Neuro Emergencies: Ischemic Stroke Flashcards by Andrew Kreutzer

What % of all strokes are ischemic?

87%

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Risk factors for ischemic stroke include?

Older age
HTN
DM
HLD
African American or Asian descent
HRT disease
Smokers
Drug abuse
Previous TIA
Coag d/os (protein C or S deficiency, antiphospholipid antibody syndrome, antithrombin III deficiency)

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Ischemic Stroke Prevention
Primary Prevention includes?

BP control
smoking cessation
DM control
Statins
A fib- anticoagulation / antiplatelet therapy
CEA/CAS w/ 60-70% stneosis
OC may be harmful
Diet and Exercise

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A-fib anticoagulation/antiplatelet therapy
Scores to calculate when patient has CHF, HTN, AGE, sex, DM, Prior stroke TIA, Vascular disease?

CHADS2 score
CHA2DS2-VASc Score

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A-fib anticoagulation/antiplatelet therapy
Scores to calculate when patient has HTN, abnormal renal function, abnormal liver function, stroke, bleeding, labile INR, elderly >65, alcohol or drug use?

HAS-BLED

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Possible Differential Diagnosis for pts experiencing stroke like symptoms

Tumors
SDH
Cerebral abscess
Todd’s paresis or paralysis
Hypoglycemia
Encephalitis
Conversion D/O
Migrainous aura
focal seizure
periveral nerve lesions

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Cincinnati Prehospital Stroke Sale components include?

Facial droop
Arm drift
Speech

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FAST components include?

Face
Arm
Speech
Time

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Clinical Manifestations for MCA stroke

Hemiparesis
Hemiplegia
Hemianesthesia
Hemianopia
Aphasia
Neglect
Gaze deviation
!

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Clinical Manifestations for Anterior Cerebral artery stroke

Lower extremity hemiplegia
Primitive reflexes
confusion
abulia
behavioral changes
disturbance in memory

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Clinical Manifestations for Vertebral and basilar artery stroke

Decreased LOC
Vertigo
Dysphagia
Diplopia
Ipsilateral CN findings
Contralateral (or bilateral) sensory and motor deficits

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Initial Evaluation
10 min or sooner from arrival

Evaluation by physician

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Initial Evaluation
</= 15 min

Stroke or neurologic expertise contacted

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Initial Evaluation
</= 20 min

NCCT or MRI

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Initial Evaluation
</= 45 min

interpretation of neuroimaging

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Initial Evaluation
</= 60 min

initiation of IV alteplase

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Initial Evaluation
What should be assessed?

ABCs
Time of Onset
Circumstances surrounding onset of neuro symptoms
Hx
Neuro eval (NIHSS)
Labs and ECG
STAT Head CT
Vascular imaging

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Initial Evaluation
Exclude stroke mimics such as

Psychogenic
Seizures
Hypoglycemia
Migraine
HTN encephalopathy
Wernicke’s encephalopathy
CNS abscess
CNS tumor
Drug toxicity

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Initial Evaluation
All patients need

Non-Con CT (NCCT)
MRI
Blood glucose
Cardiac monitoring
EKG
Troponin
BMP, CBC, PT/INR/aPTT
Maintain O2 sats > 94%

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Initial Evaluation
All patients need
For patients with suspected LVO in which MT is being considered, what should be obtained?

noninvasive vascular imaging
CTA with CTP
MRA with DW-MRI w/ or w/o MR perfusion

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Initial Evaluation
Selected Patients

TT, Ecarin clotting time or direct factor Xa activity assay
Hepatic function test
Toxicology screen
Blood alcohol level
Pregnancy test
ABG
CXR
EEG (if seizures are suspected)

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Initial Evaluation
Selected Patients
if SAH is suspected and CT is negative for blood what should be performed?

Lumbar puncture

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Initial Evaluation
Selected Patients
If seizures are suspected what should be performed?

Electroencephalogram (EEG)

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Emergent Management of Ischemic Strokes
ABCs

avoid hypotension, hypoxia and hypovolemia

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Emergent Management of Ischemic Strokes Supplemental O2 for sats of?

>94%

Emergent Management of Ischemic Strokes Antipyretic medications for temp of?

> 38 C

Emergent Management of Ischemic Strokes monitoring?

cardiac monitoring cautious BP treatment

Emergent Management of Ischemic Strokes Fluid resuscitation w/?

isotonic fluids

Emergent Management of Ischemic Strokes sugar?

glycemic control

Management of Ischemic Strokes includes?

Thrombolytic therapy Mechanical thrombectomy Antiplatelet therapy BP management

Contraindications for IV Alteplase Presentation to GI

Presentation outside window (>4.5 hrs) Mild, nondisabling stroke (NIHSS 0-5) HCT w/ extensive areas of hypoattenuation or frank hypodensity ICH AIS w/n 3 mo Severe Head Trauma w/n 3 mo Acute head trauma Intracranial or intraspinal surgery w/n 3 mo symptoms suggestive of SAH GI malignancy or GI bleed w/n 21 days

Contraindications for IV Alteplase Infective to Concomitant

Infective endocarditis Aortic arch dissection intra-axial intracranial neoplasm coagulopathy (plt count < 100,000/mm3, aPTT > 40 sec, INR >1.7 or PT > 15 sec) LMWH - therapeutic dose in last 24 hrs Thrombin or Factor Xa inhibitors w/ elevated sensitive lab test (aPTT, INR, plt count, ECT; TT; appropriate factor Xa activity assays) Concomitant Abciximab Concomitant IV Aspirin

BP requirements for pts that are candidates for reperfusion therapy Systolic and diastolic prior to infusion? IVP medications that can be given to control BP? Dose? Frequency? (2) IV infusions that can be given to control BP? Initial dose, titration parameters, max dose? (2) Systolic and diastolic following infusion? for how long?

SBP

Alteplase Admin Dose (max dose) infusion time

0.9mg/kg (max dose 90mg) over 60 min w/ 10% of dose given as bolus over 1 min

Alteplase Admin Admit pt where?

ICU or stroke unit for monitoring

Alteplase Admin What would require the discontinuation of infusion and obtaining an emergency head CT scan?

if the patient develops severe HA acute hypertension nausea or vomiting worsening neuro exam

Frequency of Neuro checks for first 24 hrs post Alteplase Admin

q15 min for 2 hr q 30 min for 6 hr q1hr for 16 hr

Alteplase Admin What would be an indication for increasing frequency of BP measurements? How to manage this?

if SBP > 180 mmHg or DBP > 105 mmHg administer antihypertensive medications to maintain BP at or below these levels

Alteplase Admin What should be delayed if patient can be managed safely w/o them?

NG tubes Indwelling bladder catheters intra-arterial pressure catheters

Alteplase Admin Before starting anticoagulants or antiplatelet what needs to be done?

Obtain a follow up CT or MRI scan at 24 hr after IV alteplase

Tenectaplase Admin dose and infusion time?

Single IV bolus of 0.25mg/kg (max of 25mg) over 10 sec

Tenectaplase Admin Must be given where? Not compatible with? What must be administered before and after?

dedicated IV dextrose containing IVF NS 0.9% flush

Management of ICH occurring w/n 24 hrs of IV alteplase or tenecteplase Initial action? Labs to get? Imaging?

Stop infusion CBC, PT(INR), aPTT, fibrinogen, type and cross Emergency non-con head CT

Management of ICH occurring w/n 24 hrs of IV alteplase or tenecteplase Blood products? Medications? Consults? Anything else?

Cryoprecipitate 10 u infused over 10-30 min Tranexamic acid 1000mg (over 10 min) or Aminocaproic acid 4-5 gm over 1 hr Hematology and Neurosurgery Supportive therapy

Mechanical Thrombectomy Criteria Prestroke mRS score? Occlusion of? Age? NIHSS socre >/=? Alberta Stroke Program Early Computed Tomography Score (ASPECTS)? Treatment can be initiated via groin w/n?

0-1 ICA or MCA >/= 18 >/= 6 6 hrs

Mechanical Thrombectomy mechanism of completion? Goal TICIa?

Direct aspiration vs Stent retrievers 2b/3

Mechanical Thrombectomy In selected pt w/ last known normal w/n how long? and have what?

6-16 hrs LVO in the anterior circulation and meet further criteria

Mechanical Thrombectomy Selected pt further criteria Occlusion? Mismatch between? Age? No what on Head CT or MRI? No evidence of infarct involving? Presentation?

LVO severity of clinical deficit and infarct volume >/= 18 ICH more than 1/3 of the territory of the MCA Late

Mechanical thrombectomy can be considered for patients with last known normal of?

16-24 (IIa B-R)

BP management for Ischemic Stroke patient Excessive BP lowering can have what effect?

worsen cerebral ischemia

BP management for Ischemic Stroke patient In patient who undergo mechanical thrombectomy, it is reasonable to maintain the BP at?

< 180/105 mmHg

BP management for Ischemic Stroke patient Some pts may have concomitant comorbidities that require acute BP lowering such as?

aortic dissection post fibrinolysis sICH acute heart failure

How much can BP be reasonably lowered if pts initial BP is >220/120 mmHg and pt did not receive Alteplase or Mechanical thrombectomy and do not have comorbid conditions? Initiating or reinitiating antihypertensive in the first 48-72 hrs is?

15% in first 24 hrs uncertain

Initial BP <220/120 mmHg; in patients that did not receive alteplase or mechanical thrombectomy and do not have comorbid conditions the benefit of initiating or reinitiating antihypertensives in the first 48-72 hours is?

no associated with improved outcomes

Post stroke management admit where? neuro monitoring for? antiplatelet agents? consider dual antiplatelet therapy for? early what? continue/start what? (check what)

stroke unit hemorrhagic transformation or edema ASA 24-48 hrs post tPA/TNK; minor noncardioembolic (NIHSS

Post stroke management Nutritional support, enteral diet started w/n? screening for? Evaluation by? DVT prophylaxis? O2 sats? Temp management?

7 days dysphagia SLP/PT/OT SCDs, SQ heparin or LMWH >94% maintain normothermia (<38C)

Post stroke management Glycemic management? treat BG of? mental health? Avoid what? Skin protection includes? Assessment of? Education? Evaluation of? Treatment of?

normoglycemia (140-180), treat BG <60mg/dL, Check HgbA1c Depression screening indwelling catheters turning, good skin hygeine, specialized mattress, wheelchair cushions functional assessment Smoking cessation; stroke education Cardiac evaluation Recurrent seizures

Management of Cerebral and Cerebellar Infarction w/ Swelling Cerebral infarction is characterized by? Causing?

progressive cerebral edema and mass effect ipsilateral sulcal effacement compression of the ipsilateral ventricular system shift of the midline structures such as the septum pellucidum and the pineal gland

Management of Cerebral and Cerebellar Infarction w/ Swelling Blockage of the Foramen of Monro or the third ventricle may cause?

entrapment and dilatation of the contralateral lateral ventricl obstructive hydrocephalus

Management of Cerebral and Cerebellar Infarction w/ Swelling Brainstem displacement may lead to? If swollen tissue eventually fills the cisterns there may be what?

widening of ipsilateral ambient cistern compression of the anterior or posterior cerebral arteries that may lead to infarctions in the corresponding vascular territories

Management of Cerebral and Cerebellar Infarction w/ Swelling In the setting of cerebellar infarction w/ swelling what is a key radiologic marker? Followed by?

effacement of the fourth ventricle basal cistern compression brainstem deformity, hydrocephalus, downward tonsillar herniation, and upward transtentorial herniation

Management of Cerebral and Cerebellar Infarction w/ Swelling Intubation may be considered for?

Decreased LOC Poor Oxygenation control of secretions

Management of Cerebral and Cerebellar Infarction w/ Swelling CO2 management? Monitoring? MAP target? HTN treatment when? IVF? No prophylactic ____ therapy.

Maintain normocarbia cardiac monitoring insufficient data to recommend a specific MAP target SBP > 220 mmHg or DBP > 105 mmHg Isotonic fluids (NS please) osmotic

Medical Management Ventriculostomy for the treatment of? Osmotic therapy should be used for?

obstructive hydrocephalus patients w/ clinical deterioration from cerebral swelling assoc. w/ cerebral infarction

Medical Management Hypothermia, barbituates and corticosteroids in the setting of ischemic cerebral or cerebellar swelling are? Brief moderate hyperventilation w/ a target PCO2 of ____ is reasonable.

not recommended 30-34

Neurosurgical Management Craniectomy with Dural expansion is effective in what patient population? Although the optimal trigger for this surgery is unknown it is reasonable to use?

patients < 60 y/o w/ unilateral MCA infarctions that deteriorate neurologically w/n 48hr despite medical therapy a decrease in LOC

Neurosurgical Management Decompressive craniectomy w/ dural expansion may be considered in what patient population?

pt > 60 y/o w/ unilateral MCA infarctions that deteriorate neurologically w/n 48 hrs despite medical therapy

Neurosurgical Management Suboccipital craniectomy with dural expansion should be performed in patients with?

cerebellar infarctions who deteriorate neurologically despite maximal medical therapy

Neuro Emergencies: Ischemic Stroke Flashcards

(68 cards)