Stroke Guidlines TIA and AF

Question 1

A patient came in with 4/5 weakness of the UE and slurring of speech. GCS 15 comfortable.
Based on stroke definition this patient has what stroke severity?

Answer 1

Mild

Mild stroke any or combi of the following

1. Mild pure motor weakness 3-4/5
2. Pure sensory deficit
3. Slurred but intelligible speech
4. Vertigo with incoordination
5. Visual field deficits

NIHSS score 0-5

Question 2

How is moderate stroke defined?

Answer 2

Significant motor/sensory/ language/ visual defect *and/or

Disoriented, drowsy, light stupor with purposeful response to painful stimuli

NIHSS 6-21

*** basically a patient that is not GCS 15 but not in deep coma

Question 3

How do you define severe stroke?

Answer 3

Depp stupor or coma

NIHSS >22

Question 4

NIHSS score for

Mild stroke

Moderate stroke

Severe stroke

Answer 4

0-5

6-21

> 22

Question 5

Based on the local Philippines guideline what is the time frame for resolution of clinical symptoms of TIA?

Answer 5

Last less than an hour

Question 6

Risk of having stroke after a TIA is highest within what time frame?

Answer 6

Within 48 hours 25-50% will have stroke

10-15 % will have stroke within 3 months

Question 7

A 66 yo, diabetic female patient claimed that he had left sided weakness 2 days ago but resolved spontaneously. Should you hospitalize the patient or advise opd monitoring?

Answer 7

Yes

ABCD2 score is >/= to 3

A age > 60 = 1
B BP > 140/90 = 1
C Clinical feat 
-> unilat weakness = 2
-> language disturbance w/o weakness = 1

D diabtes = 1
D duration
-> >60 min = 2
-> 10-59 = 1
-> <10 = 0

Patient score 2+ 1+ 1 = 4

Question 8

What is the imaging modality of choice for suspected TIA patients?

Answer 8

MRI icluding DWI if not avialble CT scan should be done

• patients with TIA should ideally have neuroimaging within 24 hours

Question 9

First choice antiplatelet for TIA

Answer 9

Aspirin

Question 10

True or false aspirin and clopidgrel combination is recommended for stroke prevention?

Answer 10

False

Question 11

For patients who are candidates for Carotid endarterectomy when is the best time to perform the procedure after a TIA event?

Answer 11

Within 2 weeks

Question 12

Leading cause of embolic stroke?

Answer 12

AF

Accounts for 15% of all strokes

Question 13

CHA2DS2VASc score means?

Answer 13

C - CHF
H - Hypertension
A - Age > 75 (2)
D - Diabetes
S - Stroke/ TIA (2)
V - Vascular disease
A- Age 65-74
Sc- Sex (Female)

All have one point except the 2s

Question 14

Management for INR >9 without significant bleeding?

Answer 14

Hold drug
Give vitamin K one dose oral 2.5-5 mg
Repeat INR daily
Resume warfarin once INR is <3 but decrease dose by 10-20%

Question 15

CHA2DS2VASc score to start anticoagulation?

Answer 15

2 or greater

CHADS2 score of > 2 start warfarin

Question 16

Target INR for high risk patients such as those with prosthetic valves?

Answer 16

INR 2.5-3.5

Question 17

Calss IB indication drug alternative for warfarin?

Answer 17

Dabigatran

Question 18

For TIA and ischemic stroke patients precipitous drop in bp is avoided. How much is the safe range for lowering BP?

Answer 18

Not >15% of baselin MAP

Question 19

For TIA patients with non-cardioembolic cause ASA is given for how long in the early phase?

Answer 19

14 days at 160-325 mg/day

Question 20

You treat with BP lowering medications for ischemic stroke patients if MAP is?

Answer 20

> 130 mmHg

Question 21

When is O2 support given for ischemic stroke patients?

Answer 21

O2 saturation < 95%

Question 22

Further workup using CT with contrast, Ct angiogram, MRA or CTA is warranted for what group of patients?

Answer 22

< 45 yo
Normotensive
Lobar ICH
Uncertain cause of ICH
Suspected AVM

Question 23

For mild stroke how soon can rehab be initiated?

Answer 23

72 hrs post stroke once clinically stable

Question 24

For severe Hemorrhagic stroke supportive management with 20% mannitol is warranted. How much is the dose?

Answer 24

0.5-1 g/kg q 4-6 x 3-7 days

Question 25

Hypotension should be avoided in stroke patients. Permissive hypertension is allowed for?

Answer 25

1st 7 days

Question 26

What is the recommended IV fluid for stroke patients?

Answer 26

Isotonic solution such as PNSS

Question 27

Patient is for rTPA. BP was 180/90. This is a contraindication for rTPA True or false?

Answer 27

False SBP >185 DBP >110 At the time of treatment

Question 28

Normal range for ICP? CPP?

Answer 28

ICP 5-10 mmHg Cerebral perfusion pressure - 70-100 mmHg

Question 29

In acute ischemic stroke treatment BP is important. When is it warranted to treat with BP lowering medications?

Answer 29

SBP >220 DBP > 120 MAP >130 Treat SBP 185-220 or DBP 105-120 only if with compeling indication like AMI, Aortic disection, CHF, etc.

Question 30

For ICH ischemic penumbra is not present so a more aggressive BP lowering is safe. What are the critical values to consider in ICH? MAP SBP

Answer 30

Maintain MAP 110 Treat MAP if > 130 Treat SBP if > 180

Question 31

SAH has a propensity for delayed cerebral ischemia. What are the critical values to consider? MAP SBP

Answer 31

MAP 130-140 SBP 180-200

Question 32

What is the dose of IV rtpa?

Answer 32

0.9 mg/kg max of 90 mg | Give 10% as bolus the remainder over 60 minutes

Question 33

What is the golden window for RtPA?

Answer 33

0-3 hours May be effective upto 4.5-6 hours

Question 34

A patient who presents with hemianopsia withoit macular sparing and memory loss/ confusion most likely haa?

Answer 34

PCA stroke syndrome

Question 35

CT scan was done 30 minutes after a patient presented with acute stroke. On imaging it was noted that 1/2 of the teritory supplied by the MCA was affected. This is an idication for RtPA. True or false?

Answer 35

False Indications for rTPA 1. Clinical dx of stroke 2. Onset of symptoms = to 4.5 hours 3. CT scan showing < 1/3 of MCA teritory 4. >/= 18 years old 5. Consent given

Question 36

CBG was taken prior to rTPA and it showed 57 mg/DL. This is a contraindication for the therapy? True or false?

Answer 36

``` False Contraindication if CBG < 50 or > 400 Other notable CI - plt < 100 - hct < 25% - heparin in the past 48 hrs - deranged bleeding parameters - rapidly improving sx - prior cvd/ head injury in the past 3 months - prior ICH - major surgery in the past 14 days - minor stroke symptoms - GI bleed in the past 3 weeks - recent MI - coma ```

Question 37

Rapid correction of warfarin induced coagulopathy can be achieved using what blood component?

Answer 37

Prothrombin complex concentrates PCCs can reverse effects of oral factor Xa inhibitors

Question 38

Medication given for pxs taking Dabigatran who presents with serious bleeding

Answer 38

Idarucizumab