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Chapter 3. Guidelines for Treatment of Acute Stroke Flashcards

1
Q

SSP Definition of Stroke Severity

A

Mild: NIHSS 0-5
Moderate: NIHSS 6-21
Severe: NIHSS >21

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2
Q

Indication for Admisision of TIA to SU

A
  1. ABCD2 score 3>
  2. TIA within 24 hours
  3. Crescendo TIA
  4. TIA with known cardiac source
  5. Known hypercoagulable state
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3
Q

Type of admission based on stroke severity

A

Mild: general room
Moderate: ASU/ICU
Severe: ICU

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4
Q

BP management of TIA

A

Only treat when MAP > 130

Avoid precipitous drop of > 15% from baseline MAP

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5
Q

In patient with ICH, consideration of further testing such as 4V angiogram, MRA or CTA if:

A
  1. < 45 years old
  2. Normotensive
  3. Lobar
  4. ICH of unknown cause
  5. Suspected aneurysm, AVM or vasculitis
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6
Q

Rehabilitation should be initiated at

A

72 hours

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7
Q

If the patient arrived 6 hours post-ictus what management should be considerd

A

Intra-arterial rTPA

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8
Q

Neurosurgical consult in ICH is considered in the following setting

A 
Not herniated
Location is lobar, putaminal, or cerebellum
Relatives willing to consent
ICP monitoring
Goal: reduction of mortality
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9
Q

What drugs are being compared to International Stroke Trial (IST)

A

ASA 300mg/day vs SQ heparin vs ASA and heparin vs placebo

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10
Q

What is the result of IST trial

A

ASA group - fewer death and recurrent stroke in 14 days with no excessive hemorrhagic stroke
Heparin group - fewer death and recurrent stroke by more hemorrhagic stroke and serious extracranial hemorrhage (NO NET BENEFIT)

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11
Q

What drugs used to compare in Chinese Acute Stroke Trial

A

ASA vs Placebo

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12
Q

What is the result of CAST trial

A

ASA reduced risk of recurrent stroke or vascular death

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13
Q

This trial compares clopidogrel 300mg then 75mg MD + ASA 80 vs ASA monotherapy

A

Fast Assessment of Stroke and TIA to Prevent Early Recurrence (FASTER trial)

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14
Q

What is the recurrence rate of stroke in ASA monotherapy in FASTER trial

A

10.1%

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15
Q

What is the recurrence rate of stroke in ASA + clopidogrel in FASTER trial

A

7.1%

increased hemorrhage in this group

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16
Q

What drugs are being compared in CHANCE trial

A

Clopidogrel + ASA vs ASA monotherapy

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17
Q

What is the result of CHANCE trial

A

Recurrence rate:
Clopidogrel + ASA: 8.2%
ASA 11.7%

No increase in rate of mod-severe bleeding in combination

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18
Q

This study compard Cilostazol to ASA in stroke treatment

A

Cilostazol in Acute Ischemic Stroke Treatment (CAIST trial)

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19
Q

What is the result of CAIST trial

A

Non-inferiority outcome of cilostazol to ASA MRS 0-2 at 90 days

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20
Q

What is the result of Metaanalysis of LMWH, heparin in acute ischemic stroke

A

LMWH and heparin decreased the venous thromboembolic event (DVT/PE) but did not have effect reducing death and disability

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21
Q

Neuroprotection is to Avoid 5 H’s

A 
Hypertension
Hypoglycemia
Hyperglycemia
Hyperthermia
Hypoxemia
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22
Q

Hyperglycemia further add to the injury of ischemic tissue by

A

increased lactic acidosis
free radical production
worsening of edema

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23
Q

Glucose levels should be maintained at what level

A

140-180

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24
Q

This condition is associated with poor outcome related to increased metabolic demand

A

Hyperthermia

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25
Q

For how many rise in body temperature is associated with increased death by 2%

A

1 degree celcius

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26
Q

3 Classification of Neuroprotection

A
  1. Drugs with neurovascular properties

2. Drugs with neurotrophic, neurorestorative properties

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27
Q

What did ICTUS trial test for

A

Global recovery for 90 days

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28
Q

What is the result of ICTUS trial

A

neutral result

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29
Q

The ceiling effect of ICTUS trial is secondary to what factor

A

Maximum effect was attributed to rTPA

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30
Q

What trial which involved Cerebrolysin

A

Cerebrolysin in Patients with Acure Ischemic Stroke in Asia (CASTA Trial)

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31
Q

What is the result of CASTA Trial

A

no over-all difference in outcomes in cerebrolysin group vs placebo

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32
Q

What is the result of ECHIMES trial

A

Significant reduction in risk of recurrent fatal events during 3 months

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33
Q

What is the other findings of ICTUS trial

A

Citicoline is beneficial in:
Ages 70 and above
Patients with moderate stroke
Patients not treated with rTPA

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34
Q

Indication for anticoagulation

A 
Intracardiac thrombi
Mechanical prosthetic valve
Recent MI
CHF
Bridging Measure
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35
Q

Contraindication for anticoagulation

A

Bleeding diasthesis
Non-petechial intracranial hemorrhage
Recent Surgery
Infective Endocarditis

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36
Q

rTPA eligibility

A

18 years old and above
Clinicla measurable stroke
Time of onset is <180

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37
Q

BP cut-off for rTPA

A

185/110mmHg

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38
Q

This trial used the 0.6mg/kg dose of rTPA

A

ENCHANTED trial

39
Q

What is the maximum dose of rTPA

40
Q

antihypertensive medication of choice in patient eligibke for rTPA

A

Labetalol 10-mg/IV (1-2mins)

Nicardipine 5mg.hour every 5-15 minutes

41
Q

BP monitoring for rTPA

A

every 2 hours for 2 hours
every 30 mins for 6 hours
every hour for 16 hours

42
Q

Systolic and diastolic cut-off that warranted antihypertensive medication for rTPA

A

> 230 SBP

121-140 DBP

43
Q

The following measure should be done if ICH is suspected

A 
D/C rTPA
Repeat CT-Scan
Draw blood for bleeding parameter
Prepare cryoprecipitate containing FVIII
Prepare 6-8 units of platelet concentrate
44
Q

Expansion of time window to 4.5 hours relative exclusion

A

80 years old
NIHSS > 25
On oral anticoagulation regardless of INR
Hx of stroke and DM

45
Q

This trial use thrombolytic agents that can be used 3-9 hours

A

Despoteplase to treat Acute Stroke (DIAS-3)

46
Q

What is the first trial on rTPA

A

National Institute of Neurological Disorder and Stroke t-PA trial (NINDS t-PA trial)

47
Q

National Institute of Neurological Disorder and Stroke t-PA trial uses what dose of rtPA

48
Q

Result of NINDS trial

A
  1. no difference in neurological outcome in 24 hours
  2. 30% in t-PA group have minimal to no disability despite more symptomatic ICH (6.4 vs 0.6)
  3. No difference in mortlity
49
Q

What is the dose and time window for ECASS trial

A

1.1mg/kg at <6 hours

50
Q

What is the result of ECASS trial

A

no difference in disability using intention to treat

Post-hoc: better recovery for tPA in 90 days

51
Q

What is the dose of ECASS II trial and time window

A

0.9mg/kg at <6 hours

52
Q

Result of ECASS II trial

A

No difference was seen in the rate of favorable outcome at 3 months between rTPA and placebo

53
Q

What does ATLANTIS A study means

A

Alteplace Thrombolysis for Acute Non-intervemtional Therapy in Ischemic Stroke

54
Q

Alteplace Thrombolysis for Acute Non-intervemtional Therapy in Ischemic Stroke used what dose and time window

A

0.9mg within 6 hours

55
Q

Result of ANTLANTIS A study

A

No significant difference of planned efficacy endpoints at 30 and 90 days between 2 groups
ICHS is increased in tPA particularly between 5-6 hours

56
Q

What is the difference between ANTLANTIS A and B

A

The ANTLANTIS B shortened the time window by 3.5 hours

57
Q

What is the dose and time window used in Japanese Alteplase Clinical Trial (J-ACT)

A

0.6mg.kg and < 3 hours

58
Q

What is the result of J-ACT

A

36.9% achieved mRS of 0-1 at 3 month in tPA group

Symptomatic ICH occurred in 5.8%

59
Q

What is the major changed in ECASS III

A

same dose but limits the time window < 3-4.5 hours

60
Q

Result of ECASS III

A
  1. Favorable outcome in tPA groups at 3 months 52.4% vs 45.2%
  2. Higher incidence of ICH in tPA group
  3. Mortality rate did not differ significantly between 2 groups
61
Q

This trial used 0.9mg/kg and a time window of < 6hours where the design is an open label study

A

3rd - International Stroke Trial

62
Q

Result of IST-III

A
  1. Proportion of alive and independent is 37% in rTPA avs 35% placebo
  2. More death rates during the first 7 days in rTPA
  3. 6 month: 27% died in both groups
63
Q

Normal ICP

64
Q

Normal CPP

65
Q

When to treat hypertension in acute stroke

A

SBP > 220
DBP > 120
MAP > 130

66
Q

A drop of how many SBP and DBP is associated with worsening of neurologic status and high rates of poor outcome

67
Q

Arterial Hypotension is associated with the following conditions:

A

Aortic dissection
Volume Depletion
MI
Arrhythmia

68
Q

This antihypertensive has a direct vasodilator on arterioles and decreased systemic resistance

A

Hydralazine

69
Q

This is a short acting B-adrenergic agent

70
Q

Mechanism of action of Nicardipine

A

Ca channel inhibition (slow chanel)

71
Q

This is a B-adernergic blocking is 7x more than alpha which provide dose dependent decrease in BP without significant HR or cardiac output reduction

72
Q

What is the result of INTERACT2

A
  1. No difference in primary outcome of death and disability between 2 groups at 90 days
  2. Lower mRS with intensive group
73
Q

INTERACT2 used to assess

A

ICH patient within 6 hours with BP 150-220 at presentation

2 groups <140 vs <180

74
Q

ATACH II subjects

A

< 140 vs < 180 withunb 24 hours of Nicardipine

75
Q

Result of ATACH II

A

110-139 SBP did not result to a lower death rate or disability than 140-179

76
Q

Recommendation on Hypertension in ICH

A

treat if SBP > 180mmHg and CPP should be maintain ? 70mmHg

77
Q

Criteria for intubation

A

< 90 O2Sat
< 60 PO2
> 55 PCO2

78
Q

Criteria for ICP catheter

A

GCS < 8
(+) IVH and hydrocephalus
CPP maintained at 60-70

79
Q

Serum Osmolality should be maintained at what level

80
Q

What is the mortality rate of malignant MCA despite maximum conservative treatment

81
Q

What are the objectives of hemicraniectomy

A

Decrease mass effect or ICP
Prevent herniation
Reduce secondary brain injury

82
Q

Criteria for patient selection for hemicraniectomy

A
  1. Severe hemispheric stroke
  2. CT Scan > 50 % of MCA
  3. 60 years old and below
  4. Dominance of hemisphere
83
Q

Mortality rate based on age in patient undergone hemicraniectomy

A

< 60 years old: 20.8%

> 60 years old 51.3%

84
Q

Exclusion Criteria for Hemicraniectomy

A
  1. terminal illness
  2. superficial co-morbid
  3. bleeding disorders
85
Q

S in STATE criteria

A

SCORE

NIHSS
GCS <8
NIHSS > 15
NIHSS > 20 dominant

86
Q

T in STATE Criteria

A

Time

< 48 hours last seen without deficit

87
Q

A in STATE Criteria

A

Age

< 60 years old

88
Q

T in STATE criteria

A

Territory

> 50% MCA

89
Q

E in STATE Criteria

A

Expectation

Life expectancy is reasonable

90
Q

External decompression measurement

A

12 cm bone flap must be removed (ant-post) by 9 cm (sup-inf) 12x9

91
Q

What is the perfect timing of replacing the bone flap if without complication

92
Q

Removal of bone flap result to how many percent of reduction of Increased ICP

93
Q

if duraplasty is added with hemicraniectomy the improved surival rate is

A

20-30% from 60-84%(hemicraniectomy only)

SSP (7 decks)

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