Acute Stroke & Status Epilepticus

Question 1

Stroke symptoms

Answer 1

Sudden onset of FOCAL, UNILATERAL neurological deficit
- dysphagia (diff swallowing), dysarthria (diff speaking)
- hemianopia (half-blindness)
- weakness
- ataxia (decreased coordination)
- sensory loss
- neglect

Question 2

NIH stroke scale 0

Answer 2

no stroke symptoms

Question 3

NIH stroke scale 1-4

Answer 3

Minor stroke

Question 4

NIH stroke scale 5-15

Answer 4

Moderate stroke

Question 5

NIH stroke scale16-20

Answer 5

Moderate-severe stroke

Question 6

NIH stroke scale > 20

Answer 6

severe stroke

Question 7

Recommended acute treatment: Within 4.5h of sx onset

Answer 7

Fibrinolysis +/- thrombectomy

Question 8

Recommended acute treatment: 4.5-24 h after sx onset (large vessel occlusion)

Answer 8

Thrombectomy

Question 9

Recommended acute treatment: 4.5-24h after sx onset (small vessel occlusion + permissive hypertension)

Answer 9

Heparin infusion

Question 10

Absolute CI to fibrinolytics

Answer 10

< 18 yo
ischemic stroke within 3 months
intracranial/intraspinal surgery w/in 3 months
GI bleed in last 21 days
LMWH within 24 h
Infective endocarditis
Intra-axial intracranial neoplasm
unclear time of onset or > 4.5 h after
current intracranial hemorrhage
severe head trauma in last 3 mo
platelet < 100,000
INR >/= 1.7
aPTT > 40
DOAC within 48 h
Aortic arch dissection

Question 11

Fibrinolytic agents

Answer 11

Alteplase
Tenecteplase

Question 12

Alteplase dosing

Answer 12

0.9 mg/kg (max 90 mg)
Bolus 10% over 1 minute
remaining 90% as infusion over 60 min

Question 13

Tenecteplase dosing

Answer 13

0.25 mg/kg (max 25mg)
IV push
more specific than alteplase

Question 14

BP required for thrombolytic bolus

Answer 14

< 185/110

Question 15

BP goal for thrombolytic infusion

Answer 15

< 180/105

Question 16

if patient meets exclusion criteria and alteplase is not given, BP is not treated unless

Answer 16

> 220/110

Question 17

First line agents for BP control in acute stroke setting

Answer 17

IV Labetalol
IV Nicardipine (preferred if HR < 55)

Question 18

Fibrinolytic complications

Answer 18

symptomatic intracranial hemorrhage
angioedema

Question 19

Symptomatic intracranial hemorrhage management

Answer 19

1.) DC fibrinolytic
2.) Cryoprecipitate 10 U infused over 10-30 min
3.) anti-fibrinolytics
- tranexamic acid 1000 mg IV
- E aminocaproic acid 4-5 g IV

Question 20

Angioedema management

Answer 20

Maintain airway
hold ACEi
Methylprednisolone 80-100 mg IV
Diphenhydramine 50 mg IV
Ranitidine 50 mg IV or famotidine 20 mg IV
Epinephrine 0.3 mL

Question 21

Post-stroke regimen

Answer 21

close monitoring for first 24h
dysphagia and aspiration risk assessment
high dose statin
antiplatelets
- aspirin
- dual antiplatelet for low NIH stroke scale or intracerebral stent x 21 d
DVT prophylaxis
Anticoagulation if cardioembolic stroke or hx of A Fib)

Question 22

Risk factors for breakthrough seizures

Answer 22

Intoxication
Withdrawal
Trauma
Meningitis
Psychiatric
Metabolic derangements

Question 23

First line agents to stop an acute seizure

Answer 23

Benzos:
Lorazepam 0.1-0.2 mg/kg IV
Diazepam 0.15 mg/kg IV
Midazolam IM (if no IV access)

Question 24

Benzodiazepine ADE

Answer 24

impaired consciousness
hypotension
respiratory depression

Question 25

(Fos)Phenytoin

Answer 25

Loading dose: 20 mg/kg IV
Maintenance dose: 4-6 mg/kg/day in 2-3 div
highly protein bound
ADE:
- CV risks (hypotension, bradycardia, QTc P, usually correlated with high infusion rate)
- extravasation

Question 26

Phenytoin ADRs (PHENYTOIN-RN)

Answer 26

P-450 interactions
Hirsutism/hypertrichosis
Enlarged gums
Nystagmus
Yellow-browning of skin (hepatitis)
Teratogenicity
Osteomalacia - VitD deficiency
Interference with folate metabolism (anemia)
Neuropathies: vertigo, ataxia, HA
Rashes/fever: SJS
Neutropenia, thrombocytopenia

Question 27

(Fos)Phenytoin Monitoring

Answer 27

Goal level: 10-20 mcg/dL (total phenytoin)
if seizing may target 15-25
levels > 30 = seizures
must correct level for low albumin (< 3.5) and poor renal function (CrCL < 30)

Question 28

Levetiracetam

Answer 28

SE dose:
- LD: 20 mg/kg IV bolus
- MD: 1000 mg IV BID
levels do not correlate with efficacy
ADE
- agitation
- drowsiness

Question 29

Valproic acid

Answer 29

Dose:
- LD 40 mg/kg
- MD 5 mg/kg IV Q8H
Goal level:
- 50-100 mcg/mL
ADE:
- drowsiness, HA
- thrombocytopenia
- pancreatitis (pediatrics)
- hyperammonemia
DDI:
- phenytoin -> increased free phenytoin levels -> increased toxicity

Question 30

Lacosamide

Answer 30

Dose: 100-200 mg IV BID
ADE:
- dizziness, abnormal vision, diplopia, ataxia
- generally well tolerated

Question 31

Refractory SE

Answer 31

If there is no response to initial anticonvulsants
OR
seizures lasting > 2hrs
OR
seizures recuring at a rate of 2 or more episodes per hour with no recovery to baseline between seizures, despite treatment

Question 32

Paralyzed patients

Answer 32

paralytics used during intubation in refractory SE -> cannot physically observe seizures

start an IV antiepileptic (propofol or midazolam)
long term EEG (LTM) monitoring

Question 33

Phenobarbital/Pentobarbital Coma

Answer 33

Pentobarbital
- 5-10 mg/kg IV x1
- 0.5-5 mg/kg/hr IV infusion
Phenobarbital:
- LD 20 mg/kg IV
- MD 1-2 mg/kg IV BID
ADE:
- respiratory depression (intubation required)
- hypotension (may need vasopressor)
- lethargy
- nystagmus
- thrombocytopenia
- suppressed immune system
- decreased GI motility

Question 34

Super Refractory Status Epilepticus

Answer 34

Ketamine infusion
- LD 1.5-3 mg/kg IV
- MD 0.1-4 mg/kg/hr