231010-Stroke and AhhhhhhhhhF-Quy Y3.pptx

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1. CASE PRESENTATION October 10th, 2023 Quy Hoang. MD VinUniversity

2. CC – HPI – PMH 1 hour Admission Suddenly alter mental status witness by family, no provoke seizure, no fever, no trauma Glasgow 6 points (E1V1M4), hemodynamical is stable, no edema, no cyanosis. 92 -year-old male PMH Heart failure, COPD, Atrial Fibrillation Medical Symbicort Nebulizer. Allergy None Social No sexually active, no smoking, no alcohol abuse, no use illicit drugs Family Normal

3. PHYSICAL EXAMINATION VS BP 147/72 mmHg, HR 113 bpm, RR19 bpm, T 37.0 o C, SpO 2 97% / Mechanical ventilation General No rash, no hematoma HEENT No pallor, no jaundice . Nose, mouth, and pharynx WNL. No enlarged thyroid Cardiovascular Tachycardia, no heart murmur Lungs Normal tactile fremitus, no reduced lung sounds, no crackles. Abdomen No tenderness, no hepatomegaly, splenomegaly Extremities No joint pain, no swollen joints Neurological No meningeal sign, pupil 3mm, reflex to light. Lymph No lymphadenopathy On ED

4. ONE LINER SUMMARIZE A 92-year-old male patient with PMH of COPD, HFpEF , AF witnessed alter mental status for 1 hour without fever, trauma before. PE was significant for tachycardia, hemodynamical is stable, mechanical ventilation and no neurological significant findings.

5. DIAGNOSTIC EVALUATION – INITIAL LAB TESTS ​ RBC 4 .03 T/L Pro-calcitonin 0. 07 HGB 140 G/L MCV 92.7 CRP 5 WBC 6 .6 G/L (neu 73%) Urine RBC ( -) PLT 182 G/L Protein ( -) Ure/Creatinin 11/132 pH 7. 45 AST / ALT 32 / 30 pCO2 35 Bili T/D 10.4/3.2 pO2 95 Na/K/Cl 132/ 4.2 /106 HCO3 2 6 Albumin 37 AG 8 NT-proBNP 320 Lactate 0.8 Troponin Ths 10

6. DIAGNOSTIC EVALUATION – INITIAL LAB TESTS ​ Head CT Scan

7. DIAGNOSIS Ischemic Stroke due to completely occlusive of right internal carotid (NIHSS 25, mRs 5)/ HFpEF / COPD/ AF.

8. Antithrombotic treatment

9. SAPT or aspirin

10. Imaging Findings After Mechanical Thrombectomy in Acute Ischemic Stroke ??? Precise data on measure confounders for final infarct volume, including edema, HT, or contrast staining are also necessary to fine-tune the use of this metric as a prognosis biomarker and enhance personalized, image-guided, therapeutic strategies after MT. Altogether, lesion detection, segmentation, and contrast are consistently superior for MRI than CT, making it the preferred modality for lesion volume measurement, evaluation of complications, and to refine the understanding of pathophysiological processes after MT. Overall, the question of whether follow-up imaging should be obtained at 24 to 48 hours or at 3 to 5 days after MT is still a matter of debate Puntonet , J., et al. (2019). "Imaging Findings After Mechanical Thrombectomy in Acute Ischemic Stroke." 50 (6): 1618-1625

11. After 1 days, the mental status was abated, take another head MRI. Show that:

12. Brain MRI: one day later, T2

13. Brain MRI: one day later, Flair T2 FLAIR R estricted diffusion on  DWI / ADC  sequences. (especially  SWI ) are useful as they are more sensitive than CT to early hemorrhage and may help direct therapy (e.g. withhold thrombolytic therapy

14. Brain MRI: one day later, SWI Acute ischemic stroke on left frontal lobe, hemorrhage transformation HI2.

15. CT 13/7

16. CLINICAL PEARL Management of anticoagulation on stroke patient with AF Kim Han Nguyen, MD VinUniversity When to initiation ? Which drug? Any Score for that Guidelines

17. Rule 1-3-6-12 from where???

18. More reliable evidence

19. Why is DOACs DOACs  – Randomized trials have demonstrated that DOACs are either superior (apixaban and dabigatran) or noninferior ( edoxaban  or rivaroxaban) to VKAs for stroke prevention. Studies have also shown that DOACs have less bleeding side effects than VKAs among patient VKA is indicated (rather than a DOAC) include the following Direct oral anticoagulant agents have a more rapid anticoagulant effect than warfarin, Moderate to severe mitral stenosis Mechanical heart valve in any location Warfarin is generally preferred for patients with severely impaired kidney function,nts with AF and ischemic stroke or transient ischemic attack (TIA) When is ANTI- Vitamin K ?

20. Feature on our patient? AGE: The age cutoff is variously defined as >60, >65, >75, or >80 years; the risk increase is approximately linear. However, the risk of bleeding attributable to older age is often overestimated, and anticoagulants are underused in older individuals who may derive more benefit than younger individuals Fall risk. Kidney Function

21. Any Score is helpful? As an example, in a prospective cohort of 515 patients, subjective estimates of bleeding risk made by the treating clinicians (mean clinical experience: three years) had similar accuracy in predicting bleeding as use of a risk score Hasbled and ATRIA is good one.