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EDIC academy > Acute Ischaemic Stroke > Flashcards

Acute Ischaemic Stroke Flashcards

1
Q

What are the 5 aspect of acute stroke management to improve outcome?

A
  • Stroke care in specialised units
  • Platelet inhibitors within 48hrs
  • IV thrombolysis within 4.5 hrs
  • Endovascular therapy within 6hrs
  • Decompressive craniectomy ASAP within 48hrs
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2
Q

Main goals of acute management of AIS?

A
  • Early recognition & resuscitation
  • Early treatment - Thrombolysis or endovascular therapy
  • Optimisation - Oxygenation, BP, Temp & glucose
  • ICU admission if required
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3
Q

What’s the first line assessment and treatment of AIS?

A
  • ETT & oxygenation
  • Haemodynamic optimisation
  • Basic monitoring including BMs
  • Clinical history
  • Physical examination
  • Symptomatic treatment (N/V, pain & agitation)
  • Assessing contraindications to treatment
  • Diagnostics & interventions
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4
Q

Diagnostic tools for rapid recognition of AIS?

A
  • FAST assessment
  • ROSIER test
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5
Q

What is ROSIER test?

A

Recognition of stroke in the emergency room

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6
Q

Neurological assessment tool for AIS?

A

NIHSS (National institute of health stroke scale)

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7
Q

What are the components of NIHSS?

A
  • GCS
  • Cranial nerves assessment
  • Higher cortical dysfunction (aphasia, neglect)
  • Limb power
  • Limb ataxia
  • Sensory examination
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8
Q

NIHSS clinical assessment? Demonstrated ?

A

Watch video

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9
Q

What assessments can be used to localise stroke in the presence of low GCS?

A
  • Pupils
  • Brainstem reflexes
  • Spontaneous activity
  • Response to stimuli
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10
Q

Non-contrast CT brain in diagnosis of AIS?

A

It can differentiate between ischaemia & haemorrhage

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11
Q

What other diagnostic imaging can be used for diagnosis of AIS?

A
  • CTA
  • CT perfusion scan
  • MRI
  • MRA (Angio)
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12
Q

Sequence of imaging for diagnosis of AIS?

A
  • Non-contrast CT head
  • CT angio - Localise vessel
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13
Q

What is the important of multiphase CT angio?

A
  • It can be used to assess collateral supply.
  • Patients with collateral supply do better with endovascular therapy than thrombolysis
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14
Q

What are the target times for evaluation of a stroke patient in ED?

A
  • Door to physician <10 mins
  • Door to stroke team <15 mins
  • Door to CT <25 mins
  • Door to CT report <45 mins
  • Door to drug <60 mins
  • Door to unit admission < 3 hrs
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15
Q

Immediate management of AIS?

A
  • Oxygen PO2 > 10 or Sats > 94%
  • BP management
  • Blood glucose (4-10)
  • Temperature (< 37.5 degrees)
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16
Q

What is the target BP after thrombolysis in AIS?

A

< 185/110 mmHg for 24 hrs after thrombolysis

> 220/120 mmHg in fit patients and not having thrombolysis

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17
Q

Pharmacological management of HTN is AIS?

A
  • Labetalol
  • Urapidil
  • Clevedipine
  • Nicardipine
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18
Q

First line management for hypotension in AIS?

A
  • IV fluids
  • Noradrenaline
  • Metataminol
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19
Q

Diagnosis of ischaemic stroke with non-contrast CT heads?

A

It is usually negative in the acute phase

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20
Q

What are the differential diagnosis of acute ischaemic stroke?

A

Intracranial haemorrhage

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21
Q

What are the clinical findings favouring ICH?

A
  • Onset during HTN crisis
  • Symptom progression within minutes
  • Vomiting
  • Immediate loss of consciousness
  • Acute onset headache
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22
Q

Stroke mimics?

A
  • Hypoglycaemia
  • Space occupying lesion
  • Seizures ; Todd’s paresis
  • Migraine
  • Encephalitis & metabolic
  • Sepsis
  • Drug toxicity
  • Functional disorder
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23
Q

Characteristics of microangiopathies or lacunar infarcts?

A
  • Preceding TIA’s (15-20%)
  • Insidious on and slow progression
  • Lacunar infarcts are small ( symptomatic in cerebral peduncles & brainstem)
  • They may present as pure motor, pure sensory, sensory-motor, ataxic hemiparesis or dysarthria-clumsy-hand syndrome
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24
Q

Cardiac conditions predisposing patients to stroke?

A
  • Valvular dysfunction
  • AF
  • LA or LV thrombus
  • Dilated cardiomyopathy
  • Recent MI < 4 wks
  • LV aneurysm
  • Sick sinus syndrome
  • Infective myocarditis
  • Atrial myxoma
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25
Q

Characteristics of embolic strikes?

A
  • Sudden onset (Maximal effect at onset)
  • Onset during activity or I’m awake state
  • Recurrent TIA’s
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26
Q

Pathophysiology of large vessel disease ?

A
  • Post-stenosic perfusion deficit
  • Artherothrombotic occlusion
  • Arterio-arterial embolism
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27
Q

What’s is amaurosis fugax?

A

Internal carotid artery stenosis.

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28
Q

Characteristic of large artery infarcts or embolism or thrombosis?

A
  • Atherogenic risk factors
  • Frequent TIA’s (amaurosis fagux) in the same arterial territory
  • Onset during sleep or activity
  • Gradual progression mins to hours
  • Gradual onset due to thrombus accumulation or low BP
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29
Q

Characteristics of basilar artery stroke?

A
  • 1% of all strokes
  • Results in thalamic or brainstem infarcts
  • Sudden & severe neurological impairments
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30
Q

Characteristics of proximal occlusion of basilar artery?

A
  • Quadriparesis
  • Preserved consciousness
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31
Q

Characteristics of distal occlusion of the basilar artery?

A
  • Visual deficit
  • Oculomotor deficit
  • Behaviour disturbances
  • Hallucinations
  • Sudden death
  • Low GCS
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32
Q

Management of acute basilar occlusion??

A

Amenable to immediate neurosurgical intervention - Endovascular procedure

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33
Q

Pathophysiology of acute vessel occlusion? 3 main mechanisms

A
  • Systemic embolism
  • Large artery thrombosis
  • Large artery embolism
34
Q

Characteristics of MCA infarcts?

A
  • Contralateral motor weakness
  • Contralateral sensory deficit
  • Face & arm more than legs
  • Aphasia - Broca, wernicke or global
  • Apraxia
  • Dysarthria
  • Ipsilateral eye deviation
  • Homonymous visual defect
  • Neglect
35
Q

Characteristics of ACA infarcts?

A
  • Contralateral hemiparesis - Lower limbs
  • Contralateral sensory deficit - Lower limbs
  • Urinary incontinence
  • Apraxia
  • Anosmia
  • B/L; Apathy, motor inertia & muteness
36
Q

Components of the posterior cerebral circulation?

A
  • Vertebral
  • Basilar
  • Posterior cerebral artery
37
Q

Characteristics of posterior cerebral circulation infarcts?

A
  • Ipsilateral cranial nerve palsy + Contralateral motor /sensory deficit
  • Bilateral motor & sensory deficit
  • Disorder of conjugate eye movement - Vertical (midbrain) & horizontal (pons)
  • Cerebellar dysfunction without ipsilateral long tract deficit
  • Altered consciousness
  • Dysarthrophonia / Dysphagia
  • Horner syndrome
  • Contralateral homonymous hemianopsia
  • Bilateral lesions: Cortical blindness (Anton’s syndrome)
  • Behavioral disturbances
38
Q

Risk factors for cervical dissection?

A
  • Trauma
  • Previous infection
  • Connective tissue disease
39
Q

What are the signs and symptoms of ICA dissection?

A
  • Focal neurology
  • Unilateral headache
  • Neck pain
  • Pulsatile tinnitus
  • Ipsilateral Horner’s syndrome
40
Q

Image modality with the highest sensitivity and specificity for detecting Ischemic stroke?

A

MRI

41
Q

Components on the Alberta Stroke Program Early CT score (ASPECT)?

A

Caudate
Putamen
Internal capsule
Insular cortex
M1: anterior MCA cortex
M2: MCA cortex lateral to insular ribbon
M3: Posterior MCA cortex
M4: Anterior MCA territory immediately superior to M1
M5: Lateral MCA territory immediately superior to M2
M6: Posterior MCA territory immediately superior to M3

42
Q

Significance of the ASPECT score?

A
  • Any score < 7 has the poorest prognosis at 3 months
  • Increased risk of thrombolysis related ICH
43
Q

What are the tests in stroke patient management ?

A
  • Electrolytes
  • Glucose
  • FBC
  • Urea & Creatinine
  • CK, CKMB, Trop I
  • Transaminases
  • Coagulation / Protein C, S & AT III
  • ESR
  • Cholesterol & Triglycerides
44
Q

Decision making in management of stroke?

A
45
Q

Reperfusion options in AIS?

A
  • Intravenous thrombolysis
  • Intra-arterial thrombolysis
  • Mechanical clot removal
  • Angioplasty/Stenting
46
Q

Reasons why reperfusion therapy might be necessary even after 5-10 mins of supposed cessation of blood flow?

A
  • Good collateral supplies
  • Only for a limited time
47
Q

What is Penumbra?

A

This is an area of ischaemic territory which can be saved.

48
Q

What is the infarct core?

A

This is an ischaemic area with none or little collateral supply - Irreversible damage

49
Q

Thrombolysis

A

Recommendation - rt-PA use within 4.5 hrs after exclusion of a haemorrhage stroke on imaging

50
Q

Considerations prior to thrombolysis ?

A
  • NIHSSS - Nat. Institute of Health Stroke Scale Score
  • Blood pressure
  • Premorbid use of anticoag or antiplatelet
  • Seizure activity
  • History of; Stroke, ICH, tumor & vascular malformation
51
Q

rt-PA? What type of drug

A

Alterplase - 90mg over 60 mins with 10mg given as a bolus over 1 min.

52
Q

Endovascular treatment efficiency?

A
  • ACA - Benefit from endovascular + Thrombolysis
  • Proximal middle cerebral or distal ICA (Between 6-24hrs)
53
Q

Blood pressure targets for thrombolysis ?

A
  • < 185/110 (For thrombolysis)
  • < 220/120 (Not for thrombolysis)
54
Q

Anti-hypertensive agents used ?

A
  • Nicardipine
  • Labetalol
  • Urapidil
  • Clevedipine
55
Q

Hyperglycaemia

A
  • Related to stroke severity
  • Related to large infarct volumes
  • Signifies susceptibility to infection
  • Associated with increased M&M @ 90days
  • Increased risk of ICH following thrombolysis
  • Target levels 8-10
56
Q

Temperature control?

A
  • Independent determinant of outcome
  • Occurs in the abscess of infection
  • Treat temperatures > 37.5 degrees
57
Q

Management of high temperatures?

A
  • First-line : Paracetamol
  • Metamizole
  • Infusion of cold saline at 4 degrees
  • Automatic cooling systems
58
Q

Anti-coagulation in stroke ?

A
  • ## Contraindicated after use of rt-PA
59
Q

Meaning of rt-PA?

A
  • Recombinant tissue plasminogen activator
  • Example - Alteplase, Reteplase & Tenecteplase
60
Q

Anti-platelet therapy in stroke?

A
  • High-dose aspirin within 48hrs
  • Shouldn’t be used within 24 hrs of thrombolysis
61
Q

Thrombophylaxis post-stroke?

A
  • LMWH
  • Delayed until > 24 hrs after thrombolysis
  • IVC filter if full VTE is contraindicated
62
Q

Hemorrhagic transformation of stroke?

A
  • ## Occurs in 5-6% of patients (Thrombolysis & Anti-coagulation induced)
63
Q

Management of haemorrhagic transformation?

A
  • Stop all anti-coagulation
  • FFP, Cryoprecipitate , Recombinant FVII
  • Repeat CTH
64
Q

Normal intracranial pressures?

A
  • < 20mmHg
65
Q

Transcranial doppler capabilities for detection of pathologies?

A
  • Acute thrombose or stenosis - All vessels
  • Assessment of response to thrombolysis
  • Prognostication tool - Extent of occlusion
  • Assess cerebral vasoreactivity - Diamox Tx
  • Detection of micro-embolism
66
Q

What is the Diamox test?

A

Used to assess cerebrovascular reactivity. Diamox (Acetazolamide) - Carbonic Anhydrase Inhibitor. It penetrates the BBB and causes vasodilation. The dose of 1000mg iV - Peak CBF is achieved in 10-15 mins. About 30-60% increase in CBF is achieved . An abnormal response will be < 10% increase in CBF

67
Q

Disadvantages of transcranial doppler?

A
  • User dependent
  • Failed if acoustic window is poor
68
Q

Main complications associated with stroke?

A
  • ICH
  • Cerebral oedema
69
Q

Complications resulting from ICH & cerebral oedema ?

A
  • Reperfusion injury
  • Intracranial HTN
70
Q

Cerebral oedema in stroke?

A
  • Develops in the first 24-48hrs
71
Q

Intracranial HTN?

A
  • Risk greater in young patients
72
Q

Reason for compensation of intracranial HTN in elderly?

A
  • Larger ventricles
  • Essential atrophy - Subarachnoid space
73
Q

Cerebellar infarcts?

A

They will have more effects than supratentorial infarcts of the same size . Posterior fossa allows for minimal compensation

74
Q

Consequences of cerebellar swelling?

A
  • Brainstem compression
  • Impaired CSF circulation
  • Hydrocephalus
75
Q

Steroids and cerebral oedema associated with AIS

A

No role in its management

76
Q

Management of intracranial HTN?

A

See image attached

77
Q

Side-effect of repeated use of osmotic agents in cerebral oedema ?

A
  • Increase in cerebral oedema
  • Herniation due to dehydration
  • Electrolyte imbalance
  • Raised serum osmolality
  • Hypervolaemia & cardiac failure
  • Renal dysfunction
78
Q

Pharmacological management of seizure following AIS?

A
  • Phenytoin
  • Levetiracetam
  • Lacosamide
  • Valproate
79
Q

Consequences of untreated seizures?

A
  • Secondary brain damage
  • Increased metabolic demand
  • Worsening of ischaemic oedema
  • Worsening of patient outcome
80
Q

Secondary prevention of ischaemic stroke?

A
  • Aspirin
  • Clopidogrel
  • Ticagrelor
81
Q

Advantages of early rehabilitation in stroke patients?

A
  • Prevention of contracture and joint pain
  • Decreased risk of decubitus ulcers
  • Decreased risk of pneumonia
  • Decreased risk of DVT

EDIC academy (20 decks)

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