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Diploma: Neurology > Stroke and TIA > Flashcards

Stroke and TIA Flashcards

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1
Q

What is a stroke? What are the different types?

A

When blood supply to the brain is blocked, leading to death in brain cells

Ischaemic stroke:

  • Most common
  • Blood clot obstructs blood supply by blocking an artery in the brain
  • Lasts more than 24 hours

Transient ischaemic stroke:

  • Temporary blockage
  • Lasts less than 24 hours
  • Blood flow returns naturally
  • Often linked to unhealthy lifestyle

Haemorrhagic stroke:

  • Weak blood vessel in brain bursts and leaked blood damages brain cells through increased pressure
  • Intracerebral (most common) or subarachnoid

Avoid any anticoagulants/antiplatelets until can rule out haemorrhagic stroke with CT scan

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2
Q

What are the symptoms of stroke? (BE FAST)

A

BE FAST

Balance loss
Eye blur
Face droop (one side)
Arm weakness (one side)
Speech slurred
Time to call 999
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3
Q

After calling 999, what do you do if the person is CONSCIOUS? (DR ABC)

A
  • Clear area of any dangerous objects
  • Ensure airways are clear
  • Put them into recovery position
  • Note any symptoms and changes
  • Reassure them help is on the way
  • AVOID any food or drinks
  • Offer coverings if they are cold
  • Loosen any tight clothing

DR ABC

  • Danger
  • Response
  • Airways
  • Breathing
  • Circulation
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4
Q

What needs to be excluded as a differential diagnosis for stroke/TIA?

A

Hypoglycaemia

Establish the stroke diagnosis rapidly using a validated tool, such as ROSIER (Recognition of Stroke in the Emergency Room) or FAST (Face Arm Speech Test) if outside the hospital

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5
Q

How would you distinguish between the different types of stroke?

A

CT scan - haemorrhagic vs ischaemic
*Brain imaging within 1 hour of arrival to hospital

MRI scan - ischaemic vs TIA

Do not offer CT brain scanning to people with a suspected TIA unless suspicion of alternative diagnosis

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6
Q

CT scan should be done for patients with suspected ischaemic stroke if they meet what criteria?

A

Any of the following:
* Indications for thrombolysis or thrombectomy
* On anticoagulant treatment
* A known bleeding tendency
* A depressed level of consciousness (Glasgow Coma Score below 13)
* Unexplained progressive or fluctuating symptoms
* Papilloedema (vision changes), neck stiffness or fever
* Severe headache at onset of stroke symptoms

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7
Q

When is the greatest risk of vascular events following a stroke/TIA?

A

Risk of vascular events may be as high as 25% within three months, half of which is within the first four days

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8
Q

People with stroke or TIA for whom secondary prevention is appropriate should be investigated for risk factors as soon as possible within 1 week of onset.

What risk factors should be investigated?

A
  • Ipsilateral carotid artery stenosis
  • Atrial fibrillation
  • Structural cardiac disease
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9
Q

What is the greatest risk factor for stroke?

A

Blood pressure

It is estimated to cause about 50% of ischaemic strokes and is the principal risk factor for intracerebral haemorrhage.

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10
Q

What is the initial management of a Ischaemic stroke?

A

Alteplase (within 4.5 hours of symptoms)
- Exclude intracranial haemorrhage via imaging

Then
Give Aspirin 300mg within 24 hours of symptoms for 14 days/until discharge if sooner than 14 days
- Add PPI if history of dyspepsia associated with Aspirin
- If hypersensitive/severe dyspepsia despite PPI: alternative antiplatelet

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11
Q

Alteplase should only be administered under what parameters?

A
  • Within 4.5 hours of symptom onset
  • Intracranial haemorrhage excluded
  • Within a well-organised stroke service with staff trained in delivering thrombolysis and in monitoring for any complications; nursing staff trained in acute stroke and thrombolysis to provide level 1 and level 2 care; immediate access to imaging and re-imaging, and staff trained to interpret the images
  • Staff in emergency departments, if appropriately trained and supported, can administer alteplase for the treatment of ischaemic stroke provided that patients can be managed within an acute stroke service
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12
Q

What is the eligibility criteria for extending thrombolysis window and using alteplate in wake-up stroke?

A
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13
Q

How long after thrombolysis with alteplase should antiplatelets be started?

A

24 hours

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14
Q

Patients with acute stroke should have their clinical status monitored closely. What parameters should be measured?

A
  • Level of consciousness
  • Blood glucose
  • Blood pressure
  • Oxygen saturation
  • Hydration and nutrition
  • Temperature
  • Cardiac rhythm and rate
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15
Q

What clinical parameters should you keep people having acute stroke at?

A

Oxygen - >95%, give supplemental oxygen if below 95%

Blood glucose - between 4 - 11 mmol/L (NICE) or 5 -15 mmol/L (NCSG)
- Provide insulin therapy (e.g. intravenous insulin and glucose) to all adults with type 1 diabetes with threatened or actual stroke

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16
Q

What is the long term management of patients following an Ischaemic stroke (not associated with AF)?

A

Clopidogrel 75mg OD (unlicensed) + High intensity statin (Atorvastatin 80mg OD)

Start Statin 48 hours after stroke symptom onset
- Immediate initiation not recommended

If already taking a statin, continue

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17
Q

When would you not start a statin for someone with a TIA or stroke?

A

Contraindicated or investigation of their stroke or TIA confirms no evidence of atherosclerosis (without high cardiovascular risk)

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18
Q

Lipid-lowering treatment for people with ischaemic stroke or TIA and evidence of atherosclerosis should aim to reduce fasting LDL-cholesterol to what level?

A

Fasting LDL below 1.8 mmol/L
(equivalent to a non-HDL-cholesterol of below 2.5 mmol/L in a non-fasting sample)

Aim to achieve in 4-6 weeks

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19
Q

When should a diagnosis of familial hypercholesterolaemia be considered?

A

In people with ischaemic stroke or TIA below 60 years old with very high cholesterol:
* Below 30 years with total cholesterol above 7.5 mmol/L or
* 30 years or older with total cholesterol above 9.0 mmol/L

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20
Q

If the target fasting LDL-cholesterol is not achieved in 4-6 weeks. What should be done?

A
  • Discuss adherence and tolerability
  • Optimise dietary and lifestyle measures through personalised advice and support
  • Consider increasing to a higher dose of statin if this was not prescribed from the outset
  • Consider adding ezetimibe 10 mg daily
  • Consider the use of additional agents such as injectables (inclisiran or monoclonal antibodies to PCSK9) or bempedoic acid (for statin-intolerant people taking ezetimibe monotherapy)
  • Continue to escalate lipid-lowering therapy (in combination if necessary)
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21
Q

Anticoagulation should be considered post stroke if the patient has AF. When should you consider aspirin before considering anticoagulation treatment?

A

If it is a disabling ischaemic stroke, give aspirin 300mg for 2 weeks

Then, consider anticoagulation

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22
Q

Following a TIA or stroke in patients with atrial fibrillation or flutter, when should anticoagulation be started?

A

Moderate-severe stroke
* From 5-14 days after onset
* Aspirin 300 mg daily should be used in the meantime

Mild stroke
* Should be considered earlier than 5 days if benefits > risk of early intracranial haemorrhage
* Aspirin 300 mg daily should be used in the meantime

TIA
* Should be initiated immediately once brain imaging has excluded haemorrhage

Should be initiated within 14 days of onset of stroke in all those considered appropriate for secondary prevention

Wherever possible these patients should be offered participation in a trial of the timing of initiation of anticoagulation after stroke

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23
Q

Oral anticoagulation should be avoided in patients with severe hypertension at what BP reading?

A

Clinic blood pressure
of 180/120mmHg or higher

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24
Q

Long term management post ischaemic stroke or TIA: If clopidogrel is contraindicated or not tolerated, what can patients have instead?

A

Modified-release dipyridamole 200 mg twice daily in combination with aspirin 75mg

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25
Q

Long term management post ischaemic stroke or TIA: if both clopidogrel and aspirin are contraindicated, what should be given?

A

Modified-release dipyridamole 200 mg twice daily alone

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26
Q

Long term management post ischaemic stroke or TIA: if both clopidogrel and MR dipyridamole are contraindicated, what should be given?

A

Aspirin alone

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27
Q

The combination of aspirin and clopidogrel is not recommended for long-term prevention
of vascular events unless there is another indication e.g. acute coronary syndrome, recent coronary stent.

True or False?

A

True

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28
Q

When should long term anticoagulation be considered post ischaemic stroke?

A

If the patient has AF or other indications (such as a cardiac source of embolism, cerebral venous thrombosis or arterial dissection) are present

Should not be used for the general long-term prevention of recurrent stroke

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29
Q

How should people with acute venous stroke be managed?

A

Offer people diagnosed with cerebral venous sinus thrombosis (including those with secondary cerebral haemorrhage) full-dose anticoagulation treatment

Initially full-dose heparin and then warfarin (INR range 2.0 - 3.0 with TTR > 72%) for at least 3 months unless there are contraindications

30
Q

How should people with stroke associated with arterial dissection be managed?

A

Offer either anticoagulants or antiplatelets

31
Q

People with acute ischaemic stroke associated with antiphospholipid syndrome should be treated in the same way to those with stroke without antiphospholipid syndrome.

True or False?

A

True

32
Q

Scoring systems, such as ABCD2, should not be used to assess risk of subsequent stroke or to inform urgency of referral for people who have had a TIA.

True or False?

A

True

33
Q

What is the initial management of a TIA?

A

If occured within 7 days: Clopidogrel (300 mg STAT then 75mg OD) plus aspirin (300 mg STAT then 75mg OD for 21 days)

If intolerant - add PPI
If still intolerant - alternative antiplatelet

If occurred longer than 7 days ago:
Refer to specialist within 7 days

34
Q

What is the long term management of patients following a TIA or minor stroke (not associated with AF)?

A

Initiate DAPT ideally within 24 hours once imaging excludes haemorrhagic stroke

  • Clopidogrel (300 mg STAT then 75mg OD) plus aspirin ( (300 mg STAT then 75mg OD for 21 days) followed by monotherapy with clopidogrel 75 mg once daily
    OR
  • Ticagrelor (180mg STAT the 90mg BD) plus aspirin (300mg STAT then 75mg OD for 30 days) followed by antiplatelet monotherapy with
    ticagrelor 90mg BD or clopidogrel 75mg OD

Consider a PPI with DAPT

If unsuitable for DAPT (e.g. bleed risk)
* Clopidogrel 300mg STAT then 75mg OD

Start high-intensity statin therapy immediately

Start blood pressure-lowering therapy

Support to modify lifestyle factors (smoking, alcohol consumption, diet, exercise)

35
Q

Why is ischaemic stroke treated with single antiplatelet therapy (rather than DAPT as for TIA and minor stroke)?

A
  • DAPT is no better than single agent therapy in major stroke
  • Major strokes, as opposed to minor ones, have a higher risk of haemorrhagic transformation
36
Q

Why are TIAs and minor strokes treated with DAPT rather than single anteplatelet therapy?

A

DAPT, when started within 24 hours of symptom onset and used for 10-21 days:
* Decreased all (ischaemic and haemorrhagic) non-fatal recurrent stroke in the first 90 days by 1.9%
* Reduces the incidence of moderate or severe
functional disability by 1.4%
* Reduces the incidence of poor quality of life by
1.3%

However, there is a small, possibly important increase in moderate or major (0.2%) and minor (0.7%) extracranial bleeding. Also no impact on all cause mortality or incidence of recurrent TIA or MI.

37
Q

What is classed as minor stroke?
What is the likelihood of progression to major stroke?

A

National Institute of Health Stroke Scale (NIHSS) score ≤3

The chance of a further stroke soon after minor stroke is likely to be around 10-12%

38
Q

What are the parameters included in the ABCD2 score for TIA severity?

What score corresponds to low, moderate and high risk of stroke?

A

Severity assessed by ABCD2 score:
* Age—1 point if ≥60 years
* Blood pressure—1 point if ≥140/90 mm Hg
* Clinically—1 point if speech disturbance only, 2 points if unilateral weakness
* Duration—1 point if 10 minutes to 1 hour, 2 points if ≥1 hour
* Diabetes—1 point if present

Subsequent risk of stroke based on ABCD2 score:
* Score 1-3 (low) = 1.2% at 7 days
* Score 4-5 (moderate) = 5.9% at 7 days
* Score 6-7 (high) = 11.7% at 7 days

39
Q

Treatment of hypertension in the acute phase of stroke/TIA can result in what?

In what situations would you want to lower the blood pressure?

A

Reduced cerebral perfusion

Only lower the blood pressure if:

  • Hypertensive emergency (>180/110mmHg)
  • In patients considered for thrombolysis
  • Hypertensive encephalopathy
  • Hypertensive nephropathy
  • Hypertensive cardiac failure or myocardial infarction
  • Aortic dissection
  • Pre-eclampsia or eclampsia
40
Q

People with stroke or TIA should have blood pressure-lowering treatment initiated prior to
the transfer of care out of hospital or at 2 weeks, whichever is the soonest, or at the first
clinic visit for people not admitted.

True or False?

A

True

41
Q

After the maintenance phase of TIA/ischaemic stroke, how should blood pressure be controlled?

A

Blood pressure should be measured and treatment initiated to achieve a target of <130/80 mmHg.
(equivalent to a home SBP below 125mmHg)
- Excluding people with severe bilateral carotid artery stenosis, for whom a SBP target of 140–150 mmHg is appropriate

Beta-blockers should not be used in the management of hypertension following a stroke, unless they are indicated for a co-existing condition.

42
Q

Patients with acute stroke admitted on antihypertensive medication should resume oral treatment once they are medically stable and as soon as they can swallow medication safely.

True or False?

A

True

43
Q

Can warfarin be started in the acute phase of TIA?

If they are experiencing symptoms or at high risk of VTE or PE, what should the management be?

A

No

Parenteral anticoagulants can be used if symptomatic of/high risk of VTE - risk vs benefit

44
Q

What VTE should be used for patients with immobility after acute stroke?

A

Use IPC within 3 days of admission to hospital

45
Q

What VTE should be used for patients with immobility after acute stroke and with symptomatic DVT/PE?

A

Anticoagulants provided there are no
contraindications

46
Q

What lifestyle modifications should all stroke patients make?

A
  • Diet
    Reduce and replace saturated fats with polyunsaturated or monounsaturated fats (eat low fat and plant/oil based fats)
    Limiting red meat intake
    Reducing salt intake
    Should not routinely take supplements unless advised otherwise
  • Exercise
  • Weight
    Targeting weight reduction in isolation is not recommended
  • Alcohol intake
    Limiting alcohol intake to 14 units a week spread over 3 days. If overweight or obese, 2 units a day or less
  • Smoking cessation
47
Q

What age group should aspirin use be avoided in? Why?

A

Patients under 16 due to the risk of Reye’s syndrome (Vomiting, fatigue, seizures).

48
Q

What red flag symptoms associated with oral antiplatelet use, should be immediately referred to a doctor?

A

Chronic GI bleeding (severe abdominal pain, vomiting blood, black/red stool), haemorrhage, hypersensitivity (aspirin), heaviness in the chest, pregnancy, breastfeeding.

49
Q

What monitoring is required when a patient is on antiplatelet?

A

Renal and hepatic function.

50
Q

After how long should MR dipyridamole capsules be discarded?

A

Six weeks.

51
Q

When should antiplatelet be taken?

A

Clopidogrel - With or without food
Dipyridamole, aspirin - without food

52
Q

Clopidogrel cannot be used during pregnancy and breastfeeding.

True or False?

A

True

53
Q

Which antiplatelet is cautioned in people with lactose allergy?

A

Clopidogrel

54
Q

Clopidogrel increases the plasma concentration of which drug?

A

Rosuvastatin

55
Q

If a patient has had a haemorrhagic stroke, at what systolic BP would you initiate antihypertensive treatment for rapid control?

What is the exclusion criteria?

A

150mmHg if present within 6 hours of symptom onset

220mmHg if >6 hours

Unless:
* The Glasgow Coma Scale score is 5 or less
* The haematoma is very large and death is expected
* A macrovascular or structural cause for the haematoma is identified
* Immediate surgery to evacuate the haematoma is planned, in which case BP should be managed according to a locally agreed protocol

56
Q

When rapidly lowering blood pressure in people with acute haemorrhagic stroke what systolic BP should you aim for?

A

Systolic BP between 130-139mmHg

Ensure that SBP does not drop by more than 60 mmHg within 1 hour of starting therapy

Sustain for at least 7 days

57
Q

What is the inital management of haemorrhagic stroke?

A

Surgical intervention to remove the haematoma and relieve intracranial pressure

Blood pressure management if presenting with high systolic blood pressure

58
Q

What is the prevalance of subarachnoid haemorrhage (SAH)?

A

SAH accounts for approximately 5% of all acute strokes.
10–15% of those affected die before reaching hospital and overall survival is about 70%, but amongst
patients admitted to a neurosurgical unit with a confirmed aneurysm, 85% will survive

59
Q

What is the exclusion criteria for blood pressure lowering therapy for haemorrhagic stroke?

A
  • Underlying structural cause (tumour, arteriovenous malformation or aneurysm)
  • Have a score on the Glasgow Coma Scale of below 6
  • Are going to have early neurosurgery to evacuate the haematoma
  • Have a massive haematoma with a poor expected prognosis.
60
Q

How long should anticoagulation be stopped for people with prosthetic valves who have disabling cerebral infarction and who are at significant risk of haemorrhagic transformation?

A

Stop anticoagulation treatment for 1 week and substitute aspirin 300 mg

61
Q

People with ischaemic stroke with acute haemorrhagic transformation should be treated
with long-term antiplatelet or anticoagulant therapy.

True or False?

A

True

Unless the prescriber considers that the risks outweigh the benefits

62
Q

Is anticoagulation or antiplatelets preferred for people with ischaemic stroke and symptomatic DVT/PE?

A

Anticoagulation
Unless there are other contraindications to anticoagulation

antiplatelet treatment should not be used as an alternative when there are absolute contraindications to anticoagulation (e.g. undiagnosed bleeding);

63
Q

What happens when someone taking an anticoagulant has a haemorrhagic stroke?

A

Patients taking anticoagulants should have this treatment stopped and reversed.

If symptomatic of DVT or PE - placement of a caval filter is an alternative to anticoagulation

64
Q

Patients who have a spontaneous (non-traumatic) intracerebral haemorrhage (ICH) whilst taking an antithrombotic (antiplatelet or anticoagulant) may be considered for restarting treatment at what time?

A

24 hours after ICH symptom onset

65
Q

What is the long term management in haemorrhagic stroke?

A

Aspirin and anticoagulation not normally recommended. Seek specialist advice in patients with AF and those at high risk of ischaemic events

Blood pressure treatment initiated

Avoid statins (Can be used with caution if risk of vascular events > risk of further haemorrhage)

66
Q

When should blood pressure management be considered for patients with haemorrhagic stroke?

A

If presenting within 6 hours of symptoms:

  • Rapid BP lowering therapy if systolic BP >150mmHg (if no exclusion criteria)
  • Aim for systolic BP 130 - 140 mmHg within 1 hour of starting treatment and maintain for at least 7 days

Can also be considered in patients presenting after 6 hours with systolic BP greater than 220mmHg

67
Q

When is alteplase contraindicated?

A
  • History of hypersensitivity to gentamicin
  • Hyperglycaemia or hypoglycaemia
  • Stroke in last 3 months
  • Convulsions accompanying stroke
  • History of stroke in patients with diabetes
68
Q

All stroke/TIA inpatients should be screened on admission for malnutrition and the risk of malnutrition.

True or False?

A

True

Repeat screening weekly for inpatients and also assess BMI and percentage unintentional weight loss

Start nutrition support for people with stroke who are at risk of malnutrition

69
Q

All stroke/TIA inpatients should be screened on admission for hydration status.

True or False?

A

True

70
Q

People who initially present with recurrent TIA or stroke should receive the same antithrombotic treatment as those who have had a single event.

True or False?

A

True

More intensive antiplatelet therapy or anticoagulation treatment should only be given as part of a clinical
trial or in exceptional clinical circumstances.

71
Q

There is evidence that oestrogen (combined oral contraceptive and HRT) increases the risk of cardiovascular events including ischaemic stroke.

What is the preferred contraceptive method?

A

Alternative hormonal (progestogen-only) and non-hormonal contraceptive methods

Post-menopausal women with ischaemic stroke or TIA who wish to start or continue hormone replacement therapy should receive advice based on the overall balance of risk and benefit, taking account of the woman’s preferences

Diploma: Neurology (3 decks)

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