Stroke, Brain, Weakness, Coma Flashcards
What is the dosing for tPA?
.9 mg/kg IV w/max dose of 90 mg
10% given as bolus, remaining is given as 60 minute infusion
CPP = ?
What is the compensatory mechanism of increased ICP?
MAP - ICP
Cerebral arteriolar vasodilation
What is the exclusion criteria for tPA in a pt on Warfarin?
What about NOAC?
Excluded if INR > 1.7 or PT > 15s or PTT > 40s
Excluded if using and evidence of anticoagulation on lab tests
What is the BP management in ICH with elevated BP?
CPP?
Lower SBP to less than 140 (lowered MRS according to 2013 study)
50-70 mmHg
How long can you do thrombectomy in acute ischemic stroke?
6-24 hours
What is the exclusion criteria contraindication of being in the < 3 hour window vs the 3-4.5 hour window for receiving tPA?
Age > 80 y/o
Severe stroke (NIH > 25)
On any anticoagulation regardless of INR
Hx of BOTH diabetes and prior ischemic stroke
Based on thennt.com/not/tPA data, what is the NNT for tPA in ischemic stroke?
NNH?
0-3 h, NNT of 10 (mRS 0-1)
3-4.5 h, NNT 19
0-3 h, NNH of 40
3-4.5 h, NNT of 50
What are common sx in Posterior strokes?
Why?
Uncommon?
LOC, N/V, visual changes, ataxia
Supplies the reticular activating system, cerebellum, brainstem, occipital lobe, brainstem vomiting centers
Ipsilateral CN deficits
According to UpToDate based on a 2014 meta-analysis using 6756 pts of NINDS, ATLANTIS, ECASS, EPITHET, what is the NNH (symptomatic ICH) for tPA? What is the 30 day mortality of these pts?
NNT < 3 hours?, 3-4.5 hours?
Using what measure?
18 (6.8%), 50%
10, 20
mRS 0 or 1 (no significant disability) at 3 or 6 months
CN 3 is usually affected by what?
Diabetic or hypertensive vasculopathy
Describe binocular diplopia?
Resolves when either eye is closed and is the result of misalignment in the visual axis
What meds to give to control BP if you want to give tPA and BP is too high?
Labetalol 10/20 mg IV over 1-2 minutes
Nicardipine infusion 5 mg/hr titrations up by 2.5 mg/hr at 5-15 minute intervals w/max dose of 15 mg/hr
Monocular Diplopia is what kind of problem?
Eye specifically
What BP is a contraindication to tPA?
> 185/110
What FHx do you need to ask about in cases of SAH?
Polycystic kidney disease
SAH
Severe HTN
Previous vascular lesion
What causes vertigo, Horner’s, ipsilateral facial numbness, loss of corneal reflex, CL loss of pain/temp?
Wallenberg syndrome (lateral medullary syndrome)
Pt presents with drooping of left eyelid, miosis of the pupil, what is going on?
How do dx?
Horner’s syndrome caused by Vertebral dissection —> look for MVC
CTA of carotid
What are the advantages of Fosphenytoin over phenytoin?
Can be give IM and quicker
Less chance to cause HoTN
MC sites of ICH?
Putamen (44%)
Thalamus (13%)
Cerebellum (9%)
What parts of the brain does the Post Cerebral artery supply?
Thalamus, red nucleus, Uncus
What kind of hallucinations are present in psychiatric cause of delirium?
What is another name for this kind of cause of delirium?
Auditory
Functional
What part of the brain does the MCA supply?
IC, Putamen, Clasutrum, GP, body of caudate
What is the post arrest Glucose target?
120 < target < 180
What does the 2018 PRISMS trial show regarding tPA and ASA?
What else does it show about in regards to treatment outcomes?
What limitations in study?
No difference of outcome using mRS (0/1) of tPA vs ASA for Acute ischemic stroke w/in 3 hours of onset for NIHSS score of 0-5
13% of pts had neurovascular mimics means pts were exposed to potentially harmful medication with NO benefit (3.3% risk of SICH)
Stopped early
Define status epilepticus
Seizure lasts > 5min OR
Recurrent seizures w/out return to baseline
What is the TMT hypothermia post-ROSC guideline?
Target of 33C
After 24h, target of 35.6C at rate of .15 C/hr
What are the 4 emergent/critical causes of confusion?
Systemic disease affecting CNS
Primary intracranial disease
Exogenous toxins
Drug withdrawal state
What causes amaurosis fugax?
Proximal carotid artery plaque embolizes to the ophthalmic artery
Triad of Wernicke’s?
Nystagmus (CN VI palsy), AMS, ataxia
In the 3-4.5 hour window, what is a contraindication?
On Warfarin
What is the goal PaCO2 in elevated ICP?
Why no hyperventilation?
35-40 mmHg
Can result in dec CBF causing cerebral ischemia
When is a pt considered to be in refractory status epilepticus?
Seizure does not terminate w/Benzo and 2nd antiepileptic drug
What is the difference between simple partial (focal) vs complex?
Simple has PRESERVED mental status
Complex = impaired mental status
What are the inhibitory neurotransmitters?
Excitatory?
GABA
Glutamate and acetylcholine
What is Todd’s paralysis?
What causes it?
Focal motor deficits that may persist up to 24 hours after generalized or complex partial seizures
Transient focal cerebral hypoperfusion
What are ACEP’s guidelines for workup in a pt with 1st time seizure and returned to normal baseline?
Serum glucose, sodium level, pregnancy test
Treatment of Wernicke’s encephalopathy?
What can cause resistance to this tx?
100mg IV thiamine
Hypomagnesium bc Mag is a cofactor for thiamine transketolase
MOA of Haldol?
Use caution in pts taking what?
Anti-dopamine
Class IA and III antiarrhythmics And CYP450 inhibitors
What neurotransmitter is decreased in Alzheimer’s disease?
ACh
What Apolipoprotein puts people at inc risk for Alzheimer’s?
What chromosomes?
ApoE4 on ch. 19
1 and 14
What is a key feature of Delerium found on clinical exam that is different from dementia?
Inattention
What maneuver to dx BPPV of the horizontal semicircular canal?
BBQ roll
Dix Hallpike is for posterior
