Pills and Prevention
Patients with TIA or AIS get this early monotherapy.
Aspirin (NNT=79 to prevent death/dependance, 140 for recurrent CVA, 89 for complete recovery).
Wait 24 hours if they had tPA
Patients who receive tPA are admitted to this unit.
ICU (BP monitoring, neuro checks)
The time of stroke onset is established based on this data point.
Last known well
What is the first imaging ordered for anyone with a suspected AIS.
Non-con CT head
Everyone admitted for stroke rule out should receive this cardiac evaluation.
Telemetry for 24-48 hours
For smokers with AIS, stroke guidelines support this intervention.
Behavioral interventions + Nicotine replacement
High-intensity behavior intervention (RR 1.37)
+Nicotine (RR 1.54)
tPA should ideally be administered within this time-frame.
<4.5 hrs from last known well
Use this physical exam to rule out a central cause of vertigo.
HINTS Exam
Head-impulse
Nystagmus
Test-of-skew
Patient was treated with tPA in the ED and you order this follow-up imaging.
What is a non-contrast CT head at 24 hours
Depression
Patients with these diagnoses get DAPT for at least 21 days.
High Risk TIA (ABCD2>3) and Minor Stroke (NIHSS<4)
HR 0.68 for recurrence at 90 days
Decrease from 6.5% to 5% ischemic events with 0.9% more major hemorrhage.
<185/110 before and <180/105 after
This scale predicts clinical outcomes and prognosis for patients with stroke.
NIH Stroke Scale (<4 good outcomes 75% 1 yr functional independence), >6 3x need for SNF or long term care). Does NOT guide tPA decisions.
Consider this imaging for patients with positional HA, vomiting, papilledema, vision Δ +/- seizures
MRV - dural venous thrombosis
Don't worry about treating blood pressures below this number for 48-72 hours.
220/110 (assuming: no TPA, no mechanical thrombectomy, and no other hypertensive issue)
Patients with AIS should start on a statin with this goal LDL.
<70
Only wait for this lab result before giving tPA.
Blood glucose.
Hypoglycemia can look like a stroke
Increased risk of hemorrhage
This score identifies patients with high risk of ischemic stroke within 1 week of TIA.
ABCD2 (Age, BP, Clinical Features, Sx Duration, Diabetes)
Some patients need an echocardiogram for secondary stroke work up. Patients at this age don't.
>60
When managing a patient with AIS, this is your glucose goal
140-180
Most patients with AIS and A-fib should start anticoagulation in this time frame.
4-14 days (conflicting evidence). Better composite outcome than <4 days.
Unless intracardiac thrombus or mechanical valve
Angioedema.
Stop infusion.
This scale is used to measure the degree of disability or dependence in people who have suffered as stroke.
modified Rankin Scale (mRS) 0-6.
Most widely used clinical outcome measure in clinical trials
A systematic review in 2012 evaluated the effect of MRI on AIS outcomes and found this.
No effect on outcomes or management.
Decision-analytical model showed routine MRI did not improve outcomes except >1 week symptoms (hemorrhage)
Guidelines 6.1
Acute ischemic stroke admission.