TNK
The maximum BP a patient can have to proceed with TNK administration
What is 185/110?
The score for Extinction/Inattention is given to the patient who is able to see both hands wiggling at the same time when testing vision, but when touching their arms simultaneously can only feel one.
What is 1?
The standard SBP goal for hemorrhagic stroke patients at LGH unless otherwise specified.
What is SBP<140? Then maintain 130-150.
Our door to CT goal for stroke alerts.
What is <15min?
Stroke mimics
seizures, migraines, hypoglycemia, Bell's Palsy, other metabolic derangements, functional neurologic disorders, radiculopathies
Complications we look out for after TNK
New or worsening headache
New or worsening altered level consciousness
New or worsening focal neuro deficits
Spontaneous bleeding elsewhere (gums, nose, mouth, etc.)
Anaphylaxis
Angioedema
The score for facial palsy when smiling but not visible at rest.
What is 1?
Components of the hemorrhagic stroke order set (List 3).
What are: Blood pressure medications (nicardipine, labetolol), NIH, GCS, dysphagia screen, check temp, BP parameters (in "notify"), HOB 30, seizure precautions, NPO
The maximum timeframe from LKW within which someone with an LVO can receive a mechanical thrombectomy.
What is 24hrs?
An assessment done on all patients with neuro chief complaint prior to giving anything PO.
What is a dysphagia screen?
The strict contraindications to TNK. (List 3)
ICH, ischemic stroke, intracranial trauma, cranial or spinal surgery in the last 3mo.
DOAC in the last 48hr.
Therapeutically anticoagulated (INR >1.7 Plts < 100K, PT >15 sec, aPTT >40 sec.
GI bleed in the last 3 weeks.
Known active bleeding
Arterial puncture at non-compressible site in the last week.
Unable to attain target BP.
CT with clear evidence of very large core and minimal penumbra.
The name for missing one quarter of the visual field in each eye. It receives a score of 1 on the NIHSS visual fields.
What is partial hemianopia?
The full name of a device that can be inserted into the brain to remove blood and CSF and monitor ICP.
What is an extraventricular drain (EVD)?
The standard window since LKW when we can give TNK.
What is 4.5hrs?
Risk factors for stroke (List 3).
HTN, HLD, DM, smoking, excessive alcohol, obesity, inactivity, age, illicit drug use, ethnicity, arrythmias (e.g. Afib), valvular disease, prior TIA or stroke
Sequence of VS and neuro checks after TNK
q15min x2hrs, Q30min x6hrs, Q1hr x16hrs
The scores for 1A and 1B on the NIHSS given to the intubated patient who grimaces and localizes to noxious stimuli.
What are 2 (1A) and 1 (1B)?
The most common cause of non-traumatic subarachnoid hemorrhages.
What is a ruptured aneurysm?
Our door to TNK goal for patients receiving TNK in the standard 4.5hr window.
What is 45min?
Posterior circulation strokes may not score as highly on NIH or LVO assessments. These strokes often present with these "5 Ds". (Name 2 of the Ds.)
dizziness, diplopia, dysarthria (or dysphonia), dysphagia, dystaxia (ataxia and/or impaired gait)
The lowest SpO2 we can document in the 24hr post-TNK without making a comment or treating it
What is 95%?
The items on the NIHSS that are scored a 0 for the comatose patient or any patient who cannot participate in the item testing (most others they score higher if unable to perform).
What are 7 (ataxia) and 11 (extinction/inattention)?
Hemorrhagic strokes can cause dangerous elevations in ICP (remember the Monro-Kellie Doctrine!). These are interventions for elevated ICP (List 3).
- elevate HOB
- align neck to promote venous return from the head
- remove noxious stimuli as possible (bright lights, loud noises, painful interventions)
- treat pain
- sedate if intubated, can consider barbituate coma and paralytics in extreme cases
- EVD for drainage
- hypertonic saline, mannitol
- craniectomy
- manage WOB
- hyperventilation (very short term intervention)
Our goal for time from arrival to puncture time in IR.
What is 60min?
The major arteries of the anterior circulation (name 2) and posterior circulation (name 2) of the brain.
Anterior: internal carotid artery (ICA), middle cerebral artery (MCA), anterior communicating artery (ACA), Posterior Communicating Artery
Posterior: Posterior cerebral artery, basilar artery (branches to pontine and superior cerebellar arteries), vertebral arteries, anterior and posterior inferior cerebellar arteries