How Well You Know About Stroke? Quiz!

Approximately 84% of strokes are ischemic and can be caused by clots that lodge in the cerebral vasculature. The other 16% are hemorrhagic, due to an aneurysm or high blood pressure causing the rupture of a blood vessel. Of note, hypertension could also cause an ischemic stroke indirectly by contributing to atherosclerosis and thus clot formation. This is an incentive for the patient to take his or her antihypertensive medication!

Before we get started with questions regarding stroke, it helps to know what a stroke entails. Please note that cerebrovascular disease/accident refers to any type of vascular disease in the brain.

Alteplase is the preferred fibrinolytic agent for stroke treatment. Streptokinase actually increased morbidity and mortality.

The higher dose of aspirin, 325 mg, is an option; give within 24-48 hours of the stroke. 81 mg is also acceptable.

The patient has just suffered a massive bleeding episode in his or her cranium, so do not administer another agent that will seriously increase their bleeding. In such situations (hemorrhagic strokes), there are few therapeutic options but focus on controlling hypertension (note the special goals), reverse warfarin if the patient was taking, and use mannitol to maintain serum osmolality and arterial pressure.

TIAs are neurological deficits in which blood flow to the brain decreases; they last from a few seconds to 24 hours. Symptoms may include transient motor and sensory loss in the face, arm, or hand; vertigo; and numbness. However, they should be taken seriously, as a stroke can occur soon after a TIA.

Blood glucose is the only assessment that must precede the initiation of IV tPA.

The symptoms selected (sudden numbness/weakness of the face, arm, or leg, especially on one side of the body; difficulty speaking; sudden changes in vision; and sudden severe headache) are signs of a stroke and should be presented to patients as situations that require emergency assistance. Decreased urination is not related to a stroke. Pain radiating from the chest to the left arm is a sign of myocardial infarction.

The blood pressure goal for a patient receiving fibrinolytic therapy is less than 185/110 mmHg. High blood pressure is keeping the blood supply to the brain, so antihypertensive medications should not be given unless the blood pressure is greater than 185/110 mmHg and fibrinolytic therapy is desired. For the 24 hours following tPA, the blood pressure should be maintained at less than 185/105 mmHg.

As mentioned in the previous question, high blood pressure during a stroke is key for preserving perfusion to the brain. Therefore, only utilize medications to lower blood pressure if the patient's blood pressure is greater than 220/120 mmHg.

Please note the intense monitoring required during and after tPA therapy. Stroke patients are often admitted to an ICU or stroke unit. Of note, increase the frequency of monitoring if the patient has blood pressure greater than 180/105 mmHg and administer medications to keep the blood pressure below 180/105 mmHg.

This is false; in certain circumstances, the fibrinolytic may be used up to 4.5 hours after the onset of symptoms.

Atrial fibrillation can lead to clots, which can enter the cerebral vasculature and cause a stroke. Diabetes is yet another modifiable risk factor, but controlled diabetes will minimize the risk of a stroke. Dyslipidemia can lead to emboli that cause an ischemic stroke. Unfortunately, there is nothing possible to solve a family history, other than to be extra healthy with diet and exercise! Hypertension is a major factor in causing strokes, so keep the patient's blood pressure under control. Smoking cessation will also decrease the risk of cardiac morbidities such as a stroke.

The dosing for Alteplase is 0.9 mg/kg (max dose 90 mg) over 60 minutes, with 10% of the dose given as a bolus over 1 minute. For a 100 kg patient, the dose would be 90 mg total, with 9 mg given as the bolus and 81 mg given over the rest of the hour. For a 70 kg patient, the dose would be 63 kg total, with 6.3 mg given as a bolus and 56.7 mg given over the rest of the hour.

Of note, ACE-I plus diuretic is the recommended choice for antihypertensive medication. The addition of a statin is without regard to prior use; the pleiotropic effects of statins will be of benefit in preventing further emboli.

Mechanical valves have greater risks for clotting than bioprosthetic valves, so they need greater anticoagulation or antiplatelet therapy. The mitral valve is of lower pressure than is the aortic valve, so in general mitral valves require more aggressive therapy (higher INR goal, etc) to prevent clot formation.

Any indications of increased risk of bleeding preclude the use of a fibrinolytic, which can cause life-threatening bleeding. Blood glucose should be normoglycemic: above 50 mg/dL. Of note is if the patient had a stroke within the past 3 months, then the patient is precluded from receiving a fibrinolytic. Also, blood pressure must be lower than 185/110 mmHg.