ACUTE ISCHEMIC STROKE Flashcards
This phase of AIS treatment reduce risk of death through diagnosis, hospital choice, and impact of time-to-time treatment
Pre-hospital phase (symptom onset to hospital door)
this phase of AIS treatment absolutely focuses on the recanalization of the artery or reduction of swelling due to bleeding
Hyperacute phase (door to first hour)
this phase of AIS treatment reduce death risk by neurological screening + close monitoring of cardiac and respiratory systems
Acute phase
1-24 hours after admission
this phase of AIS treatment reduce risk of death by close monitoring of cardiac and respiratory systems and prevent recurrent stroke
Post-acute phase (24-72 hours after admission)
what is the BE FAST acronym for stroke recognition?
BALANCE loss; headache or dizziness
EYES (blurred vision ,double vision, vision changes)
FACE one side of face is drooping
ARMS - arm or leg weakness
SPEECH - speech difficulty/ slurred speech
TIME - time to call ambulance
T/F: In hyperacute stroke, Diagnosis of ischemic stroke is done on CT imaging
F
It is done CLINICALLY
4 Steps for therapeutic decision making in hyperacute stroke
Diagnosis
Exclude Bleeding
Assess severity
Identify Contraindication
Once the patient with a suspected stroke arrives, they must be evaluated by a physician within ___ minutes (first encounter)
10 minutes
The brain attack team must arrive within ___ minutes after the door time
15 minutes
In ___ minutes after door time, the patient has to be imaged (Head CT or MRI)
25 minutes
The result of the imaging scan must be available within ___ minutes
45 minutes
Decision of administering IV alteplase must be made in __________
under 60 mins
What are the steps for immediate stabilization?
assess ABC
vital signs
O2 to maintain >94%
IV access
get blood samples
Check CBG and correct hypo- or hyperglycemia
obtain 12-LEAD ECG
Perform neurological screening assessment
Activate Brain Attack team
This is a surrogate marker to determine if patient is eligible for rtPA or thrombectomy
Ictus
Worst score for National Institute of Health Stroke Scale (NIHSS)
42 (Worst)
0 (no symptoms)
11 item analysis
T/F: Scores in the National Institute of Health Stroke Scale (NIHSS) is only based on the patient’s responses and not on the observer’s interpretations
T
T/F: NIHSS is more sensitive for posterior circulation strokes
F
It is more sensitive for anterior circulation strokes
posterior circulation strokes have lower scores even if they are large in size
T/F: Stroke is a clinical diagnosis but the type of stroke will depend on the neuroimaging
T
T/F: Neuroimaging cannot diagnose the etiology of stroke
F
4 Ps to assess in neuroimaging
Parenchyma (Brain)
Pipes (Vessels)
Perfusion (if the perfusion is good)
Penumbra (Presence of penumbra to be saved)
T/F while waiting for availability of brain imaging, a first aid therapy can first be given to patients with suspected AIS
F
imaging first before any therapy
In CT scan, infarct is seen as (hypo/hyper) dense
HYPODENSE
In CT scan, bleed is seen as (hypo/hyper) dense
HYPERDENSE
T/F: The basal ganglia are almost always involved in PCA infarction
F
MCA infarction
This is one of the earliest and most frequently seen signs in MCA infarction
Blurred Basal Ganglia on CT
This is very sensitive to ischemia as it is the furthest removed from collateral flow
Insula (insular ribbon sign)
Insular ribbon sign indicative of subtle early sign of infarction in the territory of what artery?
MCA
Purpose of CT Angiography in bleeds
looks for macrovascular causes of ICH or SAH
Purpose of CT Angiography in infarcts
detects large vessel occlusion
This can is the only imaging study that can tell if there is still a penumbra to be saved
CT Perfusion
T/F: Alberta Stroke PRogramme Early CT Score gives a clue on how big the stroke is
T
T/F: The only goal in CT Scan is to detect/exclude a bleed since infarcts cannot be detected
T
________ is more sensitive and specific than CT within the first few hours after onset of stroke
MRI
T/F: It is possible in CT scant o age or look at how old a stroke is since it employs different contrasts
F
MRI - uses different sequences
In MRI, acute stroke appears (dark/white) in DWI
white
In MRI, acute stroke appears (dark/white) in ADC
dark
Changes in T2 and Flair MRI compared to the same areas in DWI and ADC results suggest an (acute/old) stroke
Old
Lesion is seen in DWI but not on FLAR + with penumbra -> will tpa be given?
yes
Lesion is seen in both DWI and FLAIR -> no penumbra -> will TPA be given?
no
T/F: If DWI and FLAIR MRI results mismatch, it could be assumed that the stroke happened for more than 5 hours
F
If there’s mismatch, the stroke has NOT been around for longer than 4-5 hours -> can still qualify for TPA
Imaging used in patients suspected of AIS with high creatinine
MRA an- as it can be used without contrast
This type of infarct is usually caused by an embolic source involving large vessels
Large territorial infarct
This type of infarct is due to emboli formed in the heart and “showers” into the brain
Multiple Small Embolic Infarcts (Cardioembolic infarct)
This type of infarct is usually caused by a thrombotic source
Small Vessel disease/lacunar stroke
T/F Multiple small embolic infarcts behave differently from other types of strokes
F
Small Vessel Disease/Lacunar Stroke
This type of infarct involves areas in between distribution of the major vessels, and is usually caused by a decrease in flow
Watershed Infarct
This type of infarct is due to vein occlusion
Venous Stroke
This is the only assessment that must precede VI alteplase
blood glucose
Strategies performed when recanalization is the goal
Medical: Thrombolysis
Endovascular: Thrombectomy
T/F: A patient can be have thrombectomy and thrombolysis if indicated
T
Alteplase must be given in people at least ___ years old, within ___ hours after onset
19 years old
4.5 hours
T/F: Having multi lobar infarction (>1/3 cerebral hemisphere) on CT is an absolute contraindication to rtPA
T
T/F: Previous history of ICH is an absolute contraindication to rtPA
T
T/F: Having significant head trauma or prior stroke within 6 months is an absolute contraindication to rtPA
F
within 3 months
T/F: Having arteriovenous malformation is an absolute contraindication to rtPA
T
Administration and dosage of alteplase:
Infuse 0.9 mg/kg (max dose of 90 mg) over 60 mins, with 10% of the dose given as a bolus over 1 minute
Measure BP and perform neurological assessments every ___ minutes during and after IV alteplase infusion for __ hours, then every ___ minutes for 6 hours, then hourly until ___ hours after alteplase treatment
every 15 mins during and after infusion for 2 hours; every 30 mins for 6 hours; hourly until 24 hrs after alteplase tx
Increase BP monitoring and administer antihypertensive meds if SBP is >___ mmHg or DBP is >___ mmHg
SBP > 180 mmhg
DBP > 105 mmhg
T/F: CT or MRI follow up scan must be done 48 hours after IV alteplase tx
F= must be done at 24 hrs after IV alteplase tx, before starting anticoagulants or antiplatelets
Sweet spot for alteplase administration
<90 min from time of onset and between 90-180 mins, with small/short thrombus at MCA distal M1/M2
T/F: larger infarct = higher NIHSS score = High chance of hemorrhagic transformation
T
T/F: Hi-1 and Hi-2 infarcts are big infarcts -> neurosurgery or hematology service might be needed
F = it’s PH1 and PH2 infarcts
H1 and H2 infarcts are small -> repeat scan after 24 hrs before starting antiplatelet/coagulatng
Dosage of tenecteplase
by weight = 0.25/kg
T/F: Thrombectomy cannot be given WITH alteplase
F
it can be given with or without alteplase
Inclusion criteria (6) for thrombectomy
- pre-stroke mRS 0-1 - px is functionally independent before stroke
- Causative occlusion of the ICA or MCA segment (m1) - large vessel occlusion
- age >/18 yo
- NIHSS >/6 = as there would be no diff in thrombectomy and medical management if too mild
- ASPECTS>/6
- Can be initiated within 6 hrs of symptom onset via groin puncture
T/F: Relative inclusion criteria for thrombectomy includes: causative occlusion of M2, M3, ACA, VA, BA, PCA (not LVO)
T
T/F: Thrombectomy can be treated within 6 hrs as relative indication if mRS >1, NIHSS <6, Aspects <6, causative occlusion of ICA or M1
T
T/F: Collateral flow is established depending on TPA administration
F
Collateral flow is established and improved regardless of TPA administration and MT
For General supportive care: supplemental oxygen should be provided to maintain oxygen saturation at:
> 98%
It is reasonable to treat hyperglycemia to achieve CBG ________ mg.dL
140-180 mg/dl
T/F: Aspirin and other antiplatelets should be started within ___ to ___ hours after stroke onset (secondary prevention)
24 to 48 hours
