Stroke Flashcards
How much is RR reduced if pt is admitted to stroke unit vs non stroke unit?
17% RRR of death and disability
Window for giving tPA alone?
world consensus is 4.5hrs
- 6 hours based on lancet meta analysis
If there is evidence of pneumbra (perfusion imaging mismatch) and nil contraindications for tPA, what is the tPA time window?
Up to 9 hrs
If their is confirmed large vessel clot + core infart + perfusion imaging mismatch (penumbra), what is the ECR window?
up to 24 hrs
Should tPA be WH prior to ECR (assuming nil contraindications for tPA)?
No, should give tPA then ECR
Large vessel occlusive stroke, planned for tPA and ECR. Given alteplase vs tenecteplase?
tenecteplase achieved better recanilisation than alteplase prior to ECR
Best unit to treat hemorrhagic stroke pts?
Stroke unit (derives similar benefit from stroke unit care as an ischemic stroke pt)
Indication / criteria to close PFO in stroke pt?
Pt selection is key
Age <60
no other emobilic mechanism
large shunting PFO +/- atrial septal aneurysm
NAOC vs warfarin best for prevention of ischemic and haemorhagic stroke?
NOAC are best for non valvular AF
- ischemic and haeorhagic stroke RRR 19% wsith NOACs
- Haemorhagic stroke RR 51%
Note risk in GIT haemotrhage is increased with NOACs compared to warfarin
Absolute and relative contraindications for thrombinolysis?
Absolute:
- Acute ICH
- Extensive frank hypodensity on CT (>1/3 MCA territory) this should promt Ix of timing of stroke
- Active non compressible bleeding (ie GI bleeding)
- Known coagulopathy
- Plt count <100
- INR >1.7 (including on warfarin)
- theraputic LMWH within 24 hrs
- NOAC within 48hrs
- IE
- thorasic aorta dissection
Relative:
- uncontrolled HTN
- recetn intracranila surgery
some more
When should u start NOAC for NVAF following acute ischemic stroke?
2-6 days post depending on size and location of infarct
AF underlies a significant number of cryptogenic ischemic stroke. how can u improve survivial in these pts post stroke?
The longer u look for AF (ie with holter or loop recorder) the more AF u will find and (because u anticoagulate) the more future strokes us with prevent
What is andexanet? when is it used
MAB reversle agent for FXa inhibitor (apix and riva)
What is Idarucizumab?
Antidote to dabigatran
- Can be given to dabigatran pts, then tPA can be given imidiatly after
How long for DAPT therapy post minor stroke or TIA?
DAPT for 3 weeks to 3 months, then switch to monotherapy for life
WHen is teh risk of recurrent ischemic stroke teh highest post acute stroke or TIA?
first 2 weeks
Antricoagulent choiuce post cerebral artery dissection?
Any (no evidence to show one is better than the other)
Target LDL post acute stroke?
target LDL <1.8 with statin +/- fibrate
(for non cardioembolic stroke. remember that AF pts can have noncardioembolic strokes too but is less likely than cxardioembolic)
Which is better for treatment of severe asymptomatic carotid artery stenosis: CEA vs CAS?
CEA
- intervention for severe asymptomatic carotid artery stenosis remains controversial
Strongest RF predicting stroke risk recurrance following TIA or stroke?
1 multiple infarcts on imaging
#2 large artery atherosclerosis in the associated region
# ABCD2 score 6-7
Best anti HTN for control of HTN to reduce stroke risk?
Ca channel blockers
- BB actually increase stroke risk unless they are needed for heart (ie AF pt)
Insulin pump vs sliding scale for difficult to control sugars in stroke pts?
sliding scale
insulin pump is associated with more adverse risk of recurrent stroke
Encourage mobilization or rest in firs 24 hrs post stroke?
rest
Mobilisation pre 24hrs increases risk of further stroke
What is evolocumab and Alirocumab?
Treatment of resistant hypercholesterolaemia on top of statin therapy
- reduces CV death, MI and stroke by 20% in pts with CVD but VERY difficult to access
Classification of strokes?
Haemorhagic 15%
- Parenchymal
- SAH
Ischemic 85%
- Atherosclerotic disease (large vessel) leading to hypoperfusion, arterioembolic event
- Small vessel arteriosclerosis (lacunar infact)
- Cardioembolic stroke
- Cryptogenic stroke
- Other
Timeline / phases of an acute stroke?
Hyperacute period (first 6 hours from onset)
- Can given tPA without looking for salvageable penumbra
Late hyperacute period (6-24hrs)
- revasc in select cases (ie penumbra)
Acute stroke (24-72hrs)
Subacute (72hrs to 3 week)
Chroinic >3 weeks
Clinical assessment tools for stroke?
modified rankin score - functional status
NIHSS - score from 0 to 42
- changes from second to second and from observor to observor
What is amyloid angiopathy? Demographic, features on imaging
Cerebral amyloid angiopathy (CAA) is a type of cerebrovascular disorder characterized by the accumulation of amyloid within the leptomeninges and small/medium-sized cerebral blood vessels. [1] The amyloid deposition results in fragile vessels that may manifest in brain bleeds
Usually lobar distribution of bleeds / microbleds, multiple at once
Elderly patient with cognitive impairment
In contrast to amyloid angiopathy, where do HTN related bleeds occur?
Deep (ie basal ganglia, cerebellum, brain stem)
Lobar bleeds in the elderly are amyloid
Imaging features of SAH?
Star pattern in basal cistern on CTA
- due to berry aneurysm
BP target in hemorrhagic stroke?
SBP <140 for first 2 weeks
CT negative thunderclap headache? what is next test and when to do?
LP for xanthochromia, wait at least 12 hrs for this to develop
Only 2x risk factor that increases your risk of an aneurysm rupture?
Previous aneurysm rupture
- other things like smoking, hep C, HTN, etoh, FHx are not risk factors for rupture
Size of aneurysm
- Ant circ aneurysms >7mm - treat
- post circ aneurysms >5mm -treat
Treatment for unruptured AVM, ? surgical intervention vs nil?
nil
- they do bleed but usually not too badly
- do worse if intervene
In hyperacute stroke, MRI DWI mean …. ? FLAIR means…?
DWI - cytotoxic oedema, not infarcted yet
FLARI - infarcted (irreversible ischemic injury)
Intervention that reduce risk or death and morbidity in acute stroke?
thrombinolysis
ECR
Stroke unit care
aspirin
hemicraniectomy
Is tPA beneficial in >80yrs?
Yes, no age limitations
- although increased risk of bleeding
What are the FSS targets for an acute stroke pt?
Fever
- temp <37.5
Swallow
- dont eat unti SP review or asasisted swallow
Sugars
- miantain <11.1
DVT prevention in acute stroke?
Proph LMWH
SCDs - sequential compression device
Dont use TEDs
WHen is hemicraniectomy indicated in acute stroke?
Extensive MCA stroke in fit pt <60 years (TACI syndrome ie NIHSS >20 usually)
Treatment for cerebral venous sinus thrombsis?
Anticoagulation with hepartin or LMWH
Continue even if they bleed
What is valvular AF?
AF associated with mitral stenosis, mechanical heart valve, or rheumatic heart disease
