Synaptogenesis Pearls

paroxysmal AF may be undetected on standard cardiac monitoring such as continuous telemetry and 24- or 48-hour Holter monitors 🥲🥲

Oxygen administration in patient with stroke A 2018 systematic review found that supplemental oxygen in patients with normal oxygen saturation as measured by pulse oximetry (SpO2) increases mortality in patients with stroke and other acute illnesses . An international guideline makes a strong recommendation that oxygen therapy not be initiated in patients with stroke and an SpO, of 93% or greater and a weak recommendation that oxygen therapy be withheld in patients with stroke and an SpO, of 90% or greater. in patients receiving oxygen therapy, the SpO, should be maintained at less than 96% (with a suggested therapeutic range for SpO, of 93% to less than 96%). The American Heart Association/American Stroke Association (2018 guideline) recommends oxygen to maintain an oxygen saturation of 94% or greater, with no upper limit provided. and the European Academy of Neurology recommends oxygen to maintain normoxia in patients with an arterial oxygen saturation less than 95%, with no upper limit provided.

Fluids therapy in acute stroke Intravascular volume depletion is frequent in the setting of acute stroke, particularly in older adult patients , and may worsen cerebral blood flow. For most patients with acute stroke and volume depletion, isotonic saline without dextrose is the agent of choice for intravascular fluid repletion and maintenance fluid therapy . In general, it is best to avoid excess free water (eg, as in ½ isotonic saline) because hypotonic fluids may exacerbate cerebral edema in acute stroke and are less useful than isotonic solutions for replacing intravascular volume. In addition, it is best to avoid fluids containing glucose, which may exacerbate hyperglycemia. However, fluid management must be individualized based on cardiovascular status, electrolyte disturbances, and other conditions that may perturb fluid balance. In particular, hyponatremia following subarachnoid hemorrhage may be due to inappropriate secretion of antidiuretic hormone (SIADH) or rarely, to cerebral salt wasting; these are physiologically distinct and are treated differently. uptodate

The main indication for oral anticoagulation after ischemic stroke is atrial fibrillation. When indicated, oral anticoagulation can be started immediately for patients with a transient ischemic attack, and soon after ischemic stroke onset for medically stable patients with a small- or moderate-sized infarct and no bleeding complications or uncontrolled hypertension. 🚨For patients with atrial fibrillation who have a large infarct, symptomatic hemorrhagic transformation, or poorly controlled hypertension, withholding oral anticoagulation for one to two weeks is generally recommended. Uptodate

Glucose management for secondary brain injury prevention ◦ Hypoglycemia: Treat if blood glucose is < 60 mg/dL. ◦ Hyperglycemia: Treat to maintain blood glucose levels in a range of 140 to 180 mg/dL

Management of BP in ischemic stroke Management of acute hypertension in ischemic stroke differs when thrombolysis is not involved. Early treatment of hypertension is indicated when required by comorbid conditions (such as concomitant acute coronary event, acute heart failure, aorticdissection, postfibrinolysis intracranial hemorrhage, or preeclampsia/eclampsia). In patients with blood pressure 220/120 mm Hg or greater who did not receive VI alteplase or mechanical thrombectomy and have no comorbid conditions requiring urgent antihypertensive treatment, the benefit of initiating or reinitiating treatment ofhypertension within the first 48 to 72 hours is uncertain. It might be reasonable to lower blood pressure by 15% during the first 24 hours after onset of stroke. Statins have not been shown to reduce the risk of recurrent stroke when administered within 30 days but can be considered after a dysphagia evaluation has been completed, especially in those patients with an atherosclerotic stroke subtype. MKSAP19

🚨🚨Acute administration of anticoagulation in ischemic stroke (whether related to atrial fibrillation or not) does not reduce the short-term risk of recurrent stroke and increases the risk of hemorrhage into the territory of cerebral infarction (hemorrhagic conversion).

In one recent trial, aspirin was compared to ticagrelor within 24 hours of stroke onset, and no difference between the two medications in the risk of recurrent stroke during 90 days of treatment was noted. MKSAP19

Algorithm for management of acute ischemic stroke MKSAP19

MKSAP19

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bubble study echocardiogram These tests are performed with intravenous injection of agitated saline contrast at rest, with Valsalva, and with cough; the study is considered positive if microbubbles (typically three or more) appear in the left heart within three cardiac cycles of bubbles filling the right atrium. Multiple agitated saline contrast injections with provocative maneuvers may be required to enhance sensitivity for identification of a shunt via the PFO

While cardiac CT and cardiovascular magnetic resonance (CMR) imaging have been used to identify PFO, they are less sensitive than TEE

Methods to detect a right-to-left shunt associated with a PFO include TTE, TEE, and transcranial Doppler (TCD), in conjunction with agitated saline contrast (a "bubble study").