Stroke

Question 1

What percentage of strokes are ischemic?

Answer 1

88%

Question 2

Describe a noncardioembolic stroke

Answer 2

clots forms during cerebral atherosclerotic infarction

Question 3

Describe a cardioembolic stroke

Answer 3

clot forms in the heart and travels to the brain

Question 4

What are the modifiable risk factors for stroke?

Answer 4

hypertension
atrial fibrillation
dyslipidemia
diabetes
physical activity
smoking

Question 5

What are the nonmodifiable risk factors for stroke

Answer 5

prior stroke/TIA
older than 80
african american race
genetic diseases

Question 6

What does FAST stand for?

Answer 6

Face droop
Arm Weakness
Speech difficulty
Time to call 911

Question 7

A CT needs done within how many minutes to determine whether a stroke is due to hemorrhage?

Answer 7

20 minutes

Question 8

How does alteplase work?

Answer 8

Tissue plasminogen activator; binds fibrin and converts plasminogen to plasmin → fibrinolysis

Question 9

What is the dose for alteplase?

Answer 9

0.9mg/kg (MAX 90mg) given 10% as bolus over a minute, rest infused over and hour

Question 10

What are the contraindications for alteplase?

Answer 10

Active internal bleeding
Hx of recent stroke (past 3 mo)
Severe uncontrolled hypertension (>185/110)
Any prior intracranial hemorrhage
INR >1.7. aPTT >40, platelets <100,000
Use of LMWH within previous 24 hours
use of direct thrombin inhibitor/direct factor XA inhibitor (48 hours)
Taking warfarin AND INR >1.7
Blood glucose <50

Question 11

What is the side effect of alteplase?

Answer 11

Major bleed

Question 12

What should be monitored while on alteplase?

Answer 12

Hgb, Hct, signs of bleeding, neurologic assessments, BP, head CT 24 hours after treatment

Question 13

Alteplase is approved to be givin within how many hours of symptom onset?

Answer 13

3

Question 14

Aspirin should not be used within how many hours of a fibrinolytic?

Answer 14

24

Question 15

During and after alteplase, blood pressure should be maintained to ?

Answer 15

<180/105 during and for at least 24 hours after

Question 16

Which medications are used for secondary prevention of stroke?

Answer 16

Hypertension: Thiazide diuretics, ACE (-), ARB
Dyslipidemia: high intensity statin
Diabetes: GLP1 agonist or SGLT2 (-)
Atrial fibrillation: anticoagulation

Question 17

What are some lifestyle modifications that can decrease stroke risk?

Answer 17

smoking cessation
<1.5g/d of sodium
10minutes of moderate intensity exercise 4d/week
20minutes of vigorous activities 2d/week
BMI goal: 18-24.9
Waist circumference <35 (women); <40 (men)
Alcohol intake: <2 (men); <1 (women)

Question 18

Aspirin and Clopidogrel can be used together for how many days?

Answer 18

21-90 days

Question 19

What is the extended release capsule of aspirin called?

Answer 19

Durlaza

Question 20

What is the delayed release tablet of aspirin and omeprazole called?

Answer 20

Yosprala

Question 21

How does aspirin work?

Answer 21

irreversibly (-) COX-1 and COX-2 → decreases prostaglandin and TXA2 production

Question 22

What is the dose of aspirin for stroke?

Answer 22

50-325mg daily

Question 23

What are the contraindications for aspirin?

Answer 23

NSAID or Salicylate Allergy
Reye’s syndrome in children

Question 24

What are the warnings for aspirin?

Answer 24

bleeding
tinnitus (overdose)

Question 25

What are the side effects of aspirin?

Answer 25

Dyspepsia heartburn bleeding nausea

Question 26

What should be monitored while on asprin?

Answer 26

bleed/bruises

Question 27

What can be done to decrease nausea when taking aspirin?

Answer 27

use an enteric coated or buffered product take with food

Question 28

How does dipyridamole/aspirin work?

Answer 28

(-) uptake of adenosine into platelets and increases cAMP levels→ (-) platelet aggregation

Question 29

What is the warning with Dipyridamole/Aspirin?

Answer 29

hypotension and chest pain

Question 30

What is the side effect of Dipyridamole/Aspirin?

Answer 30

headache

Question 31

True or false: The aspirin dose in Dipyridamole is enough for prevention of cardiac events?

Answer 31

False

Question 32

How does clopidogrel work?

Answer 32

prodrug, irreversibly (-) P2Y12 ADP mediated platelet activation and aggregation

Question 33

What is the dose of clopidogrel when used in stroke?

Answer 33

75mg daily

Question 34

What is the boxed warning for clopidogrel?

Answer 34

CYP2C19 poor metabolizers should consider alternative

Question 35

What is the contraindication for clopidogrel?

Answer 35

active serious bleeds

Question 36

What are the warnings of clopidogrel?

Answer 36

stop 5 days prior to elective surgery do not use with omeprazole/esomeprazole premature discontinuation increases risk of thrombosis TTP

Question 37

What should be monitored while on clopidogrel?

Answer 37

bleeding symptoms Hgb Hct

Question 38

Which classes of drugs interact with clopidogrel?

Answer 38

NSAIDS SSRIs SNRIs herbals

Question 39

Clopidogrel should be avoided with which 2 proton pump inhibitors?

Answer 39

omeprazole esomeprazole

Question 40

How does hypertonic saline and mannitol work in stroke?

Answer 40

increase plasma osmolarity drawing water out of the brain

Question 41

What are the contraindications for mannitol?

Answer 41

Severe renal disease Severe hypovolemia Pulmonary edema or congestion Active intracranial bleed

Question 42

What are the warnings for mannitol?

Answer 42

CNS toxicity Extravasation Nephrotoxicity Fluid and electrolyte balances

Question 43

What are the side effects of mannitol?

Answer 43

Dehydration Headache Lethargy increase/decrease BP

Question 44

What should be monitored while on mannitol?

Answer 44

Renal fxn Is and Os Serum electrolytes Serum and urine osmolality ICP CPP

Question 45

When using mannitol what does serum osmolality need to maintained to?

Answer 45

<300-320 mOsm/kg

Question 46

If mannitol concentration is above 20% you need a filter because when left at room temperature it forms?

Answer 46

Crystals

Question 47

When is nimodipine used?

Answer 47

to prevent cerebral artery vasospasm after an acute subarachnoid hemorrhage

Question 48

What is the dosage form of nimodipine?

Answer 48

capsule or oral solution

Question 49

How does nimodipine work?

Answer 49

DHP CCB that is more selective for cerebral arteries due to increased lipophilicity

Question 50

What is the dose of nimodipine?

Answer 50

60mg q4hr x21 days

Question 51

What should nimodipine be reduced to if the patient has liver cirrhosis?

Answer 51

30mg

Question 52

How should nimodipine be taken?

Answer 52

empty stomach 1 hour before or 2 hours after meals

Question 53

What is the boxed warning for nimodipine?

Answer 53

do not administer IV

Question 54

What is the side effect of nimodipine?

Answer 54

hypotension

Question 55

What should be monitored with nimodipine?

Answer 55

CPP, ICP, BP, HR, neurological checks

Question 56

A nimodipine syringe needs which label?

Answer 56

oral use only

Question 57

What are the contraindications of nimodipine?

Answer 57

Major substrate of CYP3A4 so avoid with strong CYP3A4 (-)due to increased risk of hypotension

Question 58

Do strong CYP3A4 inducers or inhibitors decrease levels of nimodipine?

Answer 58

inducers