Stroke

Etiology/Risk Factors

100

This type of stroke accounts for >80% of cases.

What is ischemic stroke?

200

Heavy use of these two substances represent a substantial portion of an individual's risk.

What is smoking tobacco and alcohol?

300

What is a penumbra?

potentially reperfusable brain tissue (if intervention is done quickly)

400

Name 4 of the 8 biomarkers commonly associated with stroke victims.

hypercholesterolemia, proteinuria, microalbuminuria, hypokalemia, hyperuricemia, high C reactive protein level, low eGFR, and lower 25-hydroxycholecalciferol levels

500

What are 4 modifiable behavioral risk factors associated with ischemic stroke?

Smoking, alcohol use, obesity, and physical activity. HTN, Afib, heart disease, diabetes, dyslipidemia, sickle cell disease, asx carotid stenosis, postmenopausal hormone therapy, diet

Diagnosis

100

Two most common signs of acute neurologic dysfunction in stroke.

-speech (dysarthria or aphasia) -hemiparesis (limb or facial weakness) Also: -headache -nonorthostatic dizziness

200

What is the NIH stroke scale?

A formal stroke scale composed of 11 items quantifying stroke severity

300

Name the most appropriate neuroimaging tests. May help to detect intracerebral hemorrhage and ischemic stroke

-computerized tomography (CT) without contrast -magnetic resonance imaging (MRI)

400

Stoke Mimics (for differential diagnosis) (*must give 3 examples)

What is -postictal state -complicated migraine -toxic-metabolic disturbances (eg. hypoglycemia) -systemic infection (including meningitis and encephalitis) -syncope, presyncope (hypotension) -brain tumor -acute confusional state -dizziness -dementia -seizure *TIA *hypertensive encephalopathy

500

Important labs/tests/imaging. (*must give 4 examples)

-Noncontrast brain CT -Brain MRI -Finger stick blood glucose -Oxygen saturation -Electrocardiogram -Complete blood count -Cardiac enzymes and troponin -Serum electrolytes, urea nitrogen, creatinine -Prothrombin time -International normalized ratio (INR) -Activated partial thromboplastin time

Drugs/Treatment

100

Blood pressure goal for acute ischemic stroke patients receiving alteplase

<180/105 mmHg

200

Name 2 first-line anti-hypertensive drugs for use in hypertensive patients receiving t-PA

IV labetolol or nicardipine (hydralazine)

300

List 3 contraindications for t-PA

any evidence of intracranial hemorrhage severe stroke, minor stroke, rapidly improving stroke seizure at stroke onset abnormal lab tests - platelet count < 100,000/mm3, blood glucose levels < 50 mg/dL (2.8 mmol/L) or > 400 mg/dL (22.2 mmol/L), any abnormal coagulation tests recent procedures, surgery, trauma, or cardiovascular event blood pressure ≥ 185/110 mm Hg comorbidities, history of or current bleeding

400

What is the general aspirin recommendation for acute ischemic stroke patients (dose and when to initiate tx)?

Aspirin 160-325 mg daily starting 24-48h after ischemic stroke in most patients. Do not give within 24h of IV fibrinolysis

500

If t-PA is used, what is the dose and administration rate of alteplase, and when should it be given (time constraint)?

Alteplase dose 0.9 mg/kg (maximum 90 mg) IV (10% over 1 minute, 90% over 1 hour) Time constraint: given within 3 hr may increase functional independence without affecting mortality at 3-6mo At 3-4.5 hr, effect on outcomes is inconsistent and may increase 90 day mortality

Drugs/Treatment

100

Is anticoagulation recommended for initial management of noncardioembolic acute ischemic stroke?

No, Multiple guidelines recommend against anticoagulation in acute ischemic stroke for reducing morbidity, mortality, or recurrent stroke (AHA/ASA Class III, Level A, AAN/AHA Grade A, ACCP Grade 1A).

200

This new type of ischemic stroke treatment involves using aspiration or a basket device to remove a clot in a cranial vessel (name the procedure).

endovascular mechanical thrombectomy

300

List 3 of the 5 symptoms that would warrant d/c of alteplase and emergency CT

severe headache, acute hypertension, nausea, vomiting, or worsening neurologic exam

400

Which antiplatelet drug is a prodrug and what CYP enzyme activates it?

Clopidogrel, activated by CYP2C19

500

What is the monitoring frequency for blood pressure and neurologic assessment during alteplase treatment in ischemic stroke?

BP-Q15min first 2H, Q30min thereafter x6H, Q1H until 24H post tx Neuro- Q15 min during infusion, Q30min thereafter x6H, Q1H until 24H post tx

Secondary Prevention

100

What trial showed that atorvastatin 80 mg reduces risk of recurrent ischemic stroke in patients with prior stroke/TIA? a) GLITER b) SPARCL

SPARCL

200

For patients with cardioembolic stroke and contraindications to anticoagulant medication, what medications would you use?

Aspirin (AHA/ASA Class I, Level A) OR Combination of aspirin plus clopidogrel (AHA/ASA Class IIb, Level B)

300

Name 1 medication class and 2 lifestyle changes that are recommended for secondary prevention of stroke

Meds: statins, ACEi, CCB, diuretics, antiplatelets Lifestyle: aerobic exercise, smoking cessation, decrease alcohol use

400

Is antiplatelet therapy preferred in secondary prevention for noncardioembolic stroke or cardioembolic stroke?

Antiplatelets preferred over anticoagulation following noncardioembolic stroke or TIA

500

The combination of aspirin and clopidogrel may be considered for initiation for a minor ischemic stroke or TIA and continued for how many days?

Must be initiated within 24 hours of a minor ischemic stroke or TIA and continued for 90 days. When this combination is started days to years after a minor stroke or TIA, it increases the risk of hemorrhage and should not be used for routine secondary prevention