AVC stroke Flashcards
avc ddx
transient ischemic attack [TIA]
brain tumour
hypoglycemia
Brain bleed:
subdural hematoma, subarachnoid bleed
deux catégories de stroke
Hemorrhagic
Embolic/thrombotic stroke
to ensure best outcome for a pt - involve other specialists such as
physical therapist
an occupational therapist
social service personnel
physiatrist
neurologist
about what decisions to involve pt’s family
resuscitation
use of a feeding tube
treatment of pneumonia
In patients who have suffered stroke, diagnose “silent” cognitive deficits such as
inattention
impulsivity
common complications in stroke pt 2)
aspiration pneumonia (dysphagie)
decubitus ulcer (allité)
In patients at risk of stroke, treat modifiable risk factors 4
atrial fibrillation, diabetes, hyperlipidemia, and hypertension
offer antithrombotic treatment in which pt
history of TIA or completed stroke
risk factors stroke
Smoking
Obesity / hyperlipidemia
Alcohol
Hypertension
Diabetes
Prior TIA/stroke
Atrial fibrillation
Coagulopathy
Age
Aboriginal/Black
Family History
Acute eval for stroke
MOVIE
FAST
Neurological Screen (FAST: Facial droop, Arm drift, Speech disturbance, Time is tissue!)
Facial droop (show me your teeth)
Arm drift (close your eyes and extend both arms out with your palms facing upwards)
Abnormal speech (say “you can’t teach an old dog new tricks”)
stroke mimics
Recrudescence of old stroke from metabolic or infectious stress
Todd’s paralysis after seizure
Complex migraine
Psych
Mass/tumor
Hypoglycemia
CNS infections
Bells palsy (central causes will spare the forehead)
Subarachnoid hemorrhage (sudden onset severe headache, stiff neck, photophobia, diplopia)
Subdural hematoma
labs and imagerie
CBC (platelets)
Blood type and screen
Chem 7 (creatinine, eGFR)
INR
CBGM - capillary blood glucose
Consider ECG (r/o Afib)
Consider Troponin
CT head +/- CT Angio TETE et COU
tx if hemorrhagic stroke
reverse anticoag
monitor ICP
tx non hemorrhagic stroke
tPA (alteplase) if sx onset <3-4.5 hours
Contraindications to tPA
Active or history of intracranial hemorrhage
<3 months neurosurgery, head trauma, stroke
Uncontrolled hypertension >185/110
Known intracranial AV malformation, neoplasm, aneurysm
Active internal bleeding
Suspected endocarditis, suspected subarachnoid hemorrhage
Bleeding disorder (Plat<100, heparin with elevated aPTT, INR>1.7, DOAC)
Abnormal glucose <2.7mmol/L
if not candidate for alteplase give
ASA if no hemorrhage (loading dose)
target BP (pre-tx alteplase; post tx and if no tx)
Target BP <185/110 prior to treatment, and <180/105 for first 24h if thrombolytic therapy
If no thrombolytic, only treat if >220/120 or other indication
Eligibility for endovascular neurointerventional care 3
1) large vessel occlusion [MCA, ACA, Carotid], small infarct, large penumbra)
2) National Institutes of Health Stroke Scale (NIHSS) >6
3) Vision, aphasia, neglect (VAN) assessment +
post stroke team mngmt
NPO - assess dysphagia
early mobilization
assess functionnal impariment
Additional work up tests
Within 48h of TIA or stroke
- Brain imaging (CT or MRI) with vascular imaging (CTA or MRA from aortic arch to vertex, or carotid doppler)
- ECG and 24-hour cardiac monitoring + Holter (if no Afib on ECG and 24h monitor)
- TTE (or TEE if high suspicion): Thrombi, endocarditis, calcifications, tumour; Patent foramen ovale (No clear evidence for PFO closure)
- Antiphospholipid (hypercoagulable state eg pt with no risk factors)
- Vasculitis
prevention of further strokes
1) Antiplatelets
- Clopidogrel (75mg daily) vs. aspirin/dipyridamole (25/200mg BID) vs. aspirin alone (delay 24h if given tPA)
- For minor stroke and TIA, consider dual antiplatelet for 10-21d
2) Lifestyle (ROH, smoking, diet, activity)
3) Atrial fibrillation (anticoagulate as per CHADS65)
- If ECG negative, can consider prolonged ECG monitoring (Holter)
4) Lipids (Statin in all ischemic stroke/TIA)
5) Screen and Treat:
- Diabetes (HbA1c)
- Blood pressure
- Hormone (Consider stopping hormone replacement therapy and OCP)
- OSA
complications of stroke
Cardiac
Depression
Dementia
Dysphagia
Fatigue
Ulcer
Venous thromboembolus (25% early death post-stroke is from PE, consider prophylaxis)
Pain
Seizure (no evidence for prophylaxis)
