Stroke

Question 1

Types of Strokes

Answer 1

-Acute ischemic stroke: thrombus (localized clot formed in brain area) or embolus (clot in heart and travels to brain area, commonly seen with A-fib)
*87% precent of strokes

-Hemorrhagic stroke: bleeding in the brain (ICH or SAH)

-Transient ischemic attack (TIA): mini stroke caused by a temporary clot and blockage of blood flow in brain

Question 2

Stroke Risk Factors

Answer 2

HTN - most important
Atrial fibrillation
Dyslipidemia, diabetes, smoking, inactivity
Prior stroke or TIA
Age, race, genetics

Question 3

Stroke Symptoms

Answer 3

ACT FAST
-Face drooping
-Arm weakness
-Speech difficulty
-Time to call 911

CT ideally done in 20 min (to see if hemorrhage)

Question 4

Alteplase Eligibility

Answer 4

-Negative CT (no active bleeding)
-Sx onset < 4.5 hours (FDA approved is < 3 hours)
-Uncontrolled severe HTN (> 185/110 - use IV labetalol/nicardipine if this is the only CI, maintain as < 180/105 for 24 hr after infusion)
-Head trauma/surgery
-Elevated INR 1.7+, low PLT count
-AC use (LMWH within 24 hr, direct Xa within 48 hr)
-Blood glucose 50-400
-Hx recent stroke (3 months)
-Any prior ICH

*must rule out hemorrhagic stroke before use

GOTCHA PISI

Question 5

Alteplase: Dosing for stroke, CI

Answer 5

Dosing: 0.9 mg/kg (max 90 mg)
-10% as bolus over 1 min, 90% over 60 min

CI: eligibility card (GOTCHA PI SIS)

Question 6

Other Treatments for Stroke

Answer 6

-Aspirin 81-325 mg ASAP within 48 hr (not given with 24 hr of alteplase)
-Compression devices
-If AC is used, start within 24 hr of giving alteplase
-If alteplase not given, IV BP meds might not be needed (unless > 220/120 = reduce 15% in first 24 hr)
-Maintain BG 140-180

CABAG

Question 7

Antiplatelet Treatment

Answer 7

Non-cardioembolic
-Aspirin
-Aspirin/ER dipyridamole
-Clopidogrel

*Clop + baby ASA can be used within 24 hr of MINOR stroke (no alteplase, NIHSS 3 or less)

Question 8

Aspirin: Dosing, CI, AE

Answer 8

Dosing: 50-325 mg daily

CI: NSAID or salicylate allergy
-Children/teenager (Reye’s)

AE: bleeding, tinnitus (salicylate allergy), dyspepsia, heartburn, nausea
-PPIs may be used to protect the gut with chronic NSAID use

STAN B

Question 9

Yosprala

Answer 9

Yosprala 81 mg / 40 mg or 325 mg / 40 mg
-DELAYED RELEASE

Indicated for those at risk of developing aspirin-associated gastric ulcers

Question 10

ER dipyridamole/aspirin (Aggrenox)

Answer 10

200 mg / 25 mg BID

Same for ASA component plus: HAH
-Hypotension (vasodilatory effects)
-Headache

*not interchangeable with the individual components of aspirin and dipyridamole

Question 11

Clopidogrel

Answer 11

Same as other chapters
-CYP 2C19 PM
-DDI omeprazole/eso
-Bleeding, TTP
-Stop 5 days prior to elective surgery

DOC if allergy to aspirin

Question 12

ICH Treatment

Answer 12

-AC should be d/c, give reversal agents
-Treat seizures if occur, but prophylactic anti-seizure meds should NOT be given preemptively

Lower ICP
-Elevate head of the bed by 30 degrees
-IV osmotic therapy (hypertonic saline 3% or 23.4%, or mannitol - draw water out of brain)

Question 13

ICH - Mannitol: CI, AE, Notes

Answer 13

Injection 5 10 15 20 25 %s

CI: BER has CHF
-Severe renal disease, hypovolemia, pulmonary edema, active intracranial bleed

AE:
-CNS toxicity
-Dehydration
-Headache
-Lethargy
-BP can increase or decrease

*Inspect for crystals before giving (warm up if present)
*Use a filter for administration with > 20%

Question 14

SAH Treatment

Answer 14

Nimodipine (Nymalize)

60 mg PO Q4h x 21 days
-Cirrhosis: 30 mg PO Q4h x 21 days

BBW: DONT GIVE IV (bc death, serious AE)

AE: Hypotension

DDI: CYP3A4 inhibitor/inducers

Notes: If capsules cannot be swallowed and oral solution is unavailable, contents can be withdrawn with a syringe then transferred to an oral syringe
-Label “for oral use only” or “not for IV use”