Stroke therapy

Question 1

Every minute in which a large vessel ischaemic stroke is untreated, how much of the brain is lost?

Answer 1

1. 9 million neurons
2. 8 billion synapses

12 km of axonal fibres

Question 2

When does thrombolysis become more harmful for stroke treatment than beneficial?

Answer 2

4.5 hours

Question 3

What are the risk factors for haemorrhage due to thrombolysis for stroke therapy?

Answer 3

Infarct size
Vessel occlusion
Diabetes		
Blood pressure
Age
Stroke severity
Tissue changes
Antiplatelets

Question 4

What are predictors for Significant symptomatic intracerebral haemorrhage?

Answer 4

age
glucose
stroke severity
hyperdense middle cerebral artery on CT scan
ASPECTS score 
anti-platelet therapy.

Question 5

What thrombolytic agent is commonly used to treat stroke?

Answer 5

Alteplase

Question 6

What are the practicalities of fast treatment of stroke?

Answer 6

Call for help

Alert hospital team

Alert CT/radiology team

Keeping the patient + relatives informed

Question 7

Why is pre-hospital notification of a stroke patient by an incoming ambulance beneficial?

Answer 7

Reduces average door to review time

Reduces average door to CT scan time

Reduces average door to needle time

Question 8

What interventional procedure can be done alongside IVT (thrombolysis)?

Answer 8

Thrombectomy

Question 9

What does rTPA mean?

Answer 9

recombinant tissue plasminogen activator - thrombolytic agents

eg Alteplase, reteplase

Question 10

Whats better, IVT with thrombectomy or just IVT?

Answer 10

IVT + thrombectomy

Question 11

When would you not use thrombolysis to treat a stroke?

Answer 11

If it’s a haemorrhagic stroke

Question 12

What are the contraindications to thrombolysis?

Answer 12

Age > 80 
Hypertensive (even if controlled with drugs) 
Time of onset is >4 hours 
Severe stroke 
Stroke in the past 3 months 
Seizure  
Symptoms suggestive of sub-arachnoid haemorrhage 
Warfarin or Heparin 
History of prior stroke and concomitant diabetes 
Platelet count <100,000 
Hypoglycaemia or hyperglycaemia 
Haemorrhagic diathesis (tendancy)

Question 13

What aspects of a past medical history would you check before thrombolysis started?

Answer 13

Prior stroke (within last 3 months)

Intracranial haemorrhage

Other episode of severe/dangerous bleeding

Concomitant Diabetes

Haemorrhagic diathesis

Hypertension

Question 14

What is the first line investigation for stroke?

Answer 14

Urgent CT

Question 15

What scale is commonly used to grade a stroke patient?

Answer 15

NIHSS

Goes up to 42 I think (most severe)

Question 16

What is a Hemicraniectomy?

Answer 16

Surgical decompression of brain by removing part of the skull overlying the oedematous section of the brain

Used to treat cerebral oedema which can happen to people with strokes

Question 17

When should Hemicraniectomy be performed?

Answer 17

For individuals aged up to 60 years who suffer an acute Middle Cerebral Artery territory ischaemic stroke complicated by massive cerebral oedema, surgical decompression by hemicraniectomy should be offered within 48 hours of stroke onset

Question 18

Aside from thrombolysis, what other agent should be given to patients with acute stroke?

Answer 18

Aspirin

Question 19

What part of the past medical history puts someone most at risk of having a stroke?

Answer 19

Having a previous stroke

Question 20

What other cerebrovascular event increases the risk of stroke, and by how much?

Answer 20

TIA

1/3rd of people who have a TIA will have an acute stroke

Question 21

Why is early treatment of TIA/minor stroke important?

Answer 21

Early initiation of preventative treatment can reduce the risk of early recurrent stroke by 80%.

For patients with a TIA, evaluation and initiation of treatment in a specialised outpatient clinic is associated with a reduced risk of subsequent stroke

Question 22

What drugs are used in secondary prevention of another stroke?

Answer 22

Clopidogrel 75 mg
Or
Aspirin 75mg + dipyridamole MR 200mg bd

Statin

Blood pressure drugs, even if blood pressure in normal range

Question 23

What procedure can be carried out for secondary prevention of stroke?

Answer 23

Carotid endarterectomy

Question 24

How much does a carotid endarterectomy reduce the risks associated with stroke?

Answer 24

50-69% stenosis: risks of stroke or death reduced by 7-9% at 5 years after surgery

> 70% stenosis: risks of stroke or death reduced by 14-19% at 5 years after surgery

Question 25

What are the indications for a carotid endarterectomy?

Answer 25

Anterior circulation

TIA or stroke with
good recovery

70% occlusion