Ch 87- Stroke Flashcards

Question

Classic ICH presentation

Answer 1

the sudden onset of headache, vomiting, severely elevated BP, and focal neurologic deficits that progress over minutes

Answer 2

ICH score GSW 3-4 (2) 5-12 (1) 13-15 (0) ICH Volume >30ml (1) <30 (0) Intraventricular blood yes (1) no (0) Location Infratentorial (1) Supratentorial (0) Age >80 (1) <80 (0) 30 day mortality 1= 13% 2=26% 3= 72% 4= 97% 5/6= 100%

Answer 3

Door to Doctor - 10 min Door to CT - 25 min Door to treatment - 60 min Access to stroke neurology 15 min Access to neurosurgical expertise 2 h

Answer 4

Identify stroke o Early hospital notification o Rapid transport o Ensure CNS oxygenation and perfusion (sp02>95%)

Answer 5

1. Blood glucose test (+ PTT, INR, CBC) 2. ECG > to exclude atrial fibrillation or acute MI 3. Cranial imaging (CT or CT/CTA)

Answer 6

Age >18 Symptom onset >4.5 h (or confirmed wake up stroke) clinical diagnosis + significant neurologic deficits

Answer 7

Age >80 NIHSS >25 Oral AC DM and previous CVA

Answer 8

0.9 mg/kg (max 90) 10% as a bolus 90% over 1h

Answer 9

● Prevent secondary neurologic injury ○ Optimal fluid and electrolyte balance ○ Avoid hypo- or hyperglycemia ○ Prevent fever ● Start an antiplatelet (or add clopidogrel on to ASA) within 48 hrs ● Consider starting LMWH in hospital after consultation with neurology ● Start aggressive statin therapy ● Treat high blood pressure only if the hypertension is extreme (systolic blood pressure >220 mmHg or diastolic blood pressure >120 mmHg) ● Prevent aspiration, early mobilization and physiotherapy and multidisciplinary stroke unit care

Answer 10

1. Patient is a re-perfusion candidate (tPa and/or re-perfusion intervention) 2. Patient is NOT a re-perfusion candidate and has NO special medical conditions that mandate BP control - AKA avoid anti-hypertensives/ BP control NOT indicated unless... SBP >220/ DBP >120/ MAP >130 3. Patient with specific medical indications - Acute MI (SBP 100-120) -Aortic Dissection (SBP 100-120) -HTN encephalopathy (10-15% reduction) -Severe LV heart failure (10-15% reduction)

Answer 11

If Systolic >185 mm Hg or diastolic >110 mm Hg o Labetalol 10 to 20 mg IV over 1 to 2 minutes; may repeat 1 time OR o Nicardipine infusion, 5 mg/hr; titrate up by 2.5 mg/hr at 5- to 15-minute intervals, maximum dose 15 mg/hr; when desired BP attained, reduce to 3 mg/hr o Other agents (hydralazine, enalaprilat, etc.) may be considered when appropriate. * If BP does not decline and remains >185/110 mm Hg, do not administer rtPA

Answer 12

BP q 15 min during treatment AND 2 hr after treatment > then q 30 min x 6h > then q 1h for 16h IF SBP 180-230 or DBP 105-120 o Labetalol 10 mg IV over 1 to 2 minutes; may repeat every 10 to 20minutes; maximum dose of 300 mg OR o Labetalol 10 mg IV followed by an infusion at 2 to 8 mg/min IF SBP >230 or SDP >120 ...follow same labetalol protocol and consider nicardipine infusion 5 mg/hr; titrate up to desired effect by increasing 2.5 mg/hr every 5 minutes to maximum of 15 mg/hr * If BP not controlled, consider sodium nitroprusside.

Answer 13

Head trauma or prior stroke within 3 mo SxS of SAH History of ICH Known intracranial neoplasm, AVM or aneurysm Recent brain or spine surgery SBP>185 DBP > 110 Active internal bleeding Acute bleeding diathesis - PLT <100 -Heparin therapy within 48 hr causing elevated aPTT -current AC use with INR> 1.7 or PT >15 -BG <2.7 -CT shows multi-lobar infraction Relative CIs mild stroke symptoms or NIHSS >4 pregnancy seizure at onset with postictal neuro deficits Major surgery or serious trauma within 14d Recent GI or UT hemorrhage within 21d Recent MI within 3mo

Answer 14

See Table 87.5

Answer 15

* INCLUSION CRITERIA o Diagnosis of ischemic stroke causing measurable neurological deficit o Onset of symptoms within 3 to 4.5 hours before beginning treatment * RELATIVE EXCLUSION CRITERIA o Older than 80 years old o Severe stroke (NIHSS > 25) o Taking an oral anticoagulant regardless of INR o History of both diabetes and prior ischemic stroke

Answer 16

IV thrombolysis 0-4.5 hr all patients showing signs of acute ischemic stroke confirmed by CT/CTA 4.5-6h select patients with signs of disabling stroke. Based on advanced neuroimaging 6-9 hr select patients with signs of disabling stroke. Based on advanced neuroimaging and discussion with stroke expert (ie wake up stroke) Endovascular thrombectomy 0-6hr all patient showing signs of acute disabl;ing stroke with LVO . Based on CT/CTA 6-24 hr all patient showing signs of acute disabl;ing stroke with LVO based on advanced neuroimaging

Answer 17

Diagnosed with an acute ischemic stroke.  The stroke is disabling (i.e., significantly impacting function) (NIHSS)>4.  The risks and benefits of thrombolysis are within the patient’s goals of care and take into consideration their functional status prior to stroke.  Life expectancy of 3 months or more.  Age ≥18 years.  symptoms/ last well <4.5 hours before thrombolysis administration.

Answer 18

Absolute Exclusion Criteria  Any source of active hemorrhage or any condition that could increase the risk of major hemorrhage  Any hemorrhage on brain imaging. Relative Historical  History of intracranial hemorrhage.  Stroke or serious head or spinal trauma in the preceding 3 months.  Major surgery (e.g., cardiac, thoracic, abdominal, or orthopedic) in the preceding 14 days. Risk varies according to the procedure.  Arterial puncture at a non-compressible site in the previous 7 days. Clinical  Stroke symptoms due to another non-ischemic acute neurological condition such as seizure with post-ictal Todd's paralysis or focal neurological signs due to severe hypo- or hyperglycemia.  Hypertension refractory to aggressive hyperacute antihypertensive treatment such that target blood pressure <180/105 cannot be both achieved and maintained.  Currently prescribed and taking a direct non-vitamin K oral anticoagulant CT or MRI Findings  CT showing early signs of extensive infarction (e.g., >1/3 of middle cerebral artery [MCA] territory, or ASPECTS score <6). Laboratory  Blood glucose concentration <2.7 mmol/L or >22.2 mmol/L.  Elevated activated partial-thromboplastin time.  International Normalized Ratio >1.7.  Platelet count <100,000 per cubic millimetre.

Answer 19

0.25 mg/kg up to a maximum of 25 mg should be administered, given as a single bolus over 5 seconds Benefit in bolus

Answer 20

(NEW FOR 2022) Hypertension with symptomatic ICH: In patients with symptomatic ICH who are hypertensive (>185/110 mm HG), blood pressure should be lowered, however, the specific target and duration of therapy are unknown at this time. ie avoid hypotension Agents- labetalol, esmolol, nicardipine, hydralazine, clevidipine

Answer 21

● Patient on warfarin: ○ Vitamin K 10 mg IV ○ FFP 2-4 units or prothrombin complex concentrate (PCC) ● Patient on dabigatran ○ Idarucizumab ● Patient on apixaban, rivaroxaban ○ PCCprothombin complex concentrate ● Patient on ASA or Clopidogrel: ○ No current evidence to support platelet transfusion, unless plt count < 30,000

Answer 22

1. Neurosurgery consultation for patients with clinical or radiographic evidence of elevated ICP ○ Question re: benefits of an external ventricular drain (EVD) placement or hematoma evacuation 2. Cerebellar hemorrhage within 48 hrs of onset - assuming they have a sizable lobar hemorrhage that is close to the cortical surface with associated progressive neurological deterioration 3. People with intraventricular hemorrhage or posterior fossa hemorrhages may benefit from a ventricular drain **Non-cerebellar ICH is rarely intervened on

Answer 23

● Cerebral edema progressing to increased ICP and deterioration (needing ICU care) ● Hemorrhagic transformation ● GI bleeding ● CHF ● Hospital related complications: DVT, PE, UTI’s, pneumonia ● Post-stroke seizures ● Post-stroke delirium and depression

Answer 24

Big categories o Hypercoagulable states o Vasospasm o Post-infectious o Traumatic o Connective tissue disorders Specific situations o Pregnancy o Use of oral contraceptives o Antiphospholipid antibodies o Protein C and S deficiencies o Sickle cell anemia o Polycythemia o Migraine syndromes o Recreational drugs **Cocaine/Amphetamines o Recent infection from varicella or fungal meningitis o Carotid / vertebral trauma leading to dissection § Spinal manipulation / cough / yoga / vomiting

Answer 25

Wernicke’s Aphasia Receptive aphasia Can’t comprehend Often say many words that don’t make sense Broca’s Aphasia Expressive aphasia Can’t get the words out

Answer 26

A disorder of language in which the patient articulates clearly but uses language inappropriately or understands it poorly, also is common in dominant-hemisphere stroke.

Answer 27

A motor deficit of the mouth and speech muscles; the dysarthric patient articulates poorly but understands words and word choices.

Answer 28

Difficulty swallowing

Answer 29

Most findings don’t appear on routine CT scans till 6-12 hrs post infarction. However, subtle, early ischemic changes have been noted in up to 67% of noncontrast CT scans within the first 3 hours. These early ischemic changes include: 1. Hyperdense artery sign (acute thrombus in a vessel) 2. Sulcal effacement (due to edema) 3. Loss of the insular ribbon 4. Loss of gray-white interface, 5. Mass effect 6. Acute hypodensity (Fig. 91.4)

Answer 30

In patients with ischemic stroke within 3 hours, tPA administration significantly improved NIHSS scores but did not confer survival benefit.

Answer 31

1. Diagnosed with an acute ischemic stroke. 2. The stroke is disabling (i.e., significantly impacting function), usually defined as National Institutes of Health Stroke Scale (NIHSS)>4. 3. There is a proven, clinically relevant (symptomatic), intra- or extracranial acute arterial occlusion that is amenable to endovascular intervention. 4. The risks and benefits of endovascular thrombectomy are within the patient’s goals of care and take into consideration their functional status prior to stroke. 5. Age ≥18 years. (Refer to pediatric guidelines for treatment <18 years of age). a. Currently, there is no evidence for EVT in pediatric populations and the decision to treat should be based on the potential benefits and risks of the therapy, made by a physician with pediatric stroke expertise in consultation with the EVT provider and the patient and/or family or substitute decision-makers. 6. Intravenous thrombolysis: If intravenous thrombolysis is given in conjunction with endovascular thrombectomy, refer to Box 5B for additional inclusion criteria. 7. Premorbid condition criteria: In general, individuals considered eligible for EVT are those who were deemed functionally independent before their index stroke (i.e., mRS <3) and have a life expectancy >3 months. Note: These criteria are based on major clinical trial inclusion criteria. Decisions should be based on these factors, clinical judgement, and the patient’s goals of care. 8. Imaging: Patients must qualify for imaging criteria in early and late windows as described in Boxes 4B and 4C. 9. Time to treatment: The decision to proceed with EVT should be shared by the physician with clinical stroke expertise and the neuro-interventionalist, who will use the available imaging nformation as is indicated. a. Specifically: i. Patients should have immediate neurovascular imaging (see above) to determine eligibility. Patients can be considered for imaging within a 24-hour window from stroke symptom onset or last known well. ii. For patients presenting <6 hours from stroke symptom onset or last known well to initiation of treatment (i.e., arterial puncture), all patients who meet eligibility criteria should be treated. iii. For patients presenting between 6 and 24 hours from last known well, selected patients may be treated if they meet clinical and imaging criteria and based on local protocols and available expertise in EVT.

Answer 32

TIA/non-disabling stroke + ispilateral >70% stenosis Select patients with TIA/non-disabling stroke and 50 – 69% stenosis Selected asymptomatic patients with stenosis >70% TOH -> Call Vasc/Neuro for >50% Stenosis if symptomatic

Answer 33

TIA from intracardiac (LV) or valvular thrombus (only one in UTD) Crescendo TIA TIA from a cardioembolic source High-grade carotid artery stenosis, FFT Posterior circulation TIA

Ch 87- Stroke Flashcards

(58 cards)