Stroke

Question 1

DDX for stroke and important ways to distinguish

Answer 1

1. Bell’s Palsy-Will have forehead involvement whereas stroke will not
2. Ramsay hunt-Will also have forehead involvement, ear pain, and vesicle in the auditory canal
3. Migraine

Question 2

List seven risk factors for Stroke

Answer 2

Old
Obese
Family history 
HTN
MI
A fib
DM
High cholesterol
Smoking (or quit within the past 3-5 years) 
OCP 
Cocaine

Question 3

List 6 things to do to prevent stroke in the primary and secondary setting (non pharm)

Answer 3

Healthy diet (Mediterranean diet)
150 minutes of exercise per week
Smoking cessation
Wt loss to get BMI <25
Limit alcohol to <3 per day for men and <2 per day for women
Discontinue recreational drugs
Discontinue HRT or estrogen containing OCP

Question 4

When to refer to the stroke clinic and how quickly to refer

Answer 4

Symptoms of unilateral weakness or aphasia between 48hours and 2 weeks
To see stroke within 24 hours
Symptoms of stoke that aren’t unilateral weekness or aphasia between 48 and 2 weeks to see stroke within 2 weeks
Symptoms more than 2 weeks ago to see stroke within a month

Question 5

What factors increase your chance of having a stroke after a TIA

Answer 5

Age >60
BP >140/90
Clinical features of weakness and aphasia 
Duration of symptoms >10 minutes 
Diabetes 

ABCD2

Question 6

General acute stroke management
What imaging and when?
What labs?
What are BP targets?
Glucose Targets?

Answer 6

ABC MOVIES 
Serial imaging 
Do stroke scale (NIHSS) 
CT head non contrast 
If within 4.5 hours add CT angio or CT perfusion 
If 6-24 hours add CTA AND CT perfusion 

Get labs: NA K HB INR PTT, creat, trop, glucose 
Aim for BP <220/120 - reduced by 15-25%.
<185/110 concurrent with thrombolysis 
<180/105 post thrombolysis 
BG 7.8-10 mmol/L
Thyrbolytics or throbectomy

Question 7

What to give for thrombolytics and inclusion and exclusion criteria

Answer 7

Alteplase 0.9mg/kg (mg 90 mg) over 60 minutes

InclusionL Ischemic stroke causing disabling neurological deficit <4.5 hours and >18 years old

Absolute exclusions: active hemorrhage or any condition that could increase the risk of major hemorrhage after alteplase administration AND / OR any hemorrhage on brain imaging

Relative:
Hx of intracraniam hemorrhave
Head injury, CVA or spinal injury in past 3 months
Major surgery int he past 14 days
Arterial puncture at non compressible sit in past 7 days
Refractory HTN
On DOAC or LMWH (okay if on single antiplatlet)
BG<2.7 or >22,2
Increased PPT or INR > 1.7
Platlets <100

Question 8

When to give Endovascular treatment

Answer 8

> 18 yo
Unable to give tPA
Large vessle anterior ischemic stroke
Within 24 hours

Question 9

Workup following a stroke

Answer 9

A1C, Lipids

Carotid Ultrasound
Holtermonitor
Echocardiogram

Consider VTE prophylaxis if immobile (LMWH)

Proper referrals to Speech Language

Question 10

BP target after stroke recovery

Answer 10

140/90

Question 11

Complications of stroke

Answer 11

Dysphagia
Depression
Dementia
Pressure ulcer
DVT
Incontinence
Death