Stroke Acute - Fister

Question 1

Time restraints on reperfusion therapies: (3)

Answer 1

1. IV rtPA alone < 4hours
2. IA therapy: IA tPa and/or intraarterial mechanical thrombectomy.
3. With basilar artery thrombus, window may be up to 8hrs

Question 2

Which study was initial tPa study in 1995?
Patients treated with recombinant tissue plasminogen activator within 3 hours of onset were ?% more likely to have minimal or no disability at 3 months.

Answer 2

Landmark study

30%

Question 3

What are the 5 contraindications for tPA after 3h window has passed?

Answer 3

1. NIHSS > 25
2. > 80 yoa
3. Those taking oral anticoagulants
4. History of stroke
5. History of diabetes

Question 4

Patients with NIHSS < _____ and age < _____ had the greatest potential for excellent outcomes after treatment with IV tPa

Answer 4

20, 75yoa –> mild to moderate stroke

Question 5

Any intracranial hemorrhage occured in ___% of patients who received IV rtPA

Answer 5

6.4%; (however mortality rates were similar.

Question 6

Which stroke subtype showed better outcomes after IV rtPa?

Answer 6

Small vessel disease.

Question 7

Define ischemic penumbra

Answer 7

Hypoperfused area of focal ischemia that may be salvaged by timely intervention.
– the area immediately surrounding the core of infarct where blood flow is sufficient, for the moment, to maintain cellular viability, but not sufficient for normal cellular function.

**rationale for permissive HTN

Question 8

What is the current guideline for permissive HTN

Answer 8

220/120. Less if received IV tPa. Rule used to be x 2 weeks. Now more clear that not really necessary >48h. Regardless, once in acute rehab, can have normal BP control.

Question 9

What component of vitals is detrimental during acute peri-stroke period?

Answer 9

fever

Question 10

Acute elevations in ____ are common in Stroke. In what % of the stroke population? resolves spontaneously after _____

Answer 10

BP; 85%, 24-48hr

Question 11

Acutely lowering blood pressure during stroke can _____

Answer 11

can expand the area of ischemia – penumbra

Question 12

What is the current AHA guidelines for lowering blood pressure after stroke?

Answer 12

lower by 15% over the first 24h; permissive up to 220/120 unless tPa has been given.

Question 13

______ therapy should be initiated 24h post tPa

Answer 13

antiplatelet therapy

Question 14

two potential complications of a cerebellar infarct

Answer 14

1. acute hydrocephalus - always assess the 4th ventricle for patency
2. elevated ICP due to space occupying edema which could be life threatening given tiny vault with no room for swelling.

Question 15

HAMLET, DESTINY, AND DECIMAL trials are all regarding ____. What is the DESTINY 2 trial?

Answer 15

three pooled randomized trials that basically said hemicraniectomy is life-saving within 48h of event. NNT 2. DESTINY 2 gives extra contraindications for those patients >60.

Question 16

Cincinnati hemicraniectomy protocol:

1. Age _____ years
2. If greater than 60 years use _____
3. NIHSS > _____
4. > ____% of MCA territory on CT
5. Agreement of _____
6. NS involvement if: (2 things)
7. Minimum of _____ hours since tPA

Answer 16

1. 18-60 years
2. DESTINY 2
3. 10
4. 50%
5. family
6. Clinical deterioration, including subtle decrease in arousal, >4mm shift increase
7. Minimum of 6 hours since rtPA

Question 17

what are the two most common post-stroke systemic complications

Answer 17

1. Aspiration pna

2. PE

Question 18

Bacterial pneumonia causes ____% of stroke related deaths

Answer 18

15-25%

Question 19

What 4 factors place stroke patients at high risk for bacterial pneumonia

Answer 19

1. reduced consciousness
2. impaired gag or swallow problems
3. 20-25% with dysphagia may result in aspiration
4. 7x more likely in patients who aspirate

Question 20

Stroke patients who get pneumonia can potentially see what 3 outcomes?

Answer 20

1. longer hospital stays
2. readmissions
3. 3 fold increase in mortality

(mortality can be as high as 65% if patient has aspiration pneumonia)

Question 21

What 6 factors must be checked prior to advancing to swallow challenge?

Answer 21

1. strong clear voice (no dysphonia)
2. Manages own secretions, no suction required
3. Understandable speech (no dysarthria)
4. Absent facial droop
5. Normal voluntary cough
6. Normal gag reflex

Question 22

14 warning signs of dysphagia

Answer 22

1. coughing with signs of struggle
2. fever (24-48h after stroke)
3. wheezing
4. wet vocal quality
5. refusal to take foods/liquids
6. changes in respirations
7. watering eyes
8. excessive drooling
9. gagging
10. pocketing of food in mouth
11. facial grimacing
12. sudden change of color in face/lips
13. smell of formula on breath
14. increase residuals

Question 23

DVT prophy initiated by ____

Answer 23

end of day 2 (48h)

Question 24

4 pathways/etiologies of ischemic stroke

Answer 24

1. atherothrombotic cerebrovascular disease (30-40%)
2. Cryptogenic (25-30%)
3. Lacunar - small vessel disease (20-30)
4. cardioembolic (20-25%)

Question 25

2 most common pathways/etiologies of hemorrhagic stroke

Answer 25

1. ICH (70%) | 2. SAH (30%)

Question 26

4 "major" risk factors for stroke by way of Large vessel atherothrombotic cerebrovascular disease

Answer 26

1. HTN 2. HLD 3. Tobacco abuse 4. Diabetes

Question 27

4 "major" risk factors for lacunar strokes (small vessel)

Answer 27

1. HTN 2. Diabetes 3. tobacco abuse 4. age

Question 28

5 types of cardioembolic sources

Answer 28

``` mechanical valve Ventricular or atrial thrombus Afib**** bacterial endocarditis MI ```

Question 29

three sources of paradoxical embolus

Answer 29

atrial septal aneurysm patent foramen ovale PFO ASD

Question 30

8 types of hypercoagulable disorders that could lead to stroke

Answer 30

``` thalassemia sickle cell antithrombin III deficiency Protein C,S deficiency Antiphospholipid syndrome Factor V leiden mutation prothrombin gene mutation systemic malignancy ```

Question 31

three most common causes of intracerebral hemorrhage

Answer 31

1. HTN 2. amyloid angiopathy in the elderly 3. vascular malformation

Question 32

amyloid angiopathy will present as what type of stroke (region)

Answer 32

lobar

Question 33

What are the 4 most common areas for Hypertensive bleed

Answer 33

1. BG 2. pons 3. thalamus 4. cerebellum

Question 34

2 most common causes of non-traumatic SAH

Answer 34

1. aneurysmal | 2. AVM

Question 35

watershed or "boundary zone" infarcts are a result of what type of stroke. Frequently associated with: _____

Answer 35

1. hypotensive stroke - any event causing an abrupt drop in blood pressure. which critically compromises cerebral blood flow (ACA/MCA border zone) 2. Carotid stenosis.

Question 36

Hemorrhagic conversion often results due to:

Answer 36

arterial occlusion causes ischemia to capillaries, arterioles, and vascular walls in addition to deleterious effects on neurons. Hemorrhage results when the "fragile" or "injured" vessels rupture.

Question 37

hemorrhagic transformation occurs: _____ days and ____% of non-complicated ischemic strokes

Answer 37

2-14 days post ictus | 5%

Question 38

Proposed mechanisms of hemorrhagic transformation include:

Answer 38

1. reperfusion either from recanalization or collateral circulation 2. disruption of BBB

Question 39

3 risk factors for hemorrhagic conversion (in order) name 5 lesser risk factors

Answer 39

1. Large stroke 2. embolic 3. older age uncontrolled DM, labile blood pressure, richness of collateral circulation, use of anticoagulants, treatment with thrombolytic agents

Question 40

Regarding dual anteplatelet therapy 90 optimal when 14-21 days optimal when

Answer 40

symptomatic IC stenosis | otherwise -- POINT trial