Chapter 33: Stroke

Question 1

What is a stroke?

Answer 1

A stroke, or cerebrovascular accident (CVA), occurs when blood flow to an area of the brain is interrupted.

Question 2

What are the types of stroke?

Answer 2

Types of stroke include:
* Acute ischemic stroke
* Hemorrhagic stroke

Question 3

What causes acute ischemic stroke?

Answer 3

Acute ischemic stroke can be caused by:
* A thrombus (localized clot)
* An embolus (clot that travels from the heart)

Question 4

What is a non-cardioembolic stroke?

Answer 4

A thrombus that forms during a cerebral atherosclerotic infarction, indicating the origin is in the brain.

Question 5

What is a cardioembolic stroke?

Answer 5

An embolus that forms in the heart and travels to the brain, often caused by atrial fibrillation.

Question 6

What is hemorrhagic stroke?

Answer 6

Bleeding in the brain, most often an intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH).

Question 7

What is a transient ischemic attack (TIA)?

Answer 7

A TIA, or ‘mini-stroke,’ is caused by a temporary clot in the brain, with symptoms resembling acute ischemic stroke.

Question 8

What is the most important modifiable risk factors for stroke?

Answer 8

Hypertension and atrial fibrillation

Question 9

What are the non-modifiable risk factors for stroke?

Answer 9

• Prior stroke or TIA
• Advanced age (e.g., ≥ 80 years)
• Race (higher risk in African American patients)
• Genetic diseases (e.g., sickle cell disease)

Question 10

What does the ACT F.A.S.T. stand for?

Answer 10

Face drooping
Arm weakness
Speech difficulty
Time to call 911

Question 11

What is the role of brain imaging in stroke diagnosis?

Answer 11

To quickly identify whether the stroke symptoms are due to a hemorrhage.

Question 12

What is the immediate goal of treatment for ischemic stroke?

Answer 12

To restore blood flow to the ischemic area of the brain.

Question 13

What is alteplase?

Answer 13

Recombinant tissue plasminogen activator (tPA or rtPA).

Question 14

What does alteplase do?

Answer 14

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

Question 15

What is the FDA-approved timeline for administering alteplase after stroke symptom onset?

Answer 15

≤ 3 hours.

Question 16

What is the guideline recommendation for alteplase administration time after symptom onset?

Answer 16

≤ 4.5 hours.

Question 17

What is the door-to-needle time for alteplase administration?

Answer 17

Within 60 minutes of hospital arrival.

Question 18

What must be checked before administering alteplase?

Answer 18

That the patient has no contraindications to use such as
• Active internal bleed (e.g., (CH)
• Risk of internal bleed, due to:
• Severe hypertension (BP > 185/110 mmHg): if this is the only contraindication to treatment, BP should be lowered to < 185/110 mmHg with IV medications (e.g., labetalol, nicardipine) before proceeding with alteplase administration
• Other conditions (e.g., head trauma)
• Labs (e.g., elevated INR, low platelet count)
• Drug interactions (e.g., anticoagulant use)

Question 19

What blood pressure should be maintained before administering alteplase if severe hypertension is the only contraindication?

Answer 19

BP < 185/110 mmHg.

Question 20

What is the dosing for Alteplase in stroke treatment?

Answer 20

0.9 mg/kg (maximum dose 90 mg)

Administer 10% of the calculated dose as a bolus over 1 minute, then infuse the remainder over 60 minutes

Question 21

What must be ruled out before administering Alteplase?

Answer 21

Hemorrhagic stroke

Examples include CH (cerebral hemorrhage) and SAH (subarachnoid hemorrhage)

Question 22

List contraindications for Alteplase administration.

Answer 22

• Active internal bleeding
• History of recent stroke (within the past 3 months)
• Severe uncontrolled hypertension (BP > 185/110 mmHg)
• Treatment-dose LMWH within previous 24 hours
• Use of direct thrombin or factor Xa inhibitors within previous 48 hours
• Warfarin with INR > 1.7
• Blood glucose < 50 mg/dL

Question 23

What is a major side effect of Alteplase?

Answer 23

Major bleeding

Question 24

What monitoring is required after administering Alteplase?

Answer 24

• Hgb, Hct
• Signs/symptoms of bleeding
• Neurological assessments
• Blood pressure (must be ≤ 185/110 mmHg before starting and maintained at < 180/105 mmHg for 24 hours after infusion)

Question 25

What should be done if severe headache or worsening neurological function occurs during Alteplase infusion?

Answer 25

Discontinue the infusion and obtain an emergent head CT

Question 26

What is the recommended initiation of aspirin after stroke onset?

Answer 26

81 - 325 mg PO daily within 48 hours

Question 27

What is the safe reduction in blood pressure during the first 24 hours after stroke onset?

Answer 27

15% reduction if BP is severely elevated (≥ 220/120 mmHg)

Question 28

What blood glucose levels should be maintained to prevent hypoglycemia after stroke?

Answer 28

140 - 180 mg/dL

Question 29

What is the recommended blood pressure goal for most patients post-stroke?

Answer 29

BP < 130/80 mmHg ## Footnote This goal is part of hypertension management following a stroke.

Question 30

Which medications are recommended for hypertension management after a stroke?

Answer 30

* Thiazide diuretics * ACE inhibitors * ARBs ## Footnote These medications have the best evidence for stroke risk reduction.

Question 31

What is the recommended statin therapy for dyslipidemia in post-stroke patients?

Answer 31

High-intensity statin, specifically atorvastatin 80 mg/day ## Footnote Ezetimibe or a PCSK9 monoclonal antibody may be added if LDL goals are not achieved.

Question 32

How should diabetes be managed in post-stroke patients?

Answer 32

Screen for diabetes and treat according to the most recent ADA guidelines ## Footnote An A1C test is preferred for screening.

Question 33

What is the recommended antiplatelet therapy for non-cardioembolic ischemic stroke or TIA?

Answer 33

* Aspirin * Aspirin/extended-release dipyridamole * Clopidogrel ## Footnote These therapies reduce the risk of recurrent stroke, MI, or death.

Question 34

Which P12Y2 is contraindicated for patients with a history of TIA or stroke?

Answer 34

Prasugrel

Question 35

When can the combination of clopidogrel and low-dose aspirin be initiated?

Answer 35

Within 24 hours of a minor ischemic stroke

Question 36

What type of diet is recommended for heart health?

Answer 36

A Mediterranean diet

Question 37

What is the recommended sodium intake for blood pressure reduction?

Answer 37

< 1.5 grams/day

Question 38

What is the minimum physical activity recommendation for post-stroke patients?

Answer 38

At least 10 minutes of moderate-intensity exercise four days per week

Question 39

What are the target BMI and waist circumference for weight reduction in post-stroke patients?

Answer 39

* BMI 18.5 - 24.9 kg/m² * Waist < 35 inches for women and < 40 inches for men

Question 40

What is the recommended limit for alcohol intake post-stroke?

Answer 40

≤ 2 drinks/day for males and ≤ 1 drink/day for females

Question 41

Aspirin brand name

Answer 41

Bayer Bufferin Ecotrin

Question 42

What are the contraindications for aspirin use?

Answer 42

* NSAID or salicylate allergy * Children and teenagers with viral infection (risk of Reye's syndrome)

Question 43

What are some potential side effects of aspirin?

Answer 43

* Dyspepsia * Heartburn * Bleeding * Nausea

Question 44

What is a key warning associated with dipyridamole in Aggrenox?

Answer 44

Hypotension and chest pain due to vasodilatory effects

Question 45

What is the main boxed warning for Clopidogrel (Plavix)?

Answer 45

Clopidogrel is a prodrug, and its effectiveness depends on conversion by CYP450 2C19

Question 46

What are the contraindications for Clopidogrel?

Answer 46

Active serious bleeding (e.g., GI bleed, intracranial hemorrhage)

Question 47

What is the drug of choice for stroke/TIA if there is an allergy to aspirin?

Answer 47

Clopidogrel (Plavix)

Question 48

How long prior to elective surgery stop clopidogrel?

Answer 48

5 days

Question 49

What are common drug interactions with antiplatelet drugs?

Answer 49

* Anticoagulants * NSAIDs * SSRIs * SNRIs * Some herbals

Question 50

What should be avoided in combination with Clopidogrel?

Answer 50

Omeprazole and esomeprazole

Question 51

What is the primary complication of an intracerebral hemorrhage (ICH)?

Answer 51

Increased intracranial pressure (ICP)

Question 52

What are common causes of intracerebral hemorrhage (ICH) besides traditional stroke risk factors?

Answer 52

* Trauma (e.g., motor vehicle collision) * Use of antithrombotic medications (e.g., anticoagulants)

Question 53

What interventions can be used to lower increased intracranial pressure (ICP)?

Answer 53

* Elevating the head of the bed by at least 30 degrees * Administering IV osmotic therapy with hypertonic saline or mannitol

Question 54

What is the mechanism by which mannitol lowers ICP?

Answer 54

Increases plasma osmolarity, creating an osmotic gradient that draws water out of the brain parenchyma and into the intravascular space

Question 55

What are the contraindications for using mannitol?

Answer 55

* Severe renal disease (anuria)

Question 56

Fill in the blank: Mannitol should be used with a _______ for concentrations ≥ 20%.

Answer 56

filter

Question 57

What is Acute Subarachnoid Hemorrhage (SAH)?

Answer 57

Bleeding in the space between the brain and the surrounding membrane (subarachnoid space) ## Footnote Usually results from a cerebral aneurysm rupture and leads to a severe headache, often described as the 'worst headache ever experienced.'

Question 58

What are common treatments for SAH?

Answer 58

Surgical clipping or endovascular coiling to remove the aneurysm ## Footnote These procedures are performed when feasible to prevent rebleeding.

Question 59

What can occur 3 - 21 days after a SAH?

Answer 59

Cerebral artery vasospasm ## Footnote This condition can cause delayed cerebral ischemia.

Question 60

What medication is shown to improve outcomes associated with vasospasm-induced ischemia in SAH patients?

Answer 60

Nimodipine ## Footnote It should be initiated in patients with SAH.

Question 61

What are the dosing guidelines for Nimodipine?

Answer 61

60 mg PO Q4H for 21 days ## Footnote Adjusted to 30 mg PO Q4H for 21 days in patients with cirrhosis.

Question 62

What are the boxed warnings for Nimodipine?

Answer 62

Do not administer IV or by other parenteral routes; risk of death and serious life-threatening adverse events ## Footnote Including cardiac arrest and hypotension.

Question 63

What are the common side effects of Nimodipine?

Answer 63

Hypotension ## Footnote Monitoring of blood pressure is essential.

Question 64

What should be labeled on oral syringes used for Nimodipine?

Answer 64

'For Oral Use Only' or 'Not for IV Use' ## Footnote This is to prevent medication errors.

Question 65

What are strong CYP3A4 inducers that should be avoided with Nimodipine?

Answer 65

* Rifampin * Carbamazepine * Phenytoin * St. John's wort ## Footnote These can decrease the levels of Nimodipine.

Question 66

True or False: Nimodipine is used as an antihypertensive treatment.

Answer 66

False ## Footnote It is only indicated for SAH.

Question 67

Fill in the blank: Nimodipine is a ______ calcium channel blocker.

Answer 67

dihydropyridine ## Footnote It is more selective for cerebral arteries due to increased lipophilicity.