Diagnosis
What is the acronym used to define the signs and symptoms of a stroke and what does it mean?
ACT F.A.S.T
Face drooping
Arm weakness
Speech is slurred
Time to call 911
What are the two fibrinolytic options for the treatment of acute ischemic stroke?
Alteplase and Tenecteplase
Note: Tenecteplase 0.4 mg/kg single IV bolus has not been proven to be superior or inferior to alteplase but not be considered as an alternative to alteplase in patients with minor neurological impairment and no major cranial occlusion (Recommendation 3.6.2)
What is the medical term for the non-pharmacologic removal of a clot?
Mechanical thrombectomy
Threading a catheter through an artery in the groin up to the blocked artery in the brain. There, the stent will open up to grab the clot
What antithrombotic is used for secondary stroke prevention in a patient who has a cardio embolic stroke?
For a cardio embolic stroke, an anticoagulant is needed
First-line: DOAC (Apixaban, Dabigatran, Rivaroxaban, Edoxaban)
Alternative: Warfarin (Coumadin)
Note: It is also recommended for patients to control hypertension, dyslipidemia, and diabetes + smoking cessation & lifestyle modifications
What are the exclusion criteria for using IV alteplase?
Exclusion criteria:
Ischemic stroke, head trauma or surgery in last 3 months
GI hemorrhage in last 21 days
BP >185/110
Active internal bleeding
Platelet count <100,000/mm3
Current anticoagulant use with an INR >1.7 or PT >15 or aPTT >40
Head CT: Evidence of hemorrhage
What are the immediate diagnostic studies and tests to evaluate all patients who present to the Emergency Department with likely stroke signs & symptoms?
All patients
Non-contrast brain CT or brain MRI
Blood glucose
Oxygen saturation
Serum electrolytes/renal function tests*
Complete blood count, including platelet count*
Markers of cardiac ischemia*
Prothrombin time/INR*
Activated partial thromboplastin time*
ECG*
*Although it is desirable, fibrinolytic therapy should not be delayed
Selected patients (w/suspected)
TT and/or ECT
Hepatic function tests
Toxicology screen
Blood alcohol level
Pregnancy test
Arterial blood gas tests
Chest radiography
Lumbar puncture
Electroencephalogram
What is the blood pressure goal during and after administering IV rTPA or other acute reperfusion?
Maintain BP <180/105 for at least 24 hours (Recommendation I B-NR)
What are some lifestyle modifications that can help prevent secondary stroke?
Smoking Cessation:
Counseling
Oral smoking cessation medications (ie. Chantix)
1-800-QUIT-NOW (784-8669)
Decrease or eliminate alcohol consumption
Male: <2 drinks/day
Female: <1 drink/day
Weight loss
Physical activity: 30 minutes of moderate intensity 1-3 days/week
Diet
DASH Diet
Mediterranean diet
What antithrombotic is used for secondary stroke prevention in a patient who has a NONcardioembolic stroke? (List the drugs and dosing)
DOUBLE JEOPARDY: What is the name of the antithrombotic that was previously recommended for secondary stroke prevention in noncardioembolic stroke patients and is now discontinued from the market?
For a noncardio embolic stroke, an antiplatelet is needed
First-line: ASA 50-100 mg PO daily
Second-line: Clopidogrel (Plavix 75 mg daily
Note: For early secondary prevention in patients with noncardioembolic AIS, the selection of an antiplatelet agent should be individualized on the basis of patient risk factor profiles, cost, tolerance, relative known efficacy of the agents, and other clinical characteristics.
DOUBLE JEOPARDY: aspirin + dipyridamole (Aggrenox)
LL is a 78-year-old female (Ht: 175.3 cm, Wt: 76.0 kg) with a PMH of hypertension and no meds PTA who presents with gaze preference, and left hemiparesis. The last known well time was 2 hours ago. BP 156/94, total NIHSS: 19. The decision to administer tPA has been made with DKICP pharmacy consulted to dose. How much tPA should the patient receive and how should it be administered?
68.4 mg: Alteplase (Activase) inj 0.9mg/Kg = 0.9mg/kg x 76kg = 68.4mg IV
6.8 mg (10% of dose) as an IV bolus over 1 minute, followed by a 61.6 mg (90% of dose) as continuous infusion over 1 hour
What are some causes of a cardioembolic stroke?
Atrial fibrillation
Systolic heart failure
Prosthetic mitral valves
Endocarditis
Ventricular thrombi
Which antihypertensive medications are recommended by the guideline for management of blood pressure during and after reperfusion?
For hypertension management during and after reperfusion to maintain BP <180/105
Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg/min or
Nicardipine 5 mg/h IV, titrate up to desired effect by 2.5 mg/h every 5-15 min, max 15 mg/h or
Clevidipine 1-2 mg/h IV, titrate by doubling the dose every 2-5 min until desired BP reached (max 21 mg/h)
If BP is not controlled or DBP >140 mmHg, consider IV sodium nitroprusside
What is the recommendation for starting early rehabilitation for stroke patients?
It is not recommended to provide early rehabilitation for stroke patients within 24 hours
High dose, very early mobilization within 24 hours of stroke onset should not be performed because it can reduce the odds of a favorable outcome at 3 months
It is recommended that early rehabilitation for hospitalized stroke patients be provided in environments with organized, interprofessional stroke care (Recommendation 4.12.6)
RR is 66 yo male presented to a small rural hospital with CHF exacerbation and Afib on 3/9/21 0800. After diuretic & metoprolol treatment, he noted L sided weakness & L facial droop around 1100. Stroke code was activated and alteplase IV administered @1255. He was transferred to QMC for further f/u @1912. When and how do you start aspirin for him?
Start aspirin 24 hours after alteplase (alteplase was given @1255 on 3/9), so aspirin should be given on 3/10 after 1255. Dose is between 160 to 300 mg.
If not IV alteplase, aspirin is recommended within 24~48H after onset of stroke
PS is a 61 yo male, today at 1400 he complained of visual field deficits with seeing dark spots in half of his visual field. He has no history of migraines. EMS was activated and he was brought to QMC at 1450 as a stroke code. Initial head CT revealed no early ischemic or hemorrhagic abnormalities. After the Head CT, PS had full self resolution of neurologic symptoms (without intervention). What pharmacologic treatment would this patient qualify for?
This patient would be considered a TIA. PS could get clopidogrel 300 mg x1, then 75 mg daily for 90 days + Aspirin 81mg for 21 days (per CHANCE trial)
Mild Stroke, 3. NIHSS score 0-5, IV alteplase is not recommended for patients who could treated w/in 3 hours (Recommendation 3.5.3)
What risk factors that can cause a non-cardioembolic stroke?
Hypertension
Atherosclerosis
Diabetes
Dyslipidemia
Prior stroke or TIA
Smoking
Gender (female>male)
Ethnicity (highest risk in African American)
Age >55 years
Patent foramen ovale (PFO)
Sickle cell disease
Hypercoagulable states (Cancer, pregnancy, hormone therapy: estrogen, testosterone)
What treatment regimen and duration is given to patients who have a minor noncardioembolic ischemic stroke, an NIHSS score <3 and did not receive IV alteplase?
The dosing regimen: clopidogrel at an initial dose of 300 mg followed by 75 mg/d for 90 days plus aspirin at a dose of 75 mg/d for the first 21 days. (CHANCE trial)
What is the recommendation for routine screening for obstructive sleep apnea, a stroke risk factor, in patients with recent ischemic stroke?
Numerous studies have established an association between obstructive sleep apnea (OSA) and stroke, but routine screening for OSA is not recommended for acute ischemic stroke patients. (Recommendation 6.5.2)
The SAVE RCT study found no reduction of vascular events, including stroke, to (continuous positive airway pressure) CPAP vs without CPAP
Several ongoing National Institutes of Health–funded RCTs are further investigating the effects of CPAP in patients with AIS and OSA
(Case 1 of 2) DP is a 62 yo female with acute right MCA (Middle Cerebral Artery) occlusion and not eligible for IV tPA due to Eliquis use. PMH: HTN, DM, prior stroke (left MCA), obesity, high cholesterol, Afib; SCr: 0.7; LFT: WNL; Wt 85 kg
For her discharge, would you like to modify her home meds, if so how?
Meds PTA:
Lisinopril 2.5 mg PO QD, Diltiazem SR 120mg PO QD, Metformin 500 mg PO BID w/ meal, Glipizide 10 mg PO QD before breakfast, Simvastatin 10 mg PO QD, apixaban 2.5 mg PO BID
Simvastatin 10 mg → Atorvastatin 80mg (high intensity)
Apixaban 2.5mg BID → Apixaban 5mg BID
A patient comes into the ED today at 6 am with left-sided weakness, dysarthria, and left facial droop. The last known normal was the night before at 10 p.m. The head CT shows hypodensity in the right middle cerebral area (MCA) and no hemorrhage. The physician determines that this is a large vessel occlusion. NIHSS is 22. ASPECT score is 7. What acute treatment should this patient undergo?
Mechanical Thrombectomy
Name and describe the assessment tool used to evaluate all patients with a suspected stroke that may help influence treatment decisions?
The National Institutes of Health Stroke Scale (NIHSS)
1. Level of consciousness, orientation, response
2. Gaze
3. Visual fields
4. Facial movement
5. Motor function arm
6. Motor function leg
7. Limb ataxia
8. Sensory
9. Language
10. Articulation
11. Extinction and Inattention
0- No stroke symptoms
1-4 Minor stroke
5-15 Moderate stroke
16-20 Moderate-Severe stroke
21-42 Severe stroke
Patients with NIHSS score >22 are likely to have an extensive neurological deficit and may have an increase risk of intracerebral hemorrhage
What treatment is available for patients who present with stroke symptoms with unknown time of last known normal (eg, last seen normal before going to bed the night prior) who show a specific imaging result on MRI [diffusion-weighted (DW)-MRI lesion smaller than ⅓ of the middle cerebral artery (MCA) territory and no visible signal changes on fluid-attenuated inversion recovery (FLAIR)].
IV alteplase (0.9 mg/kg, max dose 90 mg over 60 minute with initial 10% of dose given as bolus over 1 minute) (Recommendation 3.5.2.3 IIa B-R; 2.2.2.3)
What is the general criteria for Mechanical thrombectomy (MT)?
Neuroimaging is consistent with small infarct core & No hemorrhage
Proximal large artery occlusion (LAO)
Performed at a stroke center with appropriate expertise in MT
The patient has a persistent, potentially disabling neurologic deficit
Treatment can be started within 24 H
(Case 2 of 2) DP is a 62 yo female with acute right MCA (Middle Cerebral Artery) occlusion and not eligible for IV tPA due to Eliquis use. PMH: HTN, DM, prior stroke (left MCA), obesity, high cholesterol, Afib; SCr: 0.7; LFT: WNL; Wt 85 kg
When would DP be able to start her DOAC for secondary stroke prevention?
DP can start apixaban between 4-14 days after the onset of right MCA occlusion
An AIS in the setting of atrial fibrillation, it is reasonable to initiate oral anticoagulation between 4 and 14 days after the onset of neurological symptoms (Recommendation 6.6.2)
A 72 yo male presents to the ED with disabling stroke symptoms (unresponsive, does not respond to commands, complete gaze palsy, unable to move BUE/BLE complete hemianopia, severe aphasia) with initial NIHSS 25. He was last seen normal 1 hour prior by his wife. Head CT showed distal occlusion with no early ischemic or hemorrhagic abnormalities. Patient was previously hospitalized 2 weeks ago for treatment of GI bleed and he currently does not take any medications at home. A1C 5.5% LDL 191 mg/dL What would be the next step for treatment?
Patient is not a tPA or thrombectomy candidate (no LVO). He should be managed medically = aspirin within 24-48 hours + high intensity statin
(Recommendation 3.9.1)
Exclusion criteria for tPA:
GI hemorrhage in the previous 21 days
Exclusion criteria for MT:
Distal occlusion and no LVO