Acute Stroke Flashcards

1
Q

Patho of acute stroke

A

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

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

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2
Q

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

A

TIME!

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3
Q

NHSS scoring system

A

Determines stroke severity

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

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4
Q

Primary goal of acute stroke management

A

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

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5
Q

Ischemic stroke can mimic what NEUROLOGICAL conditions?

A

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

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6
Q

Ischemic stroke can mimic what METABOLIC conditions?

A

hypoglycemia/hyperglycemia, hyponatremia, hepatic encephalopathy, drug OD

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7
Q

Ischemic stroke can mimc what PSYCHIATRIC conditions

A

conversion disorder, malingering

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8
Q

Neuroimaging for stroke

A

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

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9
Q

Symptoms of stroke: timing and presentation

A

Sudden onset of focal neurological deficit, usually unilateral

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10
Q

Symptoms of stroke

A

Dysphasia/dysarthria
Hemianopia
Weakness
Ataxia
Sensory loss
Neglect

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11
Q

Stroke treatment is based on what?

A

Time since symptom onset

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12
Q

Stroke treatment within 4.5 hours of symptom onset

A

Fibrinolysis +/- thrombectomy

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13
Q

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

A

Thrombectomy

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14
Q

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

A

Permissive HTN and a heparin infusion

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15
Q

MoA of fibrinolytics

A

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

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16
Q

Fibrinolytics

A

alteplase, tenecteplase

17
Q

Alteplase dosing

A

0.9mg/kg, MDD 90 mg

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

18
Q

Tenecteplase dosing

A

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

19
Q

Alteplase half-life

20
Q

Tenecteplase half-life

A

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

21
Q

Which thrombolytic is more fibrin-specific?

A

Tenecteplase

22
Q

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

A

<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

23
Q

Guideline changes for fibrinolytics: seizure at onset

A

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

24
Q

Guideline changes for fibrinolytics: BG <50 or >500

A

Correct glucose, then give fibrinolytics

25
Guideline changes for fibrinolytics: arterial puncture at non compressible site in the last 7 days
uncertain, not really sure about the safety
26
Guideline changes for fibrinolytics: recent major trauma within 14 days
can give thrombolytic if there's no head injury/trauma
27
Guideline changes for fibrinolytics: recent major surgery within 14 days
can be considered, but weigh the risk of potential bleeding and benefits
28
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)
29
Complications: angioedema
Maintain airway, hold ACEi Methylprednisolone 80-100mg IV Diphenhydramine 50mg IV Ranitidine 50mg IV or famotidine 20mg IV Epinephrine 0.3mL
30
BP control: BP for thrombolytic bolus
<185/110
31
BP control: BP for thrombolytic infusion
<180/105
32
When is permissive HTN allowed?
If patient meets the exclusion criteria but no alteplase was given
33
BP isn't treated until it reaches what level?
>220/110
34
First-line HTN meds for BP control in stroke
Labetalol, nicardipine if HR <55
35
Second-line HTN meds for BP control in stroke
Hydralazine, enalaprilat, clevedipine
36
Endovascular intervention
Thrombectomy for large vessel occlusions +/- intra-arterial thrombolytics
37
Post-fibrinolytic care: monitoring
Neurologic and blood pressure monitoring for 24h Dysphagia and aspiration risk
38
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
39
Secondary stroke prevention
Lifestyle and nutrition Smoking cessation Limit alcohol consumption Counsel on substance abuse HTN Dyslipidemia DM