Acute Stroke

Question 1

Patho of acute stroke

Answer 1

ischemic brain injury d/t blood loss to an area of the brain

Excess of extracellular excitatory amino acids, free radicals, and inflammation

Question 2

What is the most important piece of information for accurate clinical assessment of an acute stroke?

Answer 2

TIME!

Question 3

NHSS scoring system

Answer 3

Determines stroke severity

Score 0-4: minor stroke
Score >20: severe stroke

Question 4

Primary goal of acute stroke management

Answer 4

confirm the patient’s symptoms are due to ischemia rather than other neurological processes and consider stroke mimics

Question 5

Ischemic stroke can mimic what NEUROLOGICAL conditions?

Answer 5

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

Question 6

Ischemic stroke can mimic what METABOLIC conditions?

Answer 6

hypoglycemia/hyperglycemia, hyponatremia, hepatic encephalopathy, drug OD

Question 7

Ischemic stroke can mimc what PSYCHIATRIC conditions

Answer 7

conversion disorder, malingering

Question 8

Neuroimaging for stroke

Answer 8

non-contrast head CT to rule out hemorrhage; MRI is more sensitive at detecting early ischemic changes

Question 9

Symptoms of stroke: timing and presentation

Answer 9

Sudden onset of focal neurological deficit, usually unilateral

Question 10

Symptoms of stroke

Answer 10

Dysphasia/dysarthria
Hemianopia
Weakness
Ataxia
Sensory loss
Neglect

Question 11

Stroke treatment is based on what?

Answer 11

Time since symptom onset

Question 12

Stroke treatment within 4.5 hours of symptom onset

Answer 12

Fibrinolysis +/- thrombectomy

Question 13

Stroke treatment: 4.5-24 hours since symptom onset with a large vessel occlusion

Answer 13

Thrombectomy

Question 14

Stroke treatment: 4.5-24 hours since symptom onset with a small vessel occlusion

Answer 14

Permissive HTN and a heparin infusion

Question 15

MoA of fibrinolytics

Answer 15

tissue plasminogen activator; activate plasminogen → plasmin activation → dissolves fibrin

Question 16

Fibrinolytics

Answer 16

alteplase, tenecteplase

Question 17

Alteplase dosing

Answer 17

0.9mg/kg, MDD 90 mg

Bolus is 10% IV bolus over 1 minute, infusion is 90% of total dose over 60 minutes

Question 18

Tenecteplase dosing

Answer 18

0.25mg/kg, MDD 25 mg; given as IV push

Question 19

Alteplase half-life

Answer 19

5 mins

Question 20

Tenecteplase half-life

Answer 20

20-24 minutes; terminal half-life 99-120 mins

Question 21

Which thrombolytic is more fibrin-specific?

Answer 21

Tenecteplase

Question 22

ABSOLUTE CIs to fibrinolytics (there’s 16 of them)

Answer 22

<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

Question 23

Guideline changes for fibrinolytics: seizure at onset

Answer 23

can give thrombolytics if residual impairments are believed to be secondary to stroke

Question 24

Guideline changes for fibrinolytics: BG <50 or >500

Answer 24

Correct glucose, then give fibrinolytics

Question 25

Guideline changes for fibrinolytics: arterial puncture at non compressible site in the last 7 days

Answer 25

uncertain, not really sure about the safety

Question 26

Guideline changes for fibrinolytics: recent major trauma within 14 days

Answer 26

can give thrombolytic if there’s no head injury/trauma

Question 27

Guideline changes for fibrinolytics: recent major surgery within 14 days

Answer 27

can be considered, but weigh the risk of potential bleeding and benefits

Question 28

Complications: symptomatic ICH

Answer 28

Step 1: D/C alteplase infusion
Step 2: Cryoprecipitate 10 units infused over 10-30 minutes and antifibrinolytics (transexamic acid, epsilon-aminocaproic acid)

Question 29

Complications: angioedema

Answer 29

Maintain airway, hold ACEi
Methylprednisolone 80-100mg IV
Diphenhydramine 50mg IV
Ranitidine 50mg IV or famotidine 20mg IV
Epinephrine 0.3mL

Question 30

BP control: BP for thrombolytic bolus

Answer 30

<185/110

Question 31

BP control: BP for thrombolytic infusion

Answer 31

<180/105

Question 32

When is permissive HTN allowed?

Answer 32

If patient meets the exclusion criteria but no alteplase was given

Question 33

BP isn’t treated until it reaches what level?

Answer 33

> 220/110

Question 34

First-line HTN meds for BP control in stroke

Answer 34

Labetalol, nicardipine if HR <55

Question 35

Second-line HTN meds for BP control in stroke

Answer 35

Hydralazine, enalaprilat, clevedipine

Question 36

Endovascular intervention

Answer 36

Thrombectomy for large vessel occlusions +/- intra-arterial thrombolytics

Question 37

Post-fibrinolytic care: monitoring

Answer 37

Neurologic and blood pressure monitoring for 24h
Dysphagia and aspiration risk

Question 38

Post-fibrinolytic care: medications to start patients on

Answer 38

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

Question 39

Secondary stroke prevention

Answer 39

Lifestyle and nutrition
Smoking cessation
Limit alcohol consumption
Counsel on substance abuse
HTN
Dyslipidemia
DM