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Which of the following is the most common type of stroke that is clinically encountered?
A. Large vessel dissection
B. Intracerebral hemorrhagic
C. Ischemic related to a thrombus
D. Subarachnoid hemorrhagic
Annotated answer C: Ischemic related to a thrombus. Strokes can be classified as ischemic, due to an occluded artery, or as hemorrhagic, due to a ruptured artery. Ischemic stroke is by far the more common type.
An 86 YO presents with evidence of an acute ischemic stroke. Symptom onset was 2 hours ago and the deficits have been progressive and significant. The patient seized when being transported to the hospital by the EMTs. Blood pressure is 180/100. Which of the following would exclude this patient from thrombolytic therapy?
A. Age greater than 85
B. The duration of symptoms
C. The progressive deficit
D. The seizure
E. The blood pressure reading
Correct Answer D. The seizure. A small number of patients with acute ischemic stroke will be eligible for reperfusion therapy, as there are numerous exclusion criteria including: minor or improving symptoms, seizure at stroke onset, prior stroke within 3 months, major surgery within 14 days, history of intracerebral hemorrhage, sustained elevated blood pressure or aggressive medical treatment to correct blood pressure, and suspicion of subarachnoid hemorrhage. There is some laboratory data which also excludes patient from receiving t-PA including: INR >1.7, platelet count <100,000/uL, plasma glucose < 50 or >400 (mg/dL). Chronologic age is not among the definite exclusion criteria. The patient has presented inside the 3 hour window. In patients who are candidates for t-PA, blood pressure should be less than 185/110 mm Hg.
A 78 YO has an acute ischemic stroke. He presented too late after symptom onset for thrombolytic therapy. He is hypertensive. As you contemplate treating his blood pressure, how high would you permit the blood pressure to be before initiating therapy?
A. 140/80 mmHg
B. 150/90 mmHg
C. 180/110 mmHg
D. 220/120 mmHg
Correct Answer: D In patients ineligible for intravenous rtPA, blood pressure parameters are liberalized (up to 220/120 mmHg) with the intention of maintaining cerebral perfusion to ischemic areas.