Acute stroke and TIA management

Question 1

what are the 7 Rs of acute stroke management

Answer 1

Recognise; React (transfer to stroke unit); Respond (imaging etc.); Reveal (confirm diagnosis); Reperfusion (thrombolysis etc.); Rehabilitation (stoke team assessment); Reintegration

Question 2

what are two pre-hospital screening tests that can be deployed

Answer 2

FAST and MASS

Question 3

what is the immediate treatment for TIAs in order to reduce the risk of stroke

Answer 3

Aspirin 300mg (or clopidogrel if contraindicated), then 75mg daily; specialist assessment within 24hrs of onset; secondary prevention when confirmed diagnosis e.g. statin; carotid duplex scan (if in anterior circulation)

Question 4

what is the treatment for TIAs with symptoms >1week prior

Answer 4

specialist assessment ASAP; MRI (T2) to exclude haemorrhage; immediate initiation of clopidogrel; secondary prevention when confirmed diagnosis

Question 5

what is a carotid enterectomy

Answer 5

a surgery to remove plaques from the carotid arteries

Question 6

what are indication for immediate brain imaging in acute stroke (7)

Answer 6

indication for thrombolysis/early anticoagulation; been taking anticoags; known bleeding tendency; decreased level of consciousness (GSC<3); unexplained progressive/fluctuating symptoms; papilloedema/neck stiffness/ fever; severe headache at onset

Question 7

what will early CT scanning show?

Answer 7

ischemic: may be normal or only show subtle change, ischemia not seen until at least a few hours later; haemorrhagic: haemorrhage will almost always been seen even early on

Question 8

what score can be used to check early imaging for ischemic stroke?

Answer 8

ASPECT score

Question 9

what is thrombolysis

Answer 9

the activation of plasminogen to breakdown a clot

Question 10

what is plasminogen converted into during thrombolysis

Answer 10

plasmin

Question 11

what drug is currently used for thrombolysis

Answer 11

Alteplase

Question 12

what is the ischaemic penumbra

Answer 12

an area of moderate ischemia, infarction has been delayed here; this area of tissue may be saved

Question 13

what is the risk associated with thrombolysis

Answer 13

1-2% of people may haemorrhage which may result in death

Question 14

indications for thrombolysis (4)

Answer 14

definite weakness/dysphagia regardless of severity; symptom onset >30mins but <4.5hrs; 18+ yro; GCS <8

Question 15

absolute contraindications of thrombolysis (9)

Answer 15

Hx of ICH; CT shows hypodensity; INR>= 1.7 and aPPT >35 or on NOACs; platelets <100x10^9; sensory symptoms only; seizure with neurologic impairment; possible SAH; BP> 185/110 (with treatment); rapidly resolving symptoms

Question 16

what is INR?

Answer 16

international normalized ratio - prothrombin time

Question 17

what is aPPT?

Answer 17

Shortened Activated Partial Thromboplastin Time

Question 18

relative contraindications of thrombolysis (8)

Answer 18

time since onset of symptoms >4.5-6hrs; bacterial endocarditis/pericarditis; treated with LMWH within 48hts; previous stroke/head injury in the past 3 months; serious GI/Urinary bleed in the past 21 days; surgery/significant trauma in past 14days; severe liver disease/possibility of pregnancy; severe pre-stroke morbidity

Question 19

what is a thrombectomy

Answer 19

a surgery performed to remove a clot from a blood vessel

Question 20

how should acute stroke patients be treated (excluding ICHs)

Answer 20

aspirin (300mg loading dose) for 2 weeks then clopidogrel; PPI for those over 70+ alongside; if already on aspirin then can use dual anti-platelet agent (for a month); anti-coag has no routine role for ischemic stroke

Question 21

what is DVT/PE prophylaxis post stroke

Answer 21

LMWH (if ICH excluded, previous VTE or mobility restricted); Intermittent Pneumatic Compression stockings (within 3 days of event); if ischemic stroke and symptomatic for DVT then anti-coag; if haemorrhagic and symptomatic for DVT then vena caval filter

Question 22

what other treatments can be considered for MCA infarct?

Answer 22

decompressive craniotomy - if referred within 24hrs and treatment is given within 48hrs; CT shows >50% of MCA occluded by infarct

Question 23

how is a carotid/vertebral dissection treated?

Answer 23

thrombolysis, long-term anticoagulants/ anti-platelets

Question 24

how can a carotid dissection occur?

Answer 24

twisting, turning e.g. during extreme sport

Question 25

how can a venous stroke be treated

Answer 25

full dose anticoagulation treatment (heparin then warfarin)

Question 26

what can occur with a venous stroke

Answer 26

build up of pressure in the brain due to there only being one big vessel that drains the brain

Question 27

management of ICH (5)

Answer 27

1. monitor conciousness levels - refer for imaging if deteriorates;
2. if on warfarin then use a PROTHROMBRIN COMPLEX CONCENTRATE (immediate) and iv VIT K (delayed effect);
3. is secondary to DOAC then use specific reversal agent if available e.g. idarucizumab;
4. control BP (<140);
5. consider surgery if hydrocephalus/brainstem compression occurs - intervention NOT necessary for small deep haemorrhages, lobar haemorrhages, large haemorrhage + significant comorbidities; supratentorial haemorrhage with GCS <8 unless due to hydrocephalus

Question 28

how is homeostasis maintained in stroke patients (5)

Answer 28

O2 if <95%; maintain BMs between 4-15mmol/L; do NOT treat BP unless >200/120 or being considered for thrombolysis (<185/110 needed); investigate any pyrexia; lipid lowering NOT recommended

Question 29

who is in the stoke MDT (9)

Answer 29

doctors, nurses, physio, OT, SALT, dietician, social worker, psychology, relatives

Question 30

percentage of stroke patients that are dysphagic on admission

Answer 30

40-50%

Question 31

what should be done to aid nutrition (5)

Answer 31

MUST and dehydration screening repeated weekly; bedside swallow assessment on admission; SALT specialist assessment if abnormal; tube within 24hrs if fail swallow test - NG bridle/PEG if fail to keep NG tube; watch for aspiration pneumonia

Question 32

when should mobilisation occur and what positioning should be done

Answer 32

ASAP (within 24hrs of admission); active therapy to be offered 45mins/day x5 a week (max); helped to sit up ASACP; position to minimise aspiration risk/shoulder subluxation when lying/sitting

Question 33

what support is offered on discharge

Answer 33

home based stroke early supported discharge; stroke in-patient rehabilitation unit; vocational rehabilitation