Stroke

Question 1

What is the cause of stroke?

Answer 1

Cerebral infarction (ischemic stroke), or intracerebral hemorrhage

Question 2

Goals of therapy

Answer 2

• minimize brain damage
• prevent complications (pneumonia, VTE)
• reduce risk of stroke recurrence
• restore function and minimize long-term disability

Question 3

Endovascular thrombectomy

Answer 3

non-surgical, angiographic procedure, uses microcatheters to remove blood clots and re-establish arterial blood flow in the brain
-can be performed after initiating tPA or in patients who can not use tPA

Question 4

What type of compression stockings should be used to prevent VTE?

Answer 4

pneumatic compression stockings (inflate and deflate to help blood flow) within 24 hours

Question 5

What is the treatment criteria for Thrombolysis in Acute Ischemic Stroke?

Answer 5

1. patient is 18+
2. stroke onset is less than or equal to 4.5 hours before drug administration

Question 6

TIA?

Answer 6

brief episode of neurological dysfunction < 1 hr upto 24 h, no evidence of infarction on imagine (cell death)

Question 7

which stroke is more common?

Answer 7

ischemic = due to blockage of blood flow

Question 8

Mechanisms of ischemic stroke?

Answer 8

1. thrombosis (atherosclerosis, vasoconstriction)
2. emboli that contains thrombi that travel thru the blood
3. cerebral hypo-perfusion due to reduced cardiac output

Question 9

Forms of thrombolysis for acute treatment of ischemic stroke

Answer 9

1. tPA
2. TNK (tenectaplase) - not appoved yet by HC

Question 10

What are the absolute contraindications for tPA?

Answer 10

1. active hemorrhage (or any condition that can increase risk of major bleeding after tPA)
2. acute hemorrhage on intracranial imagine

Question 11

What lab values suggest a relative contraindication to tPA ?

Answer 11

1. Blood glucose < 2.7 or > 22 mmol/L
2. INR > 1.7
3. elevated aPTT (activated partial thromboplastin time)
4. platelet count <100 *10^9/L

Question 12

What clinical findings determine a relative contraindication to thrombolytic therapy (tPA)?

Answer 12

1. subarachnoid hemorrhage
2. stroke symptoms due to another nonischemic acute neurologic condition (ex. seizure with postictal Todd paralysis, severe hypo or hyperglycemia)
3. hypertension refractory to therapy - target BP of < 185/110 mmHg can not be reached.
4. patient is taking DOAC

Question 13

What BP should be targeted for a patient prior to starting thrombolysis and during treatment?

Answer 13

BP < 180/105 mmHg

Question 14

DOACs to avoid in relation to low CrCl?

Answer 14

CrCl < 30 : avoid dabigatran and rivaroxaban

CrCl < 15 : avoid apixaban and edoxaban

Question 15

When is DAPT recommended in stroke? Is it recommended for secondary prevention?

Answer 15

ONLY in acute setting with ASA + clopidrogrel short-term use between 21 and 30 days.
Not recommended for long-term or for secondary prevention.