Week 1 Clinical Relevance Flashcards
What is ambulatory blood pressure monitoring?
Ambulatory Blood Pressure Monitoring (ABPM) is when your blood pressure is measured as you move around, living your normal daily life. It is measured for up to 24 hours. A small digital blood pressure monitor is attached to a belt around your waist and connected to a cuff around your upper arm. ABPM isn’t indicated in the acute phase of a cerebrovascular accident.
CT head was performed. Figure 1 is an unenhanced CT image at the level of the bodies of the lateral ventricles. Match the labels 1-4 with the correct responses.
1) Left frontal bone
2) left lateral ventricle
3)left centrum semiovale
4) left frontal bone
5) Left sulcus
What is the diagnosis?
There is a large area of low attenuation in the right cerebral hemisphere within the middle cerebral artery territory indicating cerebral infarction.
So this is a middle cerebral artery infarct or PACS.
How do paradoxical emboli occur?
Thrombotic infarcts are most common overall.
Paradoxical emboli occur when thrombus in the venous system or right side of the heart enter the arterial circulation usually through a patent foramen ovale and cause infarction in the distal arterial circulation.
What is a stroke unit?
Stroke unit is a discrete area within the hospital that is staffed by specialist MDT with access to monitoring and rehabilitation equipment. There will also be a regular MDT for goal setting.
Brain cell death can occur due to…….
1) Blockage (ischaemia)
2) Bleeding (haemorrhage)
What is the risk stratification score for TIA cases?
The ABCD2 score.
How can we treat TIAs to reduce the risk of strokes? (pt presenting early)
If pt presents early within 24hrs:
Immediate aspirin 300mg stat, then 75mg OD.
Clopidogrel 300mg stat, then also 75mg OD for 2 weeks.
PPI cover also recommended.
Specialist assessment to be done in 24hr symptom onset.
Secondary prevention as soon as diagnosis is confirmed.
Carotid duplex scanning in anterior circulation events and carotid endarterectomy if significant carotid artery stenosed by 50%.
If pt presents late (in excess of a week) what is the treatment for suspected TIA case to prevent Stroke?
Specialist assessment ASAP.
MRI Imaging is the mode of choice to exclude haemorrhage.
Immediately initiate clopidogrel too.
Secondary prevention as soon as diagnosis is made too.
All should receive secondary preventative advice like lifestyle modification, smoking cessation, BP management and lipid controls.
what is the relation between systolic BP and the RR of stroke?
High sys bp= higher RR of stroke
When is carotid endarterectomy suggested?
As early as possible for symptomatic stenosis where the artery has stenosed by 50% or more.
Outline the ASPECTS Score for early ischaemic stroke imaging and describe the score results and meaning.
scored out of 10, score of 10 is normal, no CT evidence of acute ischaemic stroke. if score is below 7, there is a risk of sPICH after thrombolysis.
What is thrombolysis?
Thrombolytic therapy (also called thrombolysis) is the use of medications to dissolve blood clots. Thrombolysis reduces damage to your body’s organs and tissues when there are clots by improving blood flow.
You may need thrombolytic therapy:
If a blood clot suddenly blocks a major vein or artery.
If blood-thinning medications (anticoagulants) haven’t reduced blood clots related to DVT, pulmonary embolism (PE) or PAD.
What are the contraindicated population who cannot have thrombolysis?
Healthcare providers don’t recommend thrombolytic therapy if you have conditions related to an increased risk of bleeding, such as:
Active bleeding.
Recent brain bleed/hemorrhage (intracranial hemorrhage).
Recent brain surgery or spine surgery.
Severe high blood pressure (hypertension).
Severe kidney disease.
Recent traumatic brain injury.
People who are pregnant or elderly also have an increased risk of complications.
Outline the three types of thrombolysis?
Systemic thrombolysis: An IV line that delivers medication into your bloodstream. Often used as an emergency procedure for conditions such as heart attack, PE and stroke.
Catheter-directed thrombolysis: A long catheter that brings medication directly to the blood clot. Often used as a scheduled procedure to treat DVT and PAD.
Mechanical thrombectomy: A long catheter with a rotating or ultrasound device, suction cup or fluid jet at the end that breaks up or suctions the clot. Sometimes used along with catheter-directed thrombolysis.
Outline the process of IV guided or systemic thrombolysis.
Your provider will usually deliver systemic thrombolytic therapy through an IV line in an intensive care unit (ICU). Your surgical team:
Gives you a sedative to relax you.
Uses a local anesthetic to numb the area for the IV.
Inserts the IV line into a vein in your arm. The thrombolytic medication travels through your bloodstream until it reaches the blood clot.
Removes the IV after the procedure and the incision is closed with a sterile plug.
The procedure usually takes about one hour.
Outline catheter directed thrombolysis
For a scheduled procedure, your provider usually uses catheter-directed thrombolysis. The team:
Gives you a sedative to relax you.
Uses a local anesthetic to numb the area where they’ll insert a long, thin tube (catheter).
Makes a small incision in your neck, groin, arm or behind your knee. Then place the catheter through a vein.
Puts the medication into the catheter that travels to the blood clot. They may also use a device on the end of the catheter to break up or suction the clot (mechanical thrombectomy). The medication may take up to two days to work. You stay in the hospital so your team can watch the blood clot.
Looks for any narrowed areas of your vein that may have caused a blood clot. Your team can open these areas with an angioplasty or stent.
Removes the catheter after the procedure. They close the incision with a sterile plug.
While the medication is working to break up the blood clot, your team uses X-rays to monitor its progress. They will also check your heart and lungs and watch your blood pressure. It can take up to 48 hours for the clot to dissolve.
What is ischaemic penumbra?
Ischaemic penumbra denotes the part of an acute ischaemic stroke that is at risk of progressing to infarction but is still salvageable if reperfused. It is usually located around an infarct core which represents the tissue which has already infarcted or is going to infarct regardless of reperfusion.
The primary aim of current acute stroke intervention is to prevent the penumbra from proceeding to established infarct.
How does alteplase work?
It is a tissue plasminogen activator (rtPA) or fibrinolytic .Fibrinolytic drugs act as thrombolytics by activating plasminogen to form plasmin, which degrades fibrin and so breaks up thrombi.
What are the indications for alteplase?
Defininte disabling focal neurology.
AND
Symptom onset in excess of 30 mins but less than 4.5 hrs.
What are the absolute contraindications for alteplase?
1) Hx of ICH evidence
2) GCS in excess of 8
3) Hypodensity in more than 1/3rd of Hemisphere as per ASPECTS score.
4) INR is greater than or equal to 1.7 and aPTT is greater than 35 or NOACs
5) Platelets count is less than 100 x10^9
6) Possible sub arachnoid haemorrhage
7) BP is greater than 185/110 x2 even with treatment
8) Rapidly resolving symptoms
what are the relative contraindications for alteplase?
1) Time of symptom onset is greater than 4.5 hrs
2) BM is less than 2.8 OR greater than 22 mmol/l
3) Bacterial endocarditis/pericarditis patient
4) Treated with LMW Heparin within 48 hrs
5) Previous stroke/head injury in last 3 months
6) Previous significant GI or Urinary bleed in last 21 days
7) Surgery or significant trauma in the last 14 days
8) Severe Liver disease, possibility of pregnancy
9) Severe pre- stroke morbidity
What is Tenecteplase?
Tenecteplase (TNK) is a single-bolus recombinant fibrinolytic agent used to manage intravascular clots. The drug is in the tissue plasminogen activator (tPA) class of medications. This is set to replace alteplase according to British Stroke consultants.
What are the possible side effects of using Tenecteplase when compared with other fibrinolytic agents?
Adverse effects of tenecteplase, including bleeding, anaphylaxis, thromboembolism, and arrhythmia, are similar to other thrombolytics.
Bleeding is the most common complication of tenecteplase and thrombolytic use. Bleeding can occur anywhere in the body, as well as at puncture and surgical sites. Intracranial hemorrhage poses the most significant concern for increased mortality. The incidence of symptomatic intracranial hemorrhage in patients receiving tenecteplase (2.9%) is comparable to patients receiving alteplase (2.7%), another thrombolytic agent.[24] The risk of bleeding with tenecteplase is increased with concomitant use of anticoagulants and antiplatelet agents.
Thromboembolic events and cholesterol embolization have been reported using thrombolytics, including tenecteplase. In addition, cardiac dysrhythmias have been associated with thrombolytic use in STEMI as an occurrence of tissue reperfusion.
