NAPLEX 2026: Stroke

What is an acute ischemic stroke caused by?

A thrombus that forms during a cerebral atherosclerotic infarction. Aka non-cardioembolic stroke, origin is in the BRAIN

What is a cardioembolic stroke?

An ischemic stroke that occurs when an embolus (clot) forms in the heart and travels to the brain

What is a common cause of a cardioembolic stroke?

Atrial fibrillation

What is a hemorrhagic stroke caused by?

A ruptured blood vessel, bleeding in the brain

What are the 2 different types of hemorrhagic strokes?

1) Intracerebral hemorrhage (ICH)

2) Subarachnoid hemorrhage (SAH)

Which strokes are considered less serious and are caused by a temporary clot in the brain?

Transient ischemic attacks (TIAs)

Cause no permanent damage but are often a warning for a future acute ischemic stroke

What are risk factors for stroke?

-HTN !!!

-A. fib !!

-Prior stroke or TIA !!

-Race (highest risk in AA)

-Age ≥ 80 year

-Diabetes

-Smoking

-Dyslipidemia

-Genetic diseases eg Sickle cell disease

-Physical inactivity

What are S/Sx of stroke?

hint acronym

Act F.A.S.T

-Face: ask the person to smile. Does one side of the face droop or is it numb? Is the smile uneven?

-Arms: Ask the person to raise both arms. Does 1 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 these symptoms, even

if they go away, call 911 immediately

Time is brain

What testing should be done in the ED to confirm a stroke? When is the ideal time to have this test preformed?

-CT (computed tomography) scan

-ideally performed within 20 minutes of arrival to the hospital

What is the immediate treatment goal of an ischemic stroke?

Restoring blood flow to the ischemic area of the brain

What is the class and MOA of alteplase in stroke treatment?

-Tissue plasminogen activator - tPA (fibrinolytic)

-Bind to fibrin in a thrombus (clot) and converts plasminogen to plasmin, resulting in fibrinolysis

If a clot is confirmed, what is the FDA-approved and guideline recommended timeline of administering alteplase/tenecteplase for acute ischemic stroke treatment?

-FDA-approved: within 3 hours of symptom onset

-Guideline recommended: within 4.5 hours of symptom onset in select patients !!!!

At what BP is alteplase/tenecteplase contraindicated in?

What if BP is the only contraindication to the administration of fibrinolytic?

≥ 185/110

-Lower BP to < 185/110 so that fibrinolytic can be administered. Keep BP <180/105 for a least the first 24 hours after treatment

What must be ruled out before administering alteplase?

intracranial hemorrhage

What is the dosing of alteplase for acute ischemic stroke? What is the max dose?

-0.9 mg/kg

-Max dose: 90 mg

What are contraindications to using a fibrinolytic in stroke?

-Active internal bleeding

-Hx of recent stroke (within the past 3 months)

-Severe uncontrolled HTN (BP > 185/110)

-Labs that increase bleeding risk: INR > 1.7, low platelets

-Treatment with LMWH (within the previous 24 hours), use of a direct thrombin inhibitor or direct Xa inhibitor (within the previous 48 hours)

What are the common side effects of alteplase?

major bleeding (intracranial hemorrhage)

What should be monitored in patients taking alteplase?

-Hgb

-Hct

-S/Sx of bleeding

-neurological asseessments and BP (must be < 185/110 before intitation)

What other treatments should be considered (besides alteplase) in acute ischemic stroke?

-aspirin

-HTN management

-hyperglycemia management

-DVT prevention

Deep Vein Thrombosis prevention and stroke

1) Intermittent pneumatic compression devices

2) UFH or LMWH after 24 hrs of a fibrinolytic

When and at what dose should aspirin be administered for acute ischemic stroke?

81-325 mg

within 48 hours after stroke onset (but not given within 24 hours of fibrinolytic therapy)

Which antihypertensives can be used for HTN management in acute ischemic stroke? What BP should be maintained during acute treatment?

-IV antihypertensives like labetalol, nicardipine

-lower to < 185/110 prior to fibrinolytic administration

-lower ≤ 220/120 if not using fibrinolytic by 15% for the first 24 hrs after stroke onset

What should blood glucose levels be maintained at during treatment of acute ischemic stroke?

140-180

Which HTN medications are preferred in patients with HTN for secondary prevention of ischemic stroke? What is the goal BP?

ACEIs, ARBs, Thiazide diuretics

Goal < 130/80

What intensity statin should be used for dyslipidemia treatment for secondary prevention of ischemic stroke?

high-intensity

What drug class should be considered for secondary prevention of a cardioembolic stroke due to Afib?

anticoagulation

What lifestyle modifications should be counseled on for secondary prevention of ischemic stroke?

List the waist circumference for men vs women

-Na+ restriction < 1.5 g/day

-Mediterranean type-diet

-Weight reduction: BMI 18.5-24.9; waist circumference < 35" women and < 40" men

-Limit alcohol intake to ≤ 2 drinks/day in men and ≤ 1 drinks/day in women

-Smoking cessation

-Physical activity

What is the recommended antiplatelet treatment in patients with a non-cardioembolic stroke?

What is recommended if the preferred treatment is contraindicated?

-Aspirin, aspirin/extended-release dipyridamole or clopidogrel

Prasugrel is CONTRAINDICATED with a hx of TIA or STROKE due to increased risk of intracranial bleed

How long can a combo therapy with aspirin and clopidogrel be used after a stroke? When should it be initiated? Why can't this combo therapy be used for longer?

-21 to 90 days

-within 24 hours after a minor ischemic stroke (NIHSS score ≤ 3, did not receive alteplase)

-longer increases the risk of hemorrhage

Patient has a stroke and they were already on aspirin. Should we increase the aspirin dose for further prevention?

No, no added benefit

MOA of aspirin

Inhibits COX-1 and 2 which decreases PG and thromboxane 2 production

What is the MOA of dipyridamole with aspirin?

Inhibits the uptake of adenosine (into platelets and increases cAMP levels, which inhibits platelet aggregation)

What are the contraindications to using aspirin?

-NSAID or salicylate allergy

-Increased risk of Reye's syndrome in children and teens with viral infection

What are the warnings to using aspirin? (2)

-Bleeding

-tinnitus (salicylate OD)

What are the common side effects of aspirin?

-dyspepsia

-heartburn

-bleeding

Aspirin dosing

50-325mg QD

OTC aspirin formulations

Tablet

Chewable tablet

Enteric coated tab

Suppository

Rx aspirin

Delayed-release tab (Yosprala)

What should be prescribed in patients using chronic NSAID/aspirin use and why?

-PPIs used to protect the gut

What are the risks of chronic PPI use? (2)

1) Decreased bone density

2) Increased infection risk

What are additional warnings (in addition to aspirin warnings) for aspirin/extended-release dipyridamole?

hypotension and chest pain (due to vasodilatory effects of dipyridamole)

What are additional common side effects for aspirin/extended-release dipyridamole

Headache

Bleeding

Heartburn

Dyspepsia

Can the the separate components of Aggrenox (ER dipyridamole and ASA) be used if Aggrenox it self is not available?

No. The separate components are not interchangable with the combo product

Clopidogrel dose

75 mg daily

What is the BBWs for clopidgrel?

-clopidogrel is a prodrug that requires 2C19 enzymes to metabolize it to its active metabolite

-Poor metabolizers for 2C19 exhibit higher risk of CV events due to subtheraputic levels of clopidogrel active metabolite

-Patients can be tested to check for CYP2C19 genotype

What are contraindications to using clopidogrel?

active serious bleeding

What are the warnings to using clopidogrel?

-bleeding risk

-stop 5 days prior to elective surgery

-do not use with omeprazole! or esomeprazole!

-thrombotic thrombocytopenic purpura (TTP)

Clopidogrel and upcoming surgery

Stop clopidogrel 5 days prior to surgery

What PPIs are CI with clopidogrel

Omeprazole and Esomeprazole

What drugs increase the risk of bleeding if used in combo with antiplatelets?

-anticoagulants

-NSAIDs

-SSRIs/SNRIs

-some herbals

Clopidogrel is the DOC in stroke/TIA if pt has a ___ or ___ to aspirin

contraindication or allergy

Pt has an intracerebral hemorrhage and was recently on anticoagulants, what do you do

Give reversal agents for anticoagulants

Pt has an intracerebral hemorrhage and history of epilepsy, what antiseizure meds are appropriate?

Treatment meds, no prophylactic meds (ASM)

What is the purpose of mannitol or hypertonic saline (3% or 23.4% NaCl) in intracerebral hemorrhage?

Reduces intracranial pressure (ICP) by withdrawing water from the brain via osmotic diuresis

What dosage form is mannitol avaliable as?

injection

What are contraindications to using mannitol?

-Severe renal diease (anuria)

What should be done prior to the administration of mannitol?

-Check for crystals before administering; if present, warm the solution to redissolve

-use a filter for administration with mannitol concentrations ≥ 20%

What do patients normally experience when having an acute subarachnoid hemorrhage (SAH)?

severe headache, "worst headache every experienced"

Cerebral artery vasospasms can last for how long after an SAH/aneurysm?

3-21 days after the bleed

What medication can prevent vasospasms from SAH?

PO nimodipine

What class of medications is nimodipine from?

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

What are the BBWs of nimodipine?

ONLY GIVE PO !! NOT FOR IV

Do not administer IV or by other parenteral routes; death and serious life-threatening ADRs have occurred when the contents of nimodipine capsules have been inadvertently injected parenterally

Duration of nimodipine tx

21 days

What are common side effects of nimodipine?

hypotension

How can nimodipine be taken if the patient cannot swallow the medication?

The capsule contents can be withdrawn with a parenteral syringe, then transferred to a PO syringe that cannot accept a needle and then administered PO or via a nasogastric tube. The syringe also needs to be labeled "For oral use only" or "NOT for IV use"