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?

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 **stroke** 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)