Acute stroke - Revision history

Aidan: /* Post-Admission Management */

2024-07-14T19:22:41Z

Post-Admission Management

← Older revision		Revision as of 19:22, 14 July 2024
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	* Antiplatelets		* Antiplatelets
	** [[ASA]] as first-line		** [[ASA]] as first-line
	** Dual antiplatelets ASA + [[clopidogrel]] for 90 days for minor stroke (NIHSS ≤3) or TIA within 24 hours (based on CHANCE and POINT trials)		** Dual antiplatelets ASA + [[clopidogrel]] for 90 days for minor stroke (NIHSS ≤3) or TIA within 24 hours for 21 days (based on CHANCE and POINT trials)
	** [[ASA]] plus [[rivaroxaban]] may be helpful in patients with peripheral arterial disease (COMPASS trial)		** [[ASA]] plus [[rivaroxaban]] may be helpful in patients with peripheral arterial disease (COMPASS trial)
	*** Excludes previous ICH, recent stroke, lacunar strokes		*** Excludes previous ICH, recent stroke, lacunar strokes

Aidan at 12:58, 1 October 2021

2021-10-01T12:58:43Z

@@ Line 95: / Line 95: @@
 * Admit to Stroke Unit
 * Different BP parameters
 ==Further Reading==

Aidan at 12:36, 1 October 2021

2021-10-01T12:36:36Z

← Older revision		Revision as of 12:36, 1 October 2021
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	** Something else		** Something else

	===Thrombolysis==		===Thrombolysis===
	* Indicated for >18 years with symptoms within 4.5 hours of presentation		* Indicated for >18 years with symptoms within 4.5 hours of presentation
	* Contraindications		* Contraindications
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	** Risk of angioedema		** Risk of angioedema

	===Endovascular ~~thrombectomy~~		=== Endovascular Thrombectomy ===
	* Indicated within 6 hours of onset		* Indicated within 6 hours of onset
	* Functionally independent with life expectancy over 3 months		* Functionally independent with life expectancy over 3 months
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	* Maybe within 24 hours of onset based on CT perfusion or MRI		* Maybe within 24 hours of onset based on CT perfusion or MRI

			=== Admission Orders ===


	====Admission Orders With TPA====		====Admission Orders With TPA====
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	* Transfer to Stroke Unit after ICU		* Transfer to Stroke Unit after ICU

	===Admission Orders Without TPA==		====Admission Orders Without TPA====
	* Admit to Stroke Unit		* Admit to Stroke Unit
	* Different BP parameters		* Different BP parameters
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	==Further Reading==		==Further Reading==
	* Canadian Stroke Best Practice Recommendations for Acute Stroke Management 2018. doi: [https://doi.org/10.1177/1747493018786616 10.1177/1747493018786616]		* Canadian Stroke Best Practice Recommendations for Acute Stroke Management 2018. doi: [https://doi.org/10.1177/1747493018786616 10.1177/1747493018786616]
		⚫	[[Category:Strokes]]

	[Category:Neurology]
⚫	[Category:Strokes]

Aidan: Created page with "==Clinical Presentation== * ACA: contralateral leg > arm ** Gait, bladder incontinence, amnesia *MCA Contralateral sensorimotor Contralateral homonomous hemianopsia ** G..."

2021-10-01T12:32:52Z

Created page with "==Clinical Presentation== * ACA: contralateral leg > arm ** Gait, bladder incontinence, amnesia *MCA ** Contralateral sensorimotor ** Contralateral homonomous hemianopsia ** G..."

New page

==Clinical Presentation==
* ACA: contralateral leg > arm
** Gait, bladder incontinence, amnesia
*MCA
** Contralateral sensorimotor
** Contralateral homonomous hemianopsia
** Gaze deviation
** Aphasia, dysarthria, hemineglect
* PCA
** Contralateral homonymous hemianopsia
** Sensorimotor
** Aphasia
** Memory defects
** Disorientation
** Behavioural disturbance
** Visual agnosia
** Prosopagnosia
* Cerebellar: ataxia, vertigo, dysarthria, nystagmus, headache/nausea/vomiting, rapid deterioration in LOC
* Vertebroasialar stroke: loss of consciousness, nausea/vomiting, cranial nerve deficits, Horner syndrome, crossed sensory loss, crossed motor deficits, [[ataxia]]
* Thalamic stroke: contralateral sensory and/or motor loss, aphasia (if dominant side), executive dysfunction, decreased LOC, memory impairment
* Lacunar stroke
** Pure motor hemiparesis
** Pur sensory stroke
** Sensorimotor stroke
* Ataxic hemiparesis: ipsilateral leg
* Clumsy hand syndrome

==Differential Diagnosis==
* migraines, seizures, todd paresis, malignancy, MS, SAH, ...

==Investigations==
* BW:
* Imaging: CT + CTA

==Management==
* If CT head negative for ICH
** Antiplatelets
** Carotid revascularization: consider if stenosis 50-99% on symptomatic side fo TIA/stroke
** Anticoagulation
** Something else

===Thrombolysis==
* Indicated for >18 years with symptoms within 4.5 hours of presentation
* Contraindications
** Absolute:
*** Any active bleeding or any condition that raises the risk of major bleeding (but not anticoagulation, that’s relative)
*** Any hemorrhage on brain imaging
** Relative:
*** On history
**** Prior ICH, ever
**** Stroke or head trauma in the last 3 months
**** Major surgery in the last 14 days
**** Non-compressible arterial puncture in the last 7 days
*** On exam
**** Symptoms of SAH
**** Another cause of stroke syndrome (e.g. Todd’s paralysis or hypoglycemia)
**** Blood pressure ≥180/105 (must be controlled first)
**** Taking DOACs
*** On imaging
**** Signs of early extensive infarction
*** On bloodwork
**** Sugar <2.7
**** Elevated PTT
**** INR >1.7
**** Platelets <100
* No benefit if NIHSS 0-5 based on PRISMS RCT
* Dose is [[alteplase]] 0.9 mg/kg, given as 10% bolus over 1 min then 90% over 1 hour
** Max of 90 mg
* Outcomes
** Better function at 3 to 6 months
** Risk of major bleeding 5 to 7%, with 2% fatal
** Risk of angioedema

===Endovascular thrombectomy
* Indicated within 6 hours of onset
* Functionally independent with life expectancy over 3 months
* Small to moderate ischemic core with ASPECTS ≥6
* Proximal large vessel, or distal ICA/MCA
** Less clear with basilar artery
* Maybe within 24 hours of onset based on CT perfusion or MRI

====Admission Orders With TPA====
* Admit to ICU for 24 hours
* IV (before TPA)
* Foley and other catheters
* BP <185/110 at time of bolus then 180/105 for infusion
* Frequent neurovitals and BP monitoring
* Repeat CT head at 24 hours
* No anticoagulation/antithrombotics for 24 hours
* Transfer to Stroke Unit after ICU

===Admission Orders Without TPA==
* Admit to Stroke Unit
* Different BP parameters

==Further Reading==
* Canadian Stroke Best Practice Recommendations for Acute Stroke Management 2018. doi: [https://doi.org/10.1177/1747493018786616 10.1177/1747493018786616]

[Category:Neurology]
[Category:Strokes]

Acute stroke - Revision history

Aidan: /* Post-Admission Management */

Aidan at 12:58, 1 October 2021

Aidan at 12:36, 1 October 2021

Aidan: Created page with "==Clinical Presentation== * ACA: contralateral leg > arm ** Gait, bladder incontinence, amnesia *MCA ** Contralateral sensorimotor ** Contralateral homonomous hemianopsia ** G..."

Aidan: Created page with "==Clinical Presentation== * ACA: contralateral leg > arm ** Gait, bladder incontinence, amnesia *MCA Contralateral sensorimotor Contralateral homonomous hemianopsia ** G..."