Risk Factors
Single most important treatable risk factor for stroke
Hypertension
Name the 3 Inclusion Criteria for TNK
-Clinical diagnosis of ischemic stroke causing measurable neurologic deficit
-Onset of symptoms <4.5 hours before beginning treatment; if the exact time of stroke onset is not known, it is defined as the last time the patient was known to be normal or at neurologic baseline
-Age ≥18 years
What is the max value a patient can score on NIH?
42
For patients with ischemic stroke who are not treated with thrombolytic therapy, HTN should not be treated till it exceeds _____ SBP and _____ DBP.
For patients with ischemic stroke who are not treated with thrombolytic therapy, blood pressure should not be treated acutely unless the hypertension is extreme (systolic blood pressure >220 mmHg or diastolic blood pressure >120 mmHg)
What are the three most predictive examination findings for the diagnosis of acute stroke?
Facial paresis, arm drift/weakness, and abnormal speech
Name 3 risk factors for ischemic stroke other than HTN
Hyperlipidemia
Diabetes
Smoking
Name the time frame for:
- Evaluation by physician
- Head CT or MRI scan
- Start of IVT
Evaluation by physician – 10 minutes elapsed from arrival
●Stroke or neurologic expertise contacted (ie, stroke team) – ≤15 minutes elapsed
●Head CT or MRI scan – ≤25 minutes elapsed
●Interpretation of neuroimaging scan – ≤45 minutes elapsed
●Start of IVT – ≤60 minutes elapsed
How often should NIH be calculated
A minimum of every 2 hours for the first 24 hours during reperfusion; after that obtain full NIHSS scores at least every 4 hours.
Goal SBP and DBP for ischemic stroke patients that received intravenous thrombolytic therapy
<180/105 mmHg for the first 24 hours after treatment
Name 3 mimics of acute CVA
- Hypoglycemia
- Seizure
- brain mass
What diet is recommended after stroke?
Mediterranean
When can patients on DOAC receive Thrombolysis?
Contraindication to IVT unless laboratory tests such as aPTT, INR, platelet count, ecarin clotting time, thrombin time, or appropriate direct factor Xa activity assays are normal or the patient has not received a DOAC dose for more than 48 hours, assuming normal renal function
calculate NIHSS for this scenario:
Facial Droop- Abnormal: Left side of facial droop, right side normal
Arm Drift- Abnormal: Left arm drifts slightly, right side normal
Speech- Abnormal: The patient’s speech is coherent,
but somewhat slurred.
Facial droop unilateral upper/lower =+3
Arm drift slight, unilateral = +1
Dysarthria: slurred but understandable = +1
Total: 5
What work up needs to be done after ischemic stroke
Lipid panel, A1c, PT/OT, echo
What percentage of strokes are ischemic?
80-85%
What cardiac conditions can predispose someone to ischemic stroke?
PFO
Afib
24 hours
Calculate NIHSS for this scenario:
- Level of consciousness: requires repeat stimulation to arouse
- Right leg some effort against gravity
- Right arm motor drift: no effort against gravity
- Level of consciousness: requires repeat stimulation to arouse = +2
- Right leg motor drift: some effort against gravity = +2
- Right arm motor drift: no effort against gravity = +3
total: 7
What medications should be started within the first 48 hrs after ischemic event
- High intensity statin for LDL >70
- antiplatelet or antithrombotic if not otherwise contraindicated
- VTE prophylaxis
- Anticoagulation for AFIB
Why do we allow permissive HTN in the first 24 hours?
To allow blood flow in watershed areas
What is the most common cause of ischemic stroke?
Intracranial atherosclerotic stenosis
What patients should not received IVT in the 3-4.5 hour window? (4)
-Hx of diabetes and prior stroke
- >80 yo
-NIHSS <25
-Pts on OAC
-CVA involving more than 1/3 MCA territory
What region of circulation is less likely to be capture on NIH?
Posterior circulation (symptoms like headache, nausea, vertigo, horners syndrome, memory impairments, nystagmus)
In patients with NIH >3 who are not given Thrombolytics or thrombectomy how long should they be on DAPT?
Aspirin and Plavix 3 weeks. Then Aspirin indefinitely (The CHANCE trial and secondary data of POINT have shown that short term usage of dual antiplatelet therapy further reduced up to ~30% of recurrent stroke without increased major bleeding compared with aspirin alone)
What blood pressure lowering medication should be avoided in acute stroke and why?
Nitrates - potential for venous dilation and increase in intracranial pressure