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Neurology > Stroke > Flashcards

Stroke Flashcards

1
Q

Tenecteplase
Stroke Indications
Dose

A
  • Acute stroke within 4.5 hours of last known well
  • 0.25 mg/kg, maximum 25 mg
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2
Q

Alteplase vs Tenecteplase
Infusion time
Generation
Direct plasminoGEN activator?
Half-life (Min)
Fibrin selectivity
PAI-1 resistance
FDA indications

A

Plasminogen activator inhibitor-1

60 min vs 5-10 sec
2nd vs 3rd
yes vs yes
4-8 min vs 20-24 (initial) 90-130 (terminal)
++ vs +++
++ vs +++
PE, Stroke, STEMI vs STEMI

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3
Q

UH
1. How is tenecteplase prepared?

  1. Reconstituted preparation of Tenecteplase contains what concentration of tenecteplase?
A
  1. 10 mL of sterile water for injection added into tenecteplase powdered vial
    Reconstitute by swirling - DO NOT SHAKE
  2. Tenecteplase 5 mg/mL
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4
Q

How to administer Tenecteplase

Caution when sing Dextrose containing line.

A
  • Should be colorless to pale yellow without any particulates.
  • Administer over 5-10 seconds
  • Flush IV line prior to and following administration of tenecteplase with saline-containing solution. If not there may be precipitation.
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5
Q

Maximum dose for Tenecteplase

A

25 mg, thus in a reconstituted 50mg/10mL (administer no more than 5 mL)

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6
Q

Contraindications for Tenecteplase

History of ____ ?

A

Intracranial hemorrhage

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7
Q

Contraindications for Tenecteplase

Ischemic stroke within ____ (time)?

A

3 months

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8
Q

Contraindications for Tenecteplase

Symptoms suggestive of ____?

A

Subarachnoid hemorrhage

Severe headache, photophobia, seizure, loss of consciousness

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9
Q

Contraindications for Tenecteplase

Arterial puncture in ____?

A

Non-compressible site within 7 days

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10
Q

Contraindications for Tenecteplase

What type of surgery or trauma?

A

WITHIN 3 MONTHS

Intracranial or spinal sx. Recent significant head trauma.

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11
Q

Contraindications for Tenecteplase

Intracranial pathology

A

Known structural cerebrovascular disease.
Known intracranial malignant neoplasm

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12
Q

Contraindications for Tenecteplase

Blood pressure, bleeding/CBC

A

SBP >185 or DBP >110

 Active internal bleeding
 Bleeding diathesis: platelets <100,000 mm3, aPTT> 40s, PT > 15 s, INR >1.7

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13
Q

Contraindications for Tenecteplase

Anticoagulation- timing of contraindications

A 
 Anticoagulation contraindications (last dose within): 
o Apixiban (Eliquis®) within 48 hours\*\* 
o Dabigatran (Pradaxa®) within 72 hours\*\* 
o Enoxaparin (Lovenox®) therapeutic dose within 24 hours\*\* 
o Heparin therapeutic dose and aPTT \> ULN\*\* 
o Rivaroxaban (Xarelto®) within 48 hours\*\* 
o Warfarin (Coumadin®) and INR\> 1.7 
\*\* for patients with normal renal function, activity may be prolonged in patients with renal impairment
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14
Q

Contraindications for Tenecteplase

Metabolic, CTH, suspicious symptoms?

A

Blood glucose <50 mg/dL or > 400 mg/dL
 CT shows frank hypo-density or extensive hypo-attenuation
 Symptoms consistent with infective endocarditis
 Known or suspected aortic arch dissection

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15
Q

Contraindications for Tenecteplase

GI

A

Gastrointestinal hemorrhage within previous 21 days
 Gastrointestinal malignancy

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16
Q

Contraindications for Tenecteplase

Additional Exclusion Criteria for Onset 3-4.5 Hours (1)

Relative Exclusion Criteria for Onset 3-4.5 hours (3)

A

Additional Exclusion Criteria for Onset 3-4.5 Hours

Imaging evidence of ischemic injury involving more than 1/3 middle cerebral artery territory

Relative Exclusion Criteria for Onset 3-4.5 hours (3)
 NIHSS score > 25

Consider risk vs. benefit:
 Oral anticoagulant use
 History of prior stroke AND diabetes mellitus

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17
Q

Relative exclusion criteria (11) of Tenecteplase

A

 Major surgery/serious trauma within previous 14 days
 Lumbar or arterial puncture in previous 7 days
 Recent or active menorrhagia
 Pregnancy or post-partum (<14 days)
 Hemorrhagic ophthalmic condition
 Acute myocardial infarction within 3 months
 Other cardiac condition: acute pericarditis, known LV
thrombus, cardiac myxoma, papillary fibroelastoma
 Intracranial arterial dissection
 Large burden of cerebral micro-bleed on MRI
 Current systemic malignancy

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18
Q

Consider risk vs. benefit: (2)

A

 Only NON-DISABLING, mild symptoms; or rapidly improving
stroke symptoms (clearing spontaneously)
 Seizure at onset of symptoms, only if residual symptoms
are thought to be post-ictal etiology

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19
Q

Wake up stroke

Steps for workup

A
  1. MRI brain without contrast STAT
  2. Consider Alteplase use
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20
Q

Alteplase adminsitration

A
  • 0.9 mg/Kg (max 90 mg)
10% bolus (max 9mg) over 1 MINUTE 
Remaining infusion (max 81 mg) over 60 min)
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21
Q

NIHSS
How many sections and subsections?

A

11 sections

1a-c
2-11

Note: In Section 5 & 6
a = Left
b = Right

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22
Q

NIHSS

“For personal learning”

What are the categories to be tested and where do they fall in the numbering?

A

1a-c : Mental status

2: Extraocular eye movements
3: Visual Fields
4: Facial Palsy
5: Motor arm
6: Motor Leg
7: Limb Ataxia
8: Sensory
9: Language

10: Dysarthria
11: Extinction and Inattention

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23
Q

NIHSS Scoring Instructions

1a

A

Level of Consciousness: The investigator must choose a
response if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages.

3 is scored only if the patient makes no movement (other than reflexive
posturing) in response to noxious stimulation.

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24
Q

NIHSS Scoring Instructions

1b

A

1 = unable to speak because of endotracheal intubation, orotracheal trauma, severe
dysarthria from any cause, language barrier or any other problem not secondary to aphasia

2 = Aphasic and stuporous patients who do not comprehend the questions

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25
Q

NIHSS Scoring Instructions

1c

A

Credit is given if an
unequivocal attempt is made but not completed due to weakness.

If patient does not follow command can use PANTOMIME to score the results. Patients with trauma, amputation, or other
physical impediments should be given suitable one step commands. Only the first attempt is
scored.

26
Q

NIHSS Scoring Instructions

2

A

Only horizontal eye movements will be tested.

1 = If conjugate deviation can be overcome by oculocephalic reflex or if patient has an isolated peripheal CN paresis (CN III, IV, or CI).

Gaze is testable in
all aphasic patients.

Patients with ocular trauma, bandages, preexisting blindness or other disorders
of visual acuity or fields should be tested with reflexive movements and a choice made by the
investigator.

27
Q

NIHSS

3

A
  1. Visual: Tested by confrontation, using finger counting or visual threat as appropriate. Patient
    must be encouraged, but if they look at the side of the moving fingers appropriately, this can be
    scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye
    are scored. Score 1 only if a clear cut asymmetry, including quadrantanopia is found. If patient
    is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If
    there is extinction patient receives a 1, and the results are used to answer question 11.
28
Q

NIHSS

4

A
  1. Facial Palsy: Ask, or use pantomime to encourage the patient to show teeth or raise eyebrows
    and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly
    responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or
    other physical barriers obscure the face, these should be removed to the extent possible.
29
Q

NIHSS

5

A

5A & 5B. Motor Arm Left/Right: The limb is placed in the appropriate position: extend the arms
(palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before
10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not
noxious stimuli. Each limb is tested in turn, beginning with the non-paretic arm. Only in case of
amputation or joint fusion at the shoulder can it be scored as un-testable.

30
Q

NIHSS 6

A

6A & 6B. Motor Leg Left/Right: The limb is place in appropriate position: hold the leg at 30
degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient
is encouraged using urgency in the voice and pantomime, but not noxious stimuli. Each limb is
tested in turn, beginning with the non-paretic leg. Only in case of amputation or joint fusion at the
hip can it be scored as un-testable.

31
Q

NIHSS

7

A
  1. Limb Ataxia: Aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open.
    In case of visual defect, ensure testing is done in intact visual field. The finger-nose-finger and heelshin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the
    case of amputation or joint fusion should it be marked as un-testable and clearly documented why.

In case of blindness, test by having the patient touch nose from extended arm position.

32
Q

NIHSS

8

A
  1. Sensory: Sensation or grimace to pinprick when tested or withdrawal from noxious stimulus in
    the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms (not hands), legs, trunk, face) as needed to
    accurately check for hemi-sensory loss. A score of 2, “severe or total sensory loss,” should only
    be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and
    aphasic patients will, therefore, probably score a 1 or 0. The patient with brainstem stroke
    who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic,
    score 2. Patients in a coma are automatically given a 2 on this item.
33
Q

NIHSS

9

A
  1. Best Language: A great deal of information on comprehension will be obtained during the
    preceding section of the examination. For this scale item, the patient is asked to describe what is
    happening in the attached picture, to name the items on the attached naming sheet and to read from the attached list of sentences. Comprehension is judged from the response here, as well as to all the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma will automatically score 3 on this item.

The examiner must choose a score for the patient with stupor or limited cooperation, but a
score of 3 should only be used if the patient is mute and follows no one step commands.

34
Q

NIHSS

10

A
  1. Dysarthria: If patient is thought to be normal, an adequate sample of speech must be obtained
    by asking patient to read or repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to producing speech should the examiner score as un-testable and
    clearly write an explanation for this choice.
35
Q

NIHSS

11

A
  1. Extinction and Inattention: Sufficient information to identify neglect may be obtained during
    the prior testing. If the patient has a severe visual loss preventing visual double simultaneous
    stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but
    does not appear to attend to both sides, the score is normal. The presence of visual spatial neglect
    or anosognosia may also be taken as evidence of abnormality. Since the abnormality is scored
    only if present, the item is never un-testable.
36
Q

Circle of Willis

A
37
Q

Vascular Imaging studies compared

MR Angiogram

CT Angiogram

Conventional (Digital Subtraction Angiogram)

A

MR Angiogram Neck with contrast, MR Angiogram Head without contrast, MRI Brain without contrast (can increase yield of studies) along with an MRI Brain without contrast : Safer, more informative. But Slower, prone to artifacts, and overestimates stenosis.

CT Angiogram Neck and Head : Rapid and potentially more accurate. But potentially less safe with possible adverse effects to kidneys or anaphylaxis.

Conventional (Digital Subtraction Angiogram) : Gold Standard for its temporal and spatial resolution. But more invasic and expensive.

38
Q

Carotid duplex and transcranial doppler

Pro and Con

A

Excellent for screening and follow up.

Limited view of vascular tree and is technologist dependent.

39
Q

Anterior cerebral artery territory infarction

Signs

A

Contralateral: Lower extremity paresis and sensory loss

Global: Abulia (frontal) and anterograde amnesia (cignulate cortex)

Abulia - Lack of will or initiative and can be seen as a disorder of diminished motivation (DDM).

Difficulty in initiating and sustaining purposeful movements. Lack of spontaneous movement. Reduced spontaneous speech. Increased response-time to queries. Passivity. Reduced emotional responsiveness and spontaneity. Reduced social interactions. Reduced interest in usual pastimes

40
Q

Spectrum of Disorder of diminished motivation

Astasia

Abasia

A

Apathy (Less extreme) -> Abulia - > Akinetic mutism (Extreme)

Astasia - Inability to stand

Abasia - Inability to walk

Astasia-abasia : Etiology may be cause by an organic vs functional disorder

41
Q

Middle cerebral atery territory infarction

Signs

A

Contralateral : Hemianopia, gaze paresis, facial paresis, Aphasia (Dominant), Neglect (Non-dominant), Hemiparesis, Hemisensory deficits

Hemiparesis - cortical motor fibers and descending motor pathways

Facial paresis - cortical bulbar fibers

Gaze paresis - frontal eye fields

Aphasia - dominant frontal and temporal lobes

Hemisensory deficits - primary sensory cortex in parietal lobe

Hemianopia - Temporal and Parietal optic radiations

Neglect - Damage to non-dominant parietal lobe

42
Q

Handedness and hemispheric language dominance

A

Most people left hemisphere of brain is dominant for language

But right hemisphere may be dominant for language in up to:

4% Strong right-handers

15% ambidextrous

27% Strong left-handers

43
Q

What artery supplies head of caudate?

Relevance to comma shaped infarction of deep brain matter

A

Small branch of anterior cerebral artery - Recurrent artery of Heubner (medial striate artery)

Can hint to both ACA and MCA territory infarction. typically an embolism at the Internal common carotid artery terminus and transiently occluding ACA and MCA.

44
Q

Posterior cerebral artery infarction

Supply

Signs

What can it mimick and why?

A

Inferior medial temporal lobe and occipital lobe and Thalamus

Contralateral : Hemisensory, Hemianopia, Neglect (non-dominant, rare), Transcortical aphasia (dominant)

Global : Behavioral abnormalities, confusion (thalamic damage)

Thalamus - switchboard of brain. Receive and send projections to all the lobes

Can Mimick middle cerebral artery strokes because of thalamic involvement.

Thalamus:

  1. Contralateral Hemisensory (Sensory thalamic nuclei on posterior thalamus)
  2. Neglect (non-dominant, rare) - non dominant thalamus because it communicates with non-dominant parietal lobe. Clinically indistiguishable from parietal lobe damage but improves more quickly.
  3. Transcortical aphasia (dominant)

Occipital lobe

  1. Contralateral Hemianopia (Occipital lobe)
45
Q

Posterior cerebral artery territory infaction (Midbrain involvement)

A

Cerebral peduncles - contralateral hemiparesis

Red nucleus (part of cerebellar pathway) - contralateral ataxia

Oculomotor pathway - Ipsilateral CN3 palsy (ptosis, superior/inferior/medial rectus, inferior oblique weakness)

46
Q

Superior cerebellar artery territory infarction

Supply

Signs

A

Supplies anterior superior cerebellum

Ipsilateral ataxia

47
Q

Basilar artery territory infarction

Supply

A

Supplies mostly pons and anterior medulla

Anterior medial pons (motor fibers are anterior in pons) - contralateral facial paresis and hemiparesis

Intranuclear ophthalmoplegia - medial longitudinal fasciculus (connection pontine paramedian reticular formation, horizontal gaze center, and oculomotor nucleus in midbrain)

Spinothalamic tract - contralateral hemisensory loss

Lateral pons and cerebellar peduncles - contralateral ataxia

Pontine paramedian reticular formation - Ipsilateral horizontal gaze paresis

Lateral pons (CN V and VII) - Ipsilateral lower motor neuron facial paresis (involving the forehead) and facial anaesthesia

48
Q

Medial pontine stroke

Anatomy and signs

A

Contralateral

Hemiparesis, facial paresis, intranuclear ophthalmoplegia

49
Q

Lateral Pontine Stroke

Anatomy and signs

A

Contralateral : Hemisensory loss, ataxia

Ipsilateral : Horizontal gaze paresis, facial paresis, facial anaesthesia

50
Q

If present ataxic hemiparesis, begin to investigate ________?

A

Eye movement abnormalities to localize to eg. medial or lateral pontine stroke.

51
Q

Anterior inferior cerebellar artery

Signs

A

Ipsilateral

Ataxia, facial anaesthesia, horner syndrome, hearing loss

AICA gives rise to labyrinthine artery which supplies ipsilateral inner ear (Incredibly rare)

52
Q

Posterior inferior cerebellar artery territory infarction

Signs

A

Contralateral: Hemibody sensory deficits

Ipsilateral: Facial anaesthesia, horner syndrome, taste loss, dysarthria, dysphagia

53
Q

Lateral Medulla

Anatomy and signs from posterior inferior cerebellar artery occlusion

What will not be included?

A

Contralateral spinothealamic tract

Ipsilateral cerebellar pathways in inferior cereberllar peduncle and vestibular nuclei

Ipsilateral trigeminal nucleus

Ipsilateral sympathetics

Nucleus of solitarius tract - special sensations such as to the face

Nucleus ambiguous - donates motor fibers to CN IX and X

weakness is not included because that is oriented along the medial medulla supplied by the basilar artery

54
Q

Vascular territory stroke

A

Posterior inferior cerebellar artery

55
Q

Vascular territory stroke

A

Anterior inferior cerebellar artery

56
Q

Vascular territory stroke

A

Basilar perforator to the anterior medial pons

57
Q

Vascular territory infarction

A

Superior cerebellar artery

58
Q

Vascular artery territory

A

Posterior cerebral artery

59
Q

Vascular artery territory

A

Interal carotid artery leading to large stroke in ACA and MCA territories

60
Q

Vascular artery territory

A

Anterior cerebral artery

61
Q

Vascular artery territory

A

Middle cerebral artery

Neurology (6 decks)

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