Critical Care: Acute Ischemic Stroke

Question 1

deficits expeiednced after a stroke

Answer 1

• hemiparesis
• cog declie
• depression
• inability to ambulate on own
• PTSD

Question 2

CHA2DS2 VASc

Answer 2

• CHF
• HTN
• 75+ (2)
• DM
• Stroke hx (2)
• Vascular disease
• Age 65-74
• Sex category female

Question 3

neuro stroke mimics

stroke mimics that are neurologic in nature

Answer 3

• seizure/postictal state
• complciated migraine
• intracranial infection, tumor or hemorrhage
• vertigo
• Bell’s palsy
• transient global amnesia

Question 4

metabolic stroke mimics

seizure mimics that are metabolic in nature

Answer 4

• hypo/hyperglycemia
• drug overdose

Question 5

psychatirc seizure mimics

seizure mimics that are psychiatric in nature

Answer 5

• malingering
• conversiion disorder

Question 6

ischemic stroke

Answer 6

blood loss to area of brain
- excess of extracellular axcitatory amino acids, free radicals, inflammation

Question 7

stroke assessment

Answer 7

• most important consideration: time of syptom onset (last known normal)
• symptoms are focal and unilateral
• confirm s/s d/t ischemia - differentiate from mimics
• neuroimaging: non-contrast head CT scan

Question 8

stroke treatment

Answer 8

• if < 4.5 hrs from symptom onset: fibrinolytics (and maybe thrombectomy if large vessel occlusion)
• if 4.5-24 hrs from symptom onset, consider size of occlusion
  - large vessel occlusion: thrombectomy
  - small vessel occlusion: heparin and permissive HTN

Question 9

what is permissive HTN in regards to stroke treatment

Answer 9

in the setting of stroke, pt bp tends to elevate, with permissive HTN, we would NOT treat unless bp > 220/110

instances of permissive HTN
- < 4.5 hrs from symptom onset and pt meets exclusion criteria for thrombolytics
- 4.5-24 hrs from symptom onset and pt has small vessel occlusion

Question 10

fibrinolytic therapyMOA

Answer 10

TPA (tissue plasminogen activators): activate plasminogen -> activate plasmin -> dissolve fibrin

alteplase and tenecteplase

Question 11

absolute CI to TPA

Answer 11

• < 18 years old
• any of the following in past 3 months
  - ischemic sroke
  - severe head trauma
  - intracranial/intraspinal surgery
• GI malignacy or bleed in past 21 days
• use of anticoag
  - LMWH in has 24 hr
  - DOAC in past 48
• current intracranial hemorrhage (ICH)
• aortic arch dissection

if pt on warfarin AND INR < 1.7, can give

Question 12

alteplase admin and dosing

Answer 12

• 0.9 mg/kg to a max of 90mg
• admin 10% as a bolus over 1 min then the remaining 90% over 60 min

we do this infusion thing because it is super short acting

Question 13

tenectaplase admin and dosing

Answer 13

• 0.25 mg/kg to a max of 25mg
• admin as an IV push

can do IV push dt long half life

Question 14

tenetaplase v alteplase

Answer 14

tenectaplase more specific and may be better if large vessel occlusion

Question 15

bp requirments for fibrinolytic therapy

Answer 15

• < 185/110 for bolus
• < 185/105 for infusion (alteplase)

can achieve above bp with:
- first line: labetalol or nicardipine (may prefer nicardipine if HR< 55)
- second line: hydralazine, enalaprilat, clevidpine

Question 16

ADR of fibrinolytic therapy

Answer 16

• symptomatic ICH
• angiodema

Question 17

treatment of fibrinolytic induced symptoamtic ICH

Answer 17

• dc fibrinolytic
• admin cryoprecipitate (increases fibrogen)
• admin anti fibrinolytic (transexamic acid or ε-aminocaproic acid)

Question 18

treatment of fibrinolytic induced angioedema

Answer 18

• big big risk factor is conmittant ACEi
• treatment:
  - maintain airway/intubate
  - hold ACEi (if present)
  - methylrednisolone
  - diphenydramine
  - famotidine
  - epinephrie

Question 19

post fibrinolytic care

Answer 19

• neuro and bp checks regularly during first 24 h
• dysphagia and aspiration risk
• high dose statin
• asa (DAPT 21 days if low NIH score or intracerebral stent placement)
• DVT ppx after 24 h
• anticoag if cardioembolic stroke or hx of afb (can take days before we actually start this)