Stroke

Question 1

What is a stroke?

Answer 1

• Interruption of blood flow to areas of the brain

Question 2

What are the different types of strokes?

Answer 2

• Acute ischemic stroke (cardio & non-cardio)
• Hemorrhagic Stoke (bleeding in brain))

87% are Ischemic & 13% are Hemorrhagic

Question 3

What are the different types of acute ischemic strokes?

Answer 3

• Thrombus: clot that forms during cerebral artherosclerotic infarctions (NON-cardiac - starts in brain not heart)
• Embolus: clots that forms in heart and travels to brain (more common in those with Afib)

Question 4

What is a transient ischemic attack (TIA)?

Answer 4

• “mini-stroke” where there is a temporary clot that blocks the blood flow to the brain

Question 5

What are some of the modifiable risk factors for strokes?

Answer 5

• HYPERTENSION (most important)
• Afib
• Dyslipidemia
• Diabetes
• Physical Inactivity
• Smoking

Question 6

What are some of the non-modifiable risk factors for Strokes?

Answer 6

• Priors stroke or TIA
• Advanced age (> 80 yo)
• Race (higher risk in african americans)
• Sickle Cell diseases

Question 7

What are some of the signs and symptoms of someone that is having a Stroke?

ACT F.A.S.T

Answer 7

• Face drooping
• Arm weakness
• Slurred Speech
• Time to call 911

Question 8

What is one of the first things that happens (within 20 minutes of arrival) when a patient comes to the ED when they are to be having a Stroke?

Answer 8

• Computed Tomography (CT): helps determine which type of stroke it is (Hemorrhagic or not)

Question 9

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What is the MOA of Alteplase?

Answer 9

• Tissue Plasminogen Activator (tPA) that binds to Fibrin in the clot and converts that plasminogen to plasmin = Fibrinolysis (destruction of clot)
• Only FDA approved drug for Acute Ischemic Stroke

Question 10

Which patients are candidates for receiving altaplase?

Answer 10

• NO bleeding on brain scans
• Stroke symptoms onset < 4.5 hours
• Can be giving within 60 mins of arrival (door-to-needle)

Question 11

What are some things to be aware of before giving a patient altaplase for their acute ischemic stroke?

Answer 11

• Active bleed?
• Risk of internal bleed due to BP > 185/110 (NEEDS to be lowered with Labetalol or Nicardipine), head trauma, elevated INR, low platelets…

Question 12

What is the dosing for altaplase (activase)?

Answer 12

• 0.9 mg/kg (MAX 90 mg)
• MUST rule out hemorrhagic stroke before giving

Question 13

What are the contraindications for Altaplase used for Stroke?

Answer 13

• if active internal bleeding
• if history of recent strokes
• Severe Hypertension (> 185/110)
• if INR > 1.7
• if Blood glucose < 50

Question 14

What are the side effects for altaplase used for Stroke?

Answer 14

• MAJOR bleeding

Question 15

What are some things toMonitor for altaplase used for Stroke?

Answer 15

• Hgb, Hct, S/Sx of Bleeding (basically all the blood stuff)
• Neurological Assessments and BP (Must be < 185/110)

Question 16

What are some other treatments to consider when someone has had a stroke/

Answer 16

• Aspirin 81 - 325 mg ASAP: helps prevent recurrent stroke (DO NOT give within 24 hours of altaplase)
• DVT: cuffs over legs or heparins (DO NOT give within 24 hours of altaplase)
• HTN: IV antihypertensives (labetalol or Nicardipine) really only when super severe HTN (> 220/120)
• Glucose: maintain Blood sugars (too high may cause a mini stroke)

Question 17

What are some of the treatments for the Modifiable risk factors that can help with the secondary prevention of ischemia strokes?

HTN, Dyslipidemia, DM, AFib, Lifestyle?

Answer 17

• HTN: normally start few days after stroke - thiazides, ACEi & ARBs (goal of 130/80)
• Dyslipidemia: need stable LDL goals - high intensity statin or PCSK9
• Diabetes: all should be screened for diabetes if not already - treat normally
• Afib: Cardio stroke due to Afib NEEDS anticoag
• Lifestyle: smoking cessation, heart healthy diet, physical activity, loose weight limit alcohol

Question 18

For patients that have had a non-cardioembolic ischemic stroke or TIA which antiplatelet medications are recommended to be used?

Answer 18

• Aspirin, Aspirin/Extended Release dipyridamole, or Clopidogrel (helps reduce the risk of recurrent strokes)
• Prasugrl is NOT recommended due to increased risk of brain bleeds

Question 19

what is the MOA of Aspirin (Bayer, Bufferin, Ecotrin)?

Answer 19

• irreverisbly inhibits COX 1 & 2 = decreased prostaglandins & thromboxane A2 (decrese clot formations)

Question 20

What is the MOA for dipyridamole (Aggrenox)?

Answer 20

• Given with aspirin; it inhibits the reuptake of adenosine into platelets and increases cAMP = platelet aggregation inhibition

Question 21

what is the MOA for Clopidogrel (Plavix)?

Answer 21

-prodrug that irreversibly inhibits P2Y12 decreasing platelet aggreations

Question 22

What are the contraindications for Aspirin used for Stroke?

Answer 22

• NSAID or salicylate allergy
• if childern & teens have a viral infection (Reyes Syndrome

Question 23

What are the warnings for Aspirin used for Stroke?

Answer 23

• Bleeding (including GI bleed, incresaed risk with heavy alcohol use or using other drugs with bleeding risks)
• Tinnitus (toxicity)

Question 24

What are the side effects for aspirin used for Stroke?

Answer 24

• Dyspepsia, Heartburn, Bleeding

Question 25

What are the **additional notes** for **aspirin** used for **Stroke**?

Answer 25

- **PPIs** may be used for **GI protection** (reduce ulcers) - but PPIs ahve their own risks (**decreased bone density and increased infections**)

Question 26

What are the **warnings** for **aggrenox** used for **Stroke**?

Answer 26

- **hypotension** and chest pain (due to **vasodilatory effects**)

Question 27

What are the **side effects** for **aggrenox** used for **Stroke**?

Answer 27

- Headache

Question 28

What are the **additional notes** for **aggrenox** used for **Stroke**?

Answer 28

- **NOT** interchangeable with the individual components (aspirin and dipyridamole)

Question 29

What are the **boxed warnings** for **clopidogrel** used for **Stroke**?

Answer 29

- **Prodrug** - need to check on **2C19 genotypes** (Poor metabolizers have higher cardio events than normals)

Question 30

What are the **contraindiactions** for **Clopidogrel** used for **Stroke**?

Answer 30

- if having **active serious bleeding**

Question 31

What are the **warnings** for **clopidogrel** used for **Stroke**?

Answer 31

- Bleeding risk: STOP **5 days** before **surgery**, DO NOT use with **omeprazole or esomeprazole** (drug-drug interactions)

Question 32

What are the **additional notes** for **clopidogrel** used for **Stroke**?

Answer 32

- DOC in stroke/TIA if **Aspirin** is **contraindiacted or allergy**

Question 33

What is **Intracranial Pressure**?

Answer 33

- Cause by **increased blood volume** and **edema** in a relatively fixed **intracranial space** (main complicaiton of ICH) - **MEDICAL EMERGENCY** = brain death

Question 34

What are some things that need to be done if a patient has a **severe coagulation facter deficiency or thrombocyntopenia** as it relates to **intracerebral hemorrhages (ICH)**?

Answer 34

- Anticoags **SHOULD** be stopped and **reversal** agents given - If clinical evidence of **seizures**: treat them BUT should not do **prophylactic antiseizure** meds

Question 35

What are some of the **treatment options** for someone that is experiencing **intracranial pressure**?

Answer 35

- Elevating the head of the bed by **30 degrees** AND giving **IV osmotic therapies** with either **hypertonic saline** (NaCl 3%, NaCl 23.4%) or **Mannitol** ## Footnote These drugs help with **drawing water out of the brain**

Question 36

What are the **contraindications** for **Mannitol** used for **Stroke**?

Answer 36

- those with Severe **renal disease**

Question 37

What are the **side effects** for **mannitol** used for **Stroke**?

Answer 37

- Dehydration, Headache, Lethargy, Increased or Decreased BP

Question 38

What are the **Additional notes** for **mannitol** used for **Stroke**?

Answer 38

- Inspect for **crystals** before giving; if solution has crystals then warm it bruh - Use a **filter** with concencrations > 20%

Question 39

What is a **acute subarachnoid hemorrhage (SAH)**?

Answer 39

- bleeding in the space that is between the brain and the surrounding membrane that results from a **cerebral ANEURYSM rupture** causing a **severe headache** ("worst headache ever experienced")

Question 40

What medications helps with **acute subarachnoid hemorrhages**? what does it help with?

Answer 40

- Nimodipine (Nymalize) - helps with improving the outcomes of **cerebral artery vasospasms** which can occur 3 - 21 days after bleeding

Question 41

What is the **MOA** of **Nimodipine**/

Answer 41

- **Calcium Channel Blocker** that is selective for **cerebral arteries** due to the increase **lipophilicity** - **ONLY** inducatied for SAH

Question 42

What are the **boxed warnings** for **Nimodipine** used for **Stroke**?

Answer 42

- **DO NOT** give **IV** = **Death or serious life threating adverse effects** (Cardiac arrest, cardio collapse, hypotension, bradycardia) when the capsules contents have been injected

Question 43

What are the **side effects** for **Nimodipine** used for **Stroke**?

Answer 43

- Hypotension

Question 44

What are the **additional notes** for **Nimodipine** used for **Stroke**?

Answer 44

- If **caps** cannot be **swallowed** with no oral solution available then **contents from caps can be withdrawn** and transfer to **oral syringe** - Label Oral syringes **"For Oral Use Only" OR "Not for IV Use** (because of the boxed warnings)