Stroke and TIA

Question 1

How common are strokes and TIAs?

Answer 1

-Most common cause of death in the UK
-110 000 have their first / recurrent stroke each year vs 20 000 have a TIA

Question 2

Who do strokes / TIAs affect?

Answer 2

-Mostly older people (especially ischaemic)

Question 3

What causes a stroke / TIA?

Answer 3

Young people:
-Vasculitis
-Thrombophilia
-Subarachnoid haemorrhages
-Venous sinus thrombosis
-Carotid dissection
Older people:
-Thrombus in situ
-Athero-thromboembolism eg from carotids
-Heart embolism (AF, MI, endocarditis)
-CNS bleed
-Sudden BP drop
-Vasculitis
-Venous sinus thrombosis

Question 4

What risk factors are there for stroke / TIA?

Answer 4

-HTN
-Smoking
-DM
-Heart disease
-AF
-PAD
-Post-TIA
-Polycythaemia vera
-Hyperlipidaemia
-Excess alcohol
-Clotting disorders

Question 5

How does a stroke / TIA present?

Answer 5

Cerebral hemisphere infarcts:
-Contralateral hemiplegia which is initially flaccid and then becomes spastic
-Contralateral sensory loss
-Dysphasia
Posterior circulation ischaemia:
-Motor deficits (weakness, clumsiness, paralysis)
-Sensory deficits (numbness, paraesthesia)
-Ipsilateral cranial nerve dysfunction or contralateral long motor / sensory dysfunction
-Ataxia, imbalance, vertigo
-Diplopia
-Dysphagia, dysarthria
-Locked in syndrome results from complete infarction affecting the pons
Lacunar infarcts:
-Small infarcts around the basal ganglia, internal capsule, thalamus and pons
-Hemiparesis of face, arm, leg
-Mild dysarthria

Question 6

What are the differential diagnoses for stroke / TIA?

Answer 6

-Hypoglycaemia
-TIA
-CNS tumour
-Subdural bleed
-Bell’s palsy
-Drug OD

Question 7

How would you investigate a patient with suspected stroke?

Answer 7

-FBC (thrombocytopenia, polycythaemia)
-CRP, WCC (infective endocarditis)
-ESR (giant cell arteritis)
-BG and lipids
-CXR, ECG and fundoscopy to assess for HTN, AF
-Echo
-CT head (MRI for later strokes)
-Carotid duplex US

Question 8

How would you treat a stroke / TIA patient?

Answer 8

Maintenance of homeostasis:
-O2 therapy, blood sugar control, BP control
SALT assessment
Antiplatelet therapy:
-Aspirin (300mg) ASAP after onset of symptoms once haemorrhage has been excluded
-Clopidogrel 75mg daily (aspirin + dipyridamole 200mg if can’t tolerate clopidogrel)
Thrombolytic therapy:
-Alteplase
Rehab:
-Physio + mobilise as soon as possible