Acute Ischemic Stroke

Question 1

What are some deficits experienced after a stroke? (5)

Answer 1

Hemiparesis
Cognitive decline
Depression
Inability to ambulate without assistance
PTSD

Question 2

What are some modifiable COMORBIDITY risk factors of stroke?

Answer 2

HTN
Diabetes
Dyslipidemia
Arrhythmias
Carotid stenosis
Sickle cell disease

Question 3

What are some modifiable BEHAVIORAL/MEDICATION risk factors of stroke? (3/2)

Answer 3

Cigarette smoking
Physical inactivity
Obesity

Oral contraceptives
Postmenopausal hormonal therapy
(All hormonal therapy)

Question 4

What tool is used to assess ischemic stroke risk?

Answer 4

CHA2DS2-VASc Score

Question 5

Define ischemic stroke

Answer 5

Brain injury due to blood loss to a specific area from atherosclerotic rupture or cardioembolism.

Question 6

What are some considerations for diagnosing stroke?

Answer 6

Time of sx onset
Sudden onset of focal neurological deficit (weakness, sensory loss, dysphasia [think facial droop])
UNILATERAL

Question 7

What TOOL can be used for diagnosis of stroke? What score indicates a minor stroke? What score indicates a severe stroke?

Answer 7

National Institutes for Health Stroke Scale (NIHSS)
<4 = minor stroke
>20 = severe stroke

Question 8

What neurological imaging is used for ischemic stroke diagnosis? (2)

Answer 8

Non-contrast head CT scan - rule out hemorrhage
MRI - detects early ischemic changes

Question 9

What are some common MIMICS of ischemic stroke?

Answer 9

Neurologic (COMMON) - seizure, migraine, brain processes, encephalopathy, vertigo, neuropathy, amnesia
Metabolic - hypo/hyperglycemia, hyponatremia, hepatic encephalopathy, drug OD
Psychiatric - conversion disorder, malingering

Question 10

If a stroke is identified within 4.5 hr of sx onset, what is the treatment procedure?

Answer 10

1. Fibrinolytics
2. +/- Thrombectomy

Question 11

What are some absolute contraindications of using IV fibrinolytics in stroke?

Answer 11

<18 yo
Ischemic stroke/intracranial surgery/head trauma < 3 months ago
GI malignancy <21 days ago
Enoxaparin within 24 hrs
DOACs within 48 hrs
Infective endocarditis
Intracranial/axial neoplasm
Unclear time of onset
Current intracranial/subarachnoid hemorrhage
Low PLT, high INR, aPPT > 40s
Aortic arch dissection

Question 12

What are some SOFT contraindications for fibrinolytic use in stroke?

Answer 12

Seizure - use if corrected
Low or high (500+) BG = use if corrected
Recent trauma or surgery = if not involving head, weigh risk of potential bleeding

Question 13

What are two IV fibrinolytics that may be used in stroke? What are the doses (mg/kg) and t1/2?

Answer 13

1. Alteplase - bolus + infusion
   DOSE: 0.9 mg/kg
   T1/2 = 5 mins
2. Tenecteplase* - IV push
   DOSE: 0.25 mg/kg
   T1/2 = 20 mins
   (Tenecteplase = 15x more fibrin specificity)

Question 14

IV fibrinolytics cannot be given until BP is controlled. For BOLUS, BP must be <________ and for INFUSION BP must be <___________

Answer 14

Bolus: <185/110
Infusion: <180/105

Question 15

When is permissive HTN allowed in stroke patients?

Answer 15

If pt is excluded from use of fibrinolytics, then BP not corrected until >220/110

Question 16

What are some first line antihypertensives to use to control BP before using IV fibrinolytics?

Answer 16

Labetalol
Nicardipine (use if HR <55)

Question 17

When could tenecteplase potentially be MORE beneficial compared to alteplase?

Answer 17

If the stroke is from a LARGE VESSEL OCCLUSION

Question 18

IV fibrinolytics can cause complications like symptomatic ICH or angioedema. What should you do to resolve these?

Answer 18

Symptomatic ICH: d/c alteplase, cryoprecipitate 10U, anti fibrinolytics

Angioedema: maintain airway, hold any ACEi, Methylprednisolone, diphenhydramine, ranitidine, epinephrine (INTUBATE)

Question 19

After use of fibrinolytics, we can consider thromectomy for what kind of stroke?

Answer 19

Used for large vessel occlusion

Question 20

What should be monitored for 24 hrs after fibrinolytic use?

Answer 20

Check for NEUROLOGIC DECLINE and BLOOD PRESSURE

Question 21

What medications should be given to a stroke patient AFTER fibrinolysis & sx resolution?

Answer 21

High-dose statin
Antiplatelet (aspirin for all, dual for low NIH stroke x21 days OR pts with intracerebral stent)
DVT prophylaxis

Question 22

What are some secondary stroke prevention tactics? (7)

Answer 22

Lifestyle/Nutrition
Smoking cessation
Limit alcohol
Counsel on substance abuse
Hypertension control
Dyslipidemia control
Diabetes control