Stroke

Question 1

modifiable risk factors for stroke

Answer 1

HTN, smoking, HRT, oral contraceptives, physical activity, obesity, diabetes, dyslipidemia, arrhythmias

Question 2

CHA2DS2VASc score

Answer 2

-CHF or LV EF <40%
-HTN
-Age 65-74 and >75
-Diabetes
-Previous stroke
-Valvular disease (MI, PVD)
-Female

Question 3

FAST

Answer 3

-Face: smile droop?
-Arms: one fall?
-Speech: slurred?
-Time: most important

Question 4

treatment within 4.5 hours of symptom onset

Answer 4

fibrinolysis +/- thrombectomy

Question 5

treatment for 4.5-24 hours since symptom onset

Answer 5

-large vessel occlusion > thrombectomy
-small vessel occlusion > heparin infusion

Question 6

IV fibrinolytics absolute CIs

Answer 6

<18yo, ischemic stroke, severe head trauma or intracranial surgery <3mo, GI bleed <21 days, LMWH <24h, DOAC <48h, >4.5h symptom onset, intracranial or subarachnoid hemorrhage, aortic arch dissection, infective endocarditis

Question 7

alteplase

Answer 7

-0.9 mg/kg (max 90mg)
-10% bolus over 1 min
-90% inf. over 60 min

Question 8

tenecteplase

Answer 8

-0.25 mg/kg (max 25mg)
-IV push over 5-10 sec
-15-fold increase in fibrin specificity compared to alteplase

Question 9

IV fibrinolytics: BP control

Answer 9

BP required for thrombolytic bolus: <185/110 mmHg
BP goal for thrombolytic infusion: <180/105 mmHg
When to treat BP: >220/110 mmHg

Question 10

first line for BP treatment

Answer 10

labetolol and nicardipine

Question 11

how to treat symptomatic ICH

Answer 11

cryoprecipitate or tranexamic acid (1000mg IV x1)

Question 12

cryoprecipitate

Answer 12

-blood product
-1 unit = 400-450 mg fibrinogen
-dose: 1-2 pools (1 pool=5u)
-1-2 pools will increase fibrinogen by 50-100 mg/dL

Question 13

fibrinolytics complications: angioedema treatment

Answer 13

-maintain airway
-hold ACEi
-methylprednisolone 80-100mg IV
-diphenhydramine 50mg IV
-ranitidine 50mg IV or famotidine 20mg IV
-epinephrine 0.3mL

Question 14

post-fibrinolytic care

Answer 14

-neurologic and BP monitoring for 24h
-dysphagia and aspiration risk
-high-dose statin in all patients
-antiplatelets (aspirin for everyone, DAPT x21d)
-DVT prophylaxis
-anticoagulation (if cardioembolic stroke or h/o of afib)

Question 15

secondary stroke prevention

Answer 15

lifestyle modifications, nutrition, HTN management (<130/80), dyslipidemia management (LDL <70) , diabetes management (A1C<7%)