Stroke Flashcards
If thrombolytics are administered, what is the BP goal PRIOR to administration
Prior to administration, lower BP to <185/110
If thrombolytics are administered, what is the BP goal AFTER
Maintain BP <180/105 for 24 hrs
If thrombolytics are not indicated what is the BP goal?
allow permissive HTN
lower extreme BP by 15% in 1st 24 hrs so if SBP>220 or DBP>120
1st line therapy for eligible pts after a stroke is
alteplase or IV thrombolytic therapy
When is tPA given for ischemic stroke?
within 4.5 hrs of symptom onset
If pt presents outside 4.5 hr window then what to do?
give ASA and evaluate for mechanical thrombectomy which can happen within 24 hrs of stroke onset
Name criteria for strict exclusion of tPA
hemorrhage or multilobar infarct which includes >33% of cerbral hemisphere
CVA or head trauma in last 3 months
hx of ICH or neoplasm or vascular malformation
Recent intracranial or spinal surgery
active bleeding or arterial puncture in past 1 wk at a non-compressible site
BP>185/110
Plts<100K or glucose <50
AC use INR>1.7 or PT>15 or high active PTT
Name relative contraindication to tPA
minor or rapidly improving neurodeficits major surgery or trauma in last 2 wks MI in the past 3 months GU or GI bleeding in last 21 days seizure at stroke onset pregnancy
Indications for mechanical thrombectomy
large artery occlusion in anterior circulation and persistent neurodefects
Can mechanical thrombectomy happen if TPA was given
Yes it can, and don’t delay it to see if TPA worked
Additional imaging with evaluation of mechanical thrombectomy
CT or MR angiography
Role of aspirin in ischemic stroke
lowers risk reoccurrent ischemic stroke and should be given within 24-48 hrs
however if given TPA don’t give ASA within 24 hrs
How long to allow permissive hypertension
48 hrs
ONLY if not candidates for thrombolytic or mechanical thrombectomy
When to treat patients who have high BP after stroke
only extremely elevated SBP >220 or DBP>120 or active CAD, HF, aortic dissection, or hypertensive encephalopathy, acute renal failure or preeclampsia or eclampsia
Cerebellar stroke presentation
headache, vertigo, nystagmus, vomiting, gait ataxia, limb incoordination.
If someone has A fib and they got a TPA for their stroke, when do you start IV heparin?
at least 24 hrs after IV tpa if CT head shows no hemorrhagic transformation or diffusion weighted MRI of brain shows no evidence of a large completed infarct
when can a person post TPA and stroke eat?
need to remain NPO for at least 24 hrs post TPA in case there’s hemorrhagic conversion and need surgery to lower ICP.
Post TPA in a stroke besides adhering to BP goals, what stroke treatments should be delayed
Goal BP is <180/105 and need to delay feeding, AC and antiplatelets for at least 24 hrs until repeat CT scan shows no hemorrhagic conversion.
symptomatic pts with TIA or ischemic stroke with a CEA of 70-99% should have
carotid endarterectomy
when should a carotid enarterectomy CEA be offered after a ischemic stroke or TIA?
1-2 weeks after a non disabling stroke or TIA helps improve outcomes for surgery
how long to delay enarterectomy or CEA in large strokes with cerebral edema or hemorrhagic complications?
4-6 WEEKS,
in high grade stenosis prefer CEA over carotid artery stenting due to lower periprocedural mortality and stroke rates.
what is the role of anticoagulation with warfarin after ischemic stroke
none. no benefit and it can increase risk for hemorrhagic transformation
do we use nimodipine after ischemic stroke?
No it’s used as post aneurysmal subarachnoid hemorrhage and used to protect against vasospasm. not used in ischemic stroke.
Name the type of stroke/head bleed based on presentation: severe headache at onset meningeal irritation (neck stiffness) focal deficits are uncommon
spontaneous subarachnoid hemorrhage.
bleeding from arterial saccular aneurysm or AVM
Name the type of stroke/head bleed: history of uncontrolled HTN, coagulopathy, illicit drug use
symptom progression over minutes to hours
focal neurological symptoms appear early and followed by features that are seen with increased intracranial pressure.
See headache, vomiting, bradycardia, and reduced alertness
intracerebral hemorrhage. - seen with worsening symptoms and see progression with symptoms concerning for ICP.
Name the type of stroke/head bleed: history of cardiac dx (a fib or endocarditis,) or carotid atherosclerosis,
onset of symptoms is abrupt and maximal at start
multiple infarcts in different vascular territories
ischemic or embolic stroke
Name the type of stroke/head bleed: atherosclerotic risk factors (uncontrolled HTN, DM) with history of TIA. See local obstruction of an artery and symptoms may alternate with periods of improvement (stuttering progression)
ischemic (thrombotic) stroke
MCA stroke deficits are:
see contralateral somatosensory and motor weakness (face, arm, leg) and people will also have conjugate eye deviation toward side of infarct called contralateral homonymous hemianopsia (superior and inferior optic radiations).
There will be hemineglect (if stroke affected non dominant hemisphere).
There will be aphasia if stroke affected dominant hemisphere.
acute subdural hematomas (SDH) presentation
lucid interval before progression to coma within 24-48 hrs after onset. Chronic SDH may be present with progressive cognitive impairment and headaches and seizures weeks after onset.
acute spontaneous subdural hematomas occur from
rupture of bridging vein
seen in elderly where there’s volume loss and more bridging vein can get ruptured.
when do we see VTE after a stroke?
generally sen in 13-25% of pts about 2-4 weeks after stroke onset.
after TPA is given what is management for ischemic stroke:
keep BP < 180/105, get MRI/CT head after 24 hrs. Meantime hold feeding, ASA, or lovenox until after 24 hrs and imaging shoes no signs of intracranial hemorrhaging. start statin.
Ok to give thigh high pneumatic compression devices.
Midbrain stroke is also known as
Weber syndrome
Ipsilateral cranial nerve 3 palsy and contralateral lower facial weakness and hemiplegia
midbrain stroke or Weber syndrome
midbrain stroke or Weber syndrome deficit
Ipsilateral cranial nerve 3 palsy and contralateral lower facial weakness and hemiplegia
lateral medulla stroke is also known as
Wallenberg stroke
ipsilateral Horner’s syndrome (ptosis, miosis, anhidrosis), loss of facial pain and temperature,
contralateral loss of body pain and temperature
hoarseness and dysphagia
Wallenberg stroke / lateral medulla stroke
ipsilateral tongue weakness
contralateral hemiplegia and decrease positional sense
medial medulla stroke
Cerebellar stroke
nystagmus, ataxia, nausea and vomiting
medial medulla stroke symptoms
ipsilateral tongue weakness
contralateral hemiplegia and decrease positional sense
Wallenberg stroke / lateral medulla stroke symptoms are:
ipsilateral Horner’s syndrome (ptosis, miosis, anhidrosis), loss of facial pain and temperature,
contralateral loss of body pain and temperature
hoarseness and dysphagia
brain stem involves your cranial nerves and so you have the
mid brain
pons
medulla oblongata
mid brain corresponds to CN 3-4 (oculomotor and trochlear)
pons corresponds to CN 5-8 (trigeminal, abducens, facial, vestibulocochlear)
medulla oblongata (CN 9-12) glossopharyngeal, vagus, and spinal accessory and hypoglossal
Where to CN1 and 2 originate?
originates in the cerebrum and are not affected in brainstem strokes
acute cortical stroke in MCA would result deficits of:
contralateral hemiplegia and sensory loss
aphasia happens if dominant hemisphere is involved.
acute stroke in posterior limb of internal capsule would result in
lacunar stroke and can see contralateral hemiparesis and sensory loss and occasional facial weakness.
NO cranial nerve deficits or cogwheel rigidity.
TIA is a
transient episode of neurological impairment (of CNS origin) without acute infarction.
Prior TIA or minor stroke without residual deficits require immediate evaluation for risk for recurrent stroke
what is the ABCD2 score
prognostic tool to predict risk for ischemic stroke in the first TWO days following TIA. anyone with 3 or more points should be hospitalized.
ABCD2 score stands for:
Age>60 yrs (1)
Blood pressure>140/90 (1)
Clinical presentation: unilateral weakness (2) , isolated speech impairment (1) , other (0)
Duration of TIA symptoms: >60 min (2) , 10-59 min (1), <10 min (0)
D presence of diabetes (1)
>3 moderate and >6 is high
National stroke association criteria for TIA to get hospitalized is if they have the following with a TIA in the last 24-48hrs
duration of symptoms >1hr
symptomatic internal carotid artery stenosis >50%
multiple recurrent TIAs
afib or other known cardiac source of embolus
hypercoaguable state
high risk of stroke after TIA as determined by ABCD2 score
Initial TIA work up is:
ultrasound of the carotids, CT or MR angiography of brain and EKG
Negative initial studies should undergo TTE to rule out cardiac cause.
After having a TIA what should be started on pt?
aspirin and statin.
young female without risk factors has a stroke (or VTE) what do check for?
APS
start on DAPT for first 48 hrs and get MRI. don’t start anticoagulation if presenting with stroke.
Complication of stroke is
DVT which can happen up to 15% of people in the 1st 30 days with PE accounting for 25% of early death after stroke
when can DVT develop after a stroke?
24 hrs after stroke and peak incidence is 2-7 days after stroke
Risk factors: hemiparesis, a fib, immobility and advanced age
what is indicated in pts who have ischemic or hemorrhagic stroke to prevent DVT
ischemic stroke: pharmacological DVT prophylaxis
Hemorrhagic stroke: contraindicated pharmacological. can use intermittent pneumatic compression stockings or IPC within 72 hrs of acute stroke to prevent DVT
when can you start pharmacological DVT prophylaxis for hemorrhagic stroke?
can start pharmacological DVT prophylaxis within 1-4 days as long as repeat CT imaging doesn’t show any further signs of further bleeding.
recrudescence is
acute exacerbations of prior neurological deficits can happen in acute infectio nor metabolic derangement
hard to distinguish from new ischemic event
Need diffusion weighted brain MRI
carotid artery dissection is caused by:
trauma or spontaneously
risk factors: HTN, smoking and connective tissue disorders
acute trauma, thunderclap headache <1 one minute in onset and see ipsilateral horner’s syndrome
ipsilateral MCA stroke like symptoms
think carotid artery dissection
need to get a MRA or CTA to show the ICA with a tapered flame shaped appearance
Treatment of internal carotid artery dissection
prompt recognition needs to be treated with:
anticoagulation, antiplatelet therapy, endovascular or surgical endovascular repair
can decrease stroke, neurological stability and death
carotid artery dissection presentation varies in that it can prsent as:
TIA, ischemic stroke or embolic stroke
see partial ipsilateral horner’s - partial ptosis, miosis without anhidrosis
can see ipsilateral MCA stroke
what happens in an internal carotid artery dissection
blood enters the inner and outer arterial layers which form clots and can also lead to embolic stroke.
cerebral venous sinus thrombosis presents as a
thunderclap or gradual headache with focal neurological signs.
no horner’s syndrome
vertebral dissection presentation:
thunderclap headache, Horner’s syndrome if there’s infarction to lateral medulla (Wallenburg syndrome) loss of sensation to face and contralateral body and nystagmus and ataxia
what to do after an acute ischemic stroke and someone gets TPA and BP is within goal?
get a CT angiography to evaluate if they are also a candidate for endovascular therapy
People who get TPA for acute stroke can also get endovascular therapy and benefit from it. Unlikely they will have recanalization with TPA with large vessel stroke.
ABCD2 score needed to be admitted to the hospital for work up
3 or more
age BP clinical presentation duration of symptoms diabetes
if strongly suspicious for a stroke what is the FIRST imaging study to order?
CT head - rule out hemorrhagic stroke resulting in neurological detrioriation.
Highest mortality and this is a rapid test
if you see a cerebellar hemorrhage on CT scan in someone who is acting like they have a stroke, when do you get surgery involved to treat pt?
when you see cerebellar hemorrhages with diameter >3 cm
they need emergent surgical decompression
what medications is contraindicated in intracerebral hemorrhages
TPA
ASA
plavix
what is the most effective short term intervention for secondary stroke prevention?
combination of aspirin and plavix if started in 24 hrs of TIA or minor stroke.
Continue DAPT for 10 to 21 days followed by ASA monotherapy.
do we ever use prasugrel for treatment or secondary prevention for stroke?
no prasugrel (efient) has been associated with high risk of hemorrhage when used in CAD pts and history of stroke. should be avoided.
what is the best long term antiplatelet drug for secondary stroke prevention:
aspirin monotherapy
plavix (clopidogrel) monotherapy
ticagrelor monotherapy?
plavix monotherapy
more likely than aspirin to prevent recurrent stroke, MI, or vascular death after noncardioembolic ischemic stroke.
if pt had a ischemic stroke in internal capsule with a lacunar infarct, this will help the most.
