Neuro - TIA and stroke Flashcards
What is a TIA?
Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia, without acute infarction
What is your differential diagnosis for someone coming in with a suspected TIA/Stroke?
Lesions detectable on scanning:
- MS
- SAH
- Brain tumour
Clinically discernible differentials:
- Global transient amnesia
- Vestibular neuronitis
- BPPV
- Syncope
Others:
- Functional
- Hypoglycaemia
- Focal seizure
- Migraine with aura
- Meningitis/encephalitis
What are some risk factors for TIA/stroke?
- CVS disease: angina, MI, peripheral vascular disease
- AF
- Previous stroke/TIA
- HTN
- Smoking
- Vasculitis
- Thrombophilia
- COCP
Causes of TIA/Stroke
- Atherothromboembolism from carotids (most common)
- Cardioembolism: post MI, AF, valvular disease
- Shock, vasculitis
- Hyperviscosity: polycythaemia, SCD, myeloma
What investigations should to do for someone coming in with a suspected TIA/stroke?
- Diffusion-weighted MRI is gold standard but in emergency non-contrast CT is faster
- Aim to find cause and define vascular risk
- Bloods: FBC, U+E, ESR, glucose, lipids
- CXR
- ECG
- Cardiac echo
- Carotid Doppler (+/- angiography) - will show if there is need for endarterectomy (beneficial if there is >70% symptomatic stenosis: complications include stroke and death)
What treatment do you give for a TIA?
Aspirin 300mg for 2 weeks
- MR dipyridamole 200mg BD can be used if clopidogrel and aspirin are CI or not tolerated
- Clopidogrel can be used if aspirin and dipyridamole are CI
- Aspirin 75mg + MR dipyridamole can be used if clopidogrel CI or not tolerated
Important exceptions:
- Patient has bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging and CT to exclude haemorrhage)
- Patient is already taking low dose aspirin - continue current dose of aspirin until reviewed by specialise
- Aspirin is contraindicated: discuss with specialist team
What acute treatment would you give for an ischaemic stroke?
- Monitor and maintain BM, O2 saturation and temperature within normal limits
- Do not lower BP in acute phase unless there are complications (eg hypertensive encephalopathy)
- Aspirin 300mg take PO or rectally as soon as a haemorrhagic stroke has been excluded.
- If pt is in AF: do not start anticoagulation until haemorrhagic stroke excluded and until 14 days after an ischaemic stroke
- Thrombolysis with IV alteplase - must be done within 4.5h on onset of sx (exclude haemorrhage)
- Thrombectomy: offer if pt is within 6h of symptoms and have a PACS confirmed by CT/MRI. Can be offered within 24h if pts have PACS and there is potential to salvage brain tissue (eg wedge infant, limited infarct core volume)
Describe some relative contra-indications of thrombolysis
Relative
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diatheses
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery/trauma in the preceding 2 weeks
Describe some absolute contra-indications of a thrombolysis
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected SAH
- Stroke/traumatic brain injury/GI haemorrhage in last 3/12
- LP in last 7 days
- Active bleeding
- Pregnancy
- Oesophageal varies
- Uncontrolled HTN (>200/120mmHg)
what secondary treatment should you consider giving to a patient presenting with a stroke/TIA?
If source of stroke is cardio-embolic:
- Consider DOAC/warfarin after exclude haemorrhagic stroke (usually wait 14 days in ischaemic stroke)
- Can use aspirin 300mg in interim whilst waiting for green light for DOAC/warfarin
Antiplatelet treatment:
- Clopidogrel 75 mg OD is now 1st line for secondary prevention in patients who have had a stroke
- Aspirin + MR dipyridamole if clopidogrel CI/not tolerated - treatment no longer limited to 2 years
- Can give dipyridamole or aspirin alone if the other two are not tolerated/CI -
Other risk reduction
- Discuss smoking, diet, physical activity alcohol and BMI
- Lipids: statin 20-80mg (atorvastatin) if total cholesterol >3.5 (but wait 48h before starting a statin due to risk of haemorrhagic transformation)
- BP medication: aim to achieve BP <130mmHg (or 140-150mmHg if severe bilateral artery stenosis)
- Arrange F/U in primary care at discharge, 6/12 and annually
How do you treat a haemorrhagic stroke?
- Vast majority of patients are not suitable for surgical intervention
- Management is supportive
- Stop anticoagulants to minimise risk of further bleeds
- Improved outcomes for pts who have their BP lowered acutely
What do you do in the following scenarios:
Patient has had more than one TIA or has suspected cardioembolic source/severe carotid stenosis?
Discuss need for admission or observation urgently with stroke specialist
What do you do in the following scenarios:
If the patient has a suspected TIA in last 7 days
-Arrange urges assessment (within 24h) by specialist stroke physician
What do you do in the following scenarios:
If the patient has had a suspected TIA that occurred more than 1 week previously
-Refer for specialist assessment as soon as possible within 7 days
Name some tools for identifying TIA/stroke
- FAST score: used in community
- ABCD2: age (>60 = 1), BP (>140/90 = 1), C (clinical features - unilateral weakness = 2, dysphasia without weakness = 1), Duration (>60 mins = 2, 10-60 mins = 1, <10 = 0), Diabetes (1)
- A higher score suggests a higher risk of stroke within following 48h after a TIA
- Rosier score
