Section 13
Stroke & Neurocritical Care
Thrombolysis, Antithrombotics, BP & ICP Control
33 AGENTS
Alteplase
ActivaseThrombolytic (tPA)
- Forms
- IV: 50, 100mg vials
- Dose
- Acute ischemic stroke: 0.9mg/kg (max 90mg); 10% as IV bolus over 1 min, remainder over 60 min
- MOA
- Converts plasminogen to plasmin, lysing fibrin clot
Tenecteplase
TNKaseThrombolytic (tPA)
- Forms
- IV: 25, 50mg vials
- Dose
- Acute ischemic stroke: single IV bolus over ~5 sec, 0.25mg/kg (max 25mg): under 60kg 15mg | 60 to <70kg 17.5mg | 70 to <80kg 20mg | 80 to <90kg 22.5mg | 90kg+ 25mg
- MOA
- Fibrin-specific plasminogen activator
Aspirin
Bayer / genericAntiplatelet
- Forms
- Tab: 81, 325mg | EC tab: 81, 325mg
- Dose
- Acute stroke: 160-325mg within 24-48h | Secondary prevention: 50-325mg/day
- MOA
- Irreversible COX-1 inhibition (↓thromboxane A2)
Clopidogrel
PlavixAntiplatelet (P2Y12)
- Forms
- Tab: 75, 300mg
- Dose
- 75mg daily | Minor stroke/high-risk TIA: 300-600mg load, then 75mg daily + aspirin for 21 days
- MOA
- Irreversible P2Y12 receptor blockade
Ticagrelor
BrilintaAntiplatelet (P2Y12)
- Forms
- Tab: 60, 90mg
- Dose
- Minor stroke/high-risk TIA: 180mg load, then 90mg BID with aspirin for up to 30 days
- MOA
- Reversible P2Y12 receptor blockade
Aspirin-dipyridamole
AggrenoxAntiplatelet combination
- Forms
- ER cap: 25/200mg
- Dose
- 1 cap BID (secondary stroke prevention)
- MOA
- COX-1 inhibition + phosphodiesterase/adenosine reuptake inhibition
Apixaban
EliquisFactor Xa inhibitor (DOAC)
- Forms
- Tab: 2.5, 5mg
- Dose
- AF stroke prevention: 5mg BID (2.5mg BID if 2 of: age 80+, weight 60kg or less, creatinine 1.5+)
- MOA
- Direct factor Xa inhibition
Rivaroxaban
XareltoFactor Xa inhibitor (DOAC)
- Forms
- Tab: 2.5, 10, 15, 20mg
- Dose
- AF stroke prevention: 20mg once daily with evening meal (15mg if CrCl 15-50)
- MOA
- Direct factor Xa inhibition
Dabigatran
PradaxaDirect thrombin inhibitor (DOAC)
- Forms
- Cap: 75, 150mg | Pellets
- Dose
- AF stroke prevention: 150mg BID (75mg BID if CrCl 15-30)
- MOA
- Direct thrombin inhibition
Edoxaban
SavaysaFactor Xa inhibitor (DOAC)
- Forms
- Tab: 15, 30, 60mg
- Dose
- AF stroke prevention: 60mg once daily (30mg if CrCl 15-50)
- MOA
- Direct factor Xa inhibition
Warfarin
Coumadin / JantovenVitamin K antagonist
- Forms
- Tab: 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10mg
- Dose
- Individualized to INR goal (usually 2-3)
- MOA
- Inhibits vitamin K-dependent clotting factors II, VII, IX, X
Atorvastatin
LipitorHMG-CoA reductase inhibitor
- Forms
- Tab: 10, 20, 40, 80mg
- Dose
- Stroke/TIA secondary prevention: 80mg once daily (LDL goal below 70mg/dL)
- MOA
- ↓Hepatic cholesterol synthesis, ↑LDL receptors
Nimodipine
Nymalize / genericCalcium channel blocker
- Forms
- Cap: 30mg | Sol: 60mg/20mL
- Dose
- Subarachnoid hemorrhage: 60mg q4h x21 days (30mg q2h if hypotension); oral/enteral ONLY, never IV
- MOA
- Cerebrovascular L-type Ca2+ channel blockade, ↓vasospasm-related ischemia
Nicardipine IV
Cardene IVCalcium channel blocker · IV
- Forms
- IV: 25mg/10mL vial | Premixed bags: 20, 40mg
- Dose
- Start 5mg/h, increase 2.5mg/h every 5-15 min, max 15mg/h
- MOA
- Arterial vasodilation via L-type Ca2+ channel blockade
Clevidipine
CleviprexCalcium channel blocker · IV
- Forms
- IV emulsion: 0.5mg/mL (50, 100mL)
- Dose
- Start 1-2mg/h, titrate (doubling every 90 sec initially); typical max 21mg/h
- MOA
- Ultra-short-acting arterial vasodilation
Labetalol IV
TrandateAlpha/beta blocker
- Forms
- IV: 5mg/mL
- Dose
- 10-20mg IV over 1-2 min, may repeat/double every 10 min (max 300mg), or infusion 0.5-2mg/min
- MOA
- Nonselective beta + alpha-1 blockade
Mannitol
OsmitrolOsmotic diuretic
- Forms
- IV: 20%, 25%
- Dose
- 0.25-1g/kg IV over 20-30 min, may repeat q4-6h; keep serum osmolality below 320
- MOA
- ↑Plasma osmolality, draws water from brain tissue (↓ICP)
Hypertonic saline
3% / 23.4% NaClOsmotic agent
- Forms
- IV: 3% bags | 23.4% vials
- Dose
- 3%: 150-250mL bolus (or 2-5mL/kg) | 23.4%: 30mL via central line over 10-20 min; target Na 145-155
- MOA
- ↑Serum Na+/osmolality, ↓brain edema and ICP
Prothrombin complex concentrate (4F-PCC)
KcentraClotting factor concentrate (boxed warning: thromboembolism)
- Forms
- IV: lyophilized powder, 500 and 1000 unit vials
- Dose
- Warfarin reversal by INR: 25 units/kg (INR 2 to <4, max 2500) | 35 units/kg (INR 4-6, max 3500) | 50 units/kg (INR >6, max 5000); DOAC reversal (off-label): 50 units/kg or 2000 units fixed; give with vitamin K
- MOA
- Replaces vitamin K-dependent factors II, VII, IX, X plus proteins C and S
Idarucizumab
PraxbindMonoclonal antibody fragment
- Forms
- IV: 2.5g/50mL vials (2 vials per dose)
- Dose
- 5g IV (two 2.5g vials) for dabigatran reversal
- MOA
- Binds dabigatran with high affinity, neutralizing it
Phytonadione (vitamin K)
Mephyton / genericVitamin
- Forms
- Tab: 5mg | Inj: 10mg/mL
- Dose
- Warfarin reversal with PCC: 5-10mg slow IV (boxed warning: IV anaphylaxis risk)
- MOA
- Cofactor for hepatic synthesis of factors II, VII, IX, X
Propofol
DiprivanGeneral anesthetic
- Forms
- IV emulsion: 10mg/mL (20, 50, 100mL)
- Dose
- ICU sedation: start 5mcg/kg/min, titrate by 5-10mcg/kg/min every 5-10 min; maintenance 5-50mcg/kg/min | Refractory status epilepticus (off-label): 1-2mg/kg bolus then EEG-titrated infusion
- MOA
- GABA-A potentiation
Dexmedetomidine
PrecedexAlpha-2 agonist sedative
- Forms
- IV: 4mcg/mL premixed (80mcg/20mL, 200mcg/50mL, 400mcg/100mL) | Concentrate: 100mcg/mL
- Dose
- ICU sedation: optional 1mcg/kg load over 10 min, then 0.2-0.7mcg/kg/h (up to 1.5mcg/kg/h)
- MOA
- Selective central α2 agonism; sedation with minimal respiratory depression
Ketamine
KetalarNMDA antagonist anesthetic
- Forms
- IV/IM: 10, 50, 100mg/mL
- Dose
- Refractory status epilepticus (off-label): 1.5mg/kg IV bolus (may repeat), infusion 0.3-7.5mg/kg/h | Sedation-analgesia: 0.1-0.5mg/kg/h
- MOA
- Noncompetitive NMDA receptor blockade
Pentobarbital
NembutalBarbiturate
- Forms
- IV/IM: 50mg/mL
- Dose
- Refractory status epilepticus or ICP coma (off-label): load 5-15mg/kg IV (max 50mg/min), then 0.5-5mg/kg/h titrated to EEG burst suppression
- MOA
- ↑GABA-A Cl- channel open duration
Midazolam (continuous infusion)
VersedBenzodiazepine
- Forms
- IV: 1, 5mg/mL
- Dose
- Refractory status epilepticus (off-label): 0.2mg/kg IV load, then 0.1-2mg/kg/h | ICU sedation: 0.02-0.1mg/kg/h
- MOA
- ↑GABA-A Cl- channel frequency
Norepinephrine
LevophedVasopressor
- Forms
- IV: 1mg/mL vial (4mg/4mL); premixed bags
- Dose
- Start 0.05-0.2mcg/kg/min via central line, titrate to MAP/CPP goal; neurogenic shock or spinal cord injury MAP augmentation per protocol
- MOA
- α1 and β1 adrenergic agonism
Phenylephrine
Neo-SynephrineVasopressor
- Forms
- IV: 10mg/mL vial; premixed bags
- Dose
- Infusion typically 0.5-6mcg/kg/min (or 20-200mcg/min) titrated to MAP/CPP; bolus 50-250mcg
- MOA
- Selective α1 agonism
Desmopressin
DDAVPVasopressin analog (V2 agonist)
- Forms
- Inj: 4mcg/mL | NS: 10mcg/spray | Tab: 0.1, 0.2mg
- Dose
- Central diabetes insipidus: 2-4mcg/day IV/SC in 2 divided doses; nasal 10-40mcg/day; oral 0.05-0.2mg BID-TID, titrated to urine output and sodium
- MOA
- V2 receptor agonism, ↑renal water reabsorption
Enoxaparin
LovenoxLow-molecular-weight heparin
- Forms
- SC syringe: 30, 40, 60, 80, 100, 120, 150mg
- Dose
- VTE prophylaxis: 40mg SC once daily (30mg once daily if CrCl under 30mL/min); neuro-ICU start once hemorrhage is stable per guidelines
- MOA
- Potentiates antithrombin; inhibits factor Xa more than IIa
Heparin
Heparin sodiumUnfractionated heparin
- Forms
- Inj: 1,000, 5,000, 10,000 units/mL; premixed bags
- Dose
- VTE prophylaxis: 5,000 units SC every 8-12 hours; neuro-ICU start once hemorrhage is stable per guidelines
- MOA
- Potentiates antithrombin III (inhibits factors Xa and IIa)
Acetaminophen IV
OfirmevAnalgesic / antipyretic
- Forms
- IV: 1,000mg/100mL
- Dose
- Fever or pain: 1,000mg every 6 hours (or 650mg every 4 hours), max 4g/day; under 50kg 15mg/kg, max 75mg/kg/day
- MOA
- Central COX inhibition; antipyretic hypothalamic effect
Esmolol
Breviblocβ1-selective blocker · ultra-short
- Forms
- IV: 100mg/10mL vial; premixed 2,500mg/250mL
- Dose
- Load 500mcg/kg over 1 min, then 50mcg/kg/min; titrate by 50mcg/kg/min steps up to 200-300mcg/kg/min
- MOA
- β1 blockade; half-life about 9 minutes