Stroke

Question 1

TIA vs Stroke

Answer 1

TIA: Focal neurologic deficit for <24 hours without acute infarction

Stroke: Focal neurologic deficit for >24 hours

Question 2

Stroke Recognition

Answer 2

BE FAST
-Balance
-Eyes (trouble seeing)
-Face (drooping)
-Arms (drift down)
-Speech (slurring)
-Time (call 911 asap)

Question 3

NIH Stroke Scale

Answer 3

5-15: mod stroke

16-20: mod to sev

20-42: severe stroke

Question 4

General, Emergency Tx

Answer 4

1. Manage BP
2. IV Fibrinolytics
3. O2, Temp, Glucose
4. 2ndary Prevention (AP, AC, statin, BP)

Question 5

Alteplase (TPA): CFU

Answer 5

Who is eligible?
-Age: 18+
-NIHSS > 5
-CT (-) for bleed
-Glucose 50-400
-BP < 185/110
-Sx < 4.5 hours

Door to needle time is 60 minutes

Question 6

Alteplase: Dosing

Answer 6

0.9 mg/kg

Max 90 mg

Bolus: 0.09 (10%)

Infusion: 0.81 (90%)

ABW

Question 7

Alteplase: AE, Monitoring

Answer 7

AE: bleeding, angioedema

Monitor: neuro exam, BP, bleeding, CT

Question 8

Management of ICH w/in 24 hours after IV alteplase

Answer 8

-Stop alt infusion
-Cryoprecipitate 10 units IV
-Tranexamic acid or Aminocaproic acid
*help reverse altepase

Question 9

AIS: BP Control

Answer 9

Qualifies for IV thrombolysis?

IF YES
-Lower to < 185/110 before giving thrombolysis
-Maintain < 180/105 for first 24 hours

IF NO
-BP <220/110: nothing
-BP >220/110: lower 15% in first 24 hours

Question 10

AIS: BP MEDS

Answer 10

1. Nicardipine 5 mg/hr
2. Labetalol 10-20 mg
3. Clevidipine 2 mg/hr

Question 11

Antiplatelets: 2nd Prevention

Answer 11

For non-cardioembolic IS

1. Aspirin 81-325 mg/day
2. Dipyridamole ER + aspirin 1 cap BID
3. Clopidogrel 75 mg

Question 12

Anticoagulants: 2nd Prevention

Answer 12

For cardioembolic IS

1. DOACs
2. Warfarin ONLY in mitral stenosis or mechanical heart valves

Question 13

Lipids: 2nd Prevention

Answer 13

High intensity
-Atorvastatin 40-80
-Rosuvastatin 20-40

CI: acute liver disease, preg/nursing

Question 14

ICH: Warfarin Reversal

Answer 14

1. hold warfarin therapy
2. give one dose of Kcentra
   a. INR 2-3.9: 25 u
   b. INR 4-6: 35 u
   c. INR > 6: 50 u
3. give IV Vitamin K (5-10 mg / 50 mL NS)
4. FFP 10-15 ml/kg

Question 15

ICH: Dabigatran Induced

Answer 15

Idarucizumab, Praxbind

2.5 g / 50 mL IV bolus over 6 min x 2 doses (total 5 g)

Question 16

ICH: Riva/Apixa Induced + Dosing

Answer 16

Andexanet Alfa

Apixaban
-Over 5 mg and < 8 hours = 800 mg bolus, 8 mg/min infusion
-All others = 400 mg bolus, 4 mg/min infusion

Rivaroxaban
-Over 10 mg and < 8 hours = 800/8
-All others = 400/4

Question 17

Subarachnoid Hemorrhage (SAH)

Answer 17

SX
-Worst headache ever
-Stiff neck, NV

1. Nimodipine
   -60 mg PO Q4h x 21 days
2. Mg (can add to nimodipine)
   -0.5-1 g/hr IV inf