Morning Report Unknown

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Morning Report Unknown 45
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Case Neurology

• 75 yo WM PMHx DM, Dyslipid HTN c/ a 2 hr hx of
  acute R. sided hemiparesis and aphasia.
• Hemi-Colectomy 1 month prior
• CT Head Negative (no bleed)
• VS BP 180 / 105
• CBC Plt 95K Cr 2.0
• Exam deficits as above

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Question

• What is the contraindication for tPA in this pt?
• a. age (75 yo)
• b. BP (180/105)
• c. Platelet (95K)
• d. Hemicolectomy (1 month pta)
• e. Time (2 hrs since onset sxs)
• f. No contraindications

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Question 2

• In non t-PA treated ischemic strokes, the
  following have been shown to reduce mortality
• a. use of ASA
• b. use of heparin anticoagulation
• c. control of blood glucose
• d. control of hypertension
• e. supplementing O2 for Pox lt95
• f. control of fevers/hyperthermia
• g. All of the above

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Bonus Question

• Johnny Carson retired in 1992. Even after
  retirement, he continued to write monologue jokes
  to this comedian.
• a. Jay Leno
• b. David Letterman
• c. Conan OBrien
• d. Carrot Top
• e. Ed McMahon

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Answer 1

• What is the contraindication for tPA in this pt?
• a. age
• b. BP (180/105)
• c. Platelet (95K)
• d. Hemicolectomy (1 month pta)
• e. Time (2 hrs since onset sxs)
• f. No contraindications

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Question 2

• In non t-PA treated ischemic strokes, the
  following have been shown to reduce mortality
• a. use of ASA
• b. use of heparin anticoagulation
• c. control of blood glucose
• d. control of hypertension
• e. supplementing O2 for Pox lt95
• f. control of fevers/hyperthermia
• g. All of the above

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Acute Ischemic Strokes

• t-PA given lt3hr of stroke onset decreases
  disability by 30 with no increase in mortality
  BUT 6.4 risk of symptomatic intracranial
  hemorrhage

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Ischemic Strokes t-PA

• Inclusion Criteria
• lt 3 hrs after onset
• age gt18 yo
• CT s/ hemorrhage or nonstroke
  etiology of deficit

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t-PA exclusion criteria

• Improving sxs
• Seizure at onset of stroke
• iStroke, serious head trauma, brain surgery lt 3
  months
• Known AVM, aneurysm or hx of IC hemorr
• Major Surgery lt 14 days
• GI/GU Bleed lt 21 days
• LP lt 7 days
• PLT lt 100K, INR gt 1.7, abn aPTT in setting of
  heparin administration
• Sustained SBP gt 185 or DBP gt 110
• Suspected SBE or vasculitis

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Ischemic Strokes

• Heparin no evidence from clinical trials that
  heparin is safe or effective in ischemic strokes
• Hyperglycemia damages penumbra by increasing
  lactic acidosis (avoid D5 soln)
• Oxygen no evidence that routine oxygen for Pox gt
  92
• Temperature
• HyPERthermia worst outcome HyPOthermia
  neuroprotective

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Ischemic Strokes

• Hypertension Control
• Acute HTN at the time of stroke is most often a
  result of not a cause of stroke.
• Usually resolves first few hours or days after
  acute CVA.
• HTN in ischemic strokes should not be tx unless
  secondary condition requires reduction of bp
  (acute MI, CHF, dissection)

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Bonus Answer