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SSP > Chapter 3. Guidelines for Treatment of Acute Stroke > Flashcards

Chapter 3. Guidelines for Treatment of Acute Stroke Flashcards

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1
Q

SSP Definition of Stroke Severity

A

Mild: NIHSS 0-5
Moderate: NIHSS 6-21
Severe: NIHSS >21

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2
Q

Indication for Admisision of TIA to SU

A
  1. ABCD2 score 3>
  2. TIA within 24 hours
  3. Crescendo TIA
  4. TIA with known cardiac source
  5. Known hypercoagulable state
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3
Q

Type of admission based on stroke severity

A

Mild: general room
Moderate: ASU/ICU
Severe: ICU

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4
Q

BP management of TIA

A

Only treat when MAP > 130

Avoid precipitous drop of > 15% from baseline MAP

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5
Q

In patient with ICH, consideration of further testing such as 4V angiogram, MRA or CTA if:

A
  1. < 45 years old
  2. Normotensive
  3. Lobar
  4. ICH of unknown cause
  5. Suspected aneurysm, AVM or vasculitis
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6
Q

Rehabilitation should be initiated at

A

72 hours

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7
Q

If the patient arrived 6 hours post-ictus what management should be considerd

A

Intra-arterial rTPA

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8
Q

Neurosurgical consult in ICH is considered in the following setting

A 
Not herniated
Location is lobar, putaminal, or cerebellum
Relatives willing to consent
ICP monitoring
Goal: reduction of mortality
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9
Q

What drugs are being compared to International Stroke Trial (IST)

A

ASA 300mg/day vs SQ heparin vs ASA and heparin vs placebo

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10
Q

What is the result of IST trial

A

ASA group - fewer death and recurrent stroke in 14 days with no excessive hemorrhagic stroke
Heparin group - fewer death and recurrent stroke by more hemorrhagic stroke and serious extracranial hemorrhage (NO NET BENEFIT)

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11
Q

What drugs used to compare in Chinese Acute Stroke Trial

A

ASA vs Placebo

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12
Q

What is the result of CAST trial

A

ASA reduced risk of recurrent stroke or vascular death

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13
Q

This trial compares clopidogrel 300mg then 75mg MD + ASA 80 vs ASA monotherapy

A

Fast Assessment of Stroke and TIA to Prevent Early Recurrence (FASTER trial)

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14
Q

What is the recurrence rate of stroke in ASA monotherapy in FASTER trial

A

10.1%

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15
Q

What is the recurrence rate of stroke in ASA + clopidogrel in FASTER trial

A

7.1%

increased hemorrhage in this group

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16
Q

What drugs are being compared in CHANCE trial

A

Clopidogrel + ASA vs ASA monotherapy

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17
Q

What is the result of CHANCE trial

A

Recurrence rate:
Clopidogrel + ASA: 8.2%
ASA 11.7%

No increase in rate of mod-severe bleeding in combination

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18
Q

This study compard Cilostazol to ASA in stroke treatment

A

Cilostazol in Acute Ischemic Stroke Treatment (CAIST trial)

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19
Q

What is the result of CAIST trial

A

Non-inferiority outcome of cilostazol to ASA MRS 0-2 at 90 days

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20
Q

What is the result of Metaanalysis of LMWH, heparin in acute ischemic stroke

A

LMWH and heparin decreased the venous thromboembolic event (DVT/PE) but did not have effect reducing death and disability

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21
Q

Neuroprotection is to Avoid 5 H’s

A 
Hypertension
Hypoglycemia
Hyperglycemia
Hyperthermia
Hypoxemia
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22
Q

Hyperglycemia further add to the injury of ischemic tissue by

A

increased lactic acidosis
free radical production
worsening of edema

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23
Q

Glucose levels should be maintained at what level

A

140-180

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24
Q

This condition is associated with poor outcome related to increased metabolic demand

A

Hyperthermia

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25
For how many rise in body temperature is associated with increased death by 2%
1 degree celcius
26
3 Classification of Neuroprotection
1. Drugs with neurovascular properties | 2. Drugs with neurotrophic, neurorestorative properties
27
What did ICTUS trial test for
Global recovery for 90 days
28
What is the result of ICTUS trial
neutral result
29
The ceiling effect of ICTUS trial is secondary to what factor
Maximum effect was attributed to rTPA
30
What trial which involved Cerebrolysin
Cerebrolysin in Patients with Acure Ischemic Stroke in Asia (CASTA Trial)
31
What is the result of CASTA Trial
no over-all difference in outcomes in cerebrolysin group vs placebo
32
What is the result of ECHIMES trial
Significant reduction in risk of recurrent fatal events during 3 months
33
What is the other findings of ICTUS trial
Citicoline is beneficial in: Ages 70 and above Patients with moderate stroke Patients not treated with rTPA
34
Indication for anticoagulation
``` Intracardiac thrombi Mechanical prosthetic valve Recent MI CHF Bridging Measure ```
35
Contraindication for anticoagulation
Bleeding diasthesis Non-petechial intracranial hemorrhage Recent Surgery Infective Endocarditis
36
rTPA eligibility
18 years old and above Clinicla measurable stroke Time of onset is <180
37
BP cut-off for rTPA
185/110mmHg
38
This trial used the 0.6mg/kg dose of rTPA
ENCHANTED trial
39
What is the maximum dose of rTPA
90mg
40
antihypertensive medication of choice in patient eligibke for rTPA
Labetalol 10-mg/IV (1-2mins) | Nicardipine 5mg.hour every 5-15 minutes
41
BP monitoring for rTPA
every 2 hours for 2 hours every 30 mins for 6 hours every hour for 16 hours
42
Systolic and diastolic cut-off that warranted antihypertensive medication for rTPA
>230 SBP | 121-140 DBP
43
The following measure should be done if ICH is suspected
``` D/C rTPA Repeat CT-Scan Draw blood for bleeding parameter Prepare cryoprecipitate containing FVIII Prepare 6-8 units of platelet concentrate ```
44
Expansion of time window to 4.5 hours relative exclusion
80 years old NIHSS > 25 On oral anticoagulation regardless of INR Hx of stroke and DM
45
This trial use thrombolytic agents that can be used 3-9 hours
Despoteplase to treat Acute Stroke (DIAS-3)
46
What is the first trial on rTPA
National Institute of Neurological Disorder and Stroke t-PA trial (NINDS t-PA trial)
47
National Institute of Neurological Disorder and Stroke t-PA trial uses what dose of rtPA
0.9mg/kg
48
Result of NINDS trial
1. no difference in neurological outcome in 24 hours 2. 30% in t-PA group have minimal to no disability despite more symptomatic ICH (6.4 vs 0.6) 3. No difference in mortlity
49
What is the dose and time window for ECASS trial
1.1mg/kg at <6 hours
50
What is the result of ECASS trial
no difference in disability using intention to treat | Post-hoc: better recovery for tPA in 90 days
51
What is the dose of ECASS II trial and time window
0.9mg/kg at <6 hours
52
Result of ECASS II trial
No difference was seen in the rate of favorable outcome at 3 months between rTPA and placebo
53
What does ATLANTIS A study means
Alteplace Thrombolysis for Acute Non-intervemtional Therapy in Ischemic Stroke
54
Alteplace Thrombolysis for Acute Non-intervemtional Therapy in Ischemic Stroke used what dose and time window
0.9mg within 6 hours
55
Result of ANTLANTIS A study
No significant difference of planned efficacy endpoints at 30 and 90 days between 2 groups ICHS is increased in tPA particularly between 5-6 hours
56
What is the difference between ANTLANTIS A and B
The ANTLANTIS B shortened the time window by 3.5 hours
57
What is the dose and time window used in Japanese Alteplase Clinical Trial (J-ACT)
0.6mg.kg and < 3 hours
58
What is the result of J-ACT
36.9% achieved mRS of 0-1 at 3 month in tPA group | Symptomatic ICH occurred in 5.8%
59
What is the major changed in ECASS III
same dose but limits the time window < 3-4.5 hours
60
Result of ECASS III
1. Favorable outcome in tPA groups at 3 months 52.4% vs 45.2% 2. Higher incidence of ICH in tPA group 3. Mortality rate did not differ significantly between 2 groups
61
This trial used 0.9mg/kg and a time window of < 6hours where the design is an open label study
3rd - International Stroke Trial
62
Result of IST-III
1. Proportion of alive and independent is 37% in rTPA avs 35% placebo 2. More death rates during the first 7 days in rTPA 3. 6 month: 27% died in both groups
63
Normal ICP
5-10
64
Normal CPP
70-100
65
When to treat hypertension in acute stroke
SBP > 220 DBP > 120 MAP > 130
66
A drop of how many SBP and DBP is associated with worsening of neurologic status and high rates of poor outcome
> 20mmHg
67
Arterial Hypotension is associated with the following conditions:
Aortic dissection Volume Depletion MI Arrhythmia
68
This antihypertensive has a direct vasodilator on arterioles and decreased systemic resistance
Hydralazine
69
This is a short acting B-adrenergic agent
Esmolol
70
Mechanism of action of Nicardipine
Ca channel inhibition (slow chanel)
71
This is a B-adernergic blocking is 7x more than alpha which provide dose dependent decrease in BP without significant HR or cardiac output reduction
Labetalol
72
What is the result of INTERACT2
1. No difference in primary outcome of death and disability between 2 groups at 90 days 2. Lower mRS with intensive group
73
INTERACT2 used to assess
ICH patient within 6 hours with BP 150-220 at presentation | 2 groups <140 vs <180
74
ATACH II subjects
< 140 vs < 180 withunb 24 hours of Nicardipine
75
Result of ATACH II
110-139 SBP did not result to a lower death rate or disability than 140-179
76
Recommendation on Hypertension in ICH
treat if SBP > 180mmHg and CPP should be maintain ? 70mmHg
77
Criteria for intubation
< 90 O2Sat < 60 PO2 > 55 PCO2
78
Criteria for ICP catheter
GCS < 8 (+) IVH and hydrocephalus CPP maintained at 60-70
79
Serum Osmolality should be maintained at what level
300-320
80
What is the mortality rate of malignant MCA despite maximum conservative treatment
50-80%
81
What are the objectives of hemicraniectomy
Decrease mass effect or ICP Prevent herniation Reduce secondary brain injury
82
Criteria for patient selection for hemicraniectomy
1. Severe hemispheric stroke 2. CT Scan > 50 % of MCA 3. 60 years old and below 4. Dominance of hemisphere
83
Mortality rate based on age in patient undergone hemicraniectomy
< 60 years old: 20.8% | > 60 years old 51.3%
84
Exclusion Criteria for Hemicraniectomy
1. terminal illness 2. superficial co-morbid 3. bleeding disorders
85
S in STATE criteria
SCORE NIHSS GCS <8 NIHSS > 15 NIHSS > 20 dominant
86
T in STATE Criteria
Time < 48 hours last seen without deficit
87
A in STATE Criteria
Age < 60 years old
88
T in STATE criteria
Territory > 50% MCA
89
E in STATE Criteria
Expectation Life expectancy is reasonable
90
External decompression measurement
12 cm bone flap must be removed (ant-post) by 9 cm (sup-inf) 12x9
91
What is the perfect timing of replacing the bone flap if without complication
12 weeks
92
Removal of bone flap result to how many percent of reduction of Increased ICP
15%
93
if duraplasty is added with hemicraniectomy the improved surival rate is
20-30% from 60-84%(hemicraniectomy only)

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