OME - Stroke

Question 1

3 types of stroke?

Answer 1

1. Thrombotic:Ischemic
2. Embolic: Ischemic
3. Hemorrhagic stroke

Question 2

What type of hemorrhage is a hemorrhagic stroke?

Answer 2

Intracerebral

Question 3

Risk factors thrombotic stroke?

Answer 3

Same as MI:

1. Smoking
2. Obesity
3. FH
4. TIIDM, Htn, Hld

Question 4

Sources embolic stroke?

Answer 4

1. Carotid artery stenosis
2. A fib
3. Bad valve in heart
4. Septic from IE

Question 5

Presentation stroke?

Answer 5

1. Focal neurologic deficit

Question 6

What do the anterior cerebral arteries feed?

Answer 6

1. Feet

2. Legs

Question 7

What does MCA feed?

Answer 7

1. Hands
2. Arms
3. Face
4. Speech

Question 8

What to PCA feed?

Answer 8

1. Visual Cortex

Question 9

What does the basilar artery arrive from?

Answer 9

2 vertebral arteries

Question 10

What can cause locked in syndrome?

Answer 10

Occlusion basilar artery

Question 11

Presentation occlusion vertebral basilar System?

Answer 11

Syncope

Question 12

What controls coordination?

Answer 12

Cerebellum - finger to nose, ambulation (ataxia)

Question 13

What side of body does right brain stroke impact?

Answer 13

Left body, and vice versa

Question 14

Is bilateral body nuero loss ever stroke?

Answer 14

Never a SINGLE stroke

Question 15

Presentation stroke patient?

Answer 15

1. Vasculopath
2. Afib/flutter, valve no on coag
3. Young woman c/o neck pain post trauma
   - Could be a carotid dissection

Question 16

What is Cushing syndrome?

Answer 16

Sign of intracerebral hemorrhage.

1. Altered breathing
2. Bradycardia
3. Hypertension

Question 17

First step someone comes in w/ possible stroke?

Answer 17

Non contrast CT head

• The purpose is to rule out bleed
• Blood is white w/o contrast
• Also much rapider as don’t have to wait for contrast to distribute

Question 18

Next step in hemorrhagic stroke after diagnosis?

Answer 18

1. Drop BP with drip
2. Call neuro: coil? clip? craniotomy?
3. FFP if INR elevated

Question 19

How does clip work? Coil?

Answer 19

Clip: need to open brain to close off vessel
Coil: Need to go through vessel

Question 20

Next step after diagnosing nonhemorrhagic stroke?

Answer 20

Decide if we give TPA

Question 21

Work up ischemic stroke if survive?

Answer 21

1. 2d Echo (TTE) - vegetation?
2. Carotid US -
3. EGK monitoring - Afib or flutter?

Question 22

Next step if stroke and afib or flutter?

Answer 22

Anticoagulation:
1. Warfarin
or
2. NOAC
***Heparin bridge NOT needed

Question 23

Next step in stroke if thrombus on TTE?

Answer 23

Anticoagulation:
1. Warfarin
or
2. NOAC
***Heparin bridge IS needed

Question 24

Next step in stroke if Carotid artery stenosis?

Answer 24

1. Less than 70% no symptoms:
   - Medical mgmt
2. Greater 70% symptomatic:
   - Surgical mgmt
3. Greater 80% no symptoms:
   - Surgical MGMT

Question 25

What is the penumbra?

Answer 25

Area around stroked out area that is at risk - Used to wait on enterectomy to preserve - Now we no longer wait

Question 26

What is CPP?

Answer 26

"Cerebral perfusion pressure" | - MAP minus ICP

Question 27

Who gets TPA?

Answer 27

1. Over 18 2. Focal neurologic stroke 3. Less than three hours - 4.5 non diabetics 4. BP under 180/105

Question 28

Contraindication tPA?

Answer 28

1. History Brain bleed 2. Recent surgery 3. Risk of bleeding - GI bleed?

Question 29

Acute management stroke no tPA?

Answer 29

1. No heparin 2. No anticoag 3. Antiplatelet - Aspirin 325g 4. Control sugars - mildly - HYPOglycemia risk for low perfusion 5. Permissive htn first 24 hours - 220 / 120

Question 30

Why do we allow permissive htn in first 24 hours?

Answer 30

Body is upregulating BP to increase blood flow to save penumbra tissue

Question 31

Chronic management stroke no tPA?

Answer 31

1. LMWH if paralyzed or immobile 2. Anticoag - valve, fib / flutter 3. Aspirin +/- clopidogrel 4. Atorva 40 or 80 - Rosuvastatin 20 or 40 5. A1C under 8 6. Control BP

Question 32

Why not give CT contrast in stroke?

Answer 32

Contrast looks same as blood

Question 33

What are we looking for in CT perfusion?

Answer 33

Penumbra - area around infarcted tissue we can hopefully save

Question 34

At what NIH class are we thinking large occlusion?

Answer 34

Over 6

Question 35

When does TPA need to be given?

Answer 35

Within 4.5 hours

Question 36

TPA contraindications?

Answer 36

1. NOAC 2. Coumadin over 1.7 3. History head bleed 4. Platelet under 100 5. BP over 185/110 6. MI within 3 months 7. Hypoglycemia

Question 37

Dosing TPA?

Answer 37

0. 9 mg / kg with max dose 90 - 10% in first minute - Remainder over an hour

Question 38

How to manage BP after TPA?

Answer 38

180/100

Question 39

CPP equation?

Answer 39

CPP = MAP - ICP

Question 40

Timeframe thrombectomy?

Answer 40

24 hours