# data[].attributes.body
A) Time of symptoms onset/last time seen normal
B)  Stroke based on NIHS=15, right upper limb and lower limb has power of 2/5, confused and increased conciousness
so:
- oxygen saturation to be determined
- Cardiac support via ECG
- Assess eligibility for reperfusion (tPA)
-Check vitals (BP, HR)
-Stop his meds (esp. metformin as it is CI with the dye of CT) except for pantoprazole and statins

C)  - CT scan to rule out hemorrhagic stroke

- MRI (DWI and PWI for extent of ischemia)

- Blood glucose test to rule out hypoglycemia

D)

- TTE for valve abnormalities to find source of stroke
-  ECG (to determine presence of Afib)

# data[].attributes.body
A)

BP monitoring

Assess eligibility for Tpa

Uncontrolled coagulation

Uncontrolled blood glucose

DVT Prophylaxis
monitor for neurological deterioration

B)

·         Reduce infarct size

·         Reduce mortality

·         Reduce ongoing neurological injury

·         Reduce long term disability

·         Determine if patient is candidate to repurfusion

·         Prevent complications secondary to immobility and  neurologic dysfunction

·         Prevent stroke reccurence

C) If tPA eligible <185/110mmHg

If not then lower than 220/120mmHg

D) Labetalol 5mg IV for 1 minute then double the dose every 10minutes to lower it by 10-15% reduction in BP

OR

Nicardipine 5mg per hour IV then titrate to 2.5mg for 1 hour every 5 minutes max. 15mg 10-15% reduction in BP

OR

Nitroprusside 0.5ug/kg/minute to target 10-15% reduction in BP

# data[].attributes.body
A)

·         IV alteplase 0.9mg/kg (67.5mg). 10% (6.75mg) as IV bolus within 1 minute and 90% (60.75mg) within the next hour

B) ·         Inclusion:

o   Time within 4.5hr of symptoms onset

o   >18yo

o   Evidence of ischemic stroke

·         Exclusion:

o   Taking anticoagulants

o   Hemorrhagic stroke

o   History of stroke in the previous 3 months

o   Intracranial hemorrhage

·         0.9mg/kg (67.5mg). 10% (6.75mg) as IV bolus within 1 minute and 90% (60.75mg) within the next hour

C)

·         Streptokinase= increase hemorrhage (high rates of hemorrhage)

·         Urokinase, reteplase, anistreplase, staphylokinase= not studied/tested

·         Tenectoplase= long half life and higher fibrin specificity but still being studied yet shows promising effects

·         Desmoteplase= phase III studies still in place

D)
* efficacy:
- monitor for  neurological function every 15minutes for 2hrs
then check safety:
- by neurologic function every 30min for 6hr to check for intracranial hemorrhage
- GI bleeding
-BP
E)

·         IV tenecteplase 0.4mg/kg bolus

# data[].attributes.body
A) Was there anyone with him before reaching him? Is your father adherent with his medications? Was your father's BP controlled before his symptoms? Is that the first time to experience these symptoms?
B)  Ensure patient is supported from respiratory (O2 supply) and cardiac (ECG) endpoints.
Stop his medications for now (metformin can cause ketoacidosis with dyes)

Perform CT scan and MRI to determine type of stroke

C) CT scan
D) ECG, TTE, TEE, blood glucose test, electrolytes, CBC, renal function, cardiac biomarkers,

# data[].attributes.body
A- When did the symptoms started? or when is the last time her dad seen normal?
B-  Ensure that the patient is supported from a
respiratory and cardiac standpoint (O2 saturation,  BP, and blood glucose), and evaluate for reperfusion therapy
C-  necessarily diagnostic: MRI - CT Scan.
D- Others: CD studies - ECG - TTE -TEE

# data[].attributes.body
A- Look for:

- BP

- uncontrolled blood glucose (A1C):
need insulin therapy

- Further management for kidney function: [BUN and Creatinine clearance (65 ml/min)]

- Hemoglobin

- Coagulation factors

B- GoT:

-To reduce the ongoing neurologic injury and decrease mortality and long‐term disability

-Determining if patients with acute ischemic stroke are candidates for thrombolytic therapy

-Prevent complications secondary to immobility and neurologic dysfunction

-Prevent stroke recurrence

C- To qualify for tPA, BP must be maintained below 180/105 [need alteplase]

D-  Labetalol 10 mg IV for 1 minutes, then double the dose every 10 minutes to lower it by 10-15% reduction in BP, and monitor.
If BP still high during TPA ,give nitroprusside 0.5 mcg/kg/min IV.

# data[].attributes.body
A- Onset of the symptom
B- Evaluation of Respiratory and cardiac supportive care.
C- CT scan without contrast to eliminate hemorrhage.
MRI (DWI and PWI) to determine the location and extent of ischemia.
D- Blood glucose, oxygen saturation , renal function, CBC, ECG, serum electrolyte

# data[].attributes.body
A) ask the daughter about the last time she has seen her dad normal.
B) left-sided stroke(need MRI or CT to decide type of stroke)
Management: ABC
A: AIRWAY Oxygen if below 90%, B: BREATHING C: CIRCULATION by looking at VITAL SIGNS.
STOP his home medication (esp the blood pressure medication, Metformin used along with the imaging dye causes Lactic acidosis so we MUST STOP IT, (in the past 24 hours.
STOP anticoagulants and antiplatelets(even if its hemmorhagic or ischemic)
CONTINUE statin and pantoprazol
C) Require CT without contrast (to rule out hemorrhagic transformation)
THIS IS THE MOST IMPORTANT
and MRI( How much damage) NOT VERY IMP AT THE MOMENT
D) other diagnostic tests: carotid doppler(non cardioembolic origin confirmation), ECG( RULE OUT ATRIAL FIBRILATINON, to know if stroke is of cardioembolic origin), TEE,TTE (echocardiogram)
Other labs: blood glucose test, electrolytes, CBC, renal fun tion, cardiac biomarkers,

# data[].attributes.body
A- Elevated BP, Blood glucose, high aPTT
B- To reduce the ongoing neurologic injury of MA and decrease mortality and long-term disability during hospitalization.
-Prevent complications of secondary to immobility and neurological dysfunction.
-Prevent stroke recurrence.
-Improve MA's quality of life
C- For acute management maintain 180/105  (AHA 2018).
D- Labetalol

# data[].attributes.body
A) Resolve stroke symptoms, abnormalities: high HbA1C and current glucose levels, low hemoglobin, BP management. Initiate DVT prophylaxis therapy. Set-up a secondary prevention plan
B) Goals of therpay:
To reduce the ongoing neurologic injury and
decrease mortality and long‐term disability
• Determining if patients with acute ischemic
stroke are candidates for thrombolytic therapy
• Prevent complications secondary to immobility
and neurologic dysfunction
• Prevent stroke recurrence
C) Less than 180/105mmHg/ use labetalol 5mg IV bolus for 1 minute
D) Labetalol 20mg, if still elevated during t-PA we add NPS

# data[].attributes.body
A) 1. Blood pressure maintanence (labetalol)
2.Hyperglycemia (give insulin! Must control to a specific level for tpa, found in check adherance, or consider changnig agent, this is after discharge
3. Abnormal coagulation tests but not enough to make him not eligible for tpa
4. Calculating CrCl = 63 ml/min (no height given) it seems ok?
5. ASSESS Eligibility for TPA
6. VTE PROPHYLAXIS

B) eligible for tPA  less than 185/ 110
So until he gets the tPA his blood pressure should be less than 185/105 mmHg prior to tPA initiation

C)1.  Reduce the ongoing neurologic injury and

decrease mortality and long‐term disability
2. Determining if patients with acute ischemic

stroke are candidates for thrombolytic therapy
3. Prevent complications secondary to immobility

and neurologic dysfunction
4. Prevent stroke recurrence

D) Labetalol 10- 20 mg IV for 1-2 minutes, then double the dose every 10 mins, to lower by 10-15% of BP. If this fails and BP is still elevated during or after tx, give Nitroprusside add on

# data[].attributes.body
A-
B-Alteplase 6.75 bolus, then 60.75 mg over an hour  of infusion
C- Tenectaplase and Alteplase are proven efficacious (NOR-TEST) and others are unproven. However, only alteplase is FDA approved and supported by AHA guideline.
D- Neurologic assessment Q15min for 2 hr, then Q30min for 6hr including s/sx of ICH.
Monitor for GI or GU hemorrhage
Monitor BP
E

# data[].attributes.body
A) Alteplase 67.5mg divided by 6.75 bolus IV and then 60.75mg IV infusion during the next hour
B) Yup, he was diagnosed with ischemic stroke and onset of symptoms is less than 4.5 hrs. Age is more than 18 years. BP was lowered to 180/105 mmHg

C)
D)neurologic assessment every 15 minutes for 2 hours and then
every 30 minutes for 6 hours to include monitoring for signs and
symptoms of intracerebral hemorrhage (ICH) (
– decrease in the level of consciousness or worsening neurologic
deficit occurs during infusion, notify the physician and stop the
infusion
– monitored for gastrointestinal or genitourinary hemorrhage
– Monitor BP as
E)  control BP, glucose, prevention management

# data[].attributes.body
AA- IV labetalol 10 mg for 1 min. – give insulin to control blood glucose.

B- He is eligible.

Alteplase dose: 6.75 mg IV bolus then 67.5 IV infusion for the remaining of the one hour.

C- streptokinase has high rate of hemorrhage – reteplase & urukinase & anistreplase & staphylokinase have not been tested extensively. Tenecteplace appears promising.

D- Monitor:

- minor/major Bleeding

- BP and vitals q15min
- glucose level

- neurologic function q15min x 2 hr, then q30min x 6hr
- side effects such as :GIT disturbance symptoms, headache. If severe symptoms occur, discontinue the infusion.

- Obtain a follow-up CT scan or MRI at 24 hours before starting anticoagulants or antiplatelet agents

E-  blood pressure and blood glucose management during the first 24 hrs.

# data[].attributes.body
A- Antiplatelet and anticoagulant therapy: Aspirin, clopidogrel, aspirin and dipyridamole and Ticlopidine.

Blood pressure agents

Cholesterol monitoring and smoking cessation.

Diet and diabetes need further management to keep glucose within the normal range.

Education and Exercise.

B- In patients presenting with minor stroke, treatment for 21 days with dual antiplatelet therapy (aspirin and clopidogrel) begun within 24 hours can be beneficial for early secondary stroke prevention for a period of up to 90 days from symptom onset (The CHANCE trial: The primary outcome of recurrent stroke at 90 days (ischemic or

hemorrhagic) favored dual antiplatelet therapy over aspirin alone)
[Not for long-term management]

C- “ secondary prevention measures are appropriately instituted within the first 2 weeks” (AHA 2018).

D- Safety: prevent/monitor side effects: GI upset - toxicity - muscle pain - bleeding - ...
Efficacy: Prevent recurrence of stroke - monitor patient's symptoms - ...

# data[].attributes.body
a) ·         Antiplatelet (aspirin 50-325mg/day) within 48hr “CAST trial”

·         OR Anticoagulant (DOAC) (not cardioembolic)

·         Blood pressure (recontinue bisoprolol) <140/90

·         Diabetes (reassess metformin) HbA1c<6.5%

·         Statins (change to Atorvastatin 80mg) <1.4mmol LDL
b) Only recommended for TIA as per CHANCE trial with NIHSS score of less than 3
c) 24hrs after admission

# data[].attributes.body
A- HTN: HCTZ 12.5 mg once daily: goal less than 140/90
stroke prevention: Atorvastatin 80 mg once daily to target 50% reduction in LDL.
ASA 100 mg once daily indefinitely
Manage diabetes to target blood glucose less than 180 mg/dl
B
C
D

# data[].attributes.body
A) Alteplase, sliding scale insulin( well known protocol give this many units if glucose is above this much, theres a ttration criteria), give labetalol 10-20 mg  may repeat in 1 mins
B he meets criteria ( THE PATIENT WAS LAST SEEN NORMAL AT 8:00 AM, He is eligible for tpa(still within 4.5 hrs)
C)  6.75 bolus dose of alteplase over 1 minute, then give 60.75 mg of alteplase infusion during the next hour
D) immidiately
E) according to the guideline AHA, ASA 2018, use of other IV  thrombolytics else than alteplase and tenectaplase  has no proven benefit so they are not used outside RCTs. Alteplase has stronger evidence (IA) whereas Tenectaplase level of evidence is (IIb)
D) 1. Monitor neurologic assessment( NIHSS)  every 15 mins for 2 hrs then  monitor every 30 mins for the next 6 hrs, then hourly until 24 hours after tx
2. Monitor s/sx of ICH throughout alteplase ( monitor for severe headache, stop immidiately)
3. Monitor any GI beleding throughout tx
4. Monitor BP q15 mins for 2 hrs then q30 mins for 6 hrs then q1hr for 16 hrs ( make sure its elss than 180/105  mmHg
5. Watch over level of conciousness
6. Watch over level for glucose to be ( 140 - 180 mg/dl) and prevent hypoglycemia
7. Monitor for VTE
8. Monitor for signs and symptoms of bleeding (nose,gum,urine,stool)
C
D

# data[].attributes.headline
Tenecteplase: as safe as Atleplase but unclear if it is more effective than atleplase. 

# data[].attributes.subject
Tenecteplase: as safe as Atleplase but unclear if it is more effective than atleplase. 

# data[].attributes.body
no superior benefit tenecteplase over atleplase.

# data[].attributes.body
ABCD
the storke is of non cardioemobolic origin so
We will give anitplatelet therapy: (no need for dual antiplatelet, its nnot t ACS, not a minor stroke (NIHSS<3) or a tia that requires 21 days of DAPT by the CHANCE trial. )
Asprin,  clopidogrel, combination of asa+clopido, combination asa+ dipyridamole
For blood pressure;
Diuretics or combination of diuretics+ACEI
For cholesterol:
High intensity statin exm atorvastatin, rosuvastatin
We will choose:
Asprin 100mg initiate after 24 hrs based on CAST TRIAL ( 50- 325 mg/day)
Hydrochlorothiazide  25mg orally once daily, may increase 50 mg twice daily. Goal: 130/80 mmHg ( discontinue Beta blocker)
Continue atorvastatin 80 mg once daily

Monitoring for ASA, safety: bleeding s/sx, GI bleed. Efficacy: recurrence
Statin efficacy:  monitor LDL<  1.4 ( not sure) safety: jauncice for hepatic toxicity, muscle pain
BP med: acei: safety: angioedema, dry cough, efficacy: bp levels below 130/80 mmhg

# data[].attributes.body
Is MK at risk for venous thromboembolism? If so, using the risk factor assessment model, state her risk factors and her score?

# data[].attributes.body
Is MK at risk for venous thromboembolism? If so, using the risk factor assessment model, state her risk factors and her score?