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16 Cards in this Set
- Front
- Back
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What is the classification of stroke?
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Ischemic 87% :
Thrombotic (ddx atherosclerosis, vasculitis, polycythemia, arterial dissection, hypercoagulable state) Embolic (recent MI, mural thrombi, valvular vegetations, tumors, paradoxical emboli, septic emboli, particulat emboli (IVDU) Hypoperfusion (CHF) HEMMORRHAGIC ICH (10%) : HTN, amyloidosis, vascular malformations, anticoagulation, cocaine use SAH (3%) : Berry aneurysm formation, Vascular malformation rupture |
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DDx of Acute stroke syndrome
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Seizures/postictal paralysis
Syncope Brain neoplasm/abcess Epidural/subdural hematoma SAH Hypoglycemia Hyponatremia HTN encephalopathy Meningitis/encephalitis Hyperosmotic coma Wernicke encephalopathy Labynthitis Drug toxicity (Phenytoin, Carbamazepaine may present w ataxia, vertiga, N, abnormal reflex) Bell's palsy Complicated migraine Ménière disease Demyelinating disease (MS) Conversion disorder |
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What territory presents :
Contralateral sensory and motor sx in the lower extremity, w sparing of the hands and face |
Anterior cerebral Artery infarction
A L sided lesion is typically associated w akinetic mutism and transcortical motor aphasia (repetition ability retained). R sided infarction can result in confusion and motor hemineglect. |
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Typical symptom of internal carotid artery dissection
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Unilateral head pain (50-67%), face pain (10%), neck pain (25%)
A partial Horner syndrome (miosis and ptosis) occurs in less 50% of pts. Assocated CN palsy 12% |
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Typical sx of vertebral artery dissection
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posterior neck pain (46%) and headache (69%)
Headache typically occipital Other : unilateral facial paresthesia, dizziness, vertigo, N/emesis, diploplia, other visual disturbances, ataxia, lim weakness, numness |
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What is the gold for a patient who presents w an acute stroke in the ED
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the goal is to evaluate and to decide tx within 60 minutes of the patient's arrival in an ED.
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What are the recommendation for BP control in acute ischemic stroke?
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Patient who are not candidate to thrombolysis :
Permissive HTN w no attempt to lower BP unless SBP more 220 , DBP more 120 Candidate to thrombolysis : SBP more than 185, DBP more than 110 is contraindicated to thrombolysis |
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Approach to management of Arterial HTN before potential rTPA administration
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If the patient is a candidate for rtPA therapy, the target arterial BP are
SBP Less or equal 185 mmHG DBP Less or equal 110 mmHg Labetalol 10-20 mg IV over 1-2min, may R x 1 or Nitroglycerin paste, 1-2 in. to skin or Nicardipine infusion, 5mg/h titrate up by 2.5 mg/hr intervals of 5-15 min max 15mg/h When desired BP atteined, reduce to 3mg/h at 5-15 min intervals |
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What are the current recommendations for thrombolysis administration?
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Based largely on the NINDS data, the 1996 FDA approved the use of IV rtPA in acute ischemic stroke within 3 hrs or stroke onset.
The ECASS demonstrated efficacy with an expansion of the rtPA treatment window to 4.5h. Based on these data, AHA/ASA issued a scientific advisory that recommended rtPA should be administered to eligible patients who present between 3-4.5 hrs, as long as they met the ECASS criteria. |
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What is the dose of rtPA for acute stroke thrombolysis
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Total dose of rtPA is 0.9 mg/kg
Maximum dose of 90 mg 10% as a bolus remaining amount infused over 60 minutes BP + neuro VS q15min x 2 hours No anticoagulants or antiplatelet agents should be given in the initial 24hrs post tx |
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Name 10 exclusion criteria for thrombolysis in Acute Ischemic Stroke
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Sx consistent w SAH
Sz w postical residual neurologic impairments Previous head trauma or stroke within preceding 3m Previous MI within precedent 3m Previous GI or urinary tract hemorrhage within 21d Major surgery within preceding 14d Prior ICH Pretx SBP more 185 or DBP more 110 despite tx Evidence of active bleeding or acute major fracture Blood glucose less 2.7 mmol/L INR more 1.7 Use of heparin within preceding 48h AND prolonged PTT Platelet less 100 000/mm3 Head CT shows multilobar infarction or hemorrhage or tumor Failure of the pt or responsible party to understand the risks and benefits of, and alternatives to, the proposed treatment after a full discussion. |
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What is the recommended treatment for cervical artery dissection?
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IV heparin followed by warfarin
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What is indications of rTPA treatment in Acute Ischemic Stroke?
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Measurable dx of acute ischemic stroke (Use of NIHSS recommended. Stroke sx should not be clearing, minor, or isolated. Caution is advised before giving tx to pt w severe stroke (NIHSS more than 22))
Age more or equal 18 Time of onset of sx less or equal 3 h (may be extended to 3 to 4.5 hours if ECASS criteria are met) |
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What is the definition of a TIA?
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The proposed new definition of TIA is a “brief episode of neurological dysfunction caused by a focal disturbance of brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of infarction.”
TIAs are an important determinant of stroke, with 90-day risks of stroke reported as high as 10.5% and the greatest stroke risk apparent in the first week. |
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What antiplatelet therapy is recommended in TIA?
What is recommended in acute stroke? |
Current recommendations include dipyridamole plus aspirin, clopidogrol, and aspirin alone.
Oral administration of ASA within 24-48 hours after stroke onset is recommended. |
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What are CT signs of acute stroke?
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Loss of white-grey matter differentiation
Sulcal effacement (mass effect decreases visualization of sulci) Hypoattenuation on CT is highly specific for irreversible ischemic brain damage if it is detected within first 6 hours. Obscuration of the lentiform nucleus. Insular ribbon sign (hypodensity and swelling of the insular cortex) Dense MCA sign (result of thrombus or embolus in the MCA) http://www.radiologyassistant.nl/en/p483910a4b6f14/brain-ischemia-imaging-in-acute-stroke.html |
