Acute Ischemic Stroke

Question 1

Common stroke sx

Answer 1

sudden onset unilateral focal neuro deficit
* dysphasia,dysarthria
* hemianopia
* weakness
* ataxia
* sensory loss
* neglect

Question 2

Stroke severity

Answer 2

Assess using NIHSS
1-4 = minor stroke
21-42 = severe stroke

Small stroke: no visible difference MRI
Large stroke: large vessel occlusion

Question 3

Acute stroke diagnosis

Answer 3

Confirm NIHSS (+) stroke
Confirm sx dt ischemia +r/o other neuro deficit
Consider stroke mimics

Imaging!!!
1. non contrast CT head r/o hemorrhage
2. MRI sensitive for detecting early ischemic changes

Question 4

Ischemic vs hemorrhagic stroke on imaging

Answer 4

Ischemic: not seen until 12-24 hr post event
Hemorrhagic: shows up 1-2 hrs post event on CT

Question 5

Ischemic Stroke Mimics - neurological

Answer 5

• seizure/post ictal
• complicated migraine
• otherintracrainal process (infx, abcess, hemorrhage, MS)
• HTN encephalopathy
• Vertigo
• Crania/peripheral neuropathies
• Bells palsy
• transient global amnesia

Question 6

Ischemic Stroke Mimics - Metabolic

Answer 6

Hypo/hyperglycemia
Low sodium
hepatic encephalopathy
Drug overdose

Question 7

Ischemic Stroke Mimics - Psychiatric

Answer 7

Conversion disorder
malingering

Question 8

Post stroke regimen

post TPA

Answer 8

1. Neuro/BP monitor x 24 hrs (neuro decline usually occurs first 24-48hr post)
2. Dysphagia/aspiriation risk
3. HIGH INTENSITY STATIN
4. AntiPLT:
   * Everyone: spirin 81 mg
   * Low NIH or stent: 21 day DAPT
5. DVT prophy once >24 hr post TPA
6. Anticoag: if cardioembolic stroke or hx afib
   * large = 7-14 days
   * small = 3-5 days

Question 9

Stroke Prevalence

ischemic

Answer 9

4th leading cause death
cerebral ischemia = 87% strokes/yr that occur in US

Question 10

Post-stroke deficits

complications

Answer 10

50% hemiparesis
46% cognitive decline
35% depression
30% inability to ambulate w/o assistance
23% PTSD

Question 11

Risk factors of Ischemic Stroke

Answer 11

Hypertension
Cigarette smoking
Diabetes
Dyslipidema
Arrythmia conditions
Post menopausal hormone therapy (estrogens)
Oral contraceptives
Physical inactivity
Obesity
Harder to modify:
- asymptomatic carotid stenosis
- sickle cell disease

Question 12

CH A2 D S2-VASc

Answer 12

Congestive HF
HTN
Age
Diabetes
Stroke/TIA hx 2pt
Vascular disease
Female

age 75+ = 2pts

Question 13

Ischemic stroke patho

Answer 13

ischemia dt excess extracellular amino acids, free radicals, inflammation

Atherosclerotic plaque rupture
Cardiogenic afib - embolism = 20% strokes

Question 14

Acute stroke management

within 4.5 hrs sx onset

Answer 14

Fibrinolysis of no C/I
If large vessel stroke = thrombectomy

if small vessel occlusion = only heparin infusion
if >4.5 hrs, no TPA

Question 15

IV fibrinolytic contraindications

Answer 15

<18
within 3 mon:
* ischemic stroke
* intracranial/spinal surgery
GI malignancy/BIG within 21 days
LMWH within 24 hrs
Infective endocarditis
intra-axial intracranial neoplasm

Question 17

IV fibrinolytics OK use

once you correct the problems

Answer 17

Seizure at onset
hypo/hyperglycemia
arterial puncture at non-compressible site in last 7 days
recent major trauma if not involving head in last 14 days
recent major surgery within 14 days

Question 18

IV fibrinolytic choices

Answer 18

1. alteplase
2. tenecteplase

Question 19

alteplase dose

Answer 19

0.9 mg/kg
Max dose 90mg
Bolus: 10% IV bolus over 1 min
Infusion: 90% total dose over 60 min

Question 20

alteplase half life

Answer 20

5 minutes
80% cleared from plasma within 10 minutes
super short acting

Question 21

tenecteplase dose

Answer 21

0.25 mg/kg
Max dose 25mg
IV push dt longer half life

Question 22

tenecteplase half life

Answer 22

20-24 minutes
terminal: 99-120 min

Question 23

TPA specficity

Answer 23

tenecteplase 15x fold increase in fibrin specificity vs alteplase

Question 24

BP for TPA bolus

Answer 24

<185/110

Question 25

BPA for TPA infusion

Answer 25

<180/105

more fluid, lower bp goal than bolus

Question 26

BP if not qualify TPA

Answer 26

permissive HTN
no treat unless >220/110 to maintain brain perfusion

Question 27

Hypotension vs stroke

Answer 27

low bp can worsen ischemia

Question 27

HTN vs Stroke

Answer 27

> 220/120 detrimental = risk of hemorrhagic conversion

Question 28

BP control first line

Answer 28

IV labetalol bolus
IV nicardipine if HR < 55

Question 28

BP control 2nd line

Answer 28

hydralazine
enalaprilat
clevidipine

Question 29

Alteplase usage data

Answer 29

increased sx ICH (hemorrage risk)

Question 30

Alteplase vs timing

alteplase use ≥4.5 hrs

Answer 30

Wakeup/EXTEND trials
extended time frame TPA = improved functional outcomes as long as use MRI/CT guided scan for pt TX inclusion

Question 31

Tenecteplase usage data

Answer 31

EXTEND-IA trial: ≤4.5 hrs w/ large vessel occlusion
as good as alteplase if not better reperfusion/functional outcomes when used with thrombectomy

Question 32

TPA complications

Answer 32

Symptomatic ICH
1. DC TPA
2. Cryoprecipitate 10 units over 10-30 min (supplements fibrinogen by 30-60 mg/dL)
3. Anti-TPA: tranexamic acid 100mg IV or e-aminocaproic acid 4-5g IV
Angioedema 5% patient, ACEI risk factor
1. maintain airway - intubate before too late
2. Hold ACEi
3. IV steroid: MnPn 80-100mg IV
4. Benadryl 50mg IV
5. Ranitidine 50mg IV or famotidine 20mg IV
6. EPI 0.3mL
7. watch for swelling to come down

anti-TPA: displace plasminogen from fibrin (inhibit fibrinolysis)

Question 33

thrombectomy

Endovascular intervention

Answer 33

for large vessel occlusions +/- use of IA thrombolytics

Question 34

secondary stroke prevention

Answer 34

lifestyle/nutrition
smoking cessation
limit alcohol consumption
counsel SUD
HTN
Dyslipidemia
Diabetes

Question 35

MR CLEAN trial

thrombectomy

Answer 35

IA alteplase +/- thrombectomy
= significant improvement in functional outcome
no difference in mortality or ICH