Stroke
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Stroke - Details
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| 🇬🇧 | 🇬🇧 |
| When is carotid endarectomy recommended | When occlusion is > 70 % if surgeon is experience and has < 6% complication rate. Occlusion < 50% do not treat. |
| When is stunting recommended for carotid occlusion. | High risk pt: CHF class 3/4, L main Dz, previous neck irradiation, vasculitis, hx of restenosis, tracheotomy or surgically inaccessible lesion. |
| Stroke initial evaluation | ABC, CT non contrast, Glucose, CBC, Lytes, PT/INR, EKG, troponin and sed rate |
| Stroke second level testing | Echo with bubble study to look for PFO in pt age < 60, carotid US or MRA or CTA, Heart monitor 28 d, MRI head |
| Primary prevention Stroke | ASA 81 mg : Warfarin if severe LVD +/- CHF, LVD with extensive regional wall abnormalities, Post MI, mechanical heart valve, Afib with TIA |
| Secondary Prevention of Stroke | ASA 160-325 given within 48 hours : Dual Treatment with Plavix for 21 days follow ed by ASA 81 mg indefinitely. 2. High intensity statin, 3. Screen for DM and OSA, 4. DVT prophylaxis, 5. Smoking cessation 6. Depression screen 7. Limit ETOH to < 1 drink/d |
| BP control in Stroke | In acute setting do not treat unless BP > 220/120. In chronic setting start meds if BP > 140/90 Choice meds Thiazide and ACE |
| Tpa inclusion criteria | Presentation < 4.5 hours, No bleeding on CT, sx not improving on own, Age > 18 |
| TPA Exclusion criteria | Head trauma < 3 mo, stroke < 3 mo, INC neoplasm, AVM or aneurysm, recent intraspinal surgery, Seizure with stroke, Large stroke, Major surgery < 2 wk, on Direct thrombin inhibitors, pregnant, BP > 185/110, glucose < 50 or > 400, extensive hypo density on CT. |
| Primary prevention of stroke | Cha2ds2 vasc score: 0- ASA, 1-ASA or Coumadin > 2 Coumadin |
| Stroke short term complication | Infarct extension, edema, seizure, hemorrhagic conversion, delirium, depression, Aphasia |
| Stroke long term complication | Pneumonia, dysphagia, UTI, DVT/PE, CHF, MI, dehydration, malnutrition, pressure sores, disability, spasticity, cardiac |
| Definition TIA | Reversible defect < 24 hours without evidence of stroke on MRI |
| TIA risk stratification for future stroke risk | Age > 60(1pt), BP > 140/90(1pt), Unilateral weakness (2pt), DM (2pt), duration > 60min (2pt), < 60min (1pt): 0-3= 1% risk, 4-5=4%, 6-7= 8% risk highest first week up to 3 mo. |
| Stroke prognosis | Size and impairment are strongest predictors. NIHSS score 24 hour post stroke: < 5 mild, > 10 severe. |
| What are the episodic intermittent vertigo? | Benign paroxysmal positional vertigo- triggered by head movement lasting seconds. and Orthostatic vertigo when standing up SBP drops 20 and DBP drops 10. |
| What are the 5 components to the exam | 1. Orthostatic BP, 2. Hallpike maneuver 3. Nystagmus 4. HINTS 5. Cover test |
| What is the HINTS exam? | Differentiates b/w stroke and vestibular neuritis. Normal: eye stays fixed when displaced. Abnormal: suggest peripheral lesion, eye follows displacement. Move head back and forth slowly then back to center briskly. Look for catch up saccade. Reassuring HINTS exam: Unidirectional nystagmus, no vertical skew, abnormal head impulse test. Test of skew: Cover test Normal eye stays fixed when cover and uncover. Vertical movement is abnormal and suggests stroke. |
| What type of nystagmus suggests stroke? | Bidirectional nystagmus. Changes directions with gaze change. Spontaneous nystagmus, and does not extinguish. |
| What type of nystagmus suggests BPV? | Vertical upward and rotary with head movement. Only lasts seconds and extinguishes with fixation. |