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Stroke/TIA (Primary Survey (Circulation: BP, HR, cap refill, 2x IV…
Stroke/TIA
Primary Survey
Circulation: BP, HR, cap refill, 2x IV cannulas, Bloods (FBC, UEC, coags/INR, glucose), ECG
Disability: AVPU/GCS, pupils, BGL (if < 3.8 consider 50% glucose infusion, if > 10 consider insulin dextrose infusion + guideline)
Breathing: SpO2, RR, oxygenation as needed
Exposure: Temp
Airway: NBM, is the airway intact?
DRS: contact acute stroke team
Investigations
Urgent non contrast Head CT
Ischaemic: Hypodensity (black), loss of grey/white differentiation and increased density within occluded vessel
Haemorrhagic: Hyperdensity (white)
SAH: if CT negative 12 hours after onset of headache consider LP
ICH
EDH: subperiosteal leak limited by suture lines --> biconvex/lentiform (oval) shaped pattern
SDH: crescent moon shaped pattern
Ischaemic stroke: Fasting lipids and glucose, LFT's, ESR, CRP, carotid imaging +/- echo +/- 24hr holter
Ishaemic stroke further management
Antiplatelet therapy
: aspirin +/- clopidogrel (for up to 90 days if dual)
Anticoagulation (heparin): not routine due to risk of bleed, consider if AFib or suspected carotid/vertebral artery dissection. Remember 3, 6, 9, 12 rule due to
high risk of secondary bleed
BP management: avoid anti-hypertensives in first 24 hours, if concerned consult senior medical officer
Choose reperfusion method
Thrombolysis (alteplase): only if < 4.5 hours since sx onset and no exclusion criteria present, repeat CT at 24 hours
Mechanical clot retrieval: if approx < 6 hours since sx onset
Refer to local guidelines
TIA Further management
High risk patients
Urgent imaging
Manage as a ischaemic stroke including aspirin (no reperfusion therapies)
Low risk patients
Non urgent imaging
D/C and follow up with GP in 5 days
Consider other features such as AFib, high grade carotid stenosis, recent MI or multiple TIA's --> manage as high risk
Antiplatelet therapy
Educate family
ABCD2: Risk assessment tool if TIA is suspected
Out of 7- high risk: >4, low risk </= 4
Diabetes
BP > 140/90
Duration (10-59 minutes (1), >60 minutes (2)
Age > 60
Clinical features (only speech impairment (1), unilateral weakness (2))
Begin secondary prevention: antiplatelet (clopidogrel) + ACEi + statin
Haemorrhagic stroke further managment
BP management: Aim is for BP to be < 180/110, use IV labetalol/hydralazine if necessary
Coagulation management: correct any coagulopathy and seize any antiplatelet or anticoagulation therapy
Consider NSx consult: haematoma evacuation, clipping, coiling
DVT prophylaxis: do not give subcut heparin unless D/W senior officer
Discuss with local senior medical officer
Definition:
Ischaemic stroke: blockage in a blood vessel supplying brain
TIA: neurological deficit lasting from a few minutes to 24 hours
Haemorrhagic stroke: rupture of blood vessel supplying brain
Causes
Haemorrhagic (SAH/intracerebral)
AV malformations
Aneurysms
HTN
Ischaemic
Thromboembolic (most common)- from heart or from distal clot with ASD
Atherosclerosis- includes atherothrombotic and atheroembolic
Lacunar- small vessel wall thickening; does not affect cortex
Clinical Syndromes
ACA: contralateral lower limb + face (homonculus) + personality disturbance
MCA: aphasia (temp lobe) + contralateral hemiparesis (think internal capsule + homonculus)
Lacunar
Internal capsule: pure motor contralateral hemiparesis
Thalamus: contralateral hemisensory pure sensory deficit
Thalamus + internal capsule: sensorimotor (mixed)- contralateral weakness and numbness
Pons: slurred speech and weakness of contralateral hand
Pons + internal capsule: ataxia and contralateral hemiparesis
Subthalamic nucleus: contralateral limb flailing or dyskinesia
Cortical vs subcortical: involving speech/vision --> suggests cortical involvement
PCA: visual loss + aphasia
L vs R side: L will have language deficits, executive functions while R will have neglect
Long term management of ischaemic strokes
If carotid artery stenosis > 70% --> vascular surg referral to consider endarterectomy or endovascular stenting
Manage risk factors:
smoking cessation, decrease alcohol, BGL
Statin
(atorvastatin)- target LDL < 2
BP
: ACEi (perindropril) + diuretic (indapamide)- if normotensive or hypertensive; target < 130/80
Rehab
, MDT, no driving 1 month