1. What is a stroke?
    sx and focal neurologic deficits that occur d/t abrupt disruption of the vascular supply to an area of the brain that lasts for >24h
  2. What is Transient Ischemic Attack (TIA)?
    sx and focal neurologic deficits that occur d/t abrupt disruption of the vascular supply to an area of the brain that lasts for <24h (usually <30min)
  3. What are the main modifiable risk factors for stroke?
    • HTN
    • DM
    • smoking
  4. What is the pathophysiology of ischemic stroke?
    • d/t clotting
    • clot blocks blood supply to brain
  5. What are the types of ischemic stroke?
    • atherosclerotic
    • penetrating artery disease (Lacunar)
    • cardiogenic embolisms
    • unknown (cryptogenic)
    • Other (migraine, vasospasm, arteritis, etc)
  6. What are the sx of ischemic stroke?
    • one-sided numbness, weakness, or paralysis of face, arm, or leg
    • difficultyy speaking (dysarthria) or understanding simple statements (aphasia) or confusion
    • sudden blurred or decreased vision
    • loss of balance or coordination/vertigo, trouble walking, or dizziness
    • not usually painful, but may have a HA
    • visual field defects
    • altered level of consciousness
  7. What are the general management therapies for acute ischemic stroke?
    • IV fluids (no D5W)
    • bolus 50% dextrose if hypoglycemic
    • insulin if blood sugar >300
    • thiamin 100mg if malnourished or alcoholic
    • APAP if febrile
  8. What are the drug therapies for acute ischemic stroke?
    • thrombolytics (tPA):
    • no hemorrhage
    • < 3h from onset
    • after 48h, start ASA
    • ASA:
    • no hemorrhage
    • > 3h from onset
  9. When can UH be used in ischemic stroke?
    • DVT prophylaxis
    • cardioembolic stroke:
    • if CT scan shows no hemorrhage
    • delay 24-48h (7-10d if large stroke)
    • do not give bolus doses
  10. What are the inclusion criteria for tPA?
    • ischemic stroke causing measurable neurological deficit (NIH stroke score of 4-22)
    • < 3h before tx
  11. What are the exclusion criteria for tPA?
    • intracranial hemorrhage on CT scan/MRI
    • sx suggest subarachnoid hemorrhage
    • large stroke (>1/3 hemisphere)
    • rapidly improving stroke sx
    • arterial puncture at a noncompressible site in last 7d
    • major surgery or trauma within 14d
    • GI or GU bleeding within 21d
    • intracranial surgery, head trauma, MI, or stroke < 3mo ago
    • previous intracranial hemorrhage
    • platelets < 100,000 per mm3
    • blood glucose < 50 or > 400 mg/dL
    • BP > 185/110 mmHg despite tx
    • recent anticoagulant use and elevated aPTT or INR (> 1.7)
    • witnessed seizure at stroke onset
  12. What is the recommendation for seizure tx in stroke victims?
    • NO prophylactic anticonvulsants in seize-naive pts
    • strongly recommend anticonvulsants to prevent recurrence once seizures have been experienced
  13. What is the treatment for elevated intracranial pressure in a stroke pt?
    • intubation/hyperventilation
    • mannitol (osmotic diuresis)
  14. How do you treat subarachnoid hemorrhagic stroke?
    • triple H thrapy (HTN, hemodilution, hypervolemia) - NE or DA and IV fluids: maintains perfusion
    • avoids hypotension and vasospasm
    • reduces blood viscosity
    • HTN may be desirable for 7-14d
    • antihypertensives (nicardipine, labetalol, esmolol are DOC):
    • this is to provide control without cerebral vasodilation to avoid elevating ICP
    • Nimodipine:
    • DHP CCB
    • only available orallyl
    • q 4h for 21d
  15. How do you treat intracerebral (intraparenchymal) hemorrhage?
    • stop anticoag
    • give vit K
    • replace clotting factors (FFP or PCCs)
    • Mannitol (if high ICP)
    • NO steroids
    • hyperventilation (failure to respond = bad prognosis)
    • BP tx (compare to pre-bleed BP)
    • no antiepileptics until seizure occurs
  16. How can you help prevent ischemic stroke?
    • ASA
    • clopidogrel (better than ASA if cost not a factor)
    • aggrenox (ER dipyridamole + ASA)
    • Warfarin (DOC for cardioembolic stroke (a-fib))
    • Dabigatran

    DO NOT combine ASA and clopidogrel
  17. What are the rules regarding cardioembolic stroke primary prevention?
    • < 65yo:
    • ASA
    • 65-75yo:
    • ASA or warfarin (no risk factors)
    • warfarin (at least 1 risk factors)
    • > 75yo:
    • warfarin
  18. What are the risk factors for cardioembolic stroke?
    • prior TIA, embolus, or stroke
    • HTN
    • L ventricular dysfunction
    • Diabetes
    • CAD
  19. What are the rules regarding cardioembolic stroke secondary prevention?
    • If warfarin CI, give ASA
    • possibly add clopidogrel to ASA
    • dabigatran
    • rivaroxiban
  20. What is the pharmacist's role in stroke care?
    • recognize and treat risk factors in pts
    • appropriate selection of drug tx
    • pt/caregiver education
    • development of protocols for acute stroke
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