Acute stroke + TIA management

Question 1

TIA treatment early presentation (<1 week ago)

Answer 1

Immediate aspirin 300mg
Specialist assessment within 24hour symptom onset
Secondary prevention as soon as diagnosis confirmed
Carotid duplex scanning in anterior circulation events - carotid endarterectomy if significant (>50%) stenosis
Anti-coagulation if AF
Lifestyle modification (eg. BP, lipids)

Question 2

TIA treatment late presentation (>1 week ago)

Answer 2

Specialist assessment ASAP
MRI imaging (T2) mode of choice to exclude haemorrhage
Immediate initiation of clopidogrel
Secondary prevention as soon as the diagnosis conformed
Anti-coagulation if AF
Lifestyle modification (eg. BP, lipids)

Question 3

When should brain imaging be carried out in acute stroke?

Answer 3

Immediate (next slot or within 1 hour)

Question 4

What is thrombolysis?

Answer 4

IV Alteplase

Question 5

Alteplase MOA

Answer 5

tissue plasminogen activator

Question 6

Thrombolysis indications

Answer 6

Definite weakness and/or dysphasia
Symptom onset >30 mins and <4.5 hours
Age 18+
GCS >8

Question 7

Thrombolysis absolute contraindications

Answer 7

history or evidence of ICH
CT shows hypodensity >1/3rd hemisphere (ASPECTS score)
INR>1.7 and APTT >35 or NOACs
Platelets <100x10^9
Possible SAH (even if normal CT)
BP>185/110 x2 even with treatment
Rapidly resolving symptoms

Question 8

Thrombolysis relative contraindications

Answer 8

Time of symptoms onset >4.5-6 hours
BM <2.8 and >22mmol/L
Bacterial endocarditis/pericarditis
Treated with LMWH within 48 hours
Previous stroke/head injury in last 3 months
Previous significant GI or urinary bleed in last 21 days
Surgery or significant trauma in last 14 days
Severe liver disease
Possibility of pregnancy
Severe pro-stroke morbidity

Question 9

What is thrombectomy?

Answer 9

mechanical clot retrieval (MCR)

Question 10

VTE prophylaxis/treatment post-stroke

Answer 10

Anti-embolism stockings - NO
LMWH - consider only if ICH excluded, risk of bleeding is low, major restriction of mobility present, previous VTE
IPC (intermittent pneumatic compression) stockings - consider if started within 3 days of event, continue for 30 days or until mobile

Question 11

What is coning?

Answer 11

brain stem forced into foramen magnum

Question 12

What is malignant MCA syndrome?

Answer 12

pressure builds
causes coning
consider decompressive hemicraniectomy
signs on CT of an infarct at least 50% of the MCA territory

Question 13

Coning signs

Answer 13

bradycardia
hypertension
decreased consciousness
blown pupils

Question 14

Intracerebral haemorrhage management

Answer 14

monitor consciousness level
reverse anticoagulation
immediate BP management (SBP <150 mmHg)
surgical intervention if hydrocephalus/brain stem compression

Question 15

DOAC reversal agents

Answer 15

Dabigatran = Idarucizumab
Others = Andexanet alfa

Question 16

What 2 types of rehabilitation can be offered on discharge from an acute stroke unit?

Answer 16

home based stroke early supported discharge
stroke inpatient rehabilitation unit

Question 17

When can stroke/TIA patients drive?

Answer 17

minimum 1 month
multiple distinct events = 3 months
hemianopia = must pass DVLA test

Question 18

Components of infarct development in stroke

Answer 18

Core = dense ischaemia early infarction
Penumbra = moderate ischaemia, delayed infarction