Stroke

Question 1

What are the types of stroke?

Answer 1

Acute ischemic stroke, AKA non-cardioembolic stroke
* Caused by a thrombus that forms during a cerebral atherosclerotic infarction

Cardiembolic stroke
* Occurs when an embolus forms in the heart and travels to the brain
* Common cause is Afib

Hemorrhagic strokes
* Bleeding in the brain

Question 2

Risk Factors

Answer 2

• HTN
• Afib
• Gender (females > males)
• Ethnicity (highest in African Americans)
• Age >=55 years
• Atherosclerosis
• DM
• Prior stroke or TIA
• Smoking
• Dyslipidemia
• Patent foramen ovale (PFO)
• Sickle cell disease

Question 3

TIA vs Stroke

Answer 3

• TIA, sometimes called “mini-stroke” is caused by a temporary clot, or block of blood flow, in the brain
• Sx of TIA are same as stroke, but disappear on their own within minutes to a few hrs
• There is no permanent damage
• Seek immediate medical attention; TIAs are often a warning for a future full stroke

Question 4

S/Sx and Diagnosis of stroke

Answer 4

ACT F.A.S.T
Face:
* Ask person to smile. Does one side of the face droop or numb? Is the smile uneven?

Arms:
* Ask the person to raise both arms. Does one arm drift downward?

Speech:
* Ask the person to repeat a simple sentence. Are the words slurred? Is the sentence repeated correctly?

Time:
* If the person shows any of the sx, even if they go away, call 911 asap

Diagnosis: Brain imaging using CT

Question 5

Alteplase

Answer 5

• Cause clot breakdown by binding to fibrin and converting plasminogen to plasmin, resulting in fibrinolysis
• Only FDA-approved fibrinolytic drug for acute ischemic stroke
• Patients are candiates if clot is confirmed
• It can be administered within 3 hrs of sx onset
• It can be administered within 4.5 hrs of sx onset in select patients
• BP should be <185/110 BPM

Question 6

Alteplase
Cathflo Activase

Answer 6

Alteplase (Activase) - Recombinant tissue plasminogen activator
Tenecteplase (TNKase)
* CIs: active internal bleeding, Hx of recent stroke, severe uncontrolled HTN (BP >185/110), Tx dose of LMWH, use of a direct thrombin inhibitor or direct factor Xa inhibitor, INR >1.7

• SEs: bleeding (including ICH)
• Monitoring: Hgb, Hct, s/sx of bleeding, neurological assessments and BO

0.9 mg/kg (maximum dose 90 mg)
Must rule out intracranial hemorrhage before use

Question 7

Aspirin

Answer 7

162-325 mg PO within 24-48 hrs after stroke onset

Question 8

Tx of modifiable risk factors -HTN

Answer 8

• ACE inhibitors and thiazide-type diuretics
• BP goal: <130/80

Question 9

Tx of modifiable risk factors - Dyslipidemia

Answer 9

High-intensity statin

Question 10

Tx of modifiable risk factors - Afib

Answer 10

Cardioembolic stroke due to Afib requires anticoagulation

Question 11

Tx of modifiable risk factors - Lifestyle modifications

Answer 11

• Na restriction
• BP reduction
• Mediterranean-type diet
• Weight reduction: BMI 18.5-24.9 and waist <35 inches for women and <40 inches for men

Question 12

Antiplatelet Tx

Answer 12

• Non-cardioembolic stroke: reduce the risk of recurrent stroke
• Aspirin is recommended within 24- 48 hrs after onset. Clopidogrel is used when aspirin is contraindicated
• Aspirin and clopidogrel combination can be initiated within 24 hrs of minor ischemic stroke and continued for 21 day, followed by clopidogrel monotherapy
• The combination should not be used long-term for secobdary prevention of stroke or TIA due to the hemorrhage
• There is no added benefit to increasing the aspirin dose

Question 13

Antiplatelet Drugs

Aspirin

Answer 13

• Bayer, Bufferin, Ecotrin: 50-325 mg daily
• CIs: salicylate allergy; children an teenagers with viral infection due to the risk of Reye’s syndrome
• Warnings: bleeding, tinnitus
• SEs: dyspepsia, heartburn, bleeding

Notes: PPIs may be used to protect the gut; consider the risks (decreased bine density, increased infection risk)

Question 14

Antiplatelet Drugs

ER dipyridamole/aspirin

Answer 14

• Aggrenox
• Warnings: hypotension
• SEs: headache

Notes: not interchangeable

Question 15

Antiplatelet Drugs

Clopidogrel

Answer 15

• Plavix: 75 mg daily
• BW: test to check CYP2C19 genotypento reduce cardiovascular events
• CIs: serious bleeding
• Warnings: bleeding risk; stop 5 days prior to elective surgery, do not use with omeprazole or esomeprazole, TTP

Question 16

Intracerebral Hemorrhage (ICH)

Answer 16

• Patients with ICH who are anticoagulated, reversal of the anticoagulant effects should be considered
• If there is a clinical evidence of seizures, they should be treated, but prophylactic anticonvulsant medication should not be used
• Intracranial pressure (ICP) should be lowered by using mannitol or hypertonic saline

Question 17

Mannitol

Answer 17

• Produces osmotic diuresis, redues ICP by withdrawing water from the brain
• Injection
• CI: renal disease
• Inspect for crystal before administering
• Use a filter for administration

Question 18

Acute Subarachnoid Hemorrhage (SAH)

Answer 18

• Patients usually experience severe headache
• Cerebral artery vasospasm can occur 3-21 days after the bleed
• Oral nimodipine is used to prevent vasospasm

Question 19

Nimodipine

Answer 19

• Dihydropyridine CCB that is more selective for cerebral arteries due to increased lipophilicity
• BW: do not administer IV; death or serious-life threatening adverse events
• SEs: hypotension
• If capsules cannot be swallowed, content may be withdrawn with a parenteral syringe, then transferred to an oral syringe; label syrinfes “for oral use only” or “not for IV use”