Stroke and TIA

TIA

Symptoms

  • Maximal at onset
  • <24hrs (usually 10-15mins)
  • Amaurosis fugax / visual loss, diplopia
  • Unilateral weakness or sensory deficit
  • Dysarthria / dysphasia / dysphagia
  • Vertigo

A sudden onset of focal neurological deficit, maximal at onset, with complete resolution of symptoms within 24 hours

ABCD2 Score
A = Age >60
B = BP Systolic > 140 or Diastolic > 90
C = Clinical features - unilateral weakness (2), dysphasia (1)
D = Duration of symptoms - >60mins (2), 10-59mins (1)
D = Diabetes

Patients considered high risk - need urgent assessment / Score 4+ on ABCD2 score

  • Aspirin 300mg with PPI as soon as possible
  • Clopidogrel 75mg daily for secondary prevention

Management

  • ABCDE
  • ABCD2 Score
  • If >4 - 300mg Aspirin +PPI
  • Bloods: FBC, U&E, glucose, lipids, ESR, LFTs
  • Inform not to drive for 4 weeks
  • Safety net - come back to A&E if any further events
  • Secondary prevention if score >4 - Clopidogrel 75mg OD
  • Refer to TIA clinic
  • If residual or ongoing neurology - assume a stroke and admit

Secondary prevention

  • Smoking cessation
  • Diet - reduced salt, low fat
  • Regular exercise
  • Reduce alcohol
  • Body weight management
  • Statin

Other patients at high risk of subsequent stroke regardless of ABCD2 Score:

  • AF
  • Anticoagulated (require brain imaging)
  • More than one TIA in last 7 days
  • If high risk - neurovascular assessment within 24hrs
  • If low risk - neurovascular assessment within 7 days

Stroke

Risk Factors

  • AF (5x)
  • Age
  • Diabetes
  • HTN
  • Smoking
  • CCF, IHD, cardiac disease
  • Alcohol
  • Obesity
  • OCP, HRT, pregnancy
  • Sickle cell, haemophilia, SLE, PVD
  • FHx
  • IVDU
  • Long bone fracture
  • Previous TIA

Causes

  • 85% strokes are ischaemic - THROMBOSIS / EMBOLI
  • Hypotension > watershed strokes

Symptoms

  • Same as TIA but for longer, hemianopia, LOC
  • FAST

Stroke mimics

  • Hypoglycaemia
  • Migraine
  • Intoxication
  • Todd's palsy
  • Mass lesion
  • SAH
  • Syncope

Management

  • ABCDE
  • Exclude hypoglycaemia
  • FAST screen
  • Establish diagnosis - ROSIER
  • Assess for scanning and if indicated scan immediately
  • Thrombolyse if indicated (<4.5hrs from symptom onset)
  • Admit to an acute stroke unit
  • Screen for malnutrition and perform swallowing assessment
  • Early mobilisation and positioning following assessment

ISCHAEMIC

  • Aspirin 300mg unless CI
  • Control hydration, temp, BP, maintain O2, blood sugar
  • ? Surgical intervention - refer within 24 hours onset if indicated

HAEMORRHAGIC

  • Reverse anticoagulation if indicated
  • Control hydration, temp, BP, maintain O2, blood sugar
  • Surgical referral if previously fit and haemorrhage with hydrocephalus or deteriorating neurologically
  • Medical treatment if surgery not appropriate

Medical treatment prior to discharge

  • Cholesterol lowering
  • BP control
  • Dietary advice
  • Antiplatelet treatment
  • Lifestyle advice

ROSIER Scale

  • LOC (-1)
  • Seizure activity (-1)

NEW ACUTE ONSET OF

  • Asymmetric facial weakness (+1)
  • Asymmetric arm weakness (+1)
  • Asymmetric leg weakness (+1)
  • Speech disturbance (+1)
  • Visual field defect (+1)

-2-+5
Stroke is likely if score >0

Bamford Classification of Stroke

TAC - Total Anterior Circulation Stroke

  • New higher cerebral dysfunction (e.g. dysphasia)
  • Homonymous visual field defect
  • Ipsilateral motor and/or sensory deficit

PAC - Partial Anterior Circulation

  • No drowsiness
  • 2 of 3 criteria of TAC
  • OR higher cerebral dysfunction alone
  • OR restricted motor/sensory deficit e.g. one limb

LAC - Lacunar

  • Pure motor (most common)
  • Pure sensory
  • Sensori-motor
  • Ataxic hemiparesis

POC - Posterior Circulation

  • Affecting brainstem, cerebellar or occipital lobes
  • Ipsilateral cranial nerve palsy
  • Bilateral motor/sensory deficit
  • Disorder of conjugate eye movement