Stroke treatment

Question 1

Glycemic control

Answer 1

Hyperglycemia

Gaol: < 180 mg/dL

Treat with sliding scale insulin or SQ insulin

Question 2

Blood pressure

Answer 2

Within 48 hours:
Before tPA: < 185/110
tPA: < 180/105
No tPA: 220/110

After 48 hours:
< 130/80
If still elevated: resume home medications
If no home therapy, select therapy

Question 3

Monitoring blood pressure

Answer 3

Q15min x 2 hours–> q30 min x 6 hours–> q1h x 16 hours

Treatment:
Labetalol
Nicardipine
Sodium nitroprusside

Question 4

Alteplase

Answer 4

0.9 mg/kg IV–> MAX: 90 mg

Question 5

Tenecteplase

Answer 5

0.25 mg/kg IV–> MAX 25 mg

Question 6

tPA indication

Answer 6

Ischemic stroke–>DO NOT USE IN HEMORRHAGIC

No impact on mortality but can improve neurologic function

Question 7

tPA inclusion criteria

Answer 7

Ischemic stroke
Symptom onset: < or equal to 4.5 hours

Question 8

tPA exclusion criteria

Answer 8

Increased risk of bleeding (active, surgery, MI, anticoagulant)

BP > 185/110
BG < 50 mg/dL

Question 9

tPA side effects

Answer 9

Bleeding

Maintain BP < 180/105
AVOID antiplatelets or anticoagulants for 24 hours after

Cerebral edema

Question 10

Antiplatelets indication

Answer 10

Atherosclerotic: indefinitely

Cardioembolic: 2-14 days as bridge for anticoagulants

Question 11

Aspirin (high dose)

Answer 11

1st line for acute management
Who? all ischemic stroke if no CI
-wait 24 hours after tPA
-immediately if no tPA

Question 12

Aspirin + clopidogrel

Answer 12

2nd line for minor strokes (NIHSS < 4)

Question 13

Ticagrelor

Answer 13

2nd line for minor strokes (NIHSS < 4)

Question 14

Anticoagulants indication

Answer 14

Atherosclerotic: do not use
Cardioembolic: start > 2-14 days after stroke

What to do if a pt came in on an anticoagulant?
-d/c and start aspirin
-NO tPA