Acute Stroke Flashcards
Patho of acute stroke
ischemic brain injury d/t blood loss to an area of the brain
Excess of extracellular excitatory amino acids, free radicals, and inflammation
What is the most important piece of information for accurate clinical assessment of an acute stroke?
TIME!
NHSS scoring system
Determines stroke severity
Score 0-4: minor stroke
Score >20: severe stroke
Primary goal of acute stroke management
confirm the patient’s symptoms are due to ischemia rather than other neurological processes and consider stroke mimics
Ischemic stroke can mimic what NEUROLOGICAL conditions?
seizure/postictal state, complicated migraine, other intracranial process (abscess, infection, tumor, hemorrhage, MS), hypertensive encephalopathy, vertigo, cranial/peripheral neuropathies, Bell’s palsy, transient global amnesia
Ischemic stroke can mimic what METABOLIC conditions?
hypoglycemia/hyperglycemia, hyponatremia, hepatic encephalopathy, drug OD
Ischemic stroke can mimc what PSYCHIATRIC conditions
conversion disorder, malingering
Neuroimaging for stroke
non-contrast head CT to rule out hemorrhage; MRI is more sensitive at detecting early ischemic changes
Symptoms of stroke: timing and presentation
Sudden onset of focal neurological deficit, usually unilateral
Symptoms of stroke
Dysphasia/dysarthria
Hemianopia
Weakness
Ataxia
Sensory loss
Neglect
Stroke treatment is based on what?
Time since symptom onset
Stroke treatment within 4.5 hours of symptom onset
Fibrinolysis +/- thrombectomy
Stroke treatment: 4.5-24 hours since symptom onset with a large vessel occlusion
Thrombectomy
Stroke treatment: 4.5-24 hours since symptom onset with a small vessel occlusion
Permissive HTN and a heparin infusion
MoA of fibrinolytics
tissue plasminogen activator; activate plasminogen → plasmin activation → dissolves fibrin
Fibrinolytics
alteplase, tenecteplase
Alteplase dosing
0.9mg/kg, MDD 90 mg
Bolus is 10% IV bolus over 1 minute, infusion is 90% of total dose over 60 minutes
Tenecteplase dosing
0.25mg/kg, MDD 25 mg; given as IV push
Alteplase half-life
5 mins
Tenecteplase half-life
20-24 minutes; terminal half-life 99-120 mins
Which thrombolytic is more fibrin-specific?
Tenecteplase
ABSOLUTE CIs to fibrinolytics (there’s 16 of them)
<18 years old
Ischemic stroke within 3 months
Intracranial/intraspinal surgery within 3 months
GI malignancy or GIB within 21 days
LMWH within 24 hours
Infective endocarditis
Intra-axial intracranial neoplasm
Unclear time of onset or >4.5 hours since symptom onset
Current ICH
Severe head trauma within 3 months
Subarachnoid hemorrhage
Platelet count <100K, INR ≥1.7, aPTT >40s
DOAC within 48 hours
Aortic arch dissection
Guideline changes for fibrinolytics: seizure at onset
can give thrombolytics if residual impairments are believed to be secondary to stroke
Guideline changes for fibrinolytics: BG <50 or >500
Correct glucose, then give fibrinolytics
Guideline changes for fibrinolytics: arterial puncture at non compressible site in the last 7 days
uncertain, not really sure about the safety
Guideline changes for fibrinolytics: recent major trauma within 14 days
can give thrombolytic if there’s no head injury/trauma
Guideline changes for fibrinolytics: recent major surgery within 14 days
can be considered, but weigh the risk of potential bleeding and benefits
Complications: symptomatic ICH
Step 1: D/C alteplase infusion
Step 2: Cryoprecipitate 10 units infused over 10-30 minutes and antifibrinolytics (transexamic acid, epsilon-aminocaproic acid)
Complications: angioedema
Maintain airway, hold ACEi
Methylprednisolone 80-100mg IV
Diphenhydramine 50mg IV
Ranitidine 50mg IV or famotidine 20mg IV
Epinephrine 0.3mL
BP control: BP for thrombolytic bolus
<185/110
BP control: BP for thrombolytic infusion
<180/105
When is permissive HTN allowed?
If patient meets the exclusion criteria but no alteplase was given
BP isn’t treated until it reaches what level?
> 220/110
First-line HTN meds for BP control in stroke
Labetalol, nicardipine if HR <55
Second-line HTN meds for BP control in stroke
Hydralazine, enalaprilat, clevedipine
Endovascular intervention
Thrombectomy for large vessel occlusions +/- intra-arterial thrombolytics
Post-fibrinolytic care: monitoring
Neurologic and blood pressure monitoring for 24h
Dysphagia and aspiration risk
Post-fibrinolytic care: medications to start patients on
High-intensity statin
ASA (dual-anti platelets for low NIH stroke x21 days OR those with intracerebral stent placement)
DVT prophy >24 hours post-alteplase
Anticoagulant if cardioembolic stroke or Hx of afib
Secondary stroke prevention
Lifestyle and nutrition
Smoking cessation
Limit alcohol consumption
Counsel on substance abuse
HTN
Dyslipidemia
DM
