Stroke

Question 1

Risk factors for stroke?

Answer 1

HTN - most common cause (risk increases above 120/80mmHg)

A. Fib

Gender (males > females)

Ethnicity (AAs at highest risk by ethnicity)

Age (55 and older)

Atherosclerosis

DM

Transient ischemic attack (TIA)

Prior hx of stroke

Smoking

Hypercholesterolemia

Patent foramen Ovale (PFO)

SCD

Question 2

Howz type of stroke determined?

Answer 2

Via brain imaging (either ischemic - more common or hemorrhagic)

Question 3

Sx of stroke?

Answer 3

FAST

Face
Arms
Speech
Time

Question 4

Prevention of venous thromboembolism in hemorrhagic stroke?

Answer 4

Use intermittent pneumatic compression

Question 5

Tx of Intracerebral Hemorrhage?

Answer 5

Elevate bed by 30 degrees

Use Mannitol

Question 6

MOA of Mannitol (used IM Intracerebral hemorrhage - ICH)?

Answer 6

Increases osmotic pressure to reduce intracranial pressure (ICP) ass with cerebral edema

Question 7

Brand name of Mannitol?

Answer 7

Osmitrol

Question 8

SEs of Mannitol (Osmitrol)?

Answer 8

Fluid and electrolyte loss

Dehydration

Hyperosmolar-induced hyperkalemia

Acidosis

Increased osmolar gap

Question 9

What’s Subarachnoid hemorrhage?

Answer 9

SAH is bleeding in the space btw the brain and the surrounding membrane (subarachnoid space)

Question 10

Role of Oral Nimodipine in SAH?

Answer 10

Prevents vasospasm associated with delayed ischemia

Question 11

BBW of Nimodipine (Nymalize) - used in SAH?

Answer 11

Don’t admin IV….use oral route ONLY

To prevent severe cardiovascular adverse events including death

Question 12

How should syringes with Nimodipine (Nymalize) - used in SAH - be labeled?

Answer 12

“For oral use only”

Question 13

Pharmacologic management of Acute Ischemic Stroke?

Answer 13

Alteplase (recombinant tissue plasminogen activator (rt-PA) causes fibrinolysis by binding to fibrin in thrombus (clot) and converse entrapped plasminogen to plasmin

Question 14

Brand name of Atleplase - used in acute ischemic stroke?

Answer 14

Activase

rt-PA

Question 15

What must be done b4 using Atleplase (Activase; rt-PA) - used in acute ischemic stroke?

Answer 15

Must confirm clot on brain imaging (head CT scan) b4 use

Question 16

Dosing of Atleplase (Activase; rt-PA) - used in acute ischemic stroke? Max dose?

Answer 16

Infuse 0.9 mg/kg IV over 60 min
10% of dose given as bolus

Max dose: 90mg

Question 17

SEs of Atleplase (Activase; rt-PA) - used in acute ischemic stroke?

Answer 17

Major bleeding e.g ICH

Hypotension

Angioedema

Question 18

When should tx of Atleplase (Activase; rt-PA) - used in acute ischemic stroke - be initiated?

Answer 18

Must be initiated within 3 hrs of sx onset

guidelines - up to 4.5hrs, but this isn’t FDA approved

Question 19

Additional therapies in mgt of acute ischemic stroke?

Answer 19

Aspirin therapy

HTN mgt

Hyperglycemia mgt

DVT prevention

(Modifiable risk factors should be corrected)

Question 20

Role of Aspirin in Acute Ischemic Stroke?

Answer 20

Prevention of early recurrent stroke (secondary prevention)

Question 21

Dose of Aspirin in Acute Ischemic Stroke?

Answer 21

81 mg PO daily

Question 22

When should Aspirin be initiated in Acute Ischemic Stroke?

Answer 22

W/in 24-48 hrs after stroke onset

Question 23

When should Aspirin NOT be initiated in Acute Ischemic Stroke?

Answer 23

W/in 24 hrs of fibrinolytic therapy

Question 24

Role of HTN management in Acute Ischemic Stroke?

Answer 24

Qualifies patients for rt-PA or reduce BP

Use ACEIs or ARBs

Question 25

When should Atleplase (Activase; rt-PA) NOT be initiated as part of HTN management?

Answer 25

If BP is not =< 185/110 mmHg Don't give rt-PA

Question 26

Hyperglycemia management in Acute Ischemic Stroke?

Answer 26

Maintain BG levels bye 140-180 mg/dL

Question 27

When should DVT prevention NOT be initiated in management of Acute Ischemic Stroke?

Answer 27

Don't use anticoagulant therapy within 24 hrs of receiving rt-PA therapy

Question 28

List lifestyle changes used in ischemic stroke prevention

Answer 28

Increased physical exercise (at least 30 mins most days of the wk) Weight reduction if necessary (maintain BMI 18.5-24.9 kg/m^2) Women Waist circumference < 35 inches Men waist circumference < 40 inches Women alcohol, limit =< 1 drink/day Men alcohol, limit =< 2 drinks/day

Question 29

When's primary prevention of ischemic stroke recommended?

Answer 29

Only for A. Fib pts

Question 30

Secondary prevention for patients with previous cardioembolic stroke?

Answer 30

Anticoagulant therapy

Question 31

Secondary prevention for patients with previous non-cardioembolic ischemic stroke or TIA?

Answer 31

Antiplatelets, (aspirin, Clopidogrel) rather than oral anticoagulant

Question 32

List Antiplatelet agents used in patients with previous noncardioembolic ischemic stroke or TIA?

Answer 32

Aspirin Clopidogrel (Plavix) Dipyridamole ER/Aspirin (Aggrenox)

Question 33

Brand name of Asprin (used in patients with previous non-cardioembolic ischemic stroke or TIA)?

Answer 33

Ascriptin Bayer Aspirin Bufferin Bufferin Extra Strength Ecotrin St. Joseph Adult Aspirin Others

Question 34

Brand name of Clopidogrel (used in patients with previous non-cardioembolic ischemic stroke or TIA)?

Answer 34

Plavix

Question 35

Dose of Clopidogrel (Plavix) - (used in patients with previous non-cardioembolic ischemic stroke or TIA)?

Answer 35

75mg daily

Question 36

BBW of Clopidogrel (Plavix)?

Answer 36

Effectiveness depends on the activation to an active metabolite mainly by CYP 2C19. Poor metabolizers exhibit higher cardiovascular events than patients with normal 2C19 fxn CYP2C19*1 allele = fully fxnal metabolism CYP2C19*2 and *3 alleles = nonfxnal

Question 37

SEs of Clopidogrel (Plavix)?

Answer 37

Bleeding Bruising Rash Thrombotic Thrombocytopenia Purpura - TTP - (rare)

Question 38

SEs of Dipyridamole ER/Aspirin (Aggrenox)?

Answer 38

HA (> 10%)

Question 39

What's stroke?

Answer 39

Stroke or cerebrovascular accident (CVA) occurs when blood flow to an area of the brain is interrupted by ischemia due to a clot (thrombus or emboli) or a ruptured blood vessel (hemorrhage)