Ch 87- Stroke Flashcards
What percent of strokes are ischemic vs hemorrhagic?
87% ischemic
13% hemorrhagic
List 10 conditions on the ddx for ischemic stroke
● Structural
○ acute/chronic subdural or epidural hematoma
○ Brain tumour
○ Brain abscess
● Vascular
○ Air gas embolism
○ Aortic dissection
○ Carotid / cervical artery dissection
○ Migraine
○ Giant cell arteritis
○ Polyarteritis nodosa
○ Lupus / vasculitis
○ Cerebral venous sinus thrombosis
● Metabolic
○ Hypoglycemia
○ Wernicke’s encephalopathy (ophthalmoplegia, ataxia, confusion)
○ Post-seizure induced Todd’s paralysis
● Infectious
○ Bell’s palsy
○ Labyrinthitis
○ Vestibular neuronitis
● Demyelination or Peripheral Neuropathy
○ Peripheral nerve palsy
○ Demyelinating disease
○ Meniere’s disease
List 10 conditions on the ddx for hemorrhagic stroke
Same as ischemic stroke in addition to:
1. HTN encephalopathy
2. PRES
List 5 etiologies of ischemic stoke
1.Thrombotic (⅓ of ischemic strokes)
a. Large vessels
caused by ulcerated (1)atherosclerotic plaque → platelet plugs
b. Small vessels
* (2) Lacunar or small vessel strokes [DM, HTN]
- Embolic (¼ of all strokes)
a. Cardiac - (3) AFIB; (4) septic emboli 2/2 endocarditis.
b. Noncardiac
* (5) Extra-cranial proximal carotid plaque (amaurosis fugax)
* (6) AGE
List 5 specific causes of hemorrhagic stroke
o Hypertensive vasculopathy
o Cerebral amyloid angiopathy (age related amyloid deposition in the cerebral
vessel walls)
o Ateriovenous malformations ?(AVMs)
o Aneurysms
o Drug related - cocaine
o Malignant hypertension
o Bleeding disorder
o Hemorrhagic transformation of ischemic stroke/tumour
Describe anterior cerebral circulation (draw COW)
Ant. circulation perfuses 80% of the brain
The first branch off the internal carotid artery is the ophthalmic artery, which supplies the
optic nerve and retina. As a result, the sudden onset of painless monocular blindness
(amaurosis fugax) identifies the stroke as involving the anterior circulation (specifically the
ipsilateral carotid artery) at or below the level of the ophthalmic artery. The internal carotid
arteries terminate by branching into the anterior and middle cerebral arteries at the circle of
Willis.
What structures to anterior circulation supply?
- optic nerve
- retina
- fronto-parietal lobes
- anterior- temporal lobes
Describe posterior cerebral circulation (Draw )
Supplies 20% brain
1. Vertebral arteries enter through foramen magnum
2. 1st branches- posterior inferior cerebellar arteries (PICA) > supply cerebellum.
3. 2nd branch Ant. spinal artery >join to supply spinal cord
4. Vertebral arteries join to form the basilar artery.
5. 1st branch off basilar artery >Ant. inferior cerebellar artery (AICA) posterior cerebral arteries.> supply cerebellum
6. 2nd branches off basilar artery > pontine arteries
7. 3rdbranch off basilar artery > superior cerebellar artery
8. 4th (and final branch) off basilar artery > posterior cerebral artery > joins COW to form posterior communicating artery
Which brain structures does the posterior circulation supply?
1.Brainstem (LOC, movement, sensation)
2. Cerebellum
3. Thalamus
4. auditory and vestibular centres
5. medial temporal lobe
6. visual occipital cortex
Describe the expected findings with Anterior cerebral artery stroke syndrome
Affect frontal lobe function
1. aLOC > impaired judgement/ insight
2. primitive reflexes (grasp and suck)
3. (+/- ) bladder/ bowel incontinence
4. contralateral lower limb weakness»_space; upper limb (think of homunculus)
5. Apraxia (clumsy gait)
Describe the expected findings with MCA stroke?
Hallmark > motor and sensory deficits
1. Contralateral face/upper limb weakness»_space; lower limb
2. Gaze presence towards lesion
3. Aphasia (dominant hemisphere)
4. Neglect ( if non-dominant hemisphere)
5. Contralateral Homonymous Hemianopsia
Describe the expected findings with Vertbro-basilar stroke
- Cranial nerves
-Diplopia
- 3rd nerve palsy
- nystagmus
- Facial droop
- dysphagia - Cerebellar involvement
- Vertigo
- Ataxia (gait)
- Nystagmus - Neuro sensory motor tract involvement
- Weakness
- Paralysis
Describe the expected findings with posterior cerebral artery stroke
Contralateral homonymous hemianopsia
Ipsilateral CN III
Alexia (inability to read words and sentences) with or without agraphia (inability to write and spell) may be present
Prosopagnosia (inability to recognize faces)
There is usually no paralysis.
Sensory loss may be present or absent. Aphasia will not be present.
Describe the expected findings with Posterior inferior cerebellar artery stroke syndrome
PICA stroke> aka Wallenberg syndrome
Lateral part of the medulla infarcts
Very classic symptoms:
1. Pain/temp contralateral body and ipsilateral face
2. Cerebellar signs – vertigo, dizziness, ataxia (ipsilateral)
3. Horner’s syndrome (ipsilateral)
4. Ipsilateral paralysis of palate, laryngeal and pharyngeal muscles
List 6 red flag signs for posterior stroke in a patient presenting with vertigo? (Terrible Ds)
Dizziness (vertigo)
Diplopia
Dysarthria
Dysphagia
Dysmetria (cerebellar ataxia)
GAIT = Most peripheral vertigo can still walk
List four common sites for hypertensive intracranial hemorrhage
AFFECTED AREA (FREQUENCY)
o Putamen (44%)
o Thalamus (13%)
o Cerebellum (9%)
o Pons (9%)
o Other cortical areas (25%)
List six symptoms associated with hypertensive ICH
o Contralateral motor/sensory loss
o Limb pain, speech difficulty
o Uncoordinated movements of trunk and limbs
o Numbness, weakness, ataxia, dizziness
o Numbness, weakness, language disturbances
Define Transient Ischemic Attack
Newest definition (AHA) - A transient episode of neurologic dysfunction
caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.”
NB: no time window (used to be 24hrs)
Which scoring system risk stratifies patients with TIA?
ABCD2 score (ie. ABCD squared, for Age,
Blood pressure, Clinical features, Duration of symptoms, and Diabetes) was designed to
identify patients at high risk of ischemic stroke in the first seven days after TIA.
Age > 60 (1)
BP > 140/80 (1)
Clinical features >UL weakness (2) impaired speech w/o weakness (1)
Duration of Sx > 60 min (2)…10-59 m (1)
DM (1)
Score| 2d risk of CVA | Recurrence in 90d
0-3. Low 1.0 %
4-5 Moderate. 4.1%
6-7 High 8.1%
Describe the management of high risk TIA and Low risk TIA
ALL TIA-
extensive ED evaluation and treatment
BP reduction
Statins
Anti platelet Tx
Lifestyle modification
Smoking cessation
Stroke neuro consult
Low Risk - Start ASA (as long as no CIs) add second agent if already on ASA
High risk TIA or mild stroke (NIHSS <4) - DAPT with ASA and clopidigrel x90 days (CHANCE trial)
How does the presence of carotid stenosis change the management of TIA
High grade carotid stenosis and/or mural thrombus require hospital admission for anticoagulation, stenting or carotid endarterectomy
ED Evaluation of new onset TIA
- neuro-vascular imaging (CTA COWs/MRA)
- Carotid doppler
- ECG - r/o AFIB
- Coag studies
What are the 11 components of the NIHSS stroke scale?
1a. Level of consciousness
1b. LOC Questions
1c. Follows commands
2. Best gaze
3. Visual Fields
4. Facial palsy
5. Motor – arms
6. Motor – legs
7. Limb ataxia
8. Sensory
9. Best language
10. Dysarthria
11. Extinction or neglect
List 4 poor prognostic indicators for ICH.
Decreased LOC
Intraventricular hemorrhage
Infratentorial Hemorrhage
ICH volume > 30 cc
Age
Classic ICH presentation
the sudden onset of headache, vomiting, severely elevated BP, and focal neurologic deficits that progress over minutes
what scoring system is used for predicting mortality after ICH.
ICH score
GSW
3-4 (2)
5-12 (1)
13-15 (0)
ICH Volume
>30ml (1)
<30 (0)
Intraventricular blood
yes (1)
no (0)
Location
Infratentorial (1)
Supratentorial (0)
Age
>80 (1)
<80 (0)
30 day mortality
1= 13%
2=26%
3= 72%
4= 97%
5/6= 100%
What are the NINDS-Recommended stroke evaluation time targets for door to MD and door to tPA
Door to Doctor - 10 min
Door to CT - 25 min
Door to treatment - 60 min
Access to stroke neurology 15 min
Access to neurosurgical expertise 2 h
Describe pre-hospital management goals for ischemic stroke
Identify stroke
o Early hospital notification
o Rapid transport
o Ensure CNS oxygenation and perfusion (sp02>95%)
List 3 immediate diagnostic steps to be performed in the ER for stroke
- Blood glucose test (+ PTT, INR, CBC)
- ECG > to exclude atrial fibrillation or acute MI
- Cranial imaging (CT or CT/CTA)
list 3 tPA inclusion criteria for pts with ischemic stroke
Age >18
Symptom onset >4.5 h (or confirmed wake up stroke)
clinical diagnosis + significant neurologic deficits
List 4 4.5hr window exclusion criteria
Age >80
NIHSS >25
Oral AC
DM and previous CVA
tPA dose
0.9 mg/kg (max 90)
10% as a bolus
90% over 1h
Outline the management for a pt with ischemic stroke who is not eligible to receive
thrombolysis.
● Prevent secondary neurologic injury
○ Optimal fluid and electrolyte balance
○ Avoid hypo- or hyperglycemia
○ Prevent fever
● Start an antiplatelet (or add clopidogrel on to ASA) within 48 hrs
● Consider starting LMWH in hospital after consultation with neurology
● Start aggressive statin therapy
● Treat high blood pressure only if the hypertension is extreme (systolic blood pressure
>220 mmHg or diastolic blood pressure >120 mmHg)
● Prevent aspiration, early mobilization and physiotherapy and multidisciplinary stroke
unit care
3 groups of patients that should have emergency antihypertensive therapy for acute ischemic stroke
- Patient is a re-perfusion candidate (tPa and/or re-perfusion intervention)
- Patient is NOT a re-perfusion candidate and has NO special medical conditions that
mandate BP control
- AKA avoid anti-hypertensives/ BP control NOT indicated unless…
SBP >220/ DBP >120/ MAP >130 - Patient with specific medical indications
- Acute MI (SBP 100-120)
-Aortic Dissection (SBP 100-120)
-HTN encephalopathy (10-15% reduction)
-Severe LV heart failure (10-15% reduction)
What is the target BP for stroke patients where aggressive BP lowering is indicated (ex planned fribrinolytic therapy
<185/110
Describe antihypertensive management for patients who are eligible for rTPA or other acute re-perfusion intervention
If Systolic >185 mm Hg or diastolic >110 mm Hg
o Labetalol 10 to 20 mg IV over 1 to 2 minutes; may repeat 1 time OR
o Nicardipine infusion, 5 mg/hr; titrate up by 2.5 mg/hr at 5- to 15-minute
intervals, maximum dose 15 mg/hr; when desired BP attained, reduce to 3 mg/hr
o Other agents (hydralazine, enalaprilat, etc.) may be considered when appropriate.
* If BP does not decline and remains >185/110 mm Hg, do not administer rtPA
Describe BP management during and after treatment with rTPA or other acute re-perfusion intervention
BP q 15 min during treatment AND 2 hr after treatment > then q 30 min x 6h > then q 1h for 16h
IF SBP 180-230 or DBP 105-120
o Labetalol 10 mg IV over 1 to 2 minutes; may repeat every 10 to 20minutes;
maximum dose of 300 mg OR
o Labetalol 10 mg IV followed by an infusion at 2 to 8 mg/min
IF SBP >230 or SDP >120 …follow same labetalol protocol and consider nicardipine infusion 5 mg/hr; titrate up to desired effect by increasing 2.5
mg/hr every 5 minutes to maximum of 15 mg/hr
* If BP not controlled, consider sodium nitroprusside.
List 6 absolute contraindications to tPA (AHA).List 6 relative contraindications to tPA (AHA)
Head trauma or prior stroke within 3 mo
SxS of SAH
History of ICH
Known intracranial neoplasm, AVM or aneurysm
Recent brain or spine surgery
SBP>185 DBP > 110
Active internal bleeding
Acute bleeding diathesis
- PLT <100
-Heparin therapy within 48 hr causing elevated aPTT
-current AC use with INR> 1.7 or PT >15
-BG <2.7
-CT shows multi-lobar infraction
Relative CIs
mild stroke symptoms or NIHSS >4
pregnancy
seizure at onset with postictal neuro deficits
Major surgery or serious trauma within 14d
Recent GI or UT hemorrhage within 21d
Recent MI within 3mo
2019 AHA/ASA inclusion/ exclusion criteria for alteplase/ tPA in acute ischemic stroke
See Table 87.5
What are the inclusion and relative exclusion criteria for acute ischemic stroke in the 3-4.5 hr time window? (Rosens 8th edition…double check)
- INCLUSION CRITERIA
o Diagnosis of ischemic stroke causing measurable neurological deficit
o Onset of symptoms within 3 to 4.5 hours before beginning treatment - RELATIVE EXCLUSION CRITERIA
o Older than 80 years old
o Severe stroke (NIHSS > 25)
o Taking an oral anticoagulant regardless of INR
o History of both diabetes and prior ischemic stroke
Time windows for reperfusion in acute ischemic stroke
IV thrombolysis
0-4.5 hr all patients showing signs of acute ischemic stroke confirmed by CT/CTA
4.5-6h select patients with signs of disabling stroke. Based on advanced neuroimaging
6-9 hr select patients with signs of disabling stroke. Based on advanced neuroimaging and discussion with stroke expert (ie wake up stroke)
Endovascular thrombectomy
0-6hr all patient showing signs of acute disabl;ing stroke with LVO . Based on CT/CTA
6-24 hr all patient showing signs of acute disabl;ing stroke with LVO based on advanced neuroimaging
2022 inclusion criteria for thrombolysis treatment (stoke best practice box 5B)
Diagnosed with an acute ischemic stroke.
The stroke is disabling (i.e., significantly impacting function) (NIHSS)>4.
The risks and benefits of thrombolysis are within the patient’s goals of care and take into
consideration their functional status prior to stroke.
Life expectancy of 3 months or more.
Age ≥18 years.
symptoms/ last well <4.5 hours before thrombolysis
administration.
2022 exclusion criteria for thrombolysis treatment (stoke best practice box 5B)
Absolute Exclusion Criteria
Any source of active hemorrhage or any condition that could increase the risk of major
hemorrhage
Any hemorrhage on brain imaging.
Relative
Historical
History of intracranial hemorrhage.
Stroke or serious head or spinal trauma in the preceding 3 months.
Major surgery (e.g., cardiac, thoracic, abdominal, or orthopedic) in the preceding 14 days. Risk
varies according to the procedure.
Arterial puncture at a non-compressible site in the previous 7 days.
Clinical
Stroke symptoms due to another non-ischemic acute neurological condition such as seizure
with post-ictal Todd’s paralysis or focal neurological signs due to severe hypo- or
hyperglycemia.
Hypertension refractory to aggressive hyperacute antihypertensive treatment such that target
blood pressure <180/105 cannot be both achieved and maintained.
Currently prescribed and taking a direct non-vitamin K oral anticoagulant
CT or MRI Findings
CT showing early signs of extensive infarction (e.g., >1/3 of middle cerebral artery [MCA]
territory, or ASPECTS score <6).
Laboratory
Blood glucose concentration <2.7 mmol/L or >22.2 mmol/L.
Elevated activated partial-thromboplastin time.
International Normalized Ratio >1.7.
Platelet count <100,000 per cubic millimetre.
Tenecteplase may be considered as an alternative to alteplase within 4.5 hours of acute stroke symptom onset. What is the dose?
0.25 mg/kg up to a maximum of 25 mg should be administered, given as a single bolus over 5 seconds
Benefit in bolus
Describe blood pressure targets in symptomatic ICH? What are recomended agents for lowering BP.
(NEW FOR 2022) Hypertension with symptomatic ICH: In patients with symptomatic ICH who are hypertensive (>185/110 mm HG), blood pressure should be lowered, however, the specific target and duration of therapy are unknown at this time. ie avoid hypotension
Agents- labetalol, esmolol, nicardipine, hydralazine, clevidipine
Reversal agents for AC in ICH
a. warfarin
b. Dabigitran
c. apixiban, rivaroxaban
d. ASA/ clopidogrel
● Patient on warfarin:
○ Vitamin K 10 mg IV
○ FFP 2-4 units or prothrombin complex concentrate (PCC)
● Patient on dabigatran
○ Idarucizumab
● Patient on apixaban, rivaroxaban
○ PCCprothombin complex concentrate
● Patient on ASA or Clopidogrel:
○ No current evidence to support platelet transfusion, unless plt count < 30,000
Describe indications for surgery in ICH
- Neurosurgery consultation for patients with clinical or radiographic evidence of elevated ICP
○ Question re: benefits of an external ventricular drain (EVD) placement or
hematoma evacuation - Cerebellar hemorrhage within 48 hrs of onset -
assuming they have a sizable lobar hemorrhage that is close to the cortical surface
with associated progressive neurological deterioration - People with intraventricular hemorrhage or posterior fossa hemorrhages may benefit
from a ventricular drain
**Non-cerebellar ICH is rarely intervened on
List three potential complications of ischemic stroke
● Cerebral edema progressing to increased ICP and deterioration (needing ICU care)
● Hemorrhagic transformation
● GI bleeding
● CHF
● Hospital related complications: DVT, PE, UTI’s, pneumonia
● Post-stroke seizures
● Post-stroke delirium and depression
List 8 risk factors for stroke in young patients
Big categories
o Hypercoagulable states
o Vasospasm
o Post-infectious
o Traumatic
o Connective tissue disorders
Specific situations
o Pregnancy
o Use of oral contraceptives
o Antiphospholipid antibodies
o Protein C and S deficiencies
o Sickle cell anemia
o Polycythemia
o Migraine syndromes
o Recreational drugs
**Cocaine/Amphetamines
o Recent infection from varicella or fungal meningitis
o Carotid / vertebral trauma leading to dissection
§ Spinal manipulation / cough / yoga / vomiting
Differentiate between Wernicke’s and Broca’s aphasia
Wernicke’s Aphasia
Receptive aphasia
Can’t comprehend
Often say many words
that don’t make sense
Broca’s Aphasia
Expressive aphasia
Can’t get the words out
Define aphasia/ dysphasia
A disorder of language in which the patient
articulates clearly but uses language
inappropriately or understands it poorly,
also is common in dominant-hemisphere
stroke.
Define dysarthria
A motor deficit of the mouth and speech
muscles; the dysarthric patient articulates poorly but understands words and word
choices.
Define Dysphagia
Difficulty swallowing
List 5 early CT findings consistent with ischemic stroke
Most findings don’t appear on routine CT scans till 6-12 hrs post infarction. However, subtle,
early ischemic changes have been noted in up to 67% of noncontrast CT scans within the
first 3 hours.
These early ischemic changes include:
- Hyperdense artery sign (acute thrombus in a vessel)
- Sulcal effacement (due to edema)
- Loss of the insular ribbon
- Loss of gray-white interface,
- Mass effect
- Acute hypodensity (Fig. 91.4)
What did the NINDS trial show?
In patients with ischemic stroke within 3 hours, tPA administration significantly improved NIHSS
scores but did not confer survival benefit.
2022 inclusion criteria for EVT
- Diagnosed with an acute ischemic stroke.
- The stroke is disabling (i.e., significantly impacting function), usually defined as National
Institutes of Health Stroke Scale (NIHSS)>4. - There is a proven, clinically relevant (symptomatic), intra- or extracranial acute arterial occlusion that is amenable to endovascular intervention.
- The risks and benefits of endovascular thrombectomy are within the patient’s goals of care and take into consideration their functional status prior to stroke.
- Age ≥18 years. (Refer to pediatric guidelines for treatment <18 years of age).
a. Currently, there is no evidence for EVT in pediatric populations and the decision to
treat should be based on the potential benefits and risks of the therapy, made by a
physician with pediatric stroke expertise in consultation with the EVT provider and the
patient and/or family or substitute decision-makers. - Intravenous thrombolysis: If intravenous thrombolysis is given in conjunction with
endovascular thrombectomy, refer to Box 5B for additional inclusion criteria. - Premorbid condition criteria: In general, individuals considered eligible for EVT are those
who were deemed functionally independent before their index stroke (i.e., mRS <3) and have a life expectancy >3 months. Note: These criteria are based on major clinical trial inclusion
criteria. Decisions should be based on these factors, clinical judgement, and the patient’s goals of care. - Imaging: Patients must qualify for imaging criteria in early and late windows as described in
Boxes 4B and 4C. - Time to treatment: The decision to proceed with EVT should be shared by the physician with
clinical stroke expertise and the neuro-interventionalist, who will use the available imaging
nformation as is indicated.
a. Specifically:
i. Patients should have immediate neurovascular imaging (see above) to
determine eligibility. Patients can be considered for imaging within a 24-hour
window from stroke symptom onset or last known well.
ii. For patients presenting <6 hours from stroke symptom onset or last known
well to initiation of treatment (i.e., arterial puncture), all patients who meet
eligibility criteria should be treated.
iii. For patients presenting between 6 and 24 hours from last known well, selected
patients may be treated if they meet clinical and imaging criteria and based on
local protocols and available expertise in EVT.
List indications for urgent carotid endarterectomy.
TIA/non-disabling stroke + ispilateral >70% stenosis
Select patients with TIA/non-disabling stroke and 50 – 69% stenosis
Selected asymptomatic patients with stenosis >70%
TOH -> Call Vasc/Neuro for >50% Stenosis if symptomatic
With regards to TIAs, list 4 indications for heparin administration in the ED.
TIA from intracardiac (LV) or valvular thrombus (only one in UTD)
Crescendo TIA
TIA from a cardioembolic source
High-grade carotid artery stenosis, FFT
Posterior circulation TIA
