ACUTE ISCHEMIC STROKE

Question 1

This phase of AIS treatment reduce risk of death through diagnosis, hospital choice, and impact of time-to-time treatment

Answer 1

Pre-hospital phase (symptom onset to hospital door)

Question 2

this phase of AIS treatment absolutely focuses on the recanalization of the artery or reduction of swelling due to bleeding

Answer 2

Hyperacute phase (door to first hour)

Question 3

this phase of AIS treatment reduce death risk by neurological screening + close monitoring of cardiac and respiratory systems

Answer 3

Acute phase
1-24 hours after admission

Question 4

this phase of AIS treatment reduce risk of death by close monitoring of cardiac and respiratory systems and prevent recurrent stroke

Answer 4

Post-acute phase (24-72 hours after admission)

Question 5

what is the BE FAST acronym for stroke recognition?

Answer 5

BALANCE loss; headache or dizziness
EYES (blurred vision ,double vision, vision changes)
FACE one side of face is drooping
ARMS - arm or leg weakness
SPEECH - speech difficulty/ slurred speech
TIME - time to call ambulance

Question 6

T/F: In hyperacute stroke, Diagnosis of ischemic stroke is done on CT imaging

Answer 6

F
It is done CLINICALLY

Question 7

4 Steps for therapeutic decision making in hyperacute stroke

Answer 7

Diagnosis
Exclude Bleeding
Assess severity
Identify Contraindication

Question 8

Once the patient with a suspected stroke arrives, they must be evaluated by a physician within ___ minutes (first encounter)

Answer 8

10 minutes

Question 9

The brain attack team must arrive within ___ minutes after the door time

Answer 9

15 minutes

Question 10

In ___ minutes after door time, the patient has to be imaged (Head CT or MRI)

Answer 10

25 minutes

Question 11

The result of the imaging scan must be available within ___ minutes

Answer 11

45 minutes

Question 12

Decision of administering IV alteplase must be made in __________

Answer 12

under 60 mins

Question 13

What are the steps for immediate stabilization?

Answer 13

assess ABC
vital signs
O2 to maintain >94%
IV access
get blood samples
Check CBG and correct hypo- or hyperglycemia
obtain 12-LEAD ECG
Perform neurological screening assessment
Activate Brain Attack team

Question 14

This is a surrogate marker to determine if patient is eligible for rtPA or thrombectomy

Answer 14

Ictus

Question 15

Worst score for National Institute of Health Stroke Scale (NIHSS)

Answer 15

42 (Worst)
0 (no symptoms)
11 item analysis

Question 16

T/F: Scores in the National Institute of Health Stroke Scale (NIHSS) is only based on the patient’s responses and not on the observer’s interpretations

Answer 16

T

Question 17

T/F: NIHSS is more sensitive for posterior circulation strokes

Answer 17

F
It is more sensitive for anterior circulation strokes

posterior circulation strokes have lower scores even if they are large in size

Question 18

T/F: Stroke is a clinical diagnosis but the type of stroke will depend on the neuroimaging

Answer 18

T

Question 19

T/F: Neuroimaging cannot diagnose the etiology of stroke

Answer 19

F

Question 20

4 Ps to assess in neuroimaging

Answer 20

Parenchyma (Brain)
Pipes (Vessels)
Perfusion (if the perfusion is good)
Penumbra (Presence of penumbra to be saved)

Question 21

T/F while waiting for availability of brain imaging, a first aid therapy can first be given to patients with suspected AIS

Answer 21

F
imaging first before any therapy

Question 22

In CT scan, infarct is seen as (hypo/hyper) dense

Answer 22

HYPODENSE

Question 23

In CT scan, bleed is seen as (hypo/hyper) dense

Answer 23

HYPERDENSE

Question 24

T/F: The basal ganglia are almost always involved in PCA infarction

Answer 24

F
MCA infarction

Question 25

This is one of the earliest and most frequently seen signs in MCA infarction

Answer 25

Blurred Basal Ganglia on CT

Question 26

This is very sensitive to ischemia as it is the furthest removed from collateral flow

Answer 26

Insula (insular ribbon sign)

Question 27

Insular ribbon sign indicative of subtle early sign of infarction in the territory of what artery?

Answer 27

MCA

Question 28

Purpose of CT Angiography in bleeds

Answer 28

looks for macrovascular causes of ICH or SAH

Question 29

Purpose of CT Angiography in infarcts

Answer 29

detects large vessel occlusion

Question 30

This can is the only imaging study that can tell if there is still a penumbra to be saved

Answer 30

CT Perfusion

Question 31

T/F: Alberta Stroke PRogramme Early CT Score gives a clue on how big the stroke is

Answer 31

T

Question 32

T/F: The only goal in CT Scan is to detect/exclude a bleed since infarcts cannot be detected

Answer 32

T

Question 33

________ is more sensitive and specific than CT within the first few hours after onset of stroke

Answer 33

MRI

Question 34

T/F: It is possible in CT scant o age or look at how old a stroke is since it employs different contrasts

Answer 34

F MRI - uses different sequences

Question 35

In MRI, acute stroke appears (dark/white) in DWI

Answer 35

white

Question 36

In MRI, acute stroke appears (dark/white) in ADC

Answer 36

dark

Question 37

Changes in T2 and Flair MRI compared to the same areas in DWI and ADC results suggest an (acute/old) stroke

Answer 37

Old

Question 38

Lesion is seen in DWI but not on FLAR + with penumbra -> will tpa be given?

Answer 38

yes

Question 39

Lesion is seen in both DWI and FLAIR -> no penumbra -> will TPA be given?

Answer 39

no

Question 40

T/F: If DWI and FLAIR MRI results mismatch, it could be assumed that the stroke happened for more than 5 hours

Answer 40

F If there's mismatch, the stroke has NOT been around for longer than 4-5 hours -> can still qualify for TPA

Question 41

Imaging used in patients suspected of AIS with high creatinine

Answer 41

MRA an- as it can be used without contrast

Question 42

This type of infarct is usually caused by an embolic source involving large vessels

Answer 42

Large territorial infarct

Question 43

This type of infarct is due to emboli formed in the heart and "showers" into the brain

Answer 43

Multiple Small Embolic Infarcts (Cardioembolic infarct)

Question 44

This type of infarct is usually caused by a thrombotic source

Answer 44

Small Vessel disease/lacunar stroke

Question 45

T/F Multiple small embolic infarcts behave differently from other types of strokes

Answer 45

F Small Vessel Disease/Lacunar Stroke

Question 46

This type of infarct involves areas in between distribution of the major vessels, and is usually caused by a decrease in flow

Answer 46

Watershed Infarct

Question 47

This type of infarct is due to vein occlusion

Answer 47

Venous Stroke

Question 48

This is the only assessment that must precede VI alteplase

Answer 48

blood glucose

Question 49

Strategies performed when recanalization is the goal

Answer 49

Medical: Thrombolysis Endovascular: Thrombectomy

Question 50

T/F: A patient can be have thrombectomy and thrombolysis if indicated

Answer 50

T

Question 51

Alteplase must be given in people at least ___ years old, within ___ hours after onset

Answer 51

19 years old 4.5 hours

Question 52

T/F: Having multi lobar infarction (>1/3 cerebral hemisphere) on CT is an absolute contraindication to rtPA

Answer 52

T

Question 53

T/F: Previous history of ICH is an absolute contraindication to rtPA

Answer 53

T

Question 54

T/F: Having significant head trauma or prior stroke within 6 months is an absolute contraindication to rtPA

Answer 54

F within 3 months

Question 55

T/F: Having arteriovenous malformation is an absolute contraindication to rtPA

Answer 55

T

Question 56

Administration and dosage of alteplase:

Answer 56

Infuse 0.9 mg/kg (max dose of 90 mg) over 60 mins, with 10% of the dose given as a bolus over 1 minute

Question 57

Measure BP and perform neurological assessments every ___ minutes during and after IV alteplase infusion for __ hours, then every ___ minutes for 6 hours, then hourly until ___ hours after alteplase treatment

Answer 57

every 15 mins during and after infusion for 2 hours; every 30 mins for 6 hours; hourly until 24 hrs after alteplase tx

Question 58

Increase BP monitoring and administer antihypertensive meds if SBP is >___ mmHg or DBP is >___ mmHg

Answer 58

SBP > 180 mmhg DBP > 105 mmhg

Question 59

T/F: CT or MRI follow up scan must be done 48 hours after IV alteplase tx

Answer 59

F= must be done at 24 hrs after IV alteplase tx, before starting anticoagulants or antiplatelets

Question 60

Sweet spot for alteplase administration

Answer 60

<90 min from time of onset and between 90-180 mins, with small/short thrombus at MCA distal M1/M2

Question 61

T/F: larger infarct = higher NIHSS score = High chance of hemorrhagic transformation

Answer 61

T

Question 62

T/F: Hi-1 and Hi-2 infarcts are big infarcts -> neurosurgery or hematology service might be needed

Answer 62

F = it's PH1 and PH2 infarcts H1 and H2 infarcts are small -> repeat scan after 24 hrs before starting antiplatelet/coagulatng

Question 63

Dosage of tenecteplase

Answer 63

by weight = 0.25/kg

Question 64

T/F: Thrombectomy cannot be given WITH alteplase

Answer 64

F it can be given with or without alteplase

Question 65

Inclusion criteria (6) for thrombectomy

Answer 65

1. pre-stroke mRS 0-1 - px is functionally independent before stroke 2. Causative occlusion of the ICA or MCA segment (m1) - large vessel occlusion 3. age >/18 yo 4. NIHSS >/6 = as there would be no diff in thrombectomy and medical management if too mild 5. ASPECTS>/6 6. Can be initiated within 6 hrs of symptom onset via groin puncture

Question 66

T/F: Relative inclusion criteria for thrombectomy includes: causative occlusion of M2, M3, ACA, VA, BA, PCA (not LVO)

Answer 66

T

Question 67

T/F: Thrombectomy can be treated within 6 hrs as relative indication if mRS >1, NIHSS <6, Aspects <6, causative occlusion of ICA or M1

Answer 67

T

Question 68

T/F: Collateral flow is established depending on TPA administration

Answer 68

F Collateral flow is established and improved regardless of TPA administration and MT

Question 69

For General supportive care: supplemental oxygen should be provided to maintain oxygen saturation at:

Answer 69

>98%

Question 70

It is reasonable to treat hyperglycemia to achieve CBG ________ mg.dL

Answer 70

140-180 mg/dl

Question 71

T/F: Aspirin and other antiplatelets should be started within ___ to ___ hours after stroke onset (secondary prevention)

Answer 71

24 to 48 hours