Acute ischemic stroke

Question 1

What is the name of a partial seizure with post-ictal hemiparesis? (can often mimic a stroke)

Answer 1

Todd’s paralysis

Question 2

Pick the initial 4 labs and 2 studies to get when you suspect a stroke or need to rule out a ischemic stroke

Answer 2

4 labs: CBC, Chemistries (especially glucose), PT/INR/PTT, cardiac biomarkers (CK, trop-1). 12 lead ECG, noncontrast CT brain

Question 3

Should you give T-PA if CT scan shows subacute ischemia?

Answer 3

no

Question 4

What is the area/zone describing reversible ischemia around a core of irreversible infarction?

Answer 4

Penumbra

Question 5

For how long is the Penumbra salvageable after an ischemic stroke onset?

Answer 5

first few hours

Question 6

What things damage the penumbra? (4)

Answer 6

hypoperfusion, hyperglycemia, fever, seizure

Question 7

Why might a blood pressure be elevated in stroke?

Answer 7

trying to maintain perfusion to penumbra (we don’t always want to lower BP with ischemic stroke)

Question 8

To use IV t-PA, below how many hours after symptom onset can we use the medication?

Answer 8

3 (with brain CT corroborating acute ischemic stroke <3 hrs old)

Question 9

What are some contraindications of using t-PA besides timing? (Including cut offs for recent MI/stroke, recent surgery, coag levels, platelet levels, glucose levels, and BP levels)

Answer 9

seizure, symptoms are minor or they are rapidly improving, head trauma, recent stroke/MI (3 mo), recent major surgery (2wks), acute chest/back pain, h/o intracranial hemorrhage, abn PT/INR (>1.7), platelets <100000, glucose <50, BP >185/110.

Question 10

What is the dosing of tPA? and over how many hours?

Answer 10

0.9mg/kg (max 90mg). 10% as bolus, remaining 90% infused over 1 hour.

Question 11

T-PA is less effective if blood glucose is over what level?

Answer 11

150mg/dL

Question 12

T-PA when given properly decreases risk of disability by how much? Increases ICH risk by how much?

Answer 12

30% decreased disability risk, 5% ICH risk

Question 13

above which blood pressure do we NOT LOWER BP OR GIVE IV TPA

Answer 13

220/120

Question 14

What two drugs can we use to lower the BP for TPA patients?

Answer 14

nicardipine, labetalol

Question 15

How do we dose nicardipine for TPA if we need to lower BP slightly?

Answer 15

5mg/hr IV infusion (increasing 2.5mg/hr ever 5 min to max of 15mg/hr)

Question 16

How do we dose labetalol for TPA if we need to lower BP slightly?

Answer 16

10-20 mg IV blous, may repeat every 10-15 min

Question 17

To protect the penumbra, above what MAP is ideal for BP? what glucose? What O2?

Answer 17

> 100 MAP, glucose <150, O2 >95%

Question 18

Start with what noninvasive evaluations for stroke etiology?

Answer 18

MRI brain/MRA, carotid duplex, transthoracic echo

Question 19

Invasive evaluations after negative noninvasive ones include…?

Answer 19

transesophageal echo, cerebral angio

Question 20

Who gets hypercoagulable workup when they have acute ischemic stroke?

Answer 20

young patients <55 with no identifiable source

Question 21

What is the most common mechanisms of ischemic stroke?

Answer 21

Clot forms somewhere else and travels to brain - thromboembolism. Other causes: cardioembolism, larger artery atherosclerosis, hypercoag state, nonatherosclerotic vasculopathy, small vessel disease, hypotension

Question 22

Non FDA approved therapy that you can give within 6 hours of strok eonset is what?

Answer 22

intra-arterial t-PA (different from standard IV t-PA)

Question 23

What is the corkscrew device that removes embolus that is FDA approved but has controlled trials pending?

Answer 23

Merci retriever

Question 24

What medication can lower mortality and morbidity if started within 48 hours of ischemic stroke?

Answer 24

aspirin (no evidence for using heparin)

Question 25

What secondary stroke prevention for anti-thrombotic therapy do we use for large artery atherosclerosis and small vessel disease?

Answer 25

antiplatelet therapy (these are platelet clots!): aspirin 50-325mg QD, clopidogrel (plavix) 75mg daily, ASA plus dipyridamole XR (aggrenox) 25/200mg BID

Question 26

What secondary stroke prevention for anti-thrombotic therapy do we use for cardioembolism, hypercoagulable state?

Answer 26

clotting factor clots so anticoagulation: warfarin (Coumadin) but have to wait at least 24 hours and begin IV heparin with goal PTT 50-70 if TPA given, after that, then you can start warfarin 5mg PO daily and titrate to iNR 2-3

Question 27

What can we do for stroke prevention if there is carotid stenosis 50-99% with symptoms?

Answer 27

carotid endarterectomy, angioplasty and stenting only in high risk patients