THERAPEUTICS EX3 L(?) (ACUTE ISCHEMIC STROKE) (POSGAI)

Alteplase dosing for acute ischemic stroke? (three steps)

1. 0.9 mg/kg (90mg)

2. 10% as bolus over 1 min (max 9mg)

3. Remainder over 1 hour (max: 81mg)

Tenecteplase dosing for acute ischemic stroke? (two steps)

1. 0.25 mg/kg (max 25mg)

2. Admin as bolus (over 5 sec)

Approximately what percentage of strokes are ischemic in nature?

87%

Describe an ischemic stroke

Ischemic stroke is caused by occlusion within a cerebral artery

Define a TIA

Acute ischemia and transient symptoms lasting less than 24 hours

T/F: Comprehensive evaluations should still be performed post-TIA as TIAs are often a precursor of true AIS.

True

What percentage increase in risk is a patient at for AIS following TIA?

2-17%

T/F: Management of TIA focuses on secondary prevention.

True

Modifiable risk factors for AIS? (nine)

1. Cigarette smoking

2. Physical inactivity

3. Poor diet

4. Obesity

5. Hypertension

6. Diabetes

7. Dyslipidemia

8. Cardiovascular disease!!!

9. Afib

What does the FAST acronym stand for when identifying a stroke?

1. Face (drooping)

2. Arm (weakness)

3. Speech (difficulties)

4. Time (to call)

Stroke presentations? (may vary dependent on area of brain) (five)

1. Hemiplegia/unilateral weakness

2. Aphasia (difficulty speaking)

3. Altered mental status

4. Vertigo

5. Visual disturbance

At which portion of an ischemic stroke affected area is damage considered irreversible?

A. Ischemic core

B. Penumbra

A. Ischemic core

Penumbra damage is considered salvageable with reperfusion.

What is the only imaging required prior to administration of a thrombolytic?

Noncontract CT

Pre-fibrinolytic BP goal in intervention candidates?

< 185/110

Post-fibrinolytic BP goal in intervention candidates?

< 180/105

Post-thrombectomy BP goal in intervention candidates?

<180/105

BP goal in noncandidates for intervention?

<220/110 (for first 24 hours)

Antihypertensive agents used in the prevention of ischemic stroke? (four)

1. Nicardipine

2. Clevidipine

3. Labetalol

4. Hydralazine

Important consideration with nicardipine?

Caution dose stacking

Important consideration with clevidipine?

Ultra rapid onset/offset

Important consideration for hydralazine?

Not a preferred agent (except in pregnancy) due to unpredictable response & long duration

When are fibrinolytics indicated for management of an acute ischemic stroke?

Indicated if stroke onset is < 4.5

AHA recommends door to needle time of <60 min

Fibrinolytics examples? (two)

Alteplase

Tenecteplase

Exclusion criteria highlighted in red for fibrinolytic acute ischemic stroke management? (three)

1. SBP > 185 mmHg or DBP > 110 mmHg

2. Coagulopathy (or any labs that reflect that, but baseline INR > 1.7 bad)

3. Blood glucose < 50 or > 400 mg/dL

Per the 2013 AHA guidelines, what is the window from stroke -> alteplase administration?

< 4.5 hours

Per the 2023 ESO guidelines, within 4.5 hours of stroke onset, which do we prefer?

A. Tenecteplase

B. Alteplase

A. Tenecteplase

Which of the following is an FDA approved thrombolytic for treatment of acute ischemic stroke within 3h?

A. Alteplase

B. Tenecteplase

A. Alteplase

Complications associated with fibrinolytics? (two)

1. Bleeding

2. Angioedema (65% of cases associated with concurrent ACEi use)

T/F: Patients who have received a fibrinolytic are ineligible to receive a thrombectomy.

False; receipt of a fibrinolytic is NOT an exclusion.