Cerebral Blood FLow to Save Penumbra (ml/100g/min) Over 18 8-18 Below 8

Normal function Neuronal dysfunction Neuronal death

Pathophys of AIS & TIA Usually ____ (blood clot forms in vascular system, travels downstream, plugs the ____)

thromboembolism / cerebral artery

what is tPA? What do you need to know before administering?

Tissue Plasminogen Activator Time of onset & Contraindications

Contraindications for giving tPA Minor / isolated neuro signs Rapidly improving sxs Major surgery / serious trauma in previous ___ GI or urinary tract bleed in previous ___ MI in previous ___ Sz at onset of stroke w/ post-ictal neuro impairments Pregnancy Age ___ Severe stroke of NIHSS score \>___ Combo of both previous ischemic stroke and ___.

Surg: 14 days Bleed: 21 days MI: 3 months over 80 y/o NIHSS score \>25 DM

BP and Stroke Perfusion pressure distal to obstruction is ___ and dependent on systemic BP BP is usually ____ in acute stroke & may maintain perfusion to borderline ischemic areas BP \>____ increases risk of recurrent ischemic stroke BP \<____ is associated w/ excess deaths\ \ \

low elevated \>200 \ deaths (from coronary disease)

Stroke 2 Flashcards by Shea Green

In AIS (arterial ischemic stroke), what is a normal response of the body? What should you do about it?

High BP, DO NOT lower it

BP increases due to arterial occlusion (in effort to perfuse the penumbra)
Lowering BP will starve the penumbra and worsens outcome!

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Cerebral Blood FLow to Save Penumbra

(ml/100g/min)

Over 18
8-18
Below 8

Normal function
Neuronal dysfunction
Neuronal death

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Extent of Ischemic Injury

Window of Opportunity - Ischemic Penumbra

Viability of brain tissue is preserved if perfusion is restored within a critical time period of ____.

2 - 4 hours

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What is a complication of stroke from suddenly restoring blood flow/pressure?

Hemorrhagic Stroke (Red Infarct)

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Pathophys of AIS & TIA

Usually ____ (blood clot forms in vascular system, travels downstream, plugs the ____)

thromboembolism / cerebral artery

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What is the acute therapy for AIS & TIA?

Thrombolysis or Thrombectomy

(DO NOT LOWER BP)!!!***

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No infarction and no sequaelae
Infarction w/ sequelae

TIA
Ischemic stroke

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4 options for secondary prevention of AIS & TIA

Antithrombotic therapy
Vascular risk factor therapy
Carotid endarterectomy (CEA)
Carotid angioplasy

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what is tPA?
What do you need to know before administering?

Tissue Plasminogen Activator
Time of onset & Contraindications

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What is the time frame for administering tPA?

3 - 4.5 hours

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3 inclusion criteria for tx Acute Ischemic Stroke w/ tPA

Clinical dx of ischemic stroke causing measurable neurologic deficit
Onset of sxs <4.5 hrs (if exact time not known, defined as last time pt was normal)
18 years of age or older

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Historical Contraindications for giving tPA

Stroke or head trauma in the past 3 months
Previous intracranial hemorrhage
Intracranial neoplasm, arteriovenous malformation, or aneurysm
Recent intracranial / intraspinal surgery
Arterial puncture at non-compressible site in previous 7 days

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Clinical Contraindications of giving tPA

Sxs suggestive of subarachnoid hemorrhage
Persistent BP evelation 185/110
Serum glucose <50
Active internal bleeding
Acute bleeding diathesis (hematologic)

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Hematologic contraindications of giving tPA

Platelet count <100,000
Current anticoagulant use
Heparin use within 48 hrs
Current use of direct thrombin inhibitor

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Findings on head CT Contraindications for giving tPA

Evidence of hemorrhage
Extensive regions of obvious hypodensity consistent w/ irreversible injury

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Contraindications for giving tPA

Minor / isolated neuro signs
Rapidly improving sxs
Major surgery / serious trauma in previous ___
GI or urinary tract bleed in previous ___
MI in previous ___
Sz at onset of stroke w/ post-ictal neuro impairments
Pregnancy
Age ___
Severe stroke of NIHSS score >___
Combo of both previous ischemic stroke and ___.

Surg: 14 days
Bleed: 21 days
MI: 3 months
over 80 y/o
NIHSS score >25
DM

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BP and Stroke

Perfusion pressure distal to obstruction is ___ and dependent on systemic BP
BP is usually ____ in acute stroke & may maintain perfusion to borderline ischemic areas
BP >____ increases risk of recurrent ischemic stroke
BP <____ is associated w/ excess deaths***

low
elevated
>200
<120 –> deaths (from coronary disease)

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Acute MI
CHF
Aortic dissection
HTN encephalopathy
Candidate for thrombolysis & BP >185/110

Indications to decrease BP emergently in AIS

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Intracranial hemorrhage occurs most often in NIHSS score over ___.

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3 contraindications of treatment w/ tPA

Over 80 y/o
On Warfarin
NIHSS >25

3 things to do within 10 mins at triage

Review tPA criteria
Page acute stroke team
Draw pre-tPA labs, but do not let this delay care

4 things to do within 25 mins for Medical Care

O2 / BP / Weight / NIHSS
2 IVs
12 lead ECG
CT
- - bleed (no tPA)
- - bleed (give tPA)

What should be completed within the first 45 mins?

CT and Labs

obtain lab results
read CT
return pt to ED

What should be completed within the first 60 mins?

Treatment

Start IV tPA (if indicated)
Monitor for ICH sxs (HTN, HA, N/V, decreased neuro status)

* Often used in adjunct w/ tPA * MERCI retrieval system is corkscrew like apparatus designed to remove clots from vessels * PENUMBRA system aspirates the clot

Mechanical Thrombolysis

What is the biggest predictor of Hemorrhagic Transformation? 5 total (ischemic --\> hemorrhage)

* Size of infarction #1 * A-fib * NIHSS score high * Hyperglycemia * Thrombocytopenia (low platelets)

**Hemorrhagic Stroke (15% of all strokes)** * What is the primary cause (70-90%) * What is secondary cause (10-30%) * Manifests w/ sxs of \_\_\_\_\_

* **Primary:** HTN * **Secondary:** Vascular malformation (aneurysm, AVM, tumor, amyloid angiopathy, thrombolytic agents) * Increased ICP (intracranial pressure)

**Which stroke?** * Non-contrast CT + for bleed * 50% mortality (80% w/ permanent disability) * ICP monitoring * Neurosurgical intervention

Hemorrhagic

* Directly diverts blood from arteries --\> veins * May bypass brain tissue & cause chronic ischemia * Congenital, but not genetic! * Concern of weakened wall --\> dilation--\> increased risk of rupture

Arteriovenous Malformations (AVMs)

* Enlargement of blood vessel due to wall weakening * \>\_\_\_ y/o * 4 sizes

**Cerebral Aneurysm** * \>40 yrs * small, medium, large, giant

What are the most common sites of Cerebral Aneurysms?

**At bifurcations** (anterior communicating artery) --\> optic chiasm (Posterior communicating artery)

**Sxs of Hemorrhagic or Ischemic?** * Diastolic BP \>110 * **HA** * **Vomiting** * Coma * Neck stiffness * Seizures

Hemorrhagic / aneurysms?

3 common CNS Herniations

* Subfalcine * Transtentorial * Tonsillar

**Which CNS Herniation?** * Common, HA, contralateral leg weakness

Subfalcine

**Which CNS Herniation?** * Oculomotor (CN 3) paresis w/ ipsilateral dilated pupil, abnormal EOM's * Contralateral hemiparesis

Transtentorial

**Which CNS Herniation?** * Obtundation

Tonsillar

**Brain Herniation** * Life threatening * Increased ICP may cause \_\_\_\_. * Triad?

**Cushing reflex** * HTN * Bradycardia * Abnormal respirations

2 tx options for cerebral aneurysm

* Endovascular (coil embolization) * Surgery (clip)

2 causes of SAH

* Aneurysm in Circle of Willis * AVM since birth

**Presentation of SAH** * Often w/o warning, but may have had prior ___ or \_\_\_\_ * Sudden increases in \_\_\_\_ * Maybe associated w/ \_\_\_\_ * NOT \_\_\_\_

* bleeds / HAs * ICP * Valsalva * ICH

Dx for SAH

* CT w/o contrast * if negative (no bleed), then get an LP

Hemolyzed blood in CSF (golden yellow) indicating the presence of bilirubin in the cerebrospinal fluid (CSF) and is used by some to differentiate in vivo hemorrhage from a traumatic LP. * Takes how long to lyse and change color?

Xanthochromia * 1-2 hours

**Tx of SAH** * Decrease ICP w/ what 6 things? * Treat and monitor vasospasm w/ what med?

* stool softeners * cough suppressants * anxiolytics * analgesics * antiemetics * Keep HOB elevated (head of bed) **Vasospasm:** CCB

* "crescent shape" * Blood outside of brain, but in skull (pushes on brain)

Subdural hematoma

"lemon"

Epidural hematoma

**1st or 2nd tier of Acute Stroke Management?** * CBC, BMP, Glucose, PT/PTT, ESR * EKG * Head CT w/o contrast

1st

**1st or 2nd tier of Acute Stroke Management?** * Non-invasive imaging of carotids (doppler US) * TTE or TEE (localize where clot came from) * MRI/MRA * CSF eval * Cerebral angiogram

2nd

**Hyperglycemia & Acute Stroke / DM & secondary stroke prevention** * Peri-stroke hyperglycemia is associated w/ ____ clinical outcomes * Inpatient goal of BG is \<\_\_\_\_ * Chronically, each decrease in % in Hgb A1C results in significant reduction of what 4 things? * Outpatient goal of Hgb A1C is \< \_\_

* worse * 150 * death, MI, vascular complications, stroke risk * 7.0