

26
Q

When should heparin be administered after a stoke?

A

should be initiated within 24-48 hours (avoid within 24 hours of thrombolytic)

27
Q

What are the main symptoms associated with ischemic stroke?

A
  • neurologic symptoms (speech, extremity strength, facial symmetry, worsening symptoms indicate recurrence or extension)
  • blood pressure
  • electrolytes
  • complications (DVT/PE- calf and chest pain, infections )
  • adverse effects such as bleeding
28
Q

What kind of surgical intervention can be used as secondary prevention for ischemic stokes?

A
  1. carotid endarterectomy (CEA) for secondary prevention of ischemic stroke (indicated for carotid artery stenosis of >70% on the side of the neurologic deficit)
    - only performed in experienced stroke centre
  2. Carotid artery angioplasty and stenting (CAS)
    - restricted to patients refractory to medical therapy and not surgical candidates
    - higher 30 day stroke/death rate vs CEA
29
Q

For patients with nonardioembolic ischemic stroke or TIA, the use of what drug is preferred to reduce the risk of recurrent stroke or other cardiovascular event?

A
  • antiplatelets over oral anticoagulants (ASA 50-325 or clopridogrel 75 mg when ASA is contraindicated)
30
Q

What can be used as an addition to ASA for the secondary prevention of a noncardioembolic ischemic stroke?

A
  • dipyridamole can be added

- ASA 25 mg + ERDP 200 mg BID is superior to ASA alone in secondary stroke prevention

31
Q

What are the most common AE associated with ASA and dipyramidole combination?

A
  • headache
  • dyspepsia, nausea, diarrhea
  • increased risk of bleeding with combination vs ASA alone
32
Q

Is there a difference in stroke rate when using clopridogrel vs ASA?

A

no, there is not

33
Q

What are the most common SE associated with clopridogrel?

A
  • diarrhea, rash

- less GI bleeding than ASA alone

34
Q

What about ticagrelor? Is it superior to ASA?

A

NO

35
Q

What is the dose of ticagrelor?

A

180 mg loading dose and a 90 mg po bid dose after

36
Q

Is warfarin superior to ASA?

A

no! warfarin is not superior to ASA 325 mg, but does give an increased bleeding risk
- not recommended for noncardioembolic ischemic stroke

37
Q

What are the major risks associated with using a direct oral anticoagulant?

A
  • there is no measure of the anticoagulation state
  • no reversible agent in cases of severe, life threatening bleed
  • not approved for patients with valvular AF
  • safety post-thrombolytic is unknown
38
Q

What are things that should be done as secondary prevention to a stroke?

A
  • blood pressure lowering
  • statin therapy
  • diabetes management
  • lifestyle changes
  • depression screening
39
Q

What should the target blood pressure therapy be for those that are in the acute stroke phase?

A

SBP 141-150

40
Q

How long after a stroke should a person wait to restart antihypertenstives?

A

24 hours after the stroke

Clinical Pharmacy 2 (18 decks)

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