Stroke

Question 1

Ischemic vs cardioembolic vs hemorrhagic stroke

Answer 1

Ischemic = thrombus forms in the brain
cardioembolic = embolus from the heart travels to the brain
Hemorrhagic stroke = bleeding in the brain due to ruptured blood vessel

Question 2

First link in the stroke chain of survival

Answer 2

Early recognition of stroke signs and symptoms

Call 911, “time is brain”

Question 3

Initial treatment of stroke (non-pharm)

Answer 3

Supportive cardiac and respiratory care
Quickly identifying whether it’s ischemic or hemorrhagic via brain imaging
Should be read within 45 minutes of patient arrival in the emergency department

Question 4

ACT FAST and the 5 suddens

Answer 4

FAST = face, arms, speech, time “time to call 911”

5 suddens = sudden numbness or weakness of 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

Question 5

Fibrinolytic agent for ischemic stroke

Answer 5

Alteplase
recombinant tissue plasminogen activator (rTPA)
Use when clot is confirmed

Question 6

Alteplase treatment timelines

Answer 6

Use within 3 hours of symptom onset (FDA approved)

Within 4.5 hours for select patients (not FDA approved, extended for select patients)

Question 7

Contraindications to alteplase

Answer 7

Absolute contraindications (per package labeling): active bleed, recent (< 3 months) serious head injury, intracranial surgery or intraspinal surgery, presence of intracranial conditions that may increase risk of bleeding, bleeding diathesis, current severe uncontrolled BP (note if this is the only contraindication you can safely lower below and then use)

Additional exclusion criteria per AHA/ASA guidelines:
Stroke within past 3 months, previous ICH, INR > 1.7, platelets < 100,000, increased aPTT due to heparin use, use of LMWH within past 24 hours, current use of direct thrombin inhibitors or factor Xa inhibitors with elevated anticoag tests, blood glucose < 50 mg/dL, “others”

Question 8

Dose alteplase

Answer 8

0.9 mg/kg, max 90 mg

Give 10% as bolus over 1 minute then remainder over 60 minutes

Question 9

Additional treatments to stroke besides alteplase

Answer 9

Aspirin 325 mg PO within 24-48 hours after stoke onset to prevent early recurrent stroke
DO NOT give within 24 hours of fibrinolytic therapy

Question 10

Secondary prevention of ischemic stroke

Answer 10

Hypertension goal < 140/90 (per book lols)
Dyslipidemia
Diabetes
Lifestyle modifications (sodium < 2.4 g/day), weight reduction (BMI 18.5-24.9, waist circumference < 35 in for women and < 40 in for men)
Atrial fib = give anticoagulants

Question 11

When do we use clopidogrel as antiplatelet for stroke

Answer 11

Allergies to aspirin

Question 12

Side effects aspirin

Answer 12

Dyspepsia, heartburn, nausea, tinnitus (toxicity)

Question 13

Dipyrimadol/aspirin brand, dose, warnings

Answer 13

Aggrenox
200 mg/25 mg BID
Warnings hypotension
Side effects headache (if intolerable use once daily dosing in the evening plus baby aspirin in the morning then resume BID dosing within 1 week)

Question 14

Clopidogrel boxed warning, contraindications, warnings, side effects

Answer 14

Boxed: prodrug, needs conversion by 2C19 so poor metabolizers have higher cardiovascular events (test for 2C19 genotype)

Contraindications: serious bleeding

Warnings: inc bleeding risk, avoid use w omeprazole or esomeprazole. thrombotic thrombocytopenic purpura (TTP) has been reported

Side effects: Gi hemorrhage, hematoma, pruritis

Do not use in combo w aspirin for long term stroke prevention

Question 15

Treatment for hemorrhagic stroke? dose + side effects

Answer 15

Mannitol 20% dose: 0.25-1 g/kg/dose IV q6-8h PRN

Side effects: fluid and electrolyte loss, dehydration, hyperosmolar-induced hyperkalemia, acidosis, increased osmolar gap

Question 16

Prophylactic seizure meds for hemorrhagic stroke?

Answer 16

DO NOT USE - use anticonvulsants if there is clinical evidence of seizure but do not treat prophylactically

Question 17

Prophylactic seizure meds for subarachnoid hemorrhage?

Answer 17

Yes may be considered in the immediate post-hemorrhagic period to prevent seizures but routine use of long-term anticonvulsants not recommended, may be considered in patients with known risk factors for delayed seizure disorder

Question 18

Pharmacologic treatment for subarachnoid hemorrhage?

Answer 18

Usually treat w coiling, clipping but can use nimodipine (Nymalize) for vasospasm prevention (can occur 7-21 days after hemorrhage)

Dose 60 mg PO q4h for 21 days, start within 96 hours of SAH onset

Do not give IV - death and serious adverse events have occurred when contents of capsule have been injected parenterally! Oral syringes should be labeled for oral use only/not for IV use