Stroke

Question 1

Pathophysiology

Ischemic Stroke

Types: cardioembolic vs non-cardioembolic?

Answer 1

Blood clots (thrombus) block blood flow to brain
Thrombus usually formed by cerebral atherosclerotic infarction

Cardioembolic: clot forms in heart and travels to brain
* Common cause: atrial fibrillation

Non-cardioembolic: clot forms in brain, not the heart

Question 2

Acute treatments for Ischemic Stroke?

Answer 2

1. Fibrinolytics
2. Blood pressure control (if tPA not given)
3. Other treatments (antiplts, HTN management, hyperglycemia, DVT ppx)

Question 3

Acute treatments for Ischemic Stroke

Fibrinolytics

Medications and dosing?

Answer 3

1. Alteplase 0.9 mg/kg (max: 90 mg); 10% given IVP over 1 min, then 90% given IV infusion over 1 hour
2. TNKase 0.25 mg/kg (max: 25mg) IVP over 5 seconds; flush with NS

Question 4

Acute treatments for Ischemic Stroke

Fibrinolytics

tPA exclusions

Answer 4

Not hemorrhagic stroke
No active bleed – in non-compressible areas
No INR >1.7
No prior stroke/TIA (within 3 months)
No prior head trauma (within 3 months)
No BP >185/110
No LMWH within 24h OR DOAC within 48h

Question 5

Acute treatments for Ischemic Stroke

Fibrinolytics

tPA exclusion; BP control for BP >185/110

Answer 5

BP control (maintain BP <180/105)

*Labetalol 10-20 mg IV push over 1-2 minutes
*Nicardipine 5 mg/hr IV infusion
Clevidipine 1-2 mg/hr IV infusion

Question 6

Acute treatments for Ischemic Stroke

Fibrinolytics

tPA inclusion

Answer 6

Within 4.5 hours from symptom onset
Within 60 minutes (door-to-needle)

Question 7

Acute treatments for Ischemic Stroke

Blood pressure control

Answer 7

Permissive HTN: 220/120
MD will allow BP < 220/120 and hold/decrease meds up to 48 hrs after stroke

Rationale: increase BP, increase blood flow/perfusion

Question 8

Acute treatments for Ischemic Stroke

Other treatments: antiplatelets

Answer 8

1. Aspirin 160-325 mg AFTER 24 hours of tPA, but within 48 hours of stoke onset
2. Clopidrogel 300-600 mg
3. Short-term DAPT (ASA + Plavix) – indicated for patients with TIA or acute ischemic stroke who can swallow and do not have a known cardioembolic source of presentation

Question 9

Acute treatments for Ischemic Stroke

Other treatments: Hypertension management

Answer 9

Goal: <185/110
Maintain <180/105

Medications: labetalol, nicardipine, clevidipine

Question 10

Acute treatments for Ischemic Stroke

Other treatments: Hyperglycemia management

Answer 10

Goal: 140-180 mg/dL

Question 11

Acute treatments for Ischemic Stroke

Other treatments: Deep Vein Thrombosis (DVT) prevention

Answer 11

Intermittent Pneumatic Compression (IPC) devices – squeeze legs to increase blood flow
Medications: UFH, LMWH (only after 24h of receiving alteplase)

Question 12

Secondary Prevention (outpatient) for Ischemic Stroke?

Answer 12

1. Hypertension
2. Dylipidemia
3. Afib management – for cardioembolic
4. Antiplts – for non-cardioembolic

Question 13

Secondary Prevention for Ischemic Stroke

Hypertension management

Answer 13

Goal: BP <130/80
ACEi and thiazide-type diuretics

Question 14

Secondary Prevention for Ischemic Stroke

Dyslipidemia

Answer 14

Goal: LDL >70
High-intensity statins – Lipitor 40-80 mg, Crestor 20-40 mg

Question 15

Secondary Prevention for Ischemic Stroke

Atrial fibrillation

for cardioembolic

Answer 15

Anticoagulants

Question 16

Secondary Prevention for Ischemic Stroke

Antiplatelets

for non-cardioembolic

Answer 16

1. Aspirin
2. DAPT – aspirin + clopidogrel
3. Aspirin/dipyridamole (Aggrenox)
4. Cilostazol (Pletal)

Question 17

Pathophysiology

Hemorrhagic Stroke

Answer 17

Brain bleed due to ruptured blood vessel

Two types: (1) intracranial, (2) acute subarachnoid

Intracranial etiology: ↑ intracranial pressure (ICP)

Question 18

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

UFH, LMWH, warfarin, anti-Xa , Pradaxa, argatroban (just antidote)

Answer 18

Heparin –> protamine
LMWH –> Andexxa, protamine
Warfarin –> vit K, Kcentra (w/ vit K), fresh frozen plasma (FFP), Novoseven RT
Apixaban, rivaroxaban –> Andexxa
Pradaxa –> Praxbind

Question 19

Management of Hemorrhagic Stroke

Answer 19

1. reversal of anticoagulants
2. IV fluids (+ elevate head 30 deg)
3. anticonvulsants – only for seizure tx, NOT ppx
4. Non-invasive cerebral angiogram

Question 21

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

Protamine dose for UFH

Answer 21

1 mg of protamine for each ~100 units of heparin
* Since UFH has a very short half-life (1-2 hours), reverse the amount of heparin given in the last 2-2.5 hours

Question 21

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

Protamine dose for LMWH (enoxaparin, dalteparin)

Answer 21

Enoxaparin
Within 8 hours: 1 mg protamine per 1 mg
> 8 hours ago: 0.5 mg protamine per 1 mg

Dalteparin
1 mg protamine for each 100 anti-Xa units

Question 22

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

Andexxa doses (high and low) for LMWH

Answer 22

High dose: 800 mg IV bolus at 30 mg/minute over 30 minutes, followed by 960 mg IV infusion at 8 mg/minute for up to 120 minutes

Low dose:

Question 23

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

Vitamin K indication and dose for warfarin

Answer 23

1-10 mg PO/IV

Avoid SQ and IM
IV must be SLOW IV infusion and diluted
* BBW: hypersensitivty, anaphylaxis, SE: hypotension

If no significant/major bleeding → PO
* INR >10 WITHOUT bleeding –> 2.5-5mg PO
If serious bleeding → IV infusion (NEVER PUSH) AND Kcentra
* Major, life-threatening bleed –> 5-10 mg SLOW IV injection

Question 24

Management of Hemorrhagic Stroke

Reversal of Anticoagulants

KCentra indication and dose for warfarin

Answer 24

Indication: severe bleeding
Factors 2, 7, 9, 10
ALWAYS administer with vitamin K

Dosing based on body weight and INR
Do not repeat dose

Question 25

# Management of Hemorrhagic Stroke Reversal of Anticoagulants | Andexxa for factor Xa inhibitors

Answer 25

IV bolus, followed by infusion Dosing is specific to the Xa inhibitor, the dose and when the last Xa inhibitor dose was taken

Question 26

# Management of Hemorrhagic Stroke Reversal of Anticoagulants | Praxbind for Pradaxax

Answer 26

5 g IV give (2) 2.5 g doses no more than 15 min apart

Question 27

# Management of Hemorrhagic Stroke IV Fluids | (and elevate head 30 degrees)

Answer 27

Rationale: ↓ ICP Mannitol Hypertonic saline (3% NS)

Question 28

# Management of Hemorrhagic Stroke Non-invasive cerebral angiography

Answer 28

computed tomography angiography (CTA)/magnetic resonance angiography (MRA) within 48 hours of onset should be considered for all patients

Question 29

# Pathophysiology Subarachnoid Hemorrhage (SAH)

Answer 29

cerebral aneurysm rupture → sx include severe headache

Question 30

Management of Subarachnoid Hemorrhage (SAH)?

Answer 30

Nimodipine 60 mg PO q4hr * Rationale: prevent vasospasm (usually occurs 3-21 days after the bleed) * DHP CCB that is more selective for cerebralk arteries due to increasewd lipophilicity --> only indicated for SAD * BBW: NO IV, causes life-threatening adverse events (e.g. hypotension) * If it cannot be swallowed, puncture and withdraw contents of the capsule with a parenteral/needle syringe --> transfer to oral syringe to be administed through a nasogastric tube