Neuro Emergencies: Ischemic Stroke Flashcards
What % of all strokes are ischemic?
87%
Risk factors for ischemic stroke include?
Older age
HTN
DM
HLD
African American or Asian descent
HRT disease
Smokers
Drug abuse
Previous TIA
Coag d/os (protein C or S deficiency, antiphospholipid antibody syndrome, antithrombin III deficiency)
Ischemic Stroke Prevention
Primary Prevention includes?
BP control
smoking cessation
DM control
Statins
A fib- anticoagulation / antiplatelet therapy
CEA/CAS w/ 60-70% stneosis
OC may be harmful
Diet and Exercise
A-fib anticoagulation/antiplatelet therapy
Scores to calculate when patient has CHF, HTN, AGE, sex, DM, Prior stroke TIA, Vascular disease?
CHADS2 score
CHA2DS2-VASc Score
A-fib anticoagulation/antiplatelet therapy
Scores to calculate when patient has HTN, abnormal renal function, abnormal liver function, stroke, bleeding, labile INR, elderly >65, alcohol or drug use?
HAS-BLED
Possible Differential Diagnosis for pts experiencing stroke like symptoms
Tumors
SDH
Cerebral abscess
Todd’s paresis or paralysis
Hypoglycemia
Encephalitis
Conversion D/O
Migrainous aura
focal seizure
periveral nerve lesions
Cincinnati Prehospital Stroke Sale components include?
Facial droop
Arm drift
Speech
FAST components include?
Face
Arm
Speech
Time
Clinical Manifestations for MCA stroke
Hemiparesis
Hemiplegia
Hemianesthesia
Hemianopia
Aphasia
Neglect
Gaze deviation
!
Clinical Manifestations for Anterior Cerebral artery stroke
Lower extremity hemiplegia
Primitive reflexes
confusion
abulia
behavioral changes
disturbance in memory
Clinical Manifestations for Vertebral and basilar artery stroke
Decreased LOC
Vertigo
Dysphagia
Diplopia
Ipsilateral CN findings
Contralateral (or bilateral) sensory and motor deficits
Initial Evaluation
10 min or sooner from arrival
Evaluation by physician
Initial Evaluation
</= 15 min
Stroke or neurologic expertise contacted
Initial Evaluation
</= 20 min
NCCT or MRI
Initial Evaluation
</= 45 min
interpretation of neuroimaging
Initial Evaluation
</= 60 min
initiation of IV alteplase
Initial Evaluation
What should be assessed?
ABCs
Time of Onset
Circumstances surrounding onset of neuro symptoms
Hx
Neuro eval (NIHSS)
Labs and ECG
STAT Head CT
Vascular imaging
Initial Evaluation
Exclude stroke mimics such as
Psychogenic
Seizures
Hypoglycemia
Migraine
HTN encephalopathy
Wernicke’s encephalopathy
CNS abscess
CNS tumor
Drug toxicity
Initial Evaluation
All patients need
Non-Con CT (NCCT)
MRI
Blood glucose
Cardiac monitoring
EKG
Troponin
BMP, CBC, PT/INR/aPTT
Maintain O2 sats > 94%
Initial Evaluation
All patients need
For patients with suspected LVO in which MT is being considered, what should be obtained?
noninvasive vascular imaging
CTA with CTP
MRA with DW-MRI w/ or w/o MR perfusion
Initial Evaluation
Selected Patients
TT, Ecarin clotting time or direct factor Xa activity assay
Hepatic function test
Toxicology screen
Blood alcohol level
Pregnancy test
ABG
CXR
EEG (if seizures are suspected)
Initial Evaluation
Selected Patients
if SAH is suspected and CT is negative for blood what should be performed?
Lumbar puncture
Initial Evaluation
Selected Patients
If seizures are suspected what should be performed?
Electroencephalogram (EEG)
Emergent Management of Ischemic Strokes
ABCs
avoid hypotension, hypoxia and hypovolemia
Emergent Management of Ischemic Strokes
Supplemental O2 for sats of?
> 94%
Emergent Management of Ischemic Strokes
Antipyretic medications for temp of?
> 38 C
Emergent Management of Ischemic Strokes
monitoring?
cardiac monitoring
cautious BP treatment
Emergent Management of Ischemic Strokes
Fluid resuscitation w/?
isotonic fluids
Emergent Management of Ischemic Strokes
sugar?
glycemic control
Management of Ischemic Strokes includes?
Thrombolytic therapy
Mechanical thrombectomy
Antiplatelet therapy
BP management
Contraindications for IV Alteplase
Presentation to GI
Presentation outside window (>4.5 hrs)
Mild, nondisabling stroke (NIHSS 0-5)
HCT w/ extensive areas of hypoattenuation or frank hypodensity
ICH
AIS w/n 3 mo
Severe Head Trauma w/n 3 mo
Acute head trauma
Intracranial or intraspinal surgery w/n 3 mo
symptoms suggestive of SAH
GI malignancy or GI bleed w/n 21 days
Contraindications for IV Alteplase
Infective to Concomitant
Infective endocarditis
Aortic arch dissection
intra-axial intracranial neoplasm
coagulopathy (plt count < 100,000/mm3, aPTT > 40 sec, INR >1.7 or PT > 15 sec)
LMWH - therapeutic dose in last 24 hrs
Thrombin or Factor Xa inhibitors w/ elevated sensitive lab test (aPTT, INR, plt count, ECT; TT; appropriate factor Xa activity assays)
Concomitant Abciximab
Concomitant IV Aspirin
BP requirements for pts that are candidates for reperfusion therapy
Systolic and diastolic prior to infusion?
IVP medications that can be given to control BP? Dose? Frequency? (2)
IV infusions that can be given to control BP? Initial dose, titration parameters, max dose? (2)
Systolic and diastolic following infusion? for how long?
SBP </= 185 mmHg or DBP </= 110 mmHg
Labetalol, 10-20mg q1-2 min
Hydralazine, 10-20mg q1-2min
Nicardipine, 5mg/h, titrate up by 2.5mg/h at 5-15min intervals, 15mg/h
Clevidpine 1-2mg/h, titrate by doubling the dose q2-5 min until desired BP reached, 21mg/h
SBP </= 180 mmHg or DBP </= 105 mmHg for 24 hrs
Alteplase Admin
Dose (max dose)
infusion time
0.9mg/kg (max dose 90mg)
over 60 min w/ 10% of dose given as bolus over 1 min
Alteplase Admin
Admit pt where?
ICU or stroke unit for monitoring
Alteplase Admin
What would require the discontinuation of infusion and obtaining an emergency head CT scan?
if the patient develops
severe HA
acute hypertension
nausea or vomiting
worsening neuro exam
Frequency of Neuro checks for first 24 hrs post Alteplase Admin
q15 min for 2 hr
q 30 min for 6 hr
q1hr for 16 hr
Alteplase Admin
What would be an indication for increasing frequency of BP measurements?
How to manage this?
if SBP > 180 mmHg or DBP > 105 mmHg
administer antihypertensive medications to maintain BP at or below these levels
Alteplase Admin
What should be delayed if patient can be managed safely w/o them?
NG tubes
Indwelling bladder catheters
intra-arterial pressure catheters
Alteplase Admin
Before starting anticoagulants or antiplatelet what needs to be done?
Obtain a follow up CT or MRI scan at 24 hr after IV alteplase
Tenectaplase Admin
dose and infusion time?
Single IV bolus of 0.25mg/kg (max of 25mg) over 10 sec
Tenectaplase Admin
Must be given where?
Not compatible with?
What must be administered before and after?
dedicated IV
dextrose containing IVF
NS 0.9% flush
Management of ICH occurring w/n 24 hrs of IV alteplase or tenecteplase
Initial action?
Labs to get?
Imaging?
Stop infusion
CBC, PT(INR), aPTT, fibrinogen, type and cross
Emergency non-con head CT
Management of ICH occurring w/n 24 hrs of IV alteplase or tenecteplase
Blood products?
Medications?
Consults?
Anything else?
Cryoprecipitate 10 u infused over 10-30 min
Tranexamic acid 1000mg (over 10 min) or Aminocaproic acid 4-5 gm over 1 hr
Hematology and Neurosurgery
Supportive therapy
Mechanical Thrombectomy Criteria
Prestroke mRS score?
Occlusion of?
Age?
NIHSS socre >/=?
Alberta Stroke Program Early Computed Tomography Score (ASPECTS)?
Treatment can be initiated via groin w/n?
0-1
ICA or MCA
>/= 18
>/= 6
6 hrs
Mechanical Thrombectomy
mechanism of completion?
Goal TICIa?
Direct aspiration vs Stent retrievers
2b/3
Mechanical Thrombectomy
In selected pt w/ last known normal w/n how long?
and have what?
6-16 hrs
LVO in the anterior circulation and meet further criteria
Mechanical Thrombectomy
Selected pt further criteria
Occlusion?
Mismatch between?
Age?
No what on Head CT or MRI?
No evidence of infarct involving?
Presentation?
LVO
severity of clinical deficit and infarct volume
>/= 18
ICH
more than 1/3 of the territory of the MCA
Late
Mechanical thrombectomy can be considered for patients with last known normal of?
16-24 (IIa B-R)
BP management for Ischemic Stroke patient
Excessive BP lowering can have what effect?
worsen cerebral ischemia
BP management for Ischemic Stroke patient
In patient who undergo mechanical thrombectomy, it is reasonable to maintain the BP at?
< 180/105 mmHg
BP management for Ischemic Stroke patient
Some pts may have concomitant comorbidities that require acute BP lowering such as?
aortic dissection
post fibrinolysis sICH
acute heart failure
How much can BP be reasonably lowered if pts initial BP is >220/120 mmHg and pt did not receive Alteplase or Mechanical thrombectomy and do not have comorbid conditions?
Initiating or reinitiating antihypertensive in the first 48-72 hrs is?
15% in first 24 hrs
uncertain
Initial BP <220/120 mmHg; in patients that did not receive alteplase or mechanical thrombectomy and do not have comorbid conditions the benefit of initiating or reinitiating antihypertensives in the first 48-72 hours is?
no associated with improved outcomes
Post stroke management
admit where?
neuro monitoring for?
antiplatelet agents? consider dual antiplatelet therapy for?
early what?
continue/start what? (check what)
stroke unit
hemorrhagic transformation or edema
ASA 24-48 hrs post tPA/TNK; minor noncardioembolic (NIHSS </=3) AIS who did not receive iV Alteplase
Mobilization
statin (check lipid panel)
Post stroke management
Nutritional support, enteral diet started w/n?
screening for?
Evaluation by?
DVT prophylaxis?
O2 sats?
Temp management?
7 days
dysphagia
SLP/PT/OT
SCDs, SQ heparin or LMWH
>94%
maintain normothermia (<38C)
Post stroke management
Glycemic management? treat BG of?
mental health?
Avoid what?
Skin protection includes?
Assessment of?
Education?
Evaluation of?
Treatment of?
normoglycemia (140-180), treat BG <60mg/dL, Check HgbA1c
Depression screening
indwelling catheters
turning, good skin hygeine, specialized mattress, wheelchair cushions
functional assessment
Smoking cessation; stroke education
Cardiac evaluation
Recurrent seizures
Management of Cerebral and Cerebellar Infarction w/ Swelling
Cerebral infarction is characterized by?
Causing?
progressive cerebral edema and mass effect
ipsilateral sulcal effacement
compression of the ipsilateral ventricular system
shift of the midline structures such as the septum pellucidum and the pineal gland
Management of Cerebral and Cerebellar Infarction w/ Swelling
Blockage of the Foramen of Monro or the third ventricle may cause?
entrapment and dilatation of the contralateral lateral ventricl
obstructive hydrocephalus
Management of Cerebral and Cerebellar Infarction w/ Swelling
Brainstem displacement may lead to?
If swollen tissue eventually fills the cisterns there may be what?
widening of ipsilateral ambient cistern
compression of the anterior or posterior cerebral arteries that may lead to infarctions in the corresponding vascular territories
Management of Cerebral and Cerebellar Infarction w/ Swelling
In the setting of cerebellar infarction w/ swelling what is a key radiologic marker?
Followed by?
effacement of the fourth ventricle
basal cistern compression
brainstem deformity, hydrocephalus, downward tonsillar herniation, and upward transtentorial herniation
Management of Cerebral and Cerebellar Infarction w/ Swelling
Intubation may be considered for?
Decreased LOC
Poor Oxygenation
control of secretions
Management of Cerebral and Cerebellar Infarction w/ Swelling
CO2 management?
Monitoring?
MAP target?
HTN treatment when?
IVF?
No prophylactic ____ therapy.
Maintain normocarbia
cardiac monitoring
insufficient data to recommend a specific MAP target
SBP > 220 mmHg or DBP > 105 mmHg
Isotonic fluids (NS please)
osmotic
Medical Management
Ventriculostomy for the treatment of?
Osmotic therapy should be used for?
obstructive hydrocephalus
patients w/ clinical deterioration from cerebral swelling assoc. w/ cerebral infarction
Medical Management
Hypothermia, barbituates and corticosteroids in the setting of ischemic cerebral or cerebellar swelling are?
Brief moderate hyperventilation w/ a target PCO2 of ____ is reasonable.
not recommended
30-34
Neurosurgical Management
Craniectomy with Dural expansion is effective in what patient population?
Although the optimal trigger for this surgery is unknown it is reasonable to use?
patients < 60 y/o w/ unilateral MCA infarctions that deteriorate neurologically w/n 48hr despite medical therapy
a decrease in LOC
Neurosurgical Management
Decompressive craniectomy w/ dural expansion may be considered in what patient population?
pt > 60 y/o w/ unilateral MCA infarctions that deteriorate neurologically w/n 48 hrs despite medical therapy
Neurosurgical Management
Suboccipital craniectomy with dural expansion should be performed in patients with?
cerebellar infarctions who deteriorate neurologically despite maximal medical therapy
