Stroke and TIA Overview
40 Questions
0 Views

Choose a study mode

Play Quiz
Study Flashcards
Spaced Repetition
Chat to lesson

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is a common symptom associated with thrombosed ophthalmic artery?

  • Severe headache
  • Transient loss of vision (correct)
  • Difficulty speaking
  • Sudden dizziness

    • What distinguishes anterior circulation strokes from posterior circulation strokes within the first 24 hours?

  • Impaired judgment (correct)
  • Loss of consciousness
  • Lower limb paralysis
  • Visual agnosia

    • Which of the following risk factors is most commonly associated with hemorrhagic stroke?

  • High cholesterol
  • Diabetes mellitus
  • Cerebral amyloid angiopathy (correct)
  • Atrial fibrillation

    • What transportation protocol is recommended for patients with suspected large vessel occlusion stroke?

    <p>Transport to a comprehensive stroke center if travel time is under 15 minutes longer</p> Signup and view all the answers

    Which imaging method is most capable of identifying parenchymal hemorrhages greater than 1 cm?

    <p>CT scan</p> Signup and view all the answers

    What is NOT typically a symptom of posterior circulation strokes?

    <p>Impaired judgment</p> Signup and view all the answers

    Which stroke center provides the capability for advanced surgical and endovascular interventions?

    <p>Comprehensive Stroke Center</p> Signup and view all the answers

    In diagnosing ischemic stroke, how soon can early ischemic changes appear on a CT scan?

    <p>Within 3 hours</p> Signup and view all the answers

    Which type of stroke accounts for the majority of cases?

    <p>Ischemic stroke</p> Signup and view all the answers

    What is the in-hospital mortality rate for hemorrhagic stroke?

    <p>40% to 60%</p> Signup and view all the answers

    Which symptom is NOT typically associated with a transient ischemic attack (TIA)?

    <p>Acute infarction</p> Signup and view all the answers

    What is the primary treatment recommendation for high-risk TIA patients?

    <p>Aspirin alone</p> Signup and view all the answers

    Which mnemonic helps in reading a CT head in emergency settings?

    <p>BLOOD CAN BE VERY BAD</p> Signup and view all the answers

    Which of the following conditions crosses sutures but does not cross the midline?

    <p>Subdural hematoma</p> Signup and view all the answers

    What does a low ABCD2 score indicate for TIA patients?

    <p>Low risk of subsequent stroke</p> Signup and view all the answers

    What should be examined to evaluate for intracranial pressure on a CT head scan?

    <p>Cisterns appearance</p> Signup and view all the answers

    What is the primary purpose of the NIHSS scoring tool?

    <p>To assess neuro-deficit and determine treatment options</p> Signup and view all the answers

    Which subtle early ischemic change is NOT associated with increased risk of intracranial hemorrhage?

    <p>Hyperdense artery sign</p> Signup and view all the answers

    What should be the target blood glucose level for a patient after a stroke?

    <p>140-180 mg/dl</p> Signup and view all the answers

    Which condition is a contraindication for administering IV thrombolytic therapy with alteplase?

    <p>Ischemic stroke with symptom onset &gt; 3 or 4.5 hours</p> Signup and view all the answers

    What is the recommended blood pressure for administering tPA in patients with acute ischemic stroke?

    <p>Less than 185/110 mmHg</p> Signup and view all the answers

    Which of the following statements is true regarding the use of aspirin after a stroke?

    <p>Aspirin is recommended within 24 to 48 hours if tPA is not given</p> Signup and view all the answers

    What is the maximum dosage for alteplase in patients receiving thrombolytic therapy?

    <p>0.9 mg/kg (maximum dose 90 mg)</p> Signup and view all the answers

    What should be avoided to help in the management of patients with stroke?

    <p>Fluid overload</p> Signup and view all the answers

    What was the outcome of the ENCHANTED trial regarding low dose alteplase compared to standard dose alteplase?

    <p>Low dose alteplase was non-inferior to standard dose regarding death and disability.</p> Signup and view all the answers

    Which patient scenario would allow the administration of IV alteplase?

    <p>A patient with recent drug abuse history.</p> Signup and view all the answers

    What is the recommendation from AHA/ASA regarding the dose of alteplase for treatment?

    <p>Standard dose of 0.9 mg/kg is recommended.</p> Signup and view all the answers

    What effect does tenecteplase have compared to alteplase according to the EXTEND-IA TNK trial?

    <p>Associated with better functional outcomes and higher incidence of reperfusion.</p> Signup and view all the answers

    What precautions should be taken when monitoring a patient following thrombolysis?

    <p>ICU monitoring for 24 hours is recommended with repeat imaging in case of deterioration.</p> Signup and view all the answers

    What is a common complication associated with IV alteplase treatment?

    <p>Intracranial hemorrhage.</p> Signup and view all the answers

    What characterizes the intake of aspirin and clopidogrel prior to stroke treatment?

    <p>It is recommended to outweigh the risk of intracranial hemorrhage.</p> Signup and view all the answers

    What is the initial dosing recommendation for administering ticagrelor?

    <p>Implement a bolus dose over 1 minute is advised.</p> Signup and view all the answers

    What is the recommended initial treatment for a patient diagnosed with symptomatic intracerebral hemorrhage (ICH)?

    <p>Transfusion of 10 U cryoprecipitate</p> Signup and view all the answers

    Which factor is NOT a risk indicator for bleeding in patients with suspected stroke?

    <p>Presence of mild stroke symptoms</p> Signup and view all the answers

    In the comparison of mechanical thrombectomy versus dual therapy, what was a notable outcome of dual therapy?

    <p>Higher likelihood of 3-month functional independence</p> Signup and view all the answers

    Which of the following reversal agents is appropriate for a Vitamin K antagonist with an INR greater than 1.4?

    <p>3,4 PCC or FFP</p> Signup and view all the answers

    What condition is indicated for surgical evacuation in intracerebral hemorrhage management?

    <p>Neurological deterioration or coma</p> Signup and view all the answers

    Which of the following statements about hemorrhagic stroke management is true?

    <p>Avoiding fever is crucial in management</p> Signup and view all the answers

    Which neurological symptom is characterized by an inability to recognize objects despite intact sensory function?

    <p>Visual agnosia</p> Signup and view all the answers

    Which treatment has shown to be potentially more effective than mannitol in managing intracranial pressure?

    <p>Hypertonic saline (HTS)</p> Signup and view all the answers

    Study Notes

    Stroke

    • Stroke is any vascular injury that reduces cerebral blood flow (CBF) to the brain, retina, or spinal cord, causing neurologic impairment.
    • 87% of all strokes are ischemic in origin, 13% are hemorrhagic strokes
    • Ischemic stroke has an in-hospital mortality rate of 5% to 10%
    • Hemorrhagic stroke has an in-hospital mortality rate of 40% to 60%
    • Only 10% of stroke survivors will recover completely.

    Transient Ischemic Attack (TIA)

    • TIA is a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction.
    • Symptoms of TIA typically last less than 20 minutes.
    • 10% of TIA patients will have a stroke within 90 days.

    Risk Factors for TIA

    • Hypertension
    • Diabetes mellitus
    • Symptoms lasting ≥ 10 minutes
    • Motor deficits
    • Speech impairment

    ABCD2 Score

    • Used to assess the risk of stroke after a TIA.
    • A score of ≥ 4 indicates a high-risk of stroke within 90 days.

    NIHSS Score (National Institutes of Health Stroke Scale)

    • Used to assess neurologic deficit in stroke patients.
    • A score > 3 indicates a moderate to major ischemic stroke.

    Treatment for Stroke

    • Low-risk TIA or moderate to major ischemic stroke (NIHSS > 3) are treated with aspirin alone.
    • High-risk TIA (ABCD2 score ≥ 4) or minor ischemic stroke (NIHSS score ≤ 3) are treated with aspirin and other medications.
    • IV thrombolytic therapy and mechanical thrombectomy are used in acute stroke.

    CT Head Assessment

    • Use the mnemonic "Blood Can Be Very Bad" to remember what to look for in a CT head:
      • Blood - Look for blood in the cisterns (subarachnoid hemorrhage).
      • Can - Check the cisterns for signs of high intracranial pressure.
      • Be - Assess brain symmetry, sulci/gyri appearances, gray-white differentiation, and any brain shift.
      • Very - Examine the ventricles for dilation or compression/shift, and vessels for signs of clot.
      • Bad - Evaluate the bones for fractures or other abnormalities.

    Anterior Circulation Stroke

    • Symptoms progress within the first 24 hours.
    • Rarely includes loss of consciousness (LOC).
    • Frontal lobe dysfunction: AMS (altered mental status), impaired judgment and insight.
    • Paralysis and hypesthesia (decreased sensation) of the lower limb contralaterally (opposite side).
    • Ipsilateral (same side) Hemianopsia (blindness in half of the visual field).
    • Agnosia (inability to recognize objects) on the dominant side of the brain.
    • Aphasia (inability to speak) on the dominant side of the brain.

    Posterior Circulation Stroke

    • Symptoms progress for up to 3 days.
    • LOC + N/V (nausea and vomiting).
    • Brain stem and cerebellar dysfunction: Vertigo, dysphagia (difficulty swallowing), spasticity, ataxia (loss of coordination), and nystagmus (involuntary eye movements).
    • Crossed deficits (symptoms on one side of the body with the other side unaffected).
    • Homonymous hemianopsia (blindness in the same half of the visual field on both eyes).
    • Visual agnosia (inability to recognize objects seen).
    • Alexia (inability to read) + dysarthria (difficulty speaking).

    Hemorrhagic Stroke

    • Clinical presentation can be similar to ischemic stroke.
    • 30-day mortality rate of up to 50%.
    • Hypertension and cerebral amyloid angiopathy are most common risk factors.

    Pre-Hospital Stroke Assessment

    • Mission: Lifeline Severity-based Stroke Triage Algorithm for EMS recommends transport to a comprehensive stroke center for suspected large vessel occlusion stroke if travel time is < 15 minutes longer than the closest primary stroke center.

    Stroke Centers

    • ASRH (Acute Stroke Ready Hospital) - Establishes initial stroke diagnosis and provides initial care.
    • PSC (Primary Stroke Center) - Offers stroke infrastructure, including a stroke team, stroke unit, patient care protocols, and support services, including CT and lab testing availability.
    • CSC (Comprehensive Stroke Center) - Offers advanced imaging modalities, performs surgical and endovascular interventions, and has a stroke unit and stroke registry.

    Management of Stroke

    • Maintain airway.
    • Prevent dehydration and fluid overload.
    • Keep oxygen saturation above 95%.
    • Maintain blood glucose level at 140-180 mg/dl.

    BP Control

    • For patients receiving tPA: Less than 185/110 mmHg.
    • For patients not receiving tPA: Less than 220/120 mmHg or a mean arterial pressure (MAP) of 130.

    Reperfusion Therapy

    • IV thrombolytic therapy: Uses IV alteplase to dissolve the blood clot.
    • Mechanical thrombectomy: Uses a catheter to remove the clot.

    IV Alteplase Therapy

    • Eligibility: Patients must meet certain criteria, including time of onset, NIHSS score, and prior medical history.
    • Contraindications include: Onset time > 3 or 4.5 hours, history of ICH, ischemic stroke within 3 months, SAH, BP > 185/110, GI/GU bleed within 21 days, coagulopathy, LMWH within 24 hours, or DOAC use within 48 hours.

    Aspirin Therapy

    • Recommended for patients not eligible for tPA within 24-48 hours of symptom onset.

    Alteplase and Tenecteplase Dosage

    • Alteplase 0.9 mg/kg IV (maximum 90mg) over 60 minutes.
    • Tenecteplase 0.25 mg/kg IV (maximum 25mg) single bolus over 1 minute.

    Low-Dose Alteplase (ENCHANTED Trial)

    • Low-dose (0.6 mg/kg) was non-inferior to standard dose (0.9 mg/kg) in terms of death and disability at 90 days.
    • Fewer symptomatic ICH with low-dose alteplase (1.0%) compared to standard dose (2.1%).
    • Low-dose is current practice in Japan, but AHA/ASA recommend standard dose.

    Tenecteplase (EXTEND-IA TNK Trial)

    • Tenecteplase had higher incidence of reperfusion and better functional outcome compared to alteplase.
    • ICH was similar in both groups.

    Thrombolysis in Patients on Anticoagulants

    • Avoid administering IV alteplase to patients who have received a full treatment dose of LMWH within the previous 24 hours.
    • Avoid alteplase for patients taking direct thrombin inhibitors or direct factor Xa inhibitors.
    • Refer to specific guidelines for managing patients on anticoagulants.

    Symptomatic Intracerebral Hemorrhage (ICH) Following Thrombolysis

    • This is a serious complication that can occur after tPA treatment.
    • Typically occurs within 36 hours after infusion.
    • Symptoms: neurological deterioration, and new or worsening neurologic deficits.
    • Requires monitoring for 24 hours in the ICU.
    • Treatment includes cardiovascular and respiratory support, BP management, neurological monitoring, prevention of hematoma expansion, control of ICP, and seizure control.

    Mechanical Thrombectomy

    • Candidates for mechanical thrombectomy:
      • Patients with last known normal time less than 24 hours.
      • Proximal LVO (M1 branch of MCA, ICA, basilar artery).
      • Moderate to severe stroke symptoms.
      • Meeting DAWN or DEFUSE3 eligibility criteria.
      • Other inclusion criteria determined by neurology and interventional radiology.
    • Dual therapy (thrombectomy and IV thrombolytics) is associated with a higher likelihood of 3-month functional independence and lower odds of 3-month mortality compared to thrombectomy alone.
    • No randomized control trials of mechanical thrombectomy for posterior circulation LVO.

    Hemorrhagic Stroke Management

    • Intensive monitoring of airway, BP, ICP control, seizures, and herniation prevention.

    Reversal of Anticoagulants

    • Vitamin K antagonists (INR > 1.4): IV Vitamin K or 3,4 PCC, FFP.
    • Dapigatran: Idarucizumab, PCC, FFP.
    • Factor Xa inhibitors: Andexanet alfa, 4 PCC.
    • COX inhibitors or ADP receptor inhibitors: Desmopressin.
    • Platelet transfusion?

    ICP Management

    • Hypertonic saline (HTS) or mannitol: Some trials showed HTS is more effective than mannitol.
    • Avoid hypo or hyperglycemia.
    • Avoid fever.
    • Corticosteroids are not recommended.
    • Sedation and seizure control.

    Surgical Evacuation

    • Indicated for supratentorial ICH, neurological deterioration, coma, midline shift, or high ICP refractory to medical management.
    • Minimally invasive surgical approach is preferred over open craniotomy.

    Agnosia

    • An inability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss.

    Aphasia

    • An inability to comprehend or formulate language because of damage to specific brain regions.

    Visual Agnosia

    • The inability to recognize seen objects despite seemingly intact visual perception

    Studying That Suits You

    Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

    Quiz Team

    Related Documents

    Stroke Presentation & Management PDF

    Description

    This quiz covers essential information about strokes, including ischemic and hemorrhagic types, transient ischemic attacks (TIA), and their associated risk factors. Understand the significance of the ABCD2 and NIHSS scores in assessing stroke risk and patient outcomes.

    More Like This

    Use Quizgecko on...
    Browser
    Open
    Browser
    Browser