Stroke

Question 1

Acute Ischemic Stroke Can be caused by: (2 ways)

Hemorrhagic stroke: State what it is and how its caused

Answer 1

1. a thrombus that forms during a cerebral atherosclerotic infarction (this is referred to as a NON CARDIO EMBOLIC stroke)

• an embolus that forms in the heart and travels to the brain (cardioembolic stroke). common cause would be atrial fibrillation

2. bleeding in the brain; most often a ICH or Subarachnoid hemorrhage (SAH)

Question 2

1. whats referred to as a “mini stroke” and how is it caused?
2. How should this condition be medically managed?

Answer 2

1. TIA (transient ischemic attack), caused by a temporary clot and block of blood flow to the brain
2. same risk reduction strategies as ischemic stroke

Question 3

Modifiable Risk Factors for Stroke:

1. name 6

Non Modifiable Risk factors for Stroke:

2. Name 4

Answer 3

1. HTN (most important)
   AFib
   Dyslipidemia
   Diabetes
   Physical inactivity
   smoking
2. prior stroke or TIA
   advanced age (>= 80)
   Race (higher risk in african american pt’s)
   Genetic diseases (Sickle cell disease)

Question 4

When a person with a probable stroke arrives to the ED, what kind of imaging is done?

Answer 4

CT performed within 20 mins to quickly identify whether stroke sx’s are due to a hemorrhage

Question 5

Ischemic Stroke: Acute Management

1. whats the immediate goal of tx?
2. what is alteplase?
3. what does alteplase do?
4. alteplase is the ONLY fibrinolytic drug thats fda approved to treat ___

Answer 5

1. to restore blood flow
2. recombinant tissue plasminogen activator (tPA).
3. binds to fibrin in a thrombus and converts plasminogen to plasmin resulting in fibrinolysis
4. acute ischemic stroke

Question 6

Alteplase Admin:

1. A patient is a candidate if there is ____ seen on brain imaging and the following criteria for timing are met:
2. stroke sx onset is?
3. and alteplase can be administered within ?
4. before admin of alteplase one should check that the patient has NO ___ to use (see physical flashcard)

Answer 6

1. no bleeding
2. <= 4.5 hours
3. 60 mins of hospital arrival
4. contraindications

Question 7

ALTEPLASE:

1. Brand name for injection?
2. Dosing?
3. What must be done before administration?
4. CONTRAINDICATIONS:

a. active ___
b. history of ___
c. severe uncontrolled ___
d. INR of ?
e. treatment dose ___ within previous 24 hrs, use of a ___ or ___ within 48 hrs or taking ____ with an INR > 1.7
f. blood glucose < ____

5. Side effects ? (1)
6. Monitoring for? (3)
7. Monitoring that should be done before alteplase is started?
8. Note that for ACS, the __ and ___ differ

Answer 7

1. activase
2. 0.9 mg/kg (max dose 90 mg)
3. must rule out hemorrhagic stroke before use

4a. internal bleeding

b. recent stroke (within past 3 months)

c. HTN (BP > 185/110)

d. INR OF > 1.7

e. LMWH, Direct thrombin inhibitor, direct factor Xa inhib, warfarin

f. < 50

5. major bleeding (ICH)
6. Hgb, Hct, s/sx of bleeding
7. neurological assessment and BP (must be < 185/110)
8. contraindications, dosing

Question 8

Other TXs:

1. aspirin
   -initiation at what dose?
   -when should it be initiated?
   -when should it NOT be given?
2. HTN management
   -If alteplase is NOT administered IV antihypertensives MAY NOT BE REQUIRED unless?
3. DVT ppx and Hyperglycemia management should also be considered

Answer 8

1. 81-325 mg
   -asap or within 48 hrs
   -within 24 hrs of fibrinolytic therapy
2. BP is severely elevated >= 220/120

Question 9

Ischemic Stroke: Secondary Prevention

1. Treatment of Modifiable Risk Factors like:

a. HTN
-which r the best agents for stroke risk reduction?
-whats the goal BP?

b. Dyslipidemia
-what should you use?

c. AFib
-what kinda stroke requires anticoag?

d. lifestyle mods like?

Answer 9

a. thiazide diuretics, ACEi’s, and ARBS
-<130/80

b.high intensity statin

c. cardioembolic stroke due to AFib

d. smoking cessation
-heart healthy diet
-sodium restriction (<1.5 g a day) can aid with BP reduction
-weight reduction to maintain BMI 18.5-24.9 and waist circumference < 35 inches for women and <40 inches for men

Question 10

Antiplatelet Treatment:

1. This is for which patients?
2. which drugs r used?
3. what does this help reduce the risk of?
4. which agent is contraindicated in pt’s with hx of TIA or stroke?
5. which combo can be initiated within 24 hrs of minor ischemic stroke and continued for up to 90 days?
   -Note that this combo should NOT be used???

Answer 10

1. pt’s with NON CARDIOEMBOLIC ischemic stroke or TIA
2. asa, asa er dipyridamole OR clopidogrel
3. recurrent stroke
4. prasugrel
5. clopidogrel + ASA
   - LONG TERM for secondary prevention due to incr risk of hemorrhage

Question 11

Antiplatelet Drugs:

1. ASA MOA?
2. Dipyridamole inhibits?
3. Clopidogrel is a pro drug that does what?

** SEE physical flashcards for more drug specifics

Answer 11

1. Irreversibly inhibits COX 1 and COX 2 which decr prostaglandins and TXA2
2. the uptake of adenosine into platelets and incr cAMP levels which inhibits platelet aggregation
3. irreversibly inhibits P2y12 mediated platelet activation and aggregation

Question 12

Intracerebral Hemorrhage (ICH):

1. as appropriate, which meds should be dc’ed and what should be admined?
2. if there’s clinical evidence of seizures what should be done?
   -What should NOT be used though?

Answer 12

1. anticoags should be dc’ed, reversal agents should be administered
2. treat the seizure
   -prophylactic anti seizure meds should NOT be used

Question 13

Treating Elevated Intracranial Pressure

1. Incr ICP is caused by?
2. NOTE that this is the primary complication of an ICH : what can it lead to?
3. interventions to lower ICP? (2)
4. bc these drugs incr plasma osmolarity, what does that do?

Answer 13

1. incr blood volume and edema in a relatively fixed intracranial space
2. its a medical emergency that can lead to brain death
3. elevating the head of the bed by at least 30 degrees and
   -admin of IV OSMOTIC THERAPY with either HYPERTONIC SALINE or MANNITOL
4. draws water out of the brain parenchyma

Question 14

1. Mannitol is an Injection used to treat elevated intracranial pressure…
   a. what r CI’s?
   b. must inspect for __ before admin
   c. what should be used for administration?

Answer 14

1a. severe renal disease (anuria)

b. crystals

c. filter for admin

Question 15

Acute Subarachnoid Hemorrhage (SAH) :

1. what does it usually result from?
2. what can occur 3-21 days after the bleed?
3. what med has been shown to improve outcomes associated with vasospasm induced ischemia and should be initiated in pt’s with SAH?

Answer 15

1. a cerebral aneurysm rupture , resulting in a severe headache
2. cerebral artery vasospasm
3. oral nimodipine