Neuro: Stroke

Question 1

Inclusion criteria for tPA in stroke (3hrs)

Answer 1

1) Age >/18 yrs
2) Diagnosis of ischemic stroke with measurable neurological deficit
3) Onset of symptoms <3 hrs

Question 2

Exclusion criteria for tPA in stroke (3hrs)

Answer 2

Summary of contraindications: 1. Intracranial issues, 2. BP issues, 3. bleeding/bleeding diathesis, 4. CT issues

A) Intracranial issues:

1. Head trauma or stroke w/in past 3 mo
2. SS SAH
3. Hx of ICH
4. Intracranial neoplasm, AVM, aneurysm
5. Recent intracranial or intraspinal surgery

B) Exam:

1. BP >185/110
2. Glucose <2.7 mmol/L

C) Bleeding concerns/diathesis

1. Platelets <100
2. Elevated PTT (and heparin w/in 48hrs)
3. INR >1.7 or PT>15s and current use of anticoagulant
4. Current use of DOAC and elevation of sensitive lab tests (PTT, INR, plt, Xa assays, etc)
5. Active internal bleeding
6. Arterial puncture at non-compressible site within last 7days.

D) Imaging
1. CT shoes multilobar infarction with hypodensity involving >1/3 cerebral hemisphere

Question 3

Relative exclusion criteria for tPA within 3hrs

Answer 3

1) Only minor or rapidly improving stroke symptoms (spontaneously clearing)
2) Pregnancy
3) seizure at onset with postictal residual neurological impairments
4) Major surgery or serious trauma in past 14 days
5) Recent GI or urinary tract hemorrhage (within past 21 days)
6) Recent MI (within 3 mo)

Question 4

Relative exclusion criteria for tPA in 3-4.5hr window

Answer 4

1) Age >80 yrs
2) Severe stroke (NIHSS>25)
3) Taking an oral anticoagulant, regardless of INR
4) Hx of BOTH diabetes and prior ischemic stroke

Question 5

Inclusion criteria for mechanical thrombectomy

Answer 5

Ideally within 6 hrs (can be done up to 24hrs):

1) mRS score 0-1 (modified Rankin Score, measures degree of distability/independence post-stroke).
2) Acute ischemic stroke receiving tPA within 4.5hrs onset.
3) Causative occlusion is at ICA or proximal MCA (M1)
4) Age >/18 yrs
5) NIHSS score >/6
6) ASPECTS >/6 (Alberta stroke program early CT score, higher score = better outcome).