Solutions Manual/Test Bank For Acute Stroke Care THIRD EDITION M. Carter Denny MedStar Georgetown University Hospital, Washington, DC Ahmad Riad Ramadan Henry Ford Hospital, Detroit, MI Sean I. Savitz University of Texas Health Science Center, Houston, TX

Acute Stroke Care THIRD EDITION M. Carter Denny MedStar Georgetown University Hospital, Washington, DC Ahmad Riad Ramadan Henry Ford Hospital, Detroit, MI Sean I. Savitz University of Texas Health Science Center, Houston, TX James C. Grotta Memorial Hermann Hospital–Texas Medical Center, Houston, TXUniversity Printing House, Cambridge CB2 8BS, United Kingdom One Liberty Plaza, 20th Floor, New York, NY 10006, USA 477 Williamstown Road, Port Melbourne, VIC 3207, Australia 314–321, 3rd Floor, Plot 3, Splendor Forum, Jasola District Centre, New Delhi – 110025, India 79 Anson Road, #06–04/06, Singapore 079906 Cambridge University Press is part of the University of Cambridge. It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning, and research at the highest international levels of excellence. Information on this title: DOI: 10.1017/9781108759823 © Cambridge University Press 2020 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First edition published 2007 Second edition published 2011 Third edition published 2020 Printed in the United Kingdom by TJ International Ltd, Padstow Cornwall A catalogue record for this publication is available from the British Library. Library of Congress Cataloging-in-Publication Data Names: Carter Denny, M., Ramadan Riad, Ahmad, Savitz, Sean I., Grotta, James C., author. Preceded by (work): Uchino, Ken. Acute stroke care. Title: Acute stroke care / M. Carter Denny, Ahmad Riad Ramadan, Sean I. Savitz, James C. Grotta. Description: Third edition. | Cambridge, United Kingdom ; New York, NY : Cambridge University Press, 2020. | Preceded by Acute stroke care : a manual from the University of Texas-Houston Stroke Team / Ken Uchino, Jennifer K. Pary, James C. Grotta. 2nd ed. 2011. | Includes bibliographical references and index. Identifiers: LCCN | ISBN 9781108731324 (alk. paper : paperback) Subjects: | MESH: Stroke – diagnosis | Stroke – therapy | Handbook Classification: LCC RC388.5 | NLM WL 39 | DDC 616.8/1–dc23 LC record available at ISBN 978-1-108-73132-4 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.Contents Preface to the Third Edition page xi List of Abbreviations xii 1 Stroke in the Emergency Department 1 Is This a Stroke? 1 What Type of Stroke? 6 2 What to Do First 7 Airway – Breathing – Circulation (ABCs) 7 What Was the Time of Onset? 8 How Bad Are the Symptoms Now? 9 Do a Non-Contrast Head CT 9 If the CT Shows No Blood, Try to Get the Artery Open 10 Recommended Diagnostic Evaluation 10 3 Ischemic Stroke 12 Definition 12 Etiology 12 Diagnosis 12 vThe Four Components of Ischemic Stroke Care 13 Acute Therapy and Optimization of Neurological Status 13 Etiological Work-up for Secondary Prevention 21 Prevention of Neurological Deterioration or Medical Complications 24 Recovery and Rehabilitation 27 Ischemic Stroke Outcome 27 General Timeline 30 4 Stroke Radiology 32 Computed Tomography 32 Head CT with Contrast 35 Magnetic Resonance Imaging 40 MRI Sequences 41 Usual Sequences Ordered for Acute Ischemic Stroke Patients 52 Abbreviated Protocol for Uncooperative Patients 53 Usual Sequences Ordered for Acute ICH Patients 53 MRI Findings in Brain Hemorrhage 54 Cerebral Angiogram 55 Diffusion Tensor Imaging 55 5 Intravenous Thrombolysis 58 tPA Indications 60 tPA Contraindications 61 Procedure 71 Risks Versus Benefits of tPA 73 tPA-Related Intracranial Hemorrhage: Management Protocol 76 Oropharyngeal Angioedema: Management Protocol 77 vi Contents6 Endovascular Therapy 80 Time is Still Important 81 Planning an Endovascular Case 81 During the Procedure 90 After the Procedure 92 Risks and Benefits of EVT 94 Posterior Circulation 97 7 Neurological Deterioration in Acute Ischemic Stroke 101 Probable Causes 101 Initial Evaluation of Patients with Neurological Deterioration 102 Stroke Enlargement 102 Drop in Perfusion Pressure 104 Recurrent Stroke 105 Cerebral Edema and Mass Effect 107 Hemorrhagic Transformation 112 Metabolic Disturbance 114 Seizure 115 Symptom Fluctuations Without a Good Cause 115 The Uncooperative Patient 116 8 Ischemic Stroke Etiology and Secondary Prevention 119 Diagnostic Studies 119 Control Risk Factors 124 Antiplatelets and Anticoagulants 128 Atrial Fibrillation 132 Contents viiCarotid Stenosis 136 Carotid Occlusion 139 Intracranial Stenosis 140 Lacunar Strokes 141 Cervical Arterial Dissection 143 Patent Foramen Ovale 146 9 Transient Ischemic Attack 153 Definition 153 Etiology 154 Presentation 154 Differential Diagnosis 154 Clinical Approach to a Patient With Suspected TIA 155 Prognosis After TIA 157 10 Less Common Causes of Stroke 160 Causes 160 Tests to Consider 166 11 Cerebral Venous Sinus Thrombosis 168 Epidemiology 168 Pathogenesis 168 Risk Factors 168 Clinical Picture 170 Diagnosis 170 Acute Management 171 Chronic Management 172 Complications of CVST 172 Prognosis and Recurrence 173 viii Contents12 Intracerebral Hemorrhage 175 Definition 176 Etiology 177 Presentation 178 Diagnosis and Evaluation 179 Management 181 Prognosis and Outcome 192 13 Subarachnoid Hemorrhage 198 Definition 198 Epidemiology 198 Presentation 199 Diagnosis 199 Management of Ruptured Aneurysms 201 Unruptured Aneurysms 211 14 Organization of Stroke Care 215 Timely Care 215 Prehospital Stroke Care 216 Prehospital Stroke Scales 217 Drip-and-Ship versus Mothership Models 218 Stroke Centers 218 Telemedicine for Stroke (Telestroke) 221 Stroke Teams 221 Stroke Units 222 Contents ix15 Stroke Rehabilitation 226 Early Acute Stroke Rehabilitation Trials 227 Multidisciplinary Rehabilitation Team 228 Discharge Disposition 234 16 Transition to Outpatient Stroke Care 237 Psychosocial Evaluation 237 Stroke Prevention Clinics 238 Common Post-Stroke Sequelae 238 Appendix 1. IV tPA Dosing Chart 241 Appendix 2. Transcranial Doppler Ultrasound 244 Appendix 3. Medical Complications 247 Appendix 4. Brainstem Syndromes 253 Appendix 5. Anatomy of Cerebral Vasculature 256 Appendix 6. Brain Death Criteria 262 Appendix 7. Stroke Assessment Scales 266 Further In-Depth Reading 283 Index 285 Color plate section between pages 152 and 153 x ContentsPreface to the Third Edition Stroke is a classical acute medical emergency that needs to be dealt with promptly and effectively to minimize patient morbidity. This book helps answer the critical questions faced by any physician encountering a patient with suspected stroke. It provides practical advice on the care of stroke patients in a range of acute settings. The content is arranged in chronological order, covering the things to consider in assessing and treating the patient in the emergency department, the stroke unit, and then on transfer to a rehabilitation facility. All types of stroke are covered. A comprehensive set of appendices contains useful reference information, including dosing algorithms, medical complications, and stroke scales. Changes in this third edition include: • Content moved from appendices to new full chapter: & Stroke radiology • New chapters: & Endovascular therapy & Less common causes of stroke & Cerebral venous sinus thrombosis & Transition to outpatient stroke care • Expanded chapters: & Ischemic stroke etiology and secondary prevention – covers information on what a stroke specialist should consider in managing post-acute-stroke patients & Subarachnoid hemorrhage – many vascular neurologists will manage these patients & Organization of stroke care xiAbbreviations ACA anterior cerebral artery ACC American College of Cardiology ACE angiotensin-converting enzyme ADC apparent diffusion coefficient AF atrial fibrillation AHA American Heart Association AIS acute ischemic stroke APA antiplatelet agent aPTT activated partial thromboplastin time ARB angiotensin II receptor blocker ARR absolute risk reduction ASA American Stroke Association ASCVD atherosclerotic cardiovascular disease ASPECTS Alberta Stroke Programme Early CT Score AVM arteriovenous malformation BAO basilar artery occlusion BHF British Heart Foundation BHI breath-holding index bid twice a day (bis in die) BP blood pressure CAA cerebral amyloid angiopathy CAS carotid artery stenting xiiCBC complete blood count CBF cerebral blood flow CBV cerebral blood volume CEA carotid endarterectomy CI confidence interval CN cranial nerve CNS central nervous system CPP cerebral perfusion pressure CRP C-reactive protein CS conscious sedation CSF cerebrospinal fluid CT computed tomography CTA CT angiography CTP CT perfusion CTV CT venography CUS carotid ultrasound CVST cerebral venous sinus thrombosis DAPT dual antiplatelet therapy DBP diastolic blood pressure DCI delayed cerebral ischemia DIC disseminated intravascular coagulation DOAC direct oral anticoagulant DSA digital subtraction angiography DTI diffusion tensor imaging DVT deep venous thrombosis DWI diffusion-weighted imaging ECASS European Cooperative Acute Stroke Study ECG electrocardiogram ED emergency department EEG electroencephalogram EIC early ischemic change EMA European Medicines Agency List of Abbreviations xiiiEMS emergency medical services ESR erythrocyte sedimentation rate EU European Union EVD external ventricular drain EVT endovascular thrombectomy FDA Food and Drug Administration (USA) FEIBA factor eight inhibitor bypassing agent FFP fresh frozen plasma FLAIR fluid-attenuated inversion recovery GA general anesthesia GCS Glasgow Coma Scale GFR glomerular filtration rate GI gastrointestinal GRE gradient echo GU genitourinary HCTZ hydrochlorothiazide HDL high-density lipoprotein HI hemorrhagic infarction HIT heparin-induced thrombocytopenia HITS high-intensity transient signal HITTS heparin-induced thrombocytopenia with thrombotic syndrome HIV human immunodeficiency virus HU Hounsfield unit IA intra-arterial ICA internal carotid artery ICH intracerebral hemorrhage ICP intracranial pressure ICU intensive care unit IgG immunoglobulin G IgM immunoglobulin M IM intramuscular xiv List of AbbreviationsINR international normalized ratio IV intravenous IVH intraventricular hemorrhage IVT intravenous thrombolysis LACI lacunar infarction LDL low-density lipoprotein LKW last known well LMN lower motor neuron LMWH low-molecular-weight heparin LOC level of consciousness LTAC long-term acute care LVO large-vessel occlusion MAP mean arterial pressure MB microbubble MCA middle cerebral artery MI myocardial infarction MPGR multiplanar gradient recalled MRA magnetic resonance angiogram MRC Medical Research Council MRI magnetic resonance imaging mRS modified Rankin scale MRSA methicillin-resistant Staphylococcus aureus MRV magnetic resonance venography MSSA methicillin-sensitive Staphylococcus aureus MSU mobile stroke unit MTE mean time to enhancement mTICI modified Thrombolysis in Cerebral Infarction scale MTT mean transit time NCCT non-contrast CT NEI negative enhancement integral NF-1 neurofibromatosis type 1 NIH National Institutes of Health List of Abbreviations xvNIHSS National Institutes of Health Stroke Scale NINDS National Institute of Neurological Disorders and Stroke NNH number needed to harm NNT number needed to treat NPO nothing by mouth (nil per os) NSAID non-steroidal anti-inflammatory drug NSTEMI non-ST-elevation myocardial infarction OOB out of bed OR odds ratio OT occupational therapy PACI partial anterior circulation infarction PCA posterior cerebral artery PCC prothrombin complex concentrate PEG percutaneous endoscopic gastrostomy PET positron-emission tomography PFO patent foramen ovale PH parenchymal hemorrhage PO by mouth (per os) POCI posterior circulation infarction PSD post-stroke depression PT physical therapy PT prothrombin time PTT partial thromboplastin time PWI perfusion-weighted imaging qd every day (quaque die) RCT randomized controlled trial RCVS reversible cerebral vasoconstriction syndrome RLS right-to-left shunt RRR relative risk reduction SAH subarachnoid hemorrhage SBP systolic blood pressure SC subcutaneous xvi List of AbbreviationsSIADH syndrome of inappropriate antidiuretic hormone secretion SLE systemic lupus erythematosus SLP speech and language pathologist SNF skilled nursing facility SPECT single-photon emission computed tomography SSRI selective serotonin reuptake inhibitor ST speech therapy STEMI ST-elevation myocardial infarction SWI susceptibility-weighted imaging TACI total anterior circulation infarction TCD transcranial Doppler ultrasound TED thromboembolic deterrent TEE transesophageal echocardiogram TIA transient ischemic attack T max maximum of the tissue residue function TNK tenecteplase tPA tissue plasminogen activator tRNA transfer RNA (ribonucleic acid) TTE transthoracic echocardiogram TTP time to peak UFH unfractionated heparin UTI urinary tract infection VTE venous thromboembolism VZV varicella-zoster virus WBC white blood cells WFNS World Federation of Neurological Surgeons List of Abbreviations xvii1 Stroke in the Emergency Department Stroke is the most common neurological emergency, and, because effective treatments are available that must be started within minutes, most acute neurological presentations should be assumed to be a stroke until proven otherwise by history, exam, or radiographic testing. Unfortunately, there is not a quick and easy laboratory or clinical test to determine for sure that the patient lying in front of you is having a stroke, so an accurate history and exam are essential. n Is This a Stroke? DEFINITION The term “stroke” usually refers either to a cerebral infarction or to a non-traumatic cerebral hemorrhage. Although it will vary depending on the population you are seeing (ethnicity, age, comorbidities), the ratio of infarcts to hemorrhages is about 4 to 1. As will be described in more detail in Chapter 3, cerebral infarcts can be caused by a number of pathological processes, but all end with an occlusion of a cerebral artery or vein. If the arterial occlusion results in a reduction of blood flow insufficient to cause death of tissue (infarction), it is termed “ischemia.” 1As will be described in more detail in Chapter 12, non-traumatic cerebral hemorrhages are caused by a number of pathological processes which all lead to bleeding into the brain parenchyma and ventricles. Bleeding into the subarachnoid space (Chapter 13) is usually caused by a ruptured aneurysm or vascular malformation. Other types of brain bleeding, for example into the subdural or epidural space, are usually traumatic and are not considered in this book. PRESENTATION When taking the history, the most characteristic aspect of a cerebral infarct or hemorrhage is the abrupt onset, so be sure to get the exact flavor of the onset. It is also imperative to determine as precisely as possible the time of onset. The symptoms most often stay the same or improve somewhat over the next few hours, but may worsen in a smooth or stuttering course. Ischemic strokes (but not hemorrhages) may rapidly resolve, but even if they resolve completely, they may recur after minutes to hours. The second characteristic historical aspect of cerebral infarcts is that the symptoms will usually fit the distribution of a single vascular territory. This is also the most important characteristic of the neurological exam in a patient with an infarct. Therefore, patients with an infarct will present with symptoms and signs in the middle, anterior, or posterior cerebral arteries, a penetrating artery (producing a “lacunar” syndrome), or the vertebral or basilar artery (see below). Parenchymal hemorrhages also occur in characteristic locations, and usually show the same symptom complex and signs as cerebral infarcts except that early decrease in level of consciousness, nausea and vomiting, headache, and accelerated hypertension are more common with hemorrhages. Subarachnoid hemorrhages classically present as a bursting, very severe headache (“the worst headache of my life”), and are often accompanied by stiff neck, decreased consciousness, nausea, and 2 Chapter 1: Stroke in the Emergency Department n n n n n n n n n n n n n n n n n n n n n n n n nn subject to the Cambridge Core terms of use, available at Downloaded from signify associated bleeding into the parenchyma. Signs and symptoms characteristic of the various arterial territories are: . Middle cerebral – contralateral loss of strength and sensation in the face, arm, and to a lesser extent leg. Aphasia if dominant hemisphere, neglect if non-dominant. . Anterior cerebral – contralateral loss of strength and sensation in the leg and to a lesser extent arm. . Posterior cerebral – contralateral visual-field deficit. Possibly confusion and aphasia if dominant hemisphere. . Penetrating (lacunar syndrome) – contralateral weakness or sensory loss (usually not both) in face, arm, and leg. No aphasia, neglect, or visual loss. Possibly ataxia, dysarthria. . Vertebral (or posterior inferior cerebellar) – ataxia, dysarthria, dysphagia, ipsilateral sensory loss on the face, and contralateral sensory loss below the neck. . Basilar – various combinations of limb ataxia, dysarthria, dysphagia, facial and limb weakness and sensory loss (may be bilateral), pupillary asymmetry, disconjugate gaze, visual-field