Stroke Guidlines TIA and AF Flashcards
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?
Mild
Mild stroke any or combi of the following
- Mild pure motor weakness 3-4/5
- Pure sensory deficit
- Slurred but intelligible speech
- Vertigo with incoordination
- Visual field deficits
NIHSS score 0-5
How is moderate stroke defined?
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
How do you define severe stroke?
Depp stupor or coma
NIHSS >22
NIHSS score for
Mild stroke
Moderate stroke
Severe stroke
0-5
6-21
> 22
Based on the local Philippines guideline what is the time frame for resolution of clinical symptoms of TIA?
Last less than an hour
Risk of having stroke after a TIA is highest within what time frame?
Within 48 hours 25-50% will have stroke
10-15 % will have stroke within 3 months
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?
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
What is the imaging modality of choice for suspected TIA patients?
MRI icluding DWI if not avialble CT scan should be done
- patients with TIA should ideally have neuroimaging within 24 hours
First choice antiplatelet for TIA
Aspirin
True or false aspirin and clopidgrel combination is recommended for stroke prevention?
False
For patients who are candidates for Carotid endarterectomy when is the best time to perform the procedure after a TIA event?
Within 2 weeks
Leading cause of embolic stroke?
AF
Accounts for 15% of all strokes
CHA2DS2VASc score means?
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
Management for INR >9 without significant bleeding?
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%
CHA2DS2VASc score to start anticoagulation?
2 or greater
CHADS2 score of > 2 start warfarin
Target INR for high risk patients such as those with prosthetic valves?
INR 2.5-3.5
Calss IB indication drug alternative for warfarin?
Dabigatran
For TIA and ischemic stroke patients precipitous drop in bp is avoided. How much is the safe range for lowering BP?
Not >15% of baselin MAP
For TIA patients with non-cardioembolic cause ASA is given for how long in the early phase?
14 days at 160-325 mg/day
You treat with BP lowering medications for ischemic stroke patients if MAP is?
> 130 mmHg
When is O2 support given for ischemic stroke patients?
O2 saturation < 95%
Further workup using CT with contrast, Ct angiogram, MRA or CTA is warranted for what group of patients?
< 45 yo Normotensive Lobar ICH Uncertain cause of ICH Suspected AVM
For mild stroke how soon can rehab be initiated?
72 hrs post stroke once clinically stable
For severe Hemorrhagic stroke supportive management with 20% mannitol is warranted. How much is the dose?
0.5-1 g/kg q 4-6 x 3-7 days
Hypotension should be avoided in stroke patients. Permissive hypertension is allowed for?
1st 7 days
What is the recommended IV fluid for stroke patients?
Isotonic solution such as PNSS
Patient is for rTPA. BP was 180/90. This is a contraindication for rTPA
True or false?
False
SBP >185
DBP >110
At the time of treatment
Normal range for
ICP?
CPP?
ICP 5-10 mmHg
Cerebral perfusion pressure - 70-100 mmHg
In acute ischemic stroke treatment BP is important. When is it warranted to treat with BP lowering medications?
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.
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
Maintain MAP 110
Treat MAP if > 130
Treat SBP if > 180
SAH has a propensity for delayed cerebral ischemia. What are the critical values to consider?
MAP
SBP
MAP 130-140
SBP 180-200
What is the dose of IV rtpa?
0.9 mg/kg max of 90 mg
Give 10% as bolus the remainder over 60 minutes
What is the golden window for RtPA?
0-3 hours
May be effective upto 4.5-6 hours
A patient who presents with hemianopsia withoit macular sparing and memory loss/ confusion most likely haa?
PCA stroke syndrome
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?
False
Indications for rTPA
- Clinical dx of stroke
- Onset of symptoms = to 4.5 hours
- CT scan showing < 1/3 of MCA teritory
- > /= 18 years old
- Consent given
CBG was taken prior to rTPA and it showed 57 mg/DL. This is a contraindication for the therapy?
True or false?
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
Rapid correction of warfarin induced coagulopathy can be achieved using what blood component?
Prothrombin complex concentrates
PCCs can reverse effects of oral factor Xa inhibitors
Medication given for pxs taking Dabigatran who presents with serious bleeding
Idarucizumab
