Stroke and TIA

Question 1

TIA

• risk factors
• presentation and quick assessment
• referral

Answer 1

CVD risks - smoking, alcohol, HTN, DM, high cholesterol, AF, CVD
FHx

Can use
-GP - FAST
-ED - ROSIER scale
Weakness, sensory, vision, speech, swallow difficulties
Walking problems
LOC

TIA

• U1wk => same day TIA clinic assessment
• 1wk+ => same week TIA clinic assessment

Bedside
-FBC, platelets, U&E - exclude infection, electrolyte issues
-coagulation - exclude coagulopathy
-BP, cap glucose, ECG
Bloods
-lipid profile, HbA1c,
Imaging
-urgent CT - rule out hemorrhagic in AC users

Aspirin 300mg immediately if not on it => clopidogrel, high dose statin long term, AC in AF

Question 2

TIA

• investigations on referral
• acute management
• secondary prevention

Answer 2

B
-FBC, platelets, U&E - exclude infection, electrolyte issues
-coagulation - exclude coagulopathy
-BP, cap glucose, ECG
B
-lipid profile, HbA1c,
I
-urgent CT - rule out hemorrhagic in AC users

Acute
-300mg aspirin STAT if not on it

Secondary

• 75mg clopidogrel
• CV risk optimisation
• stroke/TIA recognition counselling

Carotid artery disease => endarterectomy, stenting
AF => DOAC

Question 3

TIA mimics

Answer 3

HEMI

Hypo/hyperglycemia
Epilepsy
MS/migraine
Infections (Bells, meningitis, encephalitis, labyrinthitis, abscess)

Question 4

Strokes

-types and risk factors

Answer 4

Ischemic - MOST COMMON
-thrombotic, embolic

Risk factors

• CV
• AF

Hemorrhagic

• SAH - thunderclap
• ICH - nausea and gradual LOC => coning

Risk factors

• age
• HTN
• AVM, ADPKD
• AC use

Question 5

Stroke
-presentation

Cerebral hemisphere infarcts

• ACA
• MCA
• PCA
• PCA supplying midbrain

Answer 5

PWeakness/sensory
Balance problems
Speech problems
Visual field problems - homohemi
Dysphagia

In addition

• decreased consciousness
• headache
• N+V
• seizures

ACA
-contralateral leg weakness/tingling dominant

MCA

• contralateral arm weakness/tingling dominant
• contralateral homohemi
• aphasia

PCA

• contralateral homohemi with macular sparing
• visual agnosia
• cranial nerves

PCA supplying midbrain (Webers)

• ipsilateral CN3 palsy
• contralateral weakness of upper/lower extremities

Question 6

Stroke
Presentation of
-brainstem infarcts
-retinal/opthalmic infarcts
-ant inferior cerebellar
-post inferior cerebellar

Answer 6

Quadriplegia
Locked in syndrome

Amaurosis fugax - painless curtain coming down in eye

Ant inferior cerebellar - lat pontine
FACIAL DROOP

Post inferior cerebellar - lat medullary
DYSPHAGIA, HOARSE, NO GAG REFLEX

Both have
-N/V, nystagmus, vertigo
IP
-Horners
-cerebellar ataxia
-facial temp/pain loss
-hearing loss
CONT
-body temp/pain loss

Question 7

Stroke

• investigations
• acute management of ischemic/hemorrhagic

Answer 7

REFERRAL TO HASU

B
-FBC, platelets, U&E - exclude infection, electrolyte issues
-coagulation - exclude coagulopathy
-BP, cap glucose, ECG
B
-lipid profile, HbA1c,
I
-urgent CT - ischemic/hemorrhagic
-MRI
S
-LP - SAH blood breakdown products

Ischemic confirmed => 300mg aspirin STAT
U4.5hrs of onset => thrombolysis (alteplase)
U6hrs of onset => thrombectomy

Hemorrhagic
CT confirmation => neurosurgery referral (coiling and clipping)
-stop AC
-lower HTN
-SAH - nimodipine, AEDs, analgesia