Stroke pre-lec 2

Question 1

Hemorrhagic stroke overview

Answer 1

-severe HA > than ischemic
-worse prognosis
-goal is to prevent re-bleeding/worsening

Question 2

Acute hemorrhagic management overview

Answer 2

-supportive care
-glycemic control
-reverse causative meds
-surgery
-anti-HTN
-prevention of cerebral vasospasm
-anticonvulsants

Question 3

Reversing causative meds

Answer 3

-warfarin: vit K
-heparin: protamin
-DOACs: rcomb coag factor xa (andrexxa)
-dabigatran: idaruzizumab
-no antidotes for antiplatelets

Question 4

Surgery

Answer 4

-craniotomy
-endoscopic coiling or evacuation
-surgical clipping

-just know lot of management is surgical

Question 5

Anti-HTN tx in acute hemorrhagic stroke + BP goals

Answer 5

-maybe shown to prevent acute rebleeding
-tx if SBP >180
-IV anti-HTN
-goal BP:
-<180/110 in 24h
-<160/90 after 24h
-outpt goal after 48h

Question 6

Cerebral vasospasm

Answer 6

-at risk after acute hemorrhagic stroke
-worsen ischemia and complications
-highest risk 4-21 days after subarachnoid hemorrhagic stoke
-give nimodipine

Question 7

Nimodipine

Answer 7

-DHP-CCB
-after acute subarachnoid hemorrhagic stroke
-minimize complications from vasospasm
-60mg PO q4h x 21d after stroke

Question 8

Anticonvulsants use

Answer 8

-risk of sz after hemorrhagic stroke
-NOT recommended for prophylaxis
-ONLY use if pt has sz hx

Question 9

Acute hemorrhagic stroke summary

Answer 9

-use antidote if reversible
-BP control important
-Nimodipine dec complications from cerebral vasospasm if subarachnoid hemorrhage
-most management is supportive care

Question 10

Antiplatelets vs anticoags for secondary stroke prophylaxis

Answer 10

-all ischemic stroke pt need one or the other
-determined by cause/type of ischemic stroke
-prevent future occlusion of brain vasculature to dec stroke risk
-antiplatelets: atherosclerotic
-anticoag: cardioembolic

Question 11

Antiplatelets use in secondary prevention

Answer 11

-prevent future strokes by inhibiting aggregation
-indefinite duratoin until bleeding risk/complications
-artherosclerotic

Question 12

Aspririn for secondary prevention

Answer 12

-1st line in artherosclerotic stroke
-162-325mg x2-4weeks then ≤ 162mg (81mg) qd indefinitely
-monitor bleeding and nausea

Question 13

Dipyridamole/ASA (Aggrenox) MOA + use + ADRs

Answer 13

-antiplatelet
-inhibits adenosine phosphodieterase = prevent platelet aggregation
-1st line in artherosclerotic secondary prevention
-start after 2-4 weeks of high dose ASA after stroke
-200mg/25mg PO BID indefinitely

-bad HA
-GI bleed

Question 14

Clopidogrel for secondary prevention

Answer 14

-2nd line in non-embolic ischemic stroke
-ASA allergy
-mostly combo w ASA
-75mg PO qd
-monitor bleeding

Question 15

Clopidorel + ASA for secondary prevention

Answer 15

-scondary prevention for artherosclerotic ischemic strokes
-1st line for minor strokes (≤ 3)
-2nd line for mod-severe
-75mg + 81mg qd x21-90d then monotx
-inc bleeding risk

Question 16

Other antiplatelets for secondary prevention

Answer 16

-ticagrelor + ASA: no diff in disability
-prasugrel (inc CV in pt w hx of stroke, dont use)
-neither in guidelines

Question 17

Antiplatelets in secondary prevention

Answer 17

-artherosclerotic ischemic stroke
1st: ASA, dipyramidole/asa, clopidogrel + ASA*
2nd: clopidogrel +/- ASA

• if NIHSS≤ 3

Question 18

Anticoagulants for secondary prevention

Answer 18

-cardioembolic strokes caused by AFib, valve dx, severe HF
-start 2-14 days after strok
-immediately after stroke use ASA tho then d/c ASA
-DOACs

Question 19

DOACs

Answer 19

-apixaban
-dabigatran
-edoxaban
-rivaroxaban
-warfarin
-secondary prevention in cardioembolic stroke
-**if mechanical valve/LV thrombosis you must use warfarin or rivaroxaban

Question 20

DOACs if mechanical mitral valve/LV thrombus

Answer 20

-warfarin
-rivaroxaban

Question 21

HTN management long-term

Answer 21

-BP< 130/80 for all pt w any stroke hx
-choose anti-HTN based on co-morbidities

Question 22

Anti-HTN selection

Answer 22

-black: CCB, TZD
-CKD: ACE/ARB
-CAD: BB + ACE/ARB
-DM: ACE/ARB
-HFrEF: ARNI/ACE/ARB + BB + MRA
-Afib: BB or non-DHP CCB

Question 23

1st line anti-HTN in black pt

Answer 23

-CCB
-TZD

Question 24

1st line anti-HTN in CKD

Answer 24

ACE/ARB

Question 25

1st line anti-HTN in CAD

Answer 25

BB + ACE/ARB

Question 26

1st line anti-HTN in DM

Answer 26

ACE/ARB

Question 27

1st line anti-HTN in HFrEF

Answer 27

-ARNI/ARB + BB + MRA

Question 28

1st line anti-HTN in AFib

Answer 28

-BB -non-DHP CCB

Question 29

Statins for secondary prevention

Answer 29

-artherosclerotic ischemic stroke -all pt start high intenstity statin -goal LDL <70 -atorvastatin 80mg -rosuvastatin 20-40mg -ezetimibe or PCSK9 inhibitor if unable to reach goal -DO NOT use statin if cardioembolic or hemorrhagic stroke

Question 30

Additional risk factor reduction post-stroke

Answer 30

-dec cocaine/alc use -A1c < 7% -physical activity -diet -wt loss -smoking cessation

Question 31

Antidepressants

Answer 31

-improve neurological fx after stroke -SSRIs: sertraline, fluoxetine, (es)citalopram -AVOID paroxetine (anticholinergic) -AVOID tricyclics (anticholinergic, arrhytmia) -duration unclear

Question 31

Depression after stroke

Answer 31

-25-50% of pt -worsens recovery -inc mortality -antidepression tx

Question 32

Rehabilitiation after stroke

Answer 32

-difficulties returning to ADL -speech tx -occupational tx -physical tx