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Stroke Manual Flashcards

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1
Q

What are the three components of stroke that are taken into account with the Oxfordshire Classification of Stroke?

A
  1. Hemianopia
  2. Higher cortical functions
  3. Unilateral motor or sensory deficit
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2
Q

Give the Oxfordshire Classification of Stroke: 1. Hypertensive 66M presenting with homonymous hemianopia with ipsilateral ataxia?2. 72F with left sided weakness and dressing apraxia? Both with hypodensities on CT

A
  1. POCI

2. PACI

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3
Q

What are the 5 different TOAST classifications?

A
  1. Large artery atherosclerosis 2. Cardioembolism 3. Small artery occlusion 4. Other determined causes 5. Undetermined cause (2 causes found or no cause found despite work-up)
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4
Q

What is the classification for a patient who presents with right sided weakness that on workup shows a >50% stenosis of the left ICA?

A

LAA

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5
Q 
Give the ABCD score of the patient:
50 years oldBP of 140/90
Presented with broca's aphasia
Lasting for 10 minutes
No diabetes
A

0+0+1+1+1 = 3
No admission needed: 2 day stroke risk is 1%

Age ≥60 years	1
Blood pressure elevation (systolic >140 mmHg and/or diastolic ≥90 mmHg)	1
Clinical features	
Unilateral weakness	2
Speech disturbance without weakness	1
Duration of symptoms	
≥60 minutes	2
10-59 minutes	1
Diabetes mellitus	1
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6
Q

Give the ABCD score of the patient:70 years oldBP of 141/90Presented with right sided plegiaLasting for 2 hoursWith DM

A

1+1+2+2+1= 7

ADMIT the patient
Score 1-3 (low)2 day risk = 1.0%7 day risk = 1.2%

Score 4-5 (moderate)2 day risk = 4.1%7 day risk = 5.9%

Score 6–7 (high)2 day risk = 8.1%7 day risk = 11.7%

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7
Q

How long should one wait prior to the starting of anti-platelet in a patient who underwent thrombolysis?

A

24 hours

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8
Q

What percentage of obstruction in the carotid UTZ necessitates referral to a neurosurgeon?

A

70%

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9
Q

Which among the 2 big ASA trials compared aspirin against ASA only, Heparin, ASA + Heparin and Placebo?

A

International Stroke Trial

The CAST (Chinese acute stroke trial) only compared against placebo VS ASA 160mg)

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10
Q

What antiplatelet was proved to be non-inferior to aspirin? (CAIST trial)

A

Cilostazol in Acute Ischemic Stroke

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11
Q

In the CAIST trial what was the NIHSS of the patient included? How about in the CHANCE trial?

A

CAIST: <15
CHANCE: 3 or less

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12
Q

Match the following neuroprotection agents with their trials:

  1. Cerebrolysin
  2. Citicoline
  3. NeuroAID

A. CHIMES
B. ICTUS
C. CASTA

A

1C
2B
3A

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13
Q

In what subgroups is citicoline shown to have some possible benefit according to the ICTUS trial?

A

> 70 years old
<14 NIHSS
Patients NOT treated with rtPA

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14
Q 
What laboratory values of the following would discourage the use of rTPA?
PLT
PT
INR
BP
CBG
A 
PLT <100,000
PT >15sa
PTT>40s
INR >1.7
BP >=185/110
CBG <50 >400
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15
Q

What is the period after the following events during which thrombolysis is discouraged?

  1. Head trauma
  2. CVD infarct
  3. ICH
  4. MI
  5. Major surgery or serious trauma
  6. Arterial puncture
  7. AVM or aneurysm
A
  1. Head trauma 3 months
  2. CVD infarct 3 months
  3. ICH FOREVER
  4. MI 3 months
  5. Major surgery or serious trauma 14 days
  6. Arterial puncture 7 days
  7. AVM or aneurysm FOREVER
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16
Q

How should BP be monitored during thrombolysis?

A

Q15 first 2 hours
Q30 next 6 hours
Q1 for 16 hours

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17
Q

What are the 4 relative exclusion criteria to thrombolyse within the 3-4.5 hour criteria? (This is based on the old ischemic stroke guidelines NOT the 2018 AHA)

A
  1. DM and Ischemic stroke
  2. NIHSS more than 25
  3. Oral anticoagulants REGARDLESS OF INR
  4. Older than 80
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18
Q

In the National Institute of Neurological Disorders and Stroke t-PA trial 1. what is the primary outcome result in terms of disability at 3 months2.what is the primary outcome result in terms of mortality at 3 months3. what is the rate of sICH

A
  1. 30% more likely to have minimal or no disability (defined as MRS 0-1, NIHSS < or equal to 1, 95-100 on the Barthel index) at 3 months
  2. NO difference
  3. 6.4%
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19
Q

What dosage was used in the J-ACT trial using alteplase for thrombolysis?

A

0.6mg per kg

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20
Q

Which ECASS (European Australasian Cooperative Acute Stroke Study) trial showed improved outcomes with thrombolysed patients?

A

ECASS 3. The first two used up to 6 hours window period for giving of rtpa while the 3rd used 4.5 hours

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21
Q

In IST 3, what was the golden period used? Did it improve the Oxford Handicap Score (OHS) of 0–2 at 6 months of the patients?

A

<6 hours. BUT not enough power to say that there is enough evidence to thrombolyse at 4.5-6 hours

Yes it did!

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22
Q

What factor of the STATE criteria does this man meet?NIHSS 21 with plegic right
12 hours post ictus
ASPECTS 3
Previously working as a secretary

A 
Score  >20 if dominant lobe >15 if non dominant
Timing <48 hours
Age <60 years
Territory >50% MCA territory
Expectation reasonable
5/5!
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23
Q

According to the Antiplatelet Trialists Collaboration taking ASA can have a _____% odds reduction for the composite outcome of MI, stroke or vascular death.

A

23

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24
Q

Identify which antiplatelet is studied in the following:

  1. CATS
  2. CAPRIE
  3. CHARISMA
  4. SPS 3
  5. CSPS
  6. TOSS 1, TOSS 2
  7. ESPS 1, ESPS2
  8. ESPRIT
  9. PROFESS
  10. TACIP
  11. WARSS, WASID
  12. TAPIRSS
  13. TASS
A
  1. CATS: Ticlodipine VS placebo– old study!! 1989
  2. CAPRIE: Clopidogrel vs ASA
  3. CHARISMA: Clopidogrel + ASA VS ASA alone for vascular events
  4. SPS 3: Clopidogrel + Aspirin VS ASA for recent lacunar strokes
  5. CSPS Cilostazol vs Placebo Cilostazol superior CSPS 2: Cilostazol VS Aspirin, non inferiority study– less hemrrhage with Cilostazol
  6. TOSS 1: Cilostazol + ASA VS ASA alone for IC stenosis
    TOSS 2: Cilostazol + ASA VS Cilostazol + Clopidogrel for IC stenosis
  7. ESPS 1: ASA+ Dipyridamole VS ASA + Placebo
    ESPS 2: ASA vs Dipyridamole VS ASA+ Dipyridamole VS Placebo
  8. ESPRIT: ASA+ Dipyridamole VS ASA + Placebo
  9. PROFESS: ASA-Dipyridamole VS Clopidogrel– same recurrence of stroke but more bleeding with ASA+D
  10. TACIP: Triflusal VS ASA– less hemorrhage with triflusal
  11. WARSS: Warfarin vs Aspirin for secondary prevention, neutral
    WASID: Warfarin vs Aspirin for large artery stenosis, neutral
  12. TAPIRSS: Triflusal vs ASA – less hemorrhage with triflusal, neutral
  13. TASS: Ticlodipine vs ASA– ticlodipine superior
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25
What is the CHA2DS2VASc score of the this patient? 75 F With CHF FC3 Hypertensive with DM Suffered from sudden right sided weakness With aortic plaque on x-ray
``` 1+2+1+1+2+1+1= 9 15.2% annual risk of stroke MORE THAN 2 score is considered high risk (2.2% risk of stroke) Congestive heart failure / LV dysfunction (1 point) Hypertension (1 point) Diabetes Mellitus (1 point) History of stroke TIA or thromboembolism (2 points) Vascular disese (history of MI, PVD or aortic atherosclerosis) (1 point) Age 65-74 years old (1 point) >= 75 years old (2 points) Sex: Female (1 point) ``` Threshold more than or equal to 2 score
26
What is the CHA2DS2VASc score of the this patient? 65 F NO CHF Hypertensive with DM Amputated right leg from acute limb ischemia
1+1+0+1+1+1 = 5 | 6.0% annual risk of stroke
27
``` What is the HAS BLED score of this patient? Hypertensive Normal crea and AST ALT No history of stroke With anemia Stable INR's 70 on Aspirin and drinks alcohol daily ```
1+0+0+1+0+1+1= 4 8.7 major bleeds per 100 patient years H Hypertension: (uncontrolled, >160 mmHg systolic) A Abnormal renal function: Dialysis, transplant, Cr>2.26 mg/dL or >200 µmol/L Abnormal liver function: Cirrhosis or Bilirubin >2x Normal or AST/ALT/AP >3x Normal S Stroke: Prior history of stroke B Bleeding: Prior Major Bleeding or Predisposition to Bleeding L Labile INR: (Unstable/high INR), Time in Therapeutic Range E Elderly 65 years old D Prior Alcohol or Drug Usage History (≥ 8 drinks/week) Medication Usage Predisposing to Bleeding: (Antiplatelet agents, NSAIDs) MORE THAN OR EQUAL TO 3 IS HIGH RISK!
28
Match the study with the drug: 1. Dabigatran 2. Apixaban 3. Rivaroxaban A. RELY AF B. ARISTOTLE C. ROCKET AF
1A 2B 3C
29
Which NOAC 1. has the lowest half life? 2. canNOT be given by NGT 3. given OD 20mg tab 4. superior to warfarin in ischemic stroke 5. superior to warfarin in stroke and sytemic embolism 6. superior to warfarin in terms of major bleeding (2)
1. has the lowest half life: Rivaroxaban 2. canNOT be given by NGT: Dabigatran 3. given OD 20mg tab: Rivaroxaban 4. superior to warfarin in ischemic stroke: Dabigatran 150BID 5. superior to warfarin in stroke and sytemic embolism: Dabigatran and Apixaban 6. superior to warfarin in terms of major bleeding: Dabigatran 110 BID and Apixaban
30
What HAS BLED score is a relative contraindication to warfarin therapy because it indicates a high risk of bleeding?
>=3
31
When switching from warfarin to NOAC what is the ideal INR (less than what) value before the shift happens?
<2.5
32
What ICH score gives a 100% mortality at 30 days?
``` 5 -6 GCS score 3–4 2; 5–12 1; 13–15 0 ICH volume, cm3 ≥30 1; <30 0IVH Yes 1; No 0 Infratentorial origin of ICH Yes 1; No 0 Age, y ≥80 1; <80 0 ```
33
``` What is the ICH score? GCS 8 Size 31cc NO IVH left parietal 81 years old ```
``` 1+1+0+0+1=3: 72% mortality in 30 days GCS score 3–4 2; 5–12 1; 13–15 0 ICH volume, cm3 ≥30 1; <30 0 IVH Yes 1; No 0 Infratentorial origin of ICH Yes 1; No 0 Age, y ≥80 1; <80 0 ```
34
``` What is the ICH score? GCS 3 8 cc With IVH Cerebellar 79 years old ```
``` 2+0+1+1+0=4: 87% mortality in 30 days GCS score 3–4 2; 5–12 1; 13–15 0 ICH volume, cm3 ≥30 1; <30 0 IVH Yes 1; No 0 Infratentorial origin of ICH Yes 1; No 0 Age, y ≥80 1; <80 0 ```
35
What is the sensitivity of scan 6 days after SAH headache?
57-85%
36
What HH or WFNS score? 1. GCS 13 with right hemiparesis? 2. GCS 7 with left plegia 3. GCS 4, moribund 4. GCS 14 no motor deficit, disoriented
1. HH 4 WFNS 3 2. HH 4 WFNS 4 3. HH 5 WFNS 5 4. HH 3 WFNS 2
37
What fisher grading has a localized clot or vertical layer more than 1 mm thick?
GRADE 3 Grade 1​ no subarachnoid (SAH) or intraventricular haemorrhage (IVH) detected incidence of symptomatic vasospasm: 21% Grade 2 ​diffuse thin (<1 mm) SAHno clots incidence of symptomatic vasospasm: 25% Grade 3 ​localised clots and/or layers of blood >1 mm in thickness no IV Hincidence of symptomatic vasospasm: 37% Grade 4​ diffuse or no SAH/ICH or IVH present incidence of symptomatic vasospasm: 31%
38
What is the lifetime risk of ICH in a 30 year old patient with AVM?
75% | 105- patient's age
39
What is the spletzer martin grade for an AVM: 4cmin the hypothalamuswith deep drainage
2+1+1=4 size of nidussmall (<3 cm) = 1medium (3-6 cm) = 2large (>6 cm) = 3 eloquence of adjacent brain non-eloquent = 0 eloquent = 1 venous drainage superficial veins only = 0 deep veins = 1
40
What are the 3 components of the Oxfordshire Stroke classification that needs to be fulfilled to make a diagnosis of Total Anterior Circulation?
1. Unilateral motor or sensory deficit2. Higher cortical dysfunction3. Homonymous hemianopia
41
How many features need to be fulfilled for an PAC oxfordshire classification to be made?
2 of the ff:1. Unilateral motor or sensory deficit2. Higher cortical dysfunction3. Homonymous hemianopia3 for TAC
42
According to the INTERSTROKE STUDY what are the top 2 risk factors associated with Stroke?
Hypertension and regular physical ativity
43
According to the RIFASAF Study what are the top 2 risk factors associated with Stroke?
Hypertension and MI
44
What is the absolute LDL-C value for treatment with statins for primary prevention?
more than or equal to 190mg per dl
45
Treatment with warfarin for 3 months is indicated for patients with Stroke or TIA in the setting of anterior wall STEMI if _______ is seen on 2d echo?
Anterior wall apical akinesis or dyskinesis
46
What are the valvular heart diseases that merit anticoagulation?
Prosthetic heart valves and rhematic mitral valve disease
47
How does treatment with anticoagulation vary for patients with a prosthetic aortic heart valve and mitral valve differ?
Higher target for mitral INR 2.5 to 3.5 while 2.0-3.0 for aortic
48
What factors favor the performance of CEA in patients with carotid artery stenosis of 50-69%?
Male sex, hemispheric symptoms, treatment within 2 weeks of non-disabling stroke of tia
49
What is considered a high risk CHADSVASC2 score? How about a high risk HASBLED score?
>=2 | >=3
50
Which drugs are being studies by the ff: 1. RELY AF 2. ARISTOTLE 3. ROCKET-AF
1. RELY AF: Dabigatran2. ARISTOTLE: Apixaban3. ROCKET-AF: Rivaroxaban
51
Which NOAC's are: 1. Superior to warfarin for Stroke and Systemic Embolism 2. Superior to warfarin for ischemic stroke 3. All cause mortality 4. Major bleeding
1. Superior to warfarin for Stroke and Systemic Embolism: Dabigatran 150 and Apixaban 2. Superior to warfarin for ischemic stroke: Dabigatran 150 3. All cause mortality: Apixaban 4. Major bleeding: Dabigatran 110 and apixaban
52
For non-valvular AF what score requires the use of NOACs/ anticoagulation?
More than or equal to 1 as long as one is NOT female gender
53
What is the threshold creatinine clearance for patients on NOACs?
<30ml/min-- all three NOACs are NOT recommended
54
What is the minimum decrease in BP that is associated with benefit in hypertensive?
10/5mmHg
55
What is a combination of anti HTN is NOT recommended?
ACEi + ARB
56
By how many percent does intake of antihypertensives reduce the risk of stroke?
32%
57
What is the LDL cholesterol level goal for DM patients?
<100mg dl
58
What is the goal for HBa1c for:1. Primary stroke prevention2. Secondary stroke prevention
Both <7%
59
What are the relative risks attributed to smoking for the ff stroke types:1. Total stroke2. SAH3. Ischemic stroke
1. Total stroke 1.27 2. SAH 3.60 3. Ischemic stroke 1.66
60
Cilostazol 100mg BID is given to patients with lower extremity PAD and intermittent claudication provided that the patient does not have?
Heart failure
61
What ankle brachial index ABI indicates lower extremity arterial obstructive disease?
<0.9
62
According to the ARIC study how much more likely are patients with PAD likely to develop TIA or Stroke?
4-5x
63
What is the recommended exercise regimen for stroke patients?
3-4x per week 40 minutes each
64
What is the cut off BMI for1. overweight2. obeseHow about WHR?1. Obese male2. Obese female
``` BMI 1. overweight > = 25 2. obese > = 30 WHR 1. Obese male > = 1.02. Obese female > =0.85 ```
65
What are the cut-off parameters for bariatric surgery?
>= 40 BM I>= 35 BMI if with obesity related comorbid conditions
66
How low is the sodium for stroke diet supposed to be?
<2.4g per day-- further reduction to <1.5 leads to further BP reduction
67
What are the two types of complex regional pain syndromes? (Post stroke pain)
1. Without direct nerve damage-- reflex sympathetic dystrophy 2. With direct nerve damage-- causalgia
68
What are the 4 causes of hemiplegic shoulder pain?
Adhesive capsulitis 50% Shoulder sublaxation 44% Rotator cuff tear 22% Shoulder hand syndrome 16%
69
What percentage of patients developed NEW chronic pain after stroke?
10.6% PRoFESS trial
70
What is the diagnostic criteria for complex regional pain syndrome?
1. Continuing pain disproportional to the inciting event 2. 3/4 by hx of sxs in: Motor/Trophic, Sensory, Vasomotor (skin color/ temperature), Sudomotor/edema (sweating/edema) 3. 2/4 by signs in: Motor/Trophic, Sensory, Vasomotor (skin color/ temperature), Sudomotor/edema (sweating/edema) 4. No other likely diagnosis
71
What are first line meds for Central Post Stroke pain?
1. Amitriptyline 2. Lamotrigine Both 25mg per day
72
The shoulder hand syndrome can be treated with what medications ? NB: The shoulder hand syndrome is actually a complex regional pain syndrome isolated in the upper extremties
Steriods and biphosphonates can help with the pain.
73
What type of stroke is most related to post stroke epilepsy?
ICH 4.3% SAH 4.2 Ischemic stroke 1.6
74
What drug class is recommended to treat post stroke depression?
``` SSRIs Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil, Pexeva) Sertraline (Zoloft) ```
75
What is the cumulative incidence and pooled prevalence of post stroke depression five years post ictus?
53% | 29%
76
What are the 6 strategic locations for post-stroke dementia?
1. Left angular gyrus 2. Inferomesial temporal region 3. Mesial frontal region 4. Anterior and dorsomedial thalamus 5. Left capsular genu 6. Caudate nuclei 2 left 2 mesial Thalamus + Caudate 2-2-CT
77
What drug has evidence for the treatment of vascular dementia/ post stroke dementia?
Donepezil (Malouf et al. Cochrane)
78
In what special population is acquired prothrombin complex deficiency prevalent in?
Breastfed infants who lack Vit K dependent clotting factors
79
What drug can be given for up to a week in pediatric patients with an acute ischemic stroke?
Heparin
80
What is the most common cause? 1. Ischemic stroke SITY 2. Cardioembolic ischemic stroke SITY 3. Acquired thrombophilia SITY 4. ICH SITY
1. Ischemic stroke SITY: Arteriopathy like cervical artery dissection 2. Cardioembolic ischemic stroke SITY: PFO 3. Acquired thrombophilia SITY: APAS 4. Ruptured AVM followed by cavernous angioma but in brainstem CA is number 1
81
What are the top 2 work-ups for SITY with the highest yield?
1. Cranial Angiography | 2. Cardiac Ultrasound
82
For PFO: 1. When is anticoagulation favored over anti platelet therapy? 2. When is closure of PFO considered?
1. When is anticoagulation favored over anti platelet therapy? Stroke with venous source of emboli like DVT2. Sondergaard. NEJM. 2017: The incidence of new brain infarctions was significantly lower in the PFO closure group than in the antiplatelet-only group (22 patients [5.7%] vs. 20 patients [11.3%]; relative risk, 0.51; 95% CI, 0.29 to 0.91; P=0.04), but the incidence of silent brain infarction did not differ significantly between the study groups (P=0.97). Serious adverse events occurred in 23.1% of the patients in the PFO closure group and in 27.8% of the patients in the antiplatelet-only group (P=0.22). Serious device-related adverse events occurred in 6 patients (1.4%) in the PFO closure group, and atrial fibrillation occurred in 29 patients (6.6%) after PFO closure. CONCLUSIONS Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone; however, PFO closure was associated with higher rates of device complications and atrial fibrillation.
83
In patients with hyperhomocystinuria, what supplementation can lower the levels of homocystine?
Folate, B6, B12
84
For SITY 1. What are the cumulative mortality risks at 1 month, 1 year and 5 years according to the helsinki young stroke registry? 2. What is the 5 year rate for post stroke epilepsy? 3. What 2 types of stroke has the highest mortality?
1. 2.7% 4.7% 10.7% 2. 10.5% Large artery atherosclerosis and cardioembolic 3. Large artery atherosclerosis 30% and cardioembolic 20%
85
What trimester in pregnancy is most associated with stroke?
Third. Rising to its peak association during parturition and up to 6 weeks post partum RR 8.7 for ischemic stroke 28.3 for hemorrhagic stroke
86
What population of pregnant patients are supposed to take aspirin from the 12th week of pregnancy until delivery?
Those who have been diagnosed with primary or secondary hypertension or previous pregnancy related hypertension.
87
What element is used to supplement pregnant women to prevent pre eclampsia?
calcium >1g orally daily
88
What are recommended anti hypertensives for patients in pregnancy?
Methlydopa Nifedipine Labetalol
89
What are the options for stroke related hyperkinetic movement disorders?
Anticholinergics Antipsychotics Benzodiazepenes DOPAMINE BLOCKADE!
90
How is vascular parkinsonism different from IPD?
Associated with gait apraxia rather than freezing and festinating Bilateral symptoms of rigidity and bradykinesia LE>UE
91
Which component of BP is associated with cerebral microbleeds? SBP/DBP?
DBP
92
What are the 5 criteria that favor admission of a patient with TIA?
1. TIA within 48 hours 2. TIA from high risk cardiac source of embolism 3. TIA with known hypercoaguable state and intracranial stenosis 4. TIA with ABCD score of >=4 5. TIA with multiple and increasing symptoms
93
What are the 6 routine coagulation tests for SITY patients?
1. Antithrombin 3 2. Protein C 3. Protein s 4. Homocysteine 5. Fibrinogen 6. Drug screen: MAP and cocaine
94
What is the NIHSS score for MODERATE STROKE?
6-21
95
Which trial was prematurely terminated because of slow recruitment? Tested Clopidogrel + ASA vs ASA only for ACUTE ischemic stroke recruited within 24 hours. +/- simvastatin
FASTER-- only had 392 patients.
96
Which neuroprotective agent: 1. CASTA 2. CHIMES 3. ICTUS 4. With benefit for Filipino subgroup analysis of study?
1. CASTA: Cerebrolysin 2. CHIMES: NeuroAid 3. ICTUS: Citicoline 4. With benefit for Filipino subgroup analysis of study? NeuroAid
97
Indicate if the ff are high or low risk of Cardioembolic stroke: 1. PFO 2. Atrial septal aneurysm 3. AF valvular 4. AF non valvular 5. Recent MI 6. Atrial myxoma 7. IE 8. Dilated cardiomyopathy 9. Mitral valve strands
1-2: Low3-8: High9. Low
98
Re: rTPA1. What abnormal blood glucose levels preclude the use of IV rTPA?2. What abnormal BP values preclude the use of IV rTPA?
1. What abnormal blood glucose levels preclude the use of IV rTPA? <50 >4002. What abnormal BP values preclude the use of IV rTPA? SbP>=185 DBP>=110
99
Re: rTPA 1. What abnormal bleeding parameters preclude use of rTPA? 2. Can a patient given heparin still be thrombolysed? 3. Can a patient on NOACs still be thrombolysed?
1. PT >15seconds aPTT>40s INR >1.7 PLT <100,000/mm3 2. Yes. may give if aPTT not elevated THAN THE UPPER LIMIT OF THE LABORATORY 3. Yes. If last intake was more than 48 hours and that P INT aPRR and PLT is normal AND IF RENAL FUNCTION IS NORMAL (so drug is cleared in 48 hours)
100
T or F. 1. rTPA is contraindicated for those with ischemic stroke within 3 months 2. rTPA is contraindicated for those with significant head trauma within 3 months 3. rTPA is contraindicated for those with arterial puncture in a non compressible site within 14 days
1. rTPA is contraindicated for those with ischemic stroke within 3 months T 2. rTPA is contraindicated for those with significant head trauma within 3 months T 3. rTPA is contraindicated for those with arterial puncture in a non compressible site within 14 days F SHOULD BE 7 DAYS
101
Which patients are eligible for therapy at the 3-4.5 hour window?
1. ≤80 y of age, 2. without a history of bothdiabetes mellitus and prior stroke3. NIHSS score ≤254. not taking any OACs5. without imaging evidence of ischemic injuryinvolving more than one third of the MCA territory
102
What are the 2 key messages of the ENCHANTED trial?
1. This trial involving predominantly Asian patients with acute ischemic stroke did not show the noninferiority of low-dose alteplase to standard-dose alteplase with respect to death and disability at 90 days. 2. There were significantly fewer symptomatic intracerebral hemorrhages with low-dose alteplase.
103
How often should a patient be monitored while undergoing rTPA?
Q15 mins 2 hoursQ30 mins 6 hoursQ60 mins 16 hours
104
What drug was assessed in the DIAS and DEDAS trials?
Desmoteplase for 3-9 hours post ictus patients
105
re rTPA trials 1. Which was the original trial that showed 30% more likelihood of thrombolysed patients to achieve minimal or no disability at 3 months despite more symptomatic ICH? Time cap was <3 hours 2. Which successful trial (90 day outcome) looked at rTPA with time window up to 3 to 4.5 hours? 3. Which successful trial used a 6 hour cap (but sub-analysis showed that those <3 hours were the only ones significant) and looked at outcomes up to 6 months-- this trial had the most lax inclusion criteria among the successful studies including patients more than 80 years old and those with severe strokes? 4. Japanese study with a time cap of 3 hours that confirmed the findings of #1?
1. NINDS t-PA trial 1995 2. ECASS 3 2008 3. IST 3 2012 4. J-ACT 2006
106
``` Which among these rTPA trials were successful? ECASS ECASS II ATLANTIS A ATLANTIS B J-ACT ```
Only J-ACT was successful
107
How is ATACH 2 different from INTERACT 2?
1. Various anti HTN was allowed in INTERACT while only nicardipine for ATACH2 2. Faster and lower BPs were achieved in ATACH2 for more patients Both are negative for intensive BP lowering to SBP to less than 140 as having superior outcomes (clinical and hematoma volume) for lowering to less than 180. 3. Treatment failure was significant in the treatment arm (compared to standard management) of both trials-- but much more in INTERACT (only about 33% attained goal BP at 1 hour VS about 78% at 2 hours for primary and 75% at succeeding hours (2-24 hours) for secondary in ATACH 2)
108
For increased ICP what is the goal: 1. Serum osmolality 2. pCO2 (effect only 6 hours)
1. 300-320 | 2. 30-35mmgHg
109
What is the formula for serum Osm?
Nax2 + BUN/2.8 +Glucose/18
110
What is the recommended size of hemicraniectomy?
12x9cm
111
What is the STATE criteria for immediate NSS referral for hemicraniectomy?
Sensorium NIHSS >15 for non-dominant >20 for dominantTime <48 hours post ictusAge <60Territory >50% MCA territory or >150cm2Expectations
112
What percentage of hemicraniectomy patients for main trunk infarct will have poor outcome?How about mortality?
<60 years old 33.1%, 20.8% >60 81.1% 51.3% AHA 2018: In patients ≤60 years of age with unilateral MCA infarctions who deteriorate neurologically within 48 hours despite medical therapy, decompressive craniectomy with dural expansion is reasonable because it reduces mortality by close to 50%, with 55% of the surgical survivors achieving moderate disability (able to walk) or better (mRS score 2 or 3) and 18% achieving independence (mRS score 2) at 12 months. If more than 60 reduces mortality about 50% as well BUT only 11% with MRS 3 NONE with mrs <=2
113
What does SMASH U stand-- etiologies for ICH?
Structural Medications Amyloid angiopathy Systemic disease (PLT<50, Liver enzymes 3x, spontaneous increase in INR) Hypertension (pre ICH BP of 160mmHg, If bP not known either: history of HTN + 2Decho of LVH or pre ICH use of anti HTN medications) Undetermined
114
What are the top 2 locations for hemorrhage?
``` Basal ganglia (putamen and IC) 40-50% Lobar 20-50% Thalamus 10-20% Pons 5-12% Cerebellar 5-10% ```
115
What is the cut off diameter for surgical cerebellar bleeds?
>3cm
116
What is the WFNS & H and H classification? 1. GCS 14, Drowsy but arousable with left drift 2. GCS 7 Stuporous with severe hemiparesis 3. GCS 4 Moribund appearance in coma 4. GCS 15 Moderate headache with nuchal rigidity
1. Drowsy but arousable with left drift 3, 3 2. Stuporous with severe hemiparesis 4, 4 3. Moribund appearance in coma 5, 5 4. Moderate headache with nuchal rigidity 1, 2
117
What trial showed that statins should not be given to SAH patients?
STASH
118
What is the target BP for SAH due to UNSECURED aneuryms?
<150 mmHg
119
When is early surgery recommended for SAH patients? <72 hours
WFNS 1-3 If 4-5: hematoma or HCP Ischemia and vasospasm favor delayed surgery
120
What is the ICH lifetime risk for a 35 year old with AVM?
70% (105-35)
121
What are the 4 consistent risk factors related to AVM rupture?
1. Deep venous drainage 2. Single draining vein 3. High MAP in feeding artery 4. Venous stenosis Venous stasis and intranidal aneurysms and deep location of avm ARE ONLY INCONSISTENTLY related risk factors
122
How to differentiate between AVF and AVM in 4va?
AVM has a nidus that is seen in the arterial phase.Veins and venules appear at the capillary phase for the avm and at the later arterial phase for the avf
123
What is the spletzer martin grade for an AVM: | 2cmin the cerebellar peduncles with deep drainage
``` 1+1+1 = 3 size of nidus small (<3 cm) = 1 medium (3-6 cm) = 2 large (>6 cm) = 3 eloquence of adjacent brain non-eloquent = 0 eloquent = 1 venous drainage superficial veins only = 0 deep veins = 1 ``` Eloquent: sensorimotor, language, visual cortex, hypothalamus, thalamus, brain stem, cerebellar nuclei, or regions immediately adjacent to these structures
124
What is the avm score for radiosurgery?
0.1 Volume +0.02 Age +(0.5)(location; frontal/temporal/parietal/occipital/intraventricular/corpus callosum/cerebellar = 0, basal ganglia/thalamus/brainstem = 1) If <1 89% chance of excellent outcome
125
How is Spletzer martin III further classified?How does treatment differ?
3a: >6cm size 3b: With deep venous drainage or eloquent area 3a microsurgery +/- embo 3b SRS +/- embo Size of nidus: small (<3 cm) = 1 medium (3-6 cm) = 2 large (>6 cm) = 3 Eloquence of adjacent brain non-eloquent = 0 eloquent = 1 Venous drainage superficial veins only = 0 deep veins = 1
126
What is the difference between a dural avf and a pial avf?
Dural: Meningeal artery x Leptomemingeal vein OR venus sinus Pial: Pial artery x Leptomemingeal vein
127
Which among the 6 vascular malformations need only to be observed?
DVA, Capillary telangiectasia
128
What are the 5 early signs of infarct on CT? HOLIS
``` Hyperdense MCA Obscuration of the Lentiform nucleus Loss of Gray white matter diffn Insular ribbon sign Sulcal effacement ```
129
Based on CT perfusion scanning how is the penumbra differentiated from the core infarct? NORMAL: gray matter MTT: 4 s CBF: 60 ml/100 g/min CBV: 4 ml/100 g white matter MTT: 4.8 s CBF: 25 ml/100 g/min CBV: 2 ml/100 g
Core increased MTT/ T max markedly decreased CBF markedly decreased CBV Penumbra increased MTT/ T max moderately reduced CBF near normal or increased CBV
130
Re: Infarcts and MRI 1. When does ADC become normal? 2. When does ADC become hyperintense? 3. When does FLAIR first become hyperintense?
1. When does ADC become normal? 10 to 15 days pseudonormalizationm-- distinguishes acute from subacute phase! 2. When does ADC become hyperintense? Chronic beyond 3 weeks distinguishes subacute and chronic phase! 3. When does FLAIR first become hyperintense? 6 hours
131
Re: Bleeds on MRI 1. What hemoglobin responsible for BB in the late subacute phase? 2. What hemoglobin is present in the hyperacute phase?3. When do ferritin and hemosiderin become the predominant blood products present? 4. What is are the two sensitive sequences for detecting micbleeds? 5. Which one is better?
1. What hemoglobin responsible for BB in the late subacute phase? Met Hgb leaing extracellularly 2. What hemoglobin is present in the hyperacute phase? Oxyhemoglobin 3. When do ferritin and hemosiderin become the predominant forms of hgb present? Chronic 4. What is are the two sensitive sequences for detecting micbleeds? GRE and SWI 5. Which one is better? SWI
132
Re: Infarcts and MRI 4. When does T2 first become hyperintense? 5. What pathology related to an infarct presents with T1 hyperintensity? 6. When does DWI become hypointense? 7. What does FLAIR look like with chronic bleeds VS T2?
4. When does T2 start to become hyperintense? 8 hours-- marks the start of the acute phase from hyperacute phase 5. What pathology related to an infarct presents with T1 hyperintensity? Cortical necrosis usually beyond 2 weeks 6. When does DWI become hypointense? with chronicity-- encephalomalacia 7. What does FLAIR look like with chronic bleeds VS T2? Flair hypointense T2 hyperintense
133
What is the diagnostic yield of CT for SAH after 7 days?
50% compared to 94% in the first 24 hours
134
Re: Post stroke concerns 1. When can a single TIA patient return to work? 2. When can a single TIA patient do air travel? 3. When can a stroke patient do air travel? 4. When can permanent disability status be recommended for stroke patients? 5. When can a patient with mrs 0-1 be cleared for work?
1. When can a single TIA patient return to work? 5 days-- 30 if recurrent 2. When can a single TIA patient do air travel? 2 weeks 3. When can a stroke patient do air travel? after 2 months 4. When can permanent disability status be recommended for stroke patients? If still mrs 2 after 6 months 5. 5. When can a patient with mrs 0-1 be cleared for work? after a month (should be undergoing therapy if needed)
135
Re: Post stroke concerns 6. When can TIA patients drive again? 7. When should a GS elective procedure be performed in a stroke patient? 8. How many days should a patient be off warfarin prior to OR? 9. What is the acceptable INR prior to GS or NSS?
6. When can TIA patients drive again? 4 weeks for non-pro and 6 weeks for pro 7. When should a GS elective procedure be performed in a stroke patient? 4 weeks after moderate size infarct >1/3 of MCA territory 8. How many days should a patient be off warfarin prior to OR? 5 days 9. What is the acceptable INR prior to GS or NSS? <1.5 <1.2
Brain Power: Beyond Adam
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