Stroke

Question 1

Define Thrombus

Answer 1

Localized clot that forms during a cerebral atherosclerotic infarction (non-cardioembolic)

Question 2

Define embolus

Answer 2

Forms in the hearts → travels to the brain

Question 3

What is a stroke

Answer 3

CVA where blood flow to the brain is interrupted

Question 4

What is a TIA

Answer 4

Mini stroke → temporary clot in the brain

Question 5

Modifiable risk factors of a stroke

Answer 5

HTN
A fib
DLD
Diabetes
Physical inactivity
Smoking

Question 6

Non-modifiable risk factors of a stroke

Answer 6

Prior stroke/TIA
Advanced age
African American
Genetic disease

Question 7

Sx of stroke

Answer 7

Face dropping
Arm weakness
Speech difficulty
Time to call 911

Question 8

Diagnose what type of stroke

Answer 8

CT imaging 20 min of arrival

Question 9

What is the treatment goal of ischemic stroke?

Answer 9

Restore blood flow to the brain

Question 10

MOA of fibrinolytics

Answer 10

Binds to fibrin in the thrombus and converts plasminogen to plasmic

Question 11

What fibrinolytic is approved for ischemic stroke?

Answer 11

Alteplase
TNKase (off-label)

Question 12

When to administer fibrinolytic for stroke

Answer 12

≤4.5 hrs of sx onset (FDA ≤3hr)

Alteplase can be administered within 60 min of arrival

Question 13

How to manage bleeding risk of fibrinolytics

Answer 13

1. Active internal bleed
2. Risk of internal bleed
   - Severe HTN (<185/110): Lower BP using IV HTN (labetalol, nicardipine) → then alteplase

Question 14

What is the dose of alteplase?

Answer 14

0.9 mg/kg (Max: 90 mg)

Administer 10% IV bolus → infuse the rest over 60 min

Question 15

CI of alteplase

Answer 15

Active internal bleeding
Recent stroke
Severe HTN
INR >1.7
Treatment with anticoagulants
BG <50

Question 16

ADR of alteplase

Answer 16

Major bleeding

Question 17

When should aspirin be initiated?

Answer 17

Within 48hrs

Question 18

HTN management if alteplase was not given

Answer 18

Labetalol, nicardipine may not be required unless >220/120

Permissive HTN to allow blood flow to brain, but not enough to hemmorhage

Question 19

Secondary prophylaxis for stroke

Answer 19

HTN: thiazide, ACEI, ARB
DLD: high-intensity statin
Diabetes: ADA guidelines
AF: Anticoagulation
Smoking cessation
Sodium restriction <1.5 g/day
Physical activity 150 min/wk
BMI 18.5-24.9
Waist <35 in women, <40 in men

Question 20

Anitplatelet that can be used post stroke

Answer 20

ASA, ASA/dipyridamole, clopidogrel

Question 21

When and how long do you initiate clopidogrel and low-ASA?

Answer 21

Combo given within 24 hr of minor stroke → continued for 21-90 days

Question 22

MOA of dipyrimadole

Answer 22

Inhibits the uptake of adenosine into platelets → ↑ cAMP → inhibits platelet aggregation

Question 23

CI of ASA

Answer 23

Salicylate allergy, Viral infection → Reye’s syndrome

Question 24

ADR of ASA

Answer 24

Tinnitus, bleeding, dyspepsia, heartburn

Question 25

Counseling of ASA

Answer 25

Initiate PPI to protect gut, but ↓ bone density and ↑ infection risk

Question 26

Aspirin

Answer 26

Bayer, Buffering, Ecotrin

Question 27

ER Dipyrimidamole/ASA

Answer 27

Aggrenox

Question 28

ADR of Aggrenox

Answer 28

HA, Hypotension → vasodilatory effects

Question 29

BBW of Clopidogrel

Answer 29

CYP2C19 genotyping Avoid Omeprazole and esomeprazole

Question 30

Warning and ADR of Clopidogrel

Answer 30

TTP, bleeding (stop 5 days before elective surgery) Drug of choice is CI or allergy to ASA

Question 31

Antiplatelet of choice for stroke

Answer 31

Aspirin

Question 32

What to do prior to treating ICH

Answer 32

DC anticoagulants and initiate reversal agents Avoid prophylactic seizure meds

Question 33

What is the treatment for ICH

Answer 33

IV osmotic therapy: hypertonic saline or mannitol → draws water out of brain into intravascular space

Question 34

CI of mannitol

Answer 34

Severe renal disease

Question 35

Counseling of mannitol administration

Answer 35

Inspect for crystals → warm the solution to redissolve Use filter to administer is concentration ≥20%

Question 36

Define SAH

Answer 36

Cerebral aneurysm rupture → severe headache

Question 37

Treatment of SAH

Answer 37

Surgical clipping o endovascular coiling to remove aneurysm → cerebral artery vasospasm occur 3-21 days after bleed due to delayed cerebral ischemia → Initiate nimodipine to improve outcomes and ischemia

Question 38

MOA of nimodipine

Answer 38

DHP CCB that is selective for cerebral arteries due to increased lipophilicity

Question 39

BBW of nimodipine

Answer 39

Don't administer IV → death, serious ADR

Question 40

ADR of nimodipine

Answer 40

Hypotension

Question 41

Counseling of administration of nimodipine

Answer 41

If capsules can't be swallowed → withdraw with parenteral syringe and transfer to oral syringe and administer NG tube or PO Label syringe "Oral use only" or "Not for IV use"