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NeuroRehab > Stroke Acute - Fister > Flashcards

Stroke Acute - Fister Flashcards

Initial Management Prevention of Neurologic Complications Prevention of Systemic Complications Secondary Stroke Prevention Transition of Care

1
Q

Time restraints on reperfusion therapies: (3)

A
  1. IV rtPA alone < 4hours
  2. IA therapy: IA tPa and/or intraarterial mechanical thrombectomy.
  3. With basilar artery thrombus, window may be up to 8hrs
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2
Q

Which study was initial tPa study in 1995?
Patients treated with recombinant tissue plasminogen activator within 3 hours of onset were ?% more likely to have minimal or no disability at 3 months.

A

Landmark study

30%

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3
Q

What are the 5 contraindications for tPA after 3h window has passed?

A
  1. NIHSS > 25
  2. > 80 yoa
  3. Those taking oral anticoagulants
  4. History of stroke
  5. History of diabetes
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4
Q

Patients with NIHSS < _____ and age < _____ had the greatest potential for excellent outcomes after treatment with IV tPa

A

20, 75yoa –> mild to moderate stroke

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5
Q

Any intracranial hemorrhage occured in ___% of patients who received IV rtPA

A

6.4%; (however mortality rates were similar.

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6
Q

Which stroke subtype showed better outcomes after IV rtPa?

A

Small vessel disease.

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7
Q

Define ischemic penumbra

A

Hypoperfused area of focal ischemia that may be salvaged by timely intervention.
– the area immediately surrounding the core of infarct where blood flow is sufficient, for the moment, to maintain cellular viability, but not sufficient for normal cellular function.

**rationale for permissive HTN

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8
Q

What is the current guideline for permissive HTN

A

220/120. Less if received IV tPa. Rule used to be x 2 weeks. Now more clear that not really necessary >48h. Regardless, once in acute rehab, can have normal BP control.

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9
Q

What component of vitals is detrimental during acute peri-stroke period?

A

fever

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10
Q

Acute elevations in ____ are common in Stroke. In what % of the stroke population? resolves spontaneously after _____

A

BP; 85%, 24-48hr

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11
Q

Acutely lowering blood pressure during stroke can _____

A

can expand the area of ischemia – penumbra

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12
Q

What is the current AHA guidelines for lowering blood pressure after stroke?

A

lower by 15% over the first 24h; permissive up to 220/120 unless tPa has been given.

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13
Q

______ therapy should be initiated 24h post tPa

A

antiplatelet therapy

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14
Q

two potential complications of a cerebellar infarct

A
  1. acute hydrocephalus - always assess the 4th ventricle for patency
  2. elevated ICP due to space occupying edema which could be life threatening given tiny vault with no room for swelling.
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15
Q

HAMLET, DESTINY, AND DECIMAL trials are all regarding ____. What is the DESTINY 2 trial?

A

three pooled randomized trials that basically said hemicraniectomy is life-saving within 48h of event. NNT 2. DESTINY 2 gives extra contraindications for those patients >60.

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16
Q

Cincinnati hemicraniectomy protocol:

  1. Age _____ years
  2. If greater than 60 years use _____
  3. NIHSS > _____
  4. > ____% of MCA territory on CT
  5. Agreement of _____
  6. NS involvement if: (2 things)
  7. Minimum of _____ hours since tPA
A
  1. 18-60 years
  2. DESTINY 2
  3. 10
  4. 50%
  5. family
  6. Clinical deterioration, including subtle decrease in arousal, >4mm shift increase
  7. Minimum of 6 hours since rtPA
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17
Q

what are the two most common post-stroke systemic complications

A
  1. Aspiration pna

2. PE

18
Q

Bacterial pneumonia causes ____% of stroke related deaths

A

15-25%

19
Q

What 4 factors place stroke patients at high risk for bacterial pneumonia

A
  1. reduced consciousness
  2. impaired gag or swallow problems
  3. 20-25% with dysphagia may result in aspiration
  4. 7x more likely in patients who aspirate
20
Q

Stroke patients who get pneumonia can potentially see what 3 outcomes?

A
  1. longer hospital stays
  2. readmissions
  3. 3 fold increase in mortality

(mortality can be as high as 65% if patient has aspiration pneumonia)

21
Q

What 6 factors must be checked prior to advancing to swallow challenge?

A
  1. strong clear voice (no dysphonia)
  2. Manages own secretions, no suction required
  3. Understandable speech (no dysarthria)
  4. Absent facial droop
  5. Normal voluntary cough
  6. Normal gag reflex
22
Q

14 warning signs of dysphagia

A
  1. coughing with signs of struggle
  2. fever (24-48h after stroke)
  3. wheezing
  4. wet vocal quality
  5. refusal to take foods/liquids
  6. changes in respirations
  7. watering eyes
  8. excessive drooling
  9. gagging
  10. pocketing of food in mouth
  11. facial grimacing
  12. sudden change of color in face/lips
  13. smell of formula on breath
  14. increase residuals
23
Q

DVT prophy initiated by ____

A

end of day 2 (48h)

24
Q

4 pathways/etiologies of ischemic stroke

A
  1. atherothrombotic cerebrovascular disease (30-40%)
  2. Cryptogenic (25-30%)
  3. Lacunar - small vessel disease (20-30)
  4. cardioembolic (20-25%)
25
Q

2 most common pathways/etiologies of hemorrhagic stroke

A
  1. ICH (70%)

2. SAH (30%)

26
Q

4 “major” risk factors for stroke by way of Large vessel atherothrombotic cerebrovascular disease

A
  1. HTN
  2. HLD
  3. Tobacco abuse
  4. Diabetes
27
Q

4 “major” risk factors for lacunar strokes (small vessel)

A
  1. HTN
  2. Diabetes
  3. tobacco abuse
  4. age
28
Q

5 types of cardioembolic sources

A 
mechanical valve
Ventricular or atrial thrombus
Afib****
bacterial endocarditis
MI
29
Q

three sources of paradoxical embolus

A

atrial septal aneurysm
patent foramen ovale PFO
ASD

30
Q

8 types of hypercoagulable disorders that could lead to stroke

A 
thalassemia
sickle cell
antithrombin III deficiency 
Protein C,S deficiency
Antiphospholipid syndrome
Factor V leiden mutation
prothrombin gene mutation
systemic malignancy
31
Q

three most common causes of intracerebral hemorrhage

A
  1. HTN
  2. amyloid angiopathy in the elderly
  3. vascular malformation
32
Q

amyloid angiopathy will present as what type of stroke (region)

A

lobar

33
Q

What are the 4 most common areas for Hypertensive bleed

A
  1. BG
  2. pons
  3. thalamus
  4. cerebellum
34
Q

2 most common causes of non-traumatic SAH

A
  1. aneurysmal

2. AVM

35
Q

watershed or “boundary zone” infarcts are a result of what type of stroke.
Frequently associated with: _____

A
  1. hypotensive stroke - any event causing an abrupt drop in blood pressure. which critically compromises cerebral blood flow (ACA/MCA border zone)
  2. Carotid stenosis.
36
Q

Hemorrhagic conversion often results due to:

A

arterial occlusion causes ischemia to capillaries, arterioles, and vascular walls in addition to deleterious effects on neurons. Hemorrhage results when the “fragile” or “injured” vessels rupture.

37
Q

hemorrhagic transformation occurs: _____ days and ____% of non-complicated ischemic strokes

A

2-14 days post ictus

5%

38
Q

Proposed mechanisms of hemorrhagic transformation include:

A
  1. reperfusion either from recanalization or collateral circulation
  2. disruption of BBB
39
Q

3 risk factors for hemorrhagic conversion (in order)

name 5 lesser risk factors

A
  1. Large stroke
  2. embolic
  3. older age

uncontrolled DM, labile blood pressure, richness of collateral circulation, use of anticoagulants, treatment with thrombolytic agents

40
Q

Regarding dual anteplatelet therapy
90 optimal when
14-21 days optimal when

A

symptomatic IC stenosis

otherwise – POINT trial

NeuroRehab (12 decks)

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