Stroke

Question 1

most important modifiable risk factor

Answer 1

HTN

Question 2

test to order

Answer 2

 Emergent CT Head w/o Contrast

Question 3

how to prep for tPA

Answer 3

Get last known normal
o NIHSS (11 items, more points = worse) – scale skewed towards anterior circulation and dominant (language) hemisphere. <4 or >20 = no thrombolytic rec. 4-20 = thrombolytic.
 MUST get glucose before to r/o hypoglycemia.
 Get ECG
 Provide O2 if sat<94%

Question 4

which tPA for ischemic

Answer 4

IV alteplase (after hemorrhage is r/o)

Question 5

time window for alteplase

Answer 5

<4.5 hours after symptom onset/last known well. Door to needle time <60min

Question 6

interaction w/ alteplase

Answer 6

 Do NOT give antiplatelets/ anticoags for 24 hrs after

Question 7

best standard of care treatment for ischemic

Answer 7

 Alteplase + mechanical Thrombectomy

Question 8

ischemic: when to start heparin

Answer 8

 After 24-48hrs and no hemorrhage on repeat imaging – start UFH/LMWH for VTE prophylaxis prior to 2nd midnight.

Question 9

secondary prevention for  non-cardioembolic

Answer 9

Aspirin (prior to 2nd midnight, BUT 24 hrs AFTER alteplase). DAPT if prev stroke or already on ASA.

Question 10

secondary prevention for  Cardioembolic (non-valvular afib):

Answer 10

DOAC/apixaban (start 48hrs – 14 days after). The larger then infarct, the more we delay anticoagulation

Question 11

for ischemic, Manage BP w/

Answer 11

labetolol or CCBs (nicardipine, clevidipine).

Question 12

BP treatment if not eligible for alteplase

Answer 12

treat BP if >220, reduce by 10-15%.

Question 13

treatment for TIA

Answer 13

o Aspirin – 81mg X 21+ days. If pt was already on ASA, increase dose to 325mg. If allergic to ASA, clopidogrel (Plavix) 75mg.
o Lifestyle modifications

Question 14

BP control for SAH

Answer 14

goal SBP <140
 Secondary brain injury occurs when ICP >20mmHg for > 5 minutes

Question 15

o Secondary prevention of SAH:

Answer 15

high intensity statins; RF control: HTN, dyslipidemia, smoking.

Question 16

vasospasm prevention after SAH

Answer 16

nimodipine 60mg Q4H x 21 days (peak occurence is 7-10 days after SAH)

Question 17

preferred CCB for SAH

Answer 17

Nimodipine

Question 18

PO meds in early stroke mgmt?

Answer 18

no

Question 19

CHADVASC score requiring oral anticoag

Answer 19

2+

Question 20

class: dabigatran

Answer 20

direct thrombin inhibitor

Question 21

which anti-coag can be used w/ valvular afib?

Answer 21

warfarin

Question 22

med to prevent vasospasm after SAH

Answer 22

CCB Nimodipine PO or NG tube X 21 days, Start w/in 4 days of SAH