2024 CPG acute ischemic stroke and ICH in the Phil

Question 1

Patients suspected with acute stroke within 6 hours

Answer 1

non-contrast CT or cranial MRI

Question 2

Indication of Cranial MRI
1. Patients with symptom onset <6 hours
2. Patients with unknown time of symptom onset
3. Patients with “wake-up stroke”
4. Patients with minor stroke or NIHSS <=4
5. Patients with posterior circulation stroke
6. Patients with transient ischemic attack

Answer 2

Indication of a non-contrast CT scan
1. Patients with symptoms suggestive of intracranial hemorrhage
2. Patients with head trauma
3. If patients cannot tolerate MRI procedure due to claustrophobia or discomfort
3. If patient has metallic implants, pacemakers and prosthetic valves that are MR incompatible
4. Morbidly obese patients
5. If cranial MRI is not accessible

Question 3

Recommend admission to the

Answer 3

Stroke unit

Question 4

Acute ischemic stroke

Answer 4

<4.5 hours from onset of symptoms

May use IV thrombolysis with alteplase

Question 5

Standard dose of alteplase

Answer 5

0.9 mg/kg
Maximum dose 90 mg over 60 minutes
With initial 10% of dose given as bolus over 1 minute

Given <4.5 hours onset of symptoms

Question 6

Alternative to alteplase for IV thrombolysis

Answer 6

Tenecteplase

Single IV bolus of 0.25 mg/kg
Maximum 25 mg

Question 7

Patients with acute minor non-cardioembolic acute (NIHSS<=3) ischemic stroke or high risk TIA within 24 hours give dual antiplatelet

Answer 7

Aspirin and clopidogrel for 21 days

Question 8

Against very early mobilization

Answer 8

Within 24 hours by a trained staff

Question 9

For immobilized inpatients with acute ischemic stroke, suggest to use anticoagulants (LMWH or Unfractionated heparin)

Answer 9

Suggest the use of intermittent pneumatic compression

Against the use of graduated compression stockings

Question 10

Patients with supratentorial spontaneous ICH with signs of increased ICP

Answer 10

Surgical evacuation of hematoma on top of best medical management

Question 11

Patients with malignant MCA infarction

Defined as:
1. infarction size >50% MCA territory on visual inspection
2. ischemic lesion volume >150 cm³
3. Concomitant clinical features

life-threatening brain edema occurring in 2% to 8% of patients within the first 4 days after stroke onset.

Conservative management: associated with death rates up to 80%

Answer 11

Do surgical decompression (large hemicraniectomy and duraplasty) on top of medical management

Question 12

Neuroprotectants edaravone, citicholine, cerebrolysin, neuroaid

Answer 12

Not recommended