NIHSS / RACE
NIHSS stand for...
National Institute of Health Stroke Scale
TPA stands for...
Tissue Plasminogen activator
- Mechanism of action
This is the "door-to-groin" national standard (in minutes) for treatment in patients with acute ischemic stroke eligible for mechanical thrombectomy
< 90 minutes
- FMC standard is < 60 minutes
Is the most common cause of SAH
What is trauma (80%)
- Ruptured brain aneurysm is the most common cause of spontaneous (non-traumatic) SAH
Is the most common cause of spontaneous ICH in adults
Hypertension
- Up to 70% in patients < 70 yo
- 50% of patients > 70 yo
The meaning of RACE acronym...
Rapid Arterial Occlusion Evaluation
This is the "door-to-needle" national standard (in minutes) for treatment in patients with acute ischemic stroke eligible for IV-tPA
< 60 minutes
- FMC standard is < 30 minutes
This is the vessel most likely to have an emboli (blood clot)
What is the Middle Cerebral artery (MCA)
This symptom is most commonly seen in patients with subarachnoid hemorrhage
What is thunderclap headache (WHOL)
These symptoms are more commonly seen in ICH compared to ischemic strokes
Nausea / vomiting
Severe headache on presentation
Unresponsiveness / quick deterioration of MS
Systolic BP > 220 mmHg
Blurred vision
The RACE number at which rescue should call a pre-alert and transfer patient to a CSC
RACE of 5 or more
AND/OR a PLUS (+)
20 year old female on OCPs comes with acute onset of minimal left lower face weakness that started 1 hour ago. Patient works as a Victoria Secret top model. Head CT w/o contrast showed no evidence of ICH or other acute intracranial abnormalities. NIHSS = 1. Provided no contraindications are present, would you give IV tPA to this patient.
YES / NO
- Talk to the patient and explain about ischemic strokes and understand patient's concept of disability.
- Explain the risks and benefits of IV-tPA therapy.
- "Disabling symptoms" can be absolute or patient dependent.
This trial evaluated stroke patients with LVO in the time window between 6h - 24h and its' results expanded the thrombectomy window.
What is the DAWN trial
Percentage of patients with aneurysmal SAH that are treated via neuro-endovascular approach
80%
Most important risk factor for recurrent ICH
Uncontrolled HTN
An NIHSS above this number, the use of tPA is not advised in the 3-4.5h extended window
> 25
60 year-old male with h/o HTN, DM-2, HLD, CAD, and tobacco smoking comes with acute onset of vertigo, nausea/vomiting, and RUE incoordination. Head CT w/o contrast showed no ICH. NIHSS = 1. Provided no contraindications, would you give tPA to this patient.
YES
- NIHSS was designed for strokes in the anterior circulation (Carotid system: ICA, MCA, ACA), therefore signs and symptoms of ischemic strokes in the posterior circulation (brainstem/cerebellum: vertebral arteries; Basilar artery) are underscore.
56 year-old female with h/o HTN and Atrial fibrillation was admitted with acute onset of left MCA syndrome from LVO that started 6 hours ago. Patient stopped her AC 2 days prior for a colonoscopy study. Patient underwent successful thrombectomy. 12h after her procedure an in-house stroke alert is called on this patient because of worsening neuroexam. What would be the next appropriate diagnostic image?
What is head CT w/o contrast
Is the percentage of patients with SAH that die in the field
33% (1 out of 3)
2 out of 3 make it to the hospital but:
- 50% either die or are eventually discharge with significant disability
- 50% survives with no major or none disability
These are the 4 cardinal treatment approaches in patient with spontaneous ICH
1. BP control (keep less than 140 mmHg)
2. Reverse coagulopathy if known or suspected
3. Protect airway (rapid decompensation may occur in first 3h)
4. Identify and treat possible increased intracranial hypertension (signs; Mannitol; EVD)
Percentage of likelihood for presence of LVO in patient with a RACE of 5
40%
These 2 medications have anti-thrombolytic effect and may be used in patients with post IV tPA induced brain bleed.
Tranexamic acid
Aminocaproic acid
60 year-old patient with acute onset of altered mental status, weakness in all 4 extremities, disconjugate gaze, and severe slurred speech. Head CT w/o contrast showed no ICH. This clinical presentation is very suggestive of an ischemic stroke from an occlusion of which artery?
Basilar artery
Percentage of patients with aneurysmal SAH and unprotected aneurysm that experience re-bleed 2 weeks after initial bleed
25%
This score is used to predict 30-day mortality in hemorrhagic stroke
What is ICH score
- Age of 80 or more
- ICH volume >30 cc
- Presence of intraventricular hemorrhage (IVH)
- GCS
- Infratentorial (posterior fossa)