Stroke

Question 1

What are the types of Ischemic Stroke?

Answer 1

-atherosclerotic stroke
-embolic stroke
-transient ischemic stroke (TIA)

Question 2

What are the types of Hemorrhagic stroke?

Answer 2

-subarachnoid hemorrhage
-intracerebral hemorrhage

Question 3

What are the risk factors of Ischemic stroke?

Answer 3

-age > 55yo
-race: AA > caucasian
-sex: M>F (young) & F>M (old)
-genetics
-smoking
-HTN
-DM
-dyslipidemia
-AFib
-obesity
-cardiac disease
-physical inactivity/poor diet

Question 4

What are the risk factors for Hemorrhagic stroke?

Answer 4

-genetics
-cerebral cavernous malformation
-bleeding disorders
-cerebral aneurysm
-HTN
-anticoagulants/antiplatelets
-trauma

Question 5

What are the presentations of a stroke?

Answer 5

-unilateral (one-sided)
-hemiparesis
-deficits associated with specific portions of the brain
-loss of balance
-loss of vision
-one-sided weakness
-difficulty or inability to speak
-dizziness/vertigo
-headache (more common in hemorrhagic stroke)

Question 6

What are the laboratory/vitals obtained for initial assessment of stroke?

Answer 6

-blood glucose
-INR/PT, platelets
-blood pressure

Question 7

What is the imaging obtained for initial assessment of stroke?

Answer 7

-CT (quicker than MRI)
-CT angiogram (CTA)
-carotid doppler, ECG, TTE

Question 8

What NIH Stroke Scale constitutes a mild stroke?

Answer 8

1-5

Question 9

What are the goals of therapy of stroke treatment?

Answer 9

-reduce ongoing neurologic injury
-reduce mortality
-reduce long term disability
-prevent complications
-prevent reoccurrence of stroke

Question 10

What are the pharmacological treatment options for acute management of ischemic stroke?

Answer 10

-thrombolytic
-endovascular therapies
-aspirin
-other (BP control, VTE prophylaxis, core measures)

Question 11

What is the MOA of thrombolytics?

Answer 11

initiates fibrinolysis by binding to fibrin in the clot and converts entrapped plasminogen to plasmin

Question 12

What drugs are Thrombolytics?

Answer 12

-Alteplase
-Tenecteplase

Question 13

What are the monitoring parameters when utilizing thrombolytic therapy?

Answer 13

-neurological assessments (Q15min during first hour)
-BP
-signs and symptoms of bleeding

Question 14

What NIHSS score would be appropriate to treat with thrombolytics?

Answer 14

> 5 (not mild stroke)

Question 15

How many hours after symptom onset do thrombolytics need to be administered?

Answer 15

4.5h, 3h ideal

Question 16

What are some of the requirements of using thrombolytics?

Answer 16

• > 18 yo
  -BP < 185/110mmHg
  -CT ruled out hemorrhage
  -blood glucose > 50mg/dL

Question 17

What are the absolute contraindications for using thrombolytics?

Answer 17

-SAH or ICH on imaging or signs and symptoms
-use of DOAC in past 48h
-use of warfarin or LMWH 24h prior
-infective endocarditis
-intra-axial, intracranial neoplasm
-aortic arch dissection
-active bleed
-coagulopathy
-severe head trauma in last 3 months
-GI bleed or malignancy prior 21d

Question 18

What is the Thrombolytic Assessment Checklist?

Answer 18

1. time (within 4.5h)
2. severity (moderate-severe stroke, NIHSS > 5)
3. blood pressure BP < 185/110mmHg
4. blood glucose > 50
5. contraindications

Question 19

What are the complications of thrombolytics?

Answer 19

bleeding, intracranial hemorrhage

Question 20

What is a thrombectomy?

Answer 20

vascular procedure to remove clot causing infarction (acute management)

Question 21

What is a carotid endarterectomy?

Answer 21

surgical removal of artherosclerotic plaque in carotid arteries (secondary prevention)

Question 22

What is the treatment dose of Aspirin for stroke?

Answer 22

-no thrombolytic= 160-325mg, given as soon as possible
-thrombolytic= 160-325mg, given 24h after thrombolytic

Question 23

What is permissible BP in a pt that does not receive a thrombolytic?

Answer 23

<220/120 mmHg

Question 24

What acute blood pressure agents may be administered?

Answer 24

-labetalol
-nicardipine
-clevidipine

Question 25

What is VTE prophylaxis protocol?

Answer 25

-thrombolytic= 24h after thrombolytic given -no thrombolytic= day 1 of admission

Question 26

What drugs can be given for VTE prophylaxis?

Answer 26

-heparin 5000 units SQ Q8-12h -enoxaparin 30mg SQ BID -enoxaparin 40mg SQ daily

Question 27

What is the first line antiplatelet therapy for secondary prevention of ischemic stroke?

Answer 27

aspirin 50-81mg daily

Question 28

What is the indication of P2Y12s?

Answer 28

-clopidogrel= could be monotherapy or in combo with aspirin in minor stroke (NIHSS score 3 or less) or high risk TIA -ticagrelor= only in combo with aspirin in minor stroke (NIHSS < 5) or high risk TIA

Question 29

What are the adverse effects of P2Y12s?

Answer 29

-hemorrhage -bruising, hematoma -epistaxis -additional SE of ticagrelor: dyspnea, increased uric acid, increased SCr

Question 30

What should be avoided while taking Clopidogrel?

Answer 30

CYP2C19 inhibitors (omeprazole) decrease metabolism of clopidogrel

Question 31

Which P2Y12 is contraindicated in history of stroke?

Answer 31

prasugrel

Question 32

Which P2Y12 is not indicated in stroke?

Answer 32

cangrelor

Question 33

What is the indications of Dual Antiplatelet Therapy (DAPT)

Answer 33

minor strokes or high-risk TIA

Question 34

What is the recommended statin therapy for secondary prevention of stroke?

Answer 34

high intensity statin= atorvastatin 40-80mg or rosuvastatin 20-40mg

Question 35

What is the treatment protocol for Hemorrhagic stroke?

Answer 35

*anticoagulation reversal!* -warfarin= vit K, prothrombin complex concentrate -heparin= protamine -dabigatran= idarcizumab -apixaban, rivaroxaban, edoxaban= andexanet alfa may also treat any clinical seizures or BP