Stroke

Question 1

what should a patient be given immediately if you suspect that they are having a transient ischaemic attack (TIA)

Answer 1

aspirin 300mg until diagnosis confirmed

if intolerant to aspirin: add PPI, if still intolerant use an antiplatelet drug

Question 2

what is the initial management of ischaemic stroke

Answer 2

• Alteplase within 4.5 hrs (+ intracranial haemorrhage excluded)
• Aspirin 300 mg once daily for 14 days, started as soon as possible within 24 hours of symptom onset
• note: if pt intolerant to aspirin, can give aspirin + PPI or an alternative antiplatelet*

Question 3

when is Alteplase given in the initial management of ischaemic stroke

Answer 3

it should be given if:

• it can be administered within 4.5 hrs of of symptoms onset
  AND
• imaging techniques (e.g MRI) show patient does not have an intracranial haemorrhage

Question 4

what is not recommended for treatment of stroke in patients with sinus rhythm

Answer 4

do not give anticoagulants as an alternative to antiplatelet drugs

Question 5

when may the use of parenteral anticoagulants be consider in the treatment of stroke

Answer 5

only when the patient has symptoms of deep vein thrombosis/ pulmonary embolism or if they are at high risk of developing DVT/ pulmonary embolism

Question 6

what drug should NOT be given in the acute phase of ischaemic stroke

Answer 6

warfarin

Question 7

which patients should take 300mg aspirin for 2 weeks in the acute phase of ischaemic stroke

Answer 7

patients with:

• disabling ischaemic stroke
• atrial fibrillation

Question 8

describe the long-term management of transient ischaemic stroke (TIA) and ischaemic stroke in patients who do not have AF

Answer 8

• start long term treatment with clopidogrel 75mg OD. if not tolerated, other options are :

1. modified-release dipyridamole (200mg BD) + aspirin 75mg OD
2. modified-release dipyridamole alone (if aspirin + clopidogrel both not tolerated )
3. aspirin alone (if modified-release dipyridamole + clopidogrel both not tolerated)

note: dose of modified-release dipyridamole =200mg BD, aspirin= 75mg OD

Question 9

TRUE OR FALSE

anticoagulants are routinely recommended for the long term prevention of stroke

Answer 9

FALSE

anticoagulants are NOT routinely recommended for long-term prevention of recurrent stroke. They are only used if a patient with AF has had a stroke

Question 10

what the only exceptions in which you would use anticoagulants in the long-term prevention of stroke

Answer 10

if the patient has atrial fibrillation or other conditions such as: cardiac source of embolism, cerebral venous thrombosis or arterial dissection

Question 11

when would you start a patient on high intensity statins after a transient ischaemic stroke (TIA) and ischaemic stroke

Answer 11

• high intensity statin (e.g atorvastatin) should be started within 48 hours after the onset of stroke symptoms irrespective of the patient’s serum-cholesterol concentration
• if patient already taking statins, then continue treatment with statins

Question 12

TRUE OR FALSE

A patient’s serum-cholesterol concentration is considered when deciding if they should start high intensity statins after a stroke

Answer 12

FALSE.

ALL patients are started on a high intensity statin (e.g atorvastatin) within 48 hours of stroke symptoms starting. This is irrespective of their serum-cholesterol concentration

note this includes all stroke patients unless they have had a intracerebral haemorrhage

Question 13

what is the target blood pressure for patients after a stroke

Answer 13

<130/80 mmhg

Question 14

which drug class should not be used in the treatment for hypertension after a stroke

Answer 14

beta-blockers should not be used for hypertension treatment after a stroke. Only use them if they are indicated for a coexisting condition

Question 15

what are the treatment options if a patient has intracerebral haemorrhage following a stroke

Answer 15

• surgery may be needed to remove hematoma (collection of blood within skull) and relieve intracranial pressure
• give rapid blood pressure lowering therapy within 6 hours

Question 16

which drugs should be stopped/reversed in stroke patients with intracerebral haemorrhage

Answer 16

Anticoagulants should be stopped/reversed

note some patients have had anticoagulants if they have symptomatic deep vein thrombosis/ pulmonary embolism

Question 17

TRUE OR FALSE

statins should be avoided in stroke patients with intracerebral haemorrhage

Answer 17

True

note they can be used with caution if the risk of a cardiovascular event outweighs risk of bleeding

Question 18

what are the symptoms of stroke

Answer 18

Face
Arms
Speech
Time to call 999

Question 19

what is a transient ischemic attack (TIA)

Answer 19

the same symptoms of stroke but they resolve within 24 hours. This is because the blockage of blood supply to the brain is only temporary. Also known as a “mini stroke”