Stroke

Question 1

Difference between cardioembolic and noncardioembolic stroke

Answer 1

Cardioembolic: stroke caused by a clot
Noncardioembolic: stroke caused by atherosclerosis
***both are ischemic strokes

Question 2

Common cause of cardioembolic stroke

Answer 2

afib

Question 3

Different types of hemorrhagic strokes

Answer 3

Intracerebral hemorrhage (ICH)
Subarachnoid hemorrhage (SAH)
Subdural hematoma

Question 4

Risk factors for stroke

Answer 4

HTN - most important
Afib
Gender (f>m)
Ethnicity (african american highest)
Age >55
Atherosclerosis
DM
Hx of stroke or TIA
Smoking
HLD
Sickle cell disease

Question 5

S/sx of stroke

Answer 5

F.A.S.T
Face
Arms
Speech
Time

Question 6

What drug is used for acute ischemic stroke?

Answer 6

Alteplace

Question 7

Alteplase MOA

Answer 7

binds fibrin in a thrombus and converts plasminogen to plasmin, resulting in fibrinolysis

Question 8

What are the criteria for using alteplase in an ischemic stroke?

Answer 8

Administer within 3 hours of symptom onset (4.5 hours in select patients - not FDA approved tho)
Administer within 60 minutes of presentation to hospital
BP should be <185/110

Question 9

Alteplase contraindications in ischemic stroke

Answer 9

Active internal bleeding
Hx of stroke in past 3 months
Severe or uncontrolled HTN
Prior ICH
Intracranial surgery or trauma <3 months
INR >1.7, aPTT >40; platelets <100,000
LMWH within 24 hours
direct thrombin inhibitor or factor Xa inhibitor within 48 hours
blood glucose <50

Question 10

ASA in ischemic stroke

Answer 10

162-325mg within 24-48 hours after stroke is recommended to prevent recurrent stroke
Do not use within 24 hours of alteplase

Question 11

HTN management in ischemic stroke

Give what drugs to obtain what goal?

Answer 11

use labetalol, nicardipine or clevidipine to lower BP to <185/110 before alteplase and maintain for 24 hours after infusion

Question 12

DVT prevention in someone with ischemic stroke that received alteplase

Answer 12

Do not use LMWH within 24 hours after alteplase

Use intermittent pneumatic compression (IPC) devices

Question 13

What modifiable risk factors should be addressed for secondary prevention of ischemic stroke?

Answer 13

HTN
HLD
DM
Afib
Nutrition (sodium <2.4g)
Physical activity
Weight reduction
Alcohol intake

Question 14

What HTN medications should be used as secondary prophylaxis for ischemic stroke?
What is the BP goal in someone with hx of stroke?

Answer 14

ACEi and thiazide type diuretics

<130/80

Question 15

Patients should receive ASA after ischemic stroke (24 hours after alteplase if given) - what should be used if ASA is contraindicated?

Answer 15

Clopidogrel

do NOT use prasugrel (CI in hx of stroke)

Question 16

What medication is commonly used in combination with ASA after ischemic stroke?

Answer 16

dipyridamole

Question 17

Dipyridamole MOA

Answer 17

Inhibits uptake of adenosine into platelets and increases cAMP levels which inhibits platelet aggregation

Question 18

Should seizure prophylaxis be used in patients with hemorrhagic stroke?

Answer 18

No - only treat if they occur

Question 19

Mannitol mechanism of reducing intracerebral pressure

Answer 19

Causes osmotic diuresis by preventing tubular reabsorption of water and electrolytes and increases urinary output

Question 20

Mannitol contraindications and warnings

Answer 20

CI: severe renal disease (anuria), hypovolemia, pulmonary edema
Warnings: CNS toxicity if accumulation, extravasation, nephrotoxicity

Question 21

What medication is used to prevent vasospasms in acute subarachnoid hemorrhage (SAH)

Answer 21

oral nimodipine
Vasospasms can occur 3-21 days after bleed
***this is its ONLY indication - not indicated for HTN

Question 22

Should seizure prophylaxis be used in patients with subarachnoid hemorrhage (SAH)?

Answer 22

Yes - short term only

Question 23

Why is nimodipine more selective for cerebral arteries?

Answer 23

it is more lipophilic

Question 24

Nimodipine BBW, CI

Answer 24

BBW: do not administer parenterally (IV) - can cause death and serious life-threatening adverse events
CI: increased risk of significant hypotension when used in combo with CYP3A4 inhibitors

Question 25

How to administer nimodipine if the patient cannot swallow the capsule?

Answer 25

Pull it up into a syringe and transfer into an oral syringe that cannot accept a needle