Acute Stroke Management and Evaluation

Question 1

What info do you want to get out of the history if someone presents with stroke like symptoms?

Answer 1

What happened
When were they last seen normal!!
Vascular risk factors
Stroke mimics (seizures)
TPA contraindications
PMHx, meds, allerges, SHx

Question 2

What physical exams do you do if someone presents with stroke like symptoms?

Answer 2

Vitals (check BP in both arms)
Heart
Focused neurological exam!! (NIH stroke scale and pupils)
Pulses (esp if one limb)
Trauma assessment

Question 3

What are 2 conditions that present like stroke that you really don’t want to miss

Answer 3

Aortic dissection
Neck pain (could be epidural hematoma)
If you TPA these patients, they can die or be tetraplegics

Question 4

What are the main things on the DDx for ischemic stroke

Answer 4

Hemorrhagic stroke
Seizure (with Todd's paralysis)
Migraine
Mass
Additionally:
Drugs/infection/metabolic (for a decreased LOC)
Spinal cord (esp if the head is spared)
Peripheral vascular clot (if a single limb)

Question 5

DIMS acronym

Answer 5

For causes of a decreased level of consciousness
D: drugs (of abuse, withdrawal, meds)
I: infection (encephalitis, meningitis, sepsis)
M: metabolic disturbance (sugar, sodium, etc)
S: structural or seizure (big bleeds, brain damage, seizure)

Question 6

Spot sign

Answer 6

Dot in the middle of the hemorrhage that tells you there is active bleeding
Can get a massive extension very quickly
Positive sign doubles patient mortality

Question 7

Initial investigations you want to do

Answer 7

Blood sugar levels!!
CBC
Lytes, creatinine, eGFR
INR, PTT
Troponin
ECG
CXR
Don't delay care for any of these except for blood sugar!

Question 8

TPA

Answer 8

Tissue plasminogen activator
Converts plasminogen to plasmin
Given IV
Dose is 0.9 mg/kg (bolus, then infusion)
Works pretty quickly

Question 9

3 main risks of TPA

Answer 9

Intracranial hemorrhage (can cause neurological deterioration)
Systemic hemorrhage
Angioedema

Question 10

2 main contraindications for TPA

Answer 10

Low platelet count

On an anticoagulant with INR >1.7

Question 11

You can do endovascular thrombectomy when there are what 4 characteristics

Answer 11

Large vessel occlusion (too distal and we can’t get the clot)
Good CT head scan (good brain still there)
Adequate collaterals (procedure does take a while)
Rapid access (less than 6 hours)

Question 12

Endovascular thrombectomy

Answer 12

When you use a stent retriever or aspiration device to remove the clot

Question 13

How do you know to give either TPA or EVT?

Answer 13

If the patient is a candidate for both, they get both!

Question 14

Stroke unit

Answer 14

A specialized, geographically defined hospital unit dedicated to management of stroke patients
Staffed by an experienced interprofessional stroke team
Leads to better outcomes for patients

Question 15

Use of aspirin

1. No TPA
2. TPA given

Answer 15

Used to prevent a secondary stroke

1. Can give right away
2. No aspirin for at least 24 hours. Need to check follow up CT head the next day to make sure there is no hemorrhage

Question 16

What else do we want to control while treating stroke?

Answer 16

BP (mostly let it ride)
Temperature control
Glycemic control
No eating until swallowing assessment
DVT prophylaxis
Prevent falls

Question 17

Post stroke complications

Answer 17

Aspiration pneumonia
UTI
MI
DVT/PE
Falls
Impaired nutrition
Fatigue
Mood
Cognition
Recurrent stroke
Hemorrhagic transformation of infarct
Herniation

Question 18

What type of strokes put patients at risk for herniation?

Answer 18

Large MCA or posterior fossa (huge strokes)

Especially in younger patients with little brain atrophy