Ch 81 Stroke management

Question 1

How do you manage a stroke?

Answer 1

Examination - NIHSS score CT head to rule out bleed / tumour CTA to identify large vessel occlusion Thrombectomy if within 6 hours or 6-24 hours if perfusion imaging suggests viable brain tPA within 4 hours if not candidate for thrombectomy

Question 2

What are the features of a stroke on CT?

Answer 2

Hyperdense MCA Low density area Loss of gray-white matter interface Attenuation of lentiform nucleus Loss of insula ribbon Mass effect

Question 3

How does CT perfusion estimate salvage brain?

Answer 3

Difference between the cerebral blood flow and the cerebral blood volume mismatch. Note an established stroke will have low CBF: and low CBV. Note low CBF:CBV = salvagable brain!

Question 4

What is the evidence for thrombectomy?

Answer 4

MR CLEAN 2014 = <6.5 hours thrombectomy improves outcome DAWN 2018 = Sustained improvement with thrombectomy 6-24 horus if perfusion mismatch. Functional independence improved from 10% in controls to 50% with thrombectomy

Question 5

What is the time window for tPA?

Answer 5

<4.5 hours in patients that are not candidates for thrombectomy

Question 6

Which vein commonly crosses over the carotid bifurcation?

Answer 6

The common facial vein

Question 7

What level does the common carotid bifurcate?

Answer 7

C4

Question 8

Where is the CN12 in the neck?

Answer 8

Anywhere between the carotid bifurcation (C4) to the mandible (C2) level. It crosses superficial to the ICA in relation to the common facial vein.

Question 9

Which patients should have carotid stenting?

Answer 9

High risk patients with CCF or recent MI / unstable angina