SCRN - baseline neuro assessment, tpa and endovascular reperfusion Exam 2023

NIHSS Score > 15 is associated with? - Answer- Patient at greater risk of death from stroke Examples of items not scored on NIHSS which could represent a clinically significant posterior circulation stroke - Answer- Diplopia, dysphagia, gait instability, hearing, nystagmus Hunt and Hess grading system - Answer- Used for SAH, score ranges from 0-5, significance of damage increases with score Fisher score - Answer- Used for SAH and specifically graded the thickness of blood clot. Correlated with the likelihood that the pt will develop vasospasm. Often combined with hunt score. Grade I-IV WFNS SAH classification - Answer- World federation of neurologic surgeons - quantifies significance of SAH based on the pts initial clinical presentation. Dependent on GCS. Grade 0-5 - higher score is worsened neurologic exam and the presence of major neurologic deficit ICH score - Answer- Quantifies a number of pieces of the patients initial presentation. Correlated with mortality at 30 days ABCD2 scoring system purpose? - Answer- To predict stroke after TIA at 2, 7, 30, 90 days BP parameters for IV tPA administration - Answer- Initial BP should be <185/110 and should maintain <180/105 x 24 hrs post treatment Most common med options to lower BP for eligibility for acute reperfusion therapy - Answer- Labetalol 10-20mg IV over 1-2 min (may repeat x1) then may start drip at 2-8mg/min or nicardipine 5mg/h titrate up by 2.5 mg every 5-15 min to max of 15mg BP monitoring when starting tPA therapy - Answer- Q 15 min for 2 hrs then q 30 min for 6 hrs then q hr for 16 hrs tPA dosing - Answer- Weight based - 0.9mg/kg to max dose of 90 mg. 10% of dose in bonus over 1-2 minutes then the remaining 90% over 1 hr Mixing tPA - Answer- 100mg powder and 100cc sterile water in 2 glass vials. Swirl - DO NOT SHAKE. FDA time frame approval for tPA - Answer- Within 3 hrs of LKW INCLUSION criteria for tpa in stroke - Answer- ≥ 18 Onset < 3 hrs Ischemic stroke with measurable deficit Exclusion criteria for tPA - Answer- Significant head trauma or stroke in past 3 months, symptoms suggestive of SAH, arterial puncture at non compressible site in past 7 days, history of ICH, recent intracranial neoplasm or intraspinal surgery, active internal bleeding, platelet count <100,000/mm, heparin in past 48 hrs with PTT greater than upper limit of normal, current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated lab tests, blood glucose <50 or of CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere) Relative exclusion for tPA - Answer- Consider risk/benefit ration, minor or rapidly improving symptoms, pregnancy, surgery or serious trauma within 14 days, recent GI or urinary tract hemorrhage (21 days), or recent AMI (3 months), Additional exclusion criteria to be considered if treated pt in 3-4.5 hr window - Answer- Age>80, NIHSS >25, oral anticoagulant use regardless of INR, hx of DM with prior ischemic stroke If there is a significant neurologic change during tPA treatment next steps would be to... - Answer- Stop tPA and get STAT non contrast head CT Treatment for orolingual angioedema which develops in 1-5% of pts being treated with tPA - Answer- IV ranitidine, diphenhydramine, methylprednisolone, allergic treatment pathways Elevated BP during tPA associated with - Answer- Hemorrhagic transformation in first 24 hrs When can ASA, heparin or oral anticoagulation begin post tPA - Answer- After 24hrs 2015 trials established this as standard of care for large vessel strokes - Answer- Mechanical embolectomy/thrombectomy Mechanical reperfusion may include... - Answer- Thrombectomy, intra-arterial administration of tPA, angioplasty, placement of stents Time window for intra arterial treatment bas