Stroke Management Flashcards
What is the acronym used for assessing stroke symptoms?
FAST
FAST stands for Face, Arms, Speech, and Time to call emergency services.
What is the primary question to determine treatment options for a stroke patient?
Other line of questioning?
When was the patient last seen well?
● Nature of Sx
● Handedness - important for any neurological history & exam
● Important C/I to thrombolysis:
○ Recent surgery or trauma
○ Cranial: recent stroke, head injury, or brain cancer
○ Bleeding risk: anticoagulation or bleeding diathesis
What are the two main types of strokes?
- Ischemic stroke
- Hemorrhagic stroke
What is the percentage of ischemic strokes compared to hemorrhagic strokes?
Ischemic ~87%, Hemorrhagic ~13%
List the risk factors for ischemic stroke.
- Embolism (AF)
- Thrombosis (arteriopathy: HTN, hyperlipidaemia, DM, smoking, alcohol)
- Systemic hypoperfusion (shock)
- Cerebral venous sinus thrombosis (antiphospholipid syndrome, thrombophilia)
What are the symptoms suggestive of a hemorrhagic stroke?
- Meningism
- Severe headache
- Coma
What are the symptoms suggestive of a ischemic stroke?
- Carotid bruit
- AF
- IHD
- Past TIA
Classification of Ischemic Strokes?
Oxford/Bamford classification
based on initial Sx and not imaging
What is the NIHSS used for?
To measure severity of stroke and determine treatment and prognosis.
● <4: Px better, thrombolysis not recommended
● 4-25: good candidate for thrombolysis
What is the maximum score on the NIHSS?
42
Higher score = larger deficit
● <4: Px better, thrombolysis not recommended
● 4-25: good candidate for thrombolysis
What imaging is vital to exclude hemorrhagic stroke?
Non-contrast CT brain
Investigations for Stroke
Finger-prick glucose
Bloods:
- Glucose
- FBC
- U&E (pre-contrast renal baseline, hyponatraemia, etc)
- Coag studies
- BP: Must be <180/110
● Weight (thrombolysis dosing)
● ECG (AF) - Stroke Protocol Imaging
Contraindication to thrombolysis ?
C/I to thrombolysis:
■ Active internal bleeding
■ Recent haemorrhage, trauma, or surgery
■ Coagulation and bleeding disorders
■ Intracranial neoplasm
■ Stroke <3 months
■ Aortic dissection
■ Recent head injury
■ Severe HTN
■ BP >180/110
What to outrule in stroke patient prior to thrombolysis?
1) hypoglycaemia
2) hemorrhagic stroke on imaging
Timing for thrombolysis?
<4.5 hours since Sx onset
Considerations for Thrombolysis
Alteplase: 0.9 mg/kg (10% as IV slow bolus, other 90% as an infusion over 1 hour). Maximum 90 mg.
Patients are re-scanned 24 hours after thrombolysis to look for hemorrhagic transformation. If there is none, then patients can be commenced on 2 weeks of Dual Antiplatelet Therapy (aspirin + clopidogrel) followed by lifelong mono-antiplatelet therapy (clopidogrel).
Timing for Thrombectomy?
Thrombectomy is generally considered if the patient is <12 hours since stroke onset.
■ <6 hours (routinely)
■ <24 hours for certain cases
■ <48 hours in basilar artery thrombus
What lifestyle changes are recommended for secondary prevention of stroke?
- Smoking cessation
- Alcohol intake reduction
- Diet & exercise
- Diabetes management
What is the target LDL level for statin therapy after a stroke?
LDL <1.8
What does the Modified Rankin Scale assess?
Disability in patients who have suffered a stroke.
Fill in the blank: Patients should be re-scanned _______ hours after thrombolysis to check for hemorrhagic transformation.
24
What screening is recommended for young stroke patients (<65 years old)?
- Viral screen
- Vasculitis screen
- Thrombophilia screen
- Antiphospholipid syndrome screen
What is the indication for carotid endarterectomy (CEA)?
50-99% stenosis with recent CVA or TIA and good recovery
Asymptomatic (no TIA or stroke) but >70% stenosis in low risk patient
● 50-69% stenosis: only modest effect
● >70% stenosis: highly beneficial
What are the contraindications for carotid endarterectomy?
- Severe neurological deficits
- 100% occlusion
- Severe comorbidities (high ASA score)
