AIS

Question 1

pathogenesis of AIS

Answer 1

atherosclerosis -> plaque rupture -> clot block artery in brain -> symptoms

Question 2

clinical presentation of AIS

Answer 2

FAST

• Face dropping
• Arm weakness
• Slurring of speech
• Time to call 995

Question 3

types of diagnostic tests used for AIS

Answer 3

1) NIHSS: used for minor stroke
2) ABCD2: estimate risk of AIS after transient ischaemic attack (TIA)

Question 4

NIHSS for AIS

Answer 4

• 0 - 5: minor stroke
• > 5: not minor stroke

Question 5

ABCD2 for AIS

Answer 5

1) Scoring criteria

• A: Age
  **≥ 60 = 1 point
• B: BP
  ** ≥ 140/90 mmHg = 1 point
• C: clinical presentation
  ** unilateral weakness = 2 point
  ** isolated speech disturbances = 1 point
• D1: duration of TIA symptoms
  ** ≥ 60 mins = 2 points
  ** 10 - 59 mins = 1 point
• D2: diabetes
  ** present = 1 point

2) what the scores mean

• ≥ 4 = high risk

Question 6

treatment process of AIS

Answer 6

1) enter A&E: unknown mechanism, new onset, not on anti-thrombolytics

• assess eligibility for r-tPA (alteplase)

** IF eligible (stroke within 3 - 4.5h) then start alteplase immediately -> stop alteplase after 24h and within 48h -> start SAPT -> evaluate stroke mechanism

** if not eligible (stroke happen more than 3 - 4.5h) then:

~ minor stroke/high risk TIA: start DAPT (clopi) immediately for 21d -> evaluate stroke mechanism
~ not minor stroke and high risk TIA: start SAPT immediately -> evaluate stroke mechanism

2) known stroke mechanism

• cardioembolic: stop antiplatelet, start DOAC/warfarin for same duration as SPAF, consider rosu/ator
• noncardioembolic

** stroke in severe ICAS (major vessel): start DAPT for 90 days -> lifelong SAPT
** stroke not in severe ICAS but minor stroke/high risk TIA: start DAPT for 21 days -> lifelong SAPT
** stroke not ICAS: lifelong SAPT
** consider rosu/ator

3) if bedridden for period of time (stasis -> VTE)

• VTE prophylaxis: DOAC/warfarin + LMWH after > 24h and before 48h of alteplase
• if too high bleeding risk: IPC (intermittent pneumatic compression)

Question 7

monitoring and follow up for AIS

Answer 7

• FBC
• SE (shit blood, pee blood, cough blood)
• adherence
• dyspnoea (ticagrelor)
• minimise other risk factors

Question 8

aspirin for AIS

Answer 8

• SAPT, DAPT
• 300mg loading then 100mg PO OM lifelong

Question 9

ticagrelor for AIS

Answer 9

• DAPT with aspirin
• dosage: 180mg loading then 90mg BD lifelong
• stop 2 - 3 days before surgery
• CI: Severe liver impariment

Question 10

clopidogrel for AIS

Answer 10

• DAPT with aspirin
• dosage: 600mg loading then 75mg OM lifelong
• stop 5 days before surgery
• CYP2C19 polymorphism
  ** 2* 3* loss in function -> ticagrelor
  ** 17* gain in function

Question 11

dipyridamole for AIS

Answer 11

• DAPT with aspirin for high bleeding risk
• 20 - 150mg PO TDS