Thread by @POPCoRNetwork

Stroke got you thinking of freestyle & butterfly? Do you avoid people w/ focal neuro deficits? Let’s channel our inner Michael Phelps as we swim thru this #POPCoRNtweetorial adapted by @robertdaulton on our way to mastering the Stroke/TIA work-up #POPCoRNet #COVIDPOPCoRN 1/

Ischemic: occlusion from thrombus/embolus/hypoperfusion
-Large vessel atheroscler./small vessel dz/cardioemboli
Hemorrhagic: intracerebral/subarachnoid hem from intracranial vessels
-HTN, aneurysm rupture, cerebral amyloid angiopathy, vasc malform #POPCoRNtweetorial 2/

DDx: TIA (transient, no CT findings, resolves in 24 hrs), complex/hemiplegic migraine (slow spread of symps), venous sinus thrombus
Now for the work-up:
1. Est timeline, last known well (LKW)
2. POC Glucose
3. Neuro Exam: NIHSS (mdcalc.com/nih-stroke-sca…) #POPCoRNtweetorial 3/

4. Call Stroke Team if <24 hrs from LKW vs. call Neuro
5. Non-con Head CT
-CT head is neg for intracranial hemorrhage (ICH): NIHSS> 6 → CT Angio head+neck; NIHSS>6 & LKW>6 hrs → CT perfusion
-CT head w/ ICH: call neurosurg; no neurosurgeon? → transfer #POPCoRNtweetorial 4/

Ischemic Stroke Tx:
1. IV tPA: 0.9mg/kg (max 90mg); 10% bolus in 1m + 90% via 1 hr infusion
-If <4.5hrs from LKW
-Major Contraindications (CI): active/inc risk of bleed, poor clotting
-30% improved outcome vs. not receiving tx; 2-5% upfront risk of worse brain bleed 5/

2. Endovascular Candidate: consider if large vessel occl on CTA, intracranial occl of ICA/MCA/Basilar aa.
-Still give IV tPA if candidate
-Call Comprehensive/Thrombectomy Capable Stroke Center for transfer
-CT Perfusion to guide endovascular tx #POPCoRNtweetorial 6/

3. No tPA/endovasc? Dual Anti-plt Therapy (DAPT)
-ASA (325mg→81mg qd) + Clopidogrel (300-600mg→ 75mg qd)
-Daily dose 24hr after IV tPA
-CT/deficits suggest large infarct = risk of hemorrhagic conversion
-Minor stroke/TIA: risk of recurrence & low bleed risk→ load DAPT
7/

Continuing Care (Pt. 1):
-BP Goals: if tPA <180/100; no TPA <220/120, permissive HTN for 1st 24hr
-Imaging: MRI (CT Head if MR not avail) 24 hr after IV tPA (sooner if worse)
-Head/Neck vessel MR/CT (US last resort)
-A1c+Lipids (call Endo if A1C >8%) #POPCoRNtweetorial 8/

Continuing Care (Pt. 2):
-TTE for <3 eval; bubble study in young for PFO
-Holter monitor (esp if >50) for Afib
-Neuro/Vasc surg for CEA if large vessel atherosclerosis >50% ipsilateral to ischemic stroke; minor stroke/TIA→CEA in 2 wks #POPCoRNtweetorial 9/

Grab your team and celebrate! You brushed up on your neuro exam, recognized the signs & called the right people. Refer to our one-pager (popcornetwork.org/neuro) to review this awesome #POPCoRNtweetorial. Check out popcornetwork.org for more phenomenal resources 11/x