Stroke

Question 1

What is the time window for tPA from last known well?

Answer 1

3 hours from LKW

Question 2

What are the contraindications to tPA?

Answer 2

• Age > 80
• NIHSS > 25
• Oral anticoagulation (irrespective of coag studies)
• INR > 1.7
• Platelets < 100,000
• Hx diabetes with previous stoke
• Head trauma in last 3 months
• Glucose < 50 (can increase, then give tPA)
• Glucose > 300 (can reduce, then give tPA)
• BP > 185/110 (can reduce, then give tPA)

Question 3

Patient presents with stroke. Their LKW is 2 hours ago. Their BP is is 210/115.

What is the next step in mangement?

Answer 3

Reduce BP to < 185/110 using labetalol or nicardipine

Then, give tPA unless there is another indication.

Question 4

Pt presents following minor stroke or TIA. Their LKW is 4 hours ago.

What is the next best step?

Answer 4

Begin dual antiplatelet therapy

SBP < 220

Search for stroke etiology (RF labs, carotid US, etc)

Question 5

Patient receives tPA for a stroke.

When should aspirin be started?

Answer 5

24 hours post tPA

Question 6

Secondary stroke prevention in patients with ischemic stroke

Answer 6

Low-dose ASA and dypyridamole

Question 7

Secondary stroke prevention in patients with cardiac embolism

Answer 7

Anticoagulation (likely DOAC)

Question 8

Secondary stroke prevention in patient with diabetes

Answer 8

Treatment of HTN

Initiate statin

Stricter glucose control

Question 9

Permissive HTN goal in patients who do vs don’t receive tPA

Answer 9

tPA: < 180 SBP

No tPA: < 220 SBP