Stroke and TIA

Question 1

Components of the FAST test and what it means

Answer 1

Face - ask them to smile - any droop?
Arms - ask to lift arms, quick power assessment, any drift?
Speech - ask them to repeat a simple sentence. any slurring/dysphasia

Timing - if any of the above +ve, immediate referral to ED

Question 2

What examinations/investigations would you want in suspected Stroke/TIA

Answer 2

A-E assessment
Cardiac exam, Neuro Exam, FAST test
Check blood glucose (<3.3mmol/L - correct)

At ED:
Time between arrival and CT head should be <25 minutes

Question 3

How long between arrival in ED and thrombolysis in confirmed ischaemic stroke

Answer 3

<25 minutes to CT

<60 minutes to Alteplase infusion

Question 4

What are the most important contraindications to thrombolysis?

Answer 4

Any suspicion/confirmed haemorrhage
Presentation >4.5 hrs
History of cranial trauma/surgery/bleed <3 months
GI malignancy/bleed <21 days
Patient is taking direct thrombin inhibitors / LMWH <24hrs
INR of >1.7

Question 5

Management of a confirmed ischaemic stroke, <4.5 hrs, No CI

Answer 5

Alteplase infusion - 0.9mg/Kg/1hr infusion
Re-CT at 24hrs to confirm no bleeds

Start Aspirin 300mg after 24hrs

Question 6

Management of confirmed ischaemic stroke, >4.5 hrs, no CI

Answer 6

Aspirin 300mg PO - for 2 weeks

AF assessment
Start appropriate anti-platelet/anti-coagulant agent after 2 weeks

Question 7

Management of suspected TIA, presenting within 1 week

Answer 7

Aspirin 300mg immediately with PPI cover if appropriate

Assessment by stroke physician within 24hrs

Question 8

Management of suspected TIA presenting over 1 week

Answer 8

Refer for assessment within 7 days

Assess for AF and any other arrhythmias

Question 9

Follow-up schedule following a stroke/TIA

Answer 9

Primary care follow-up on discharge, 6 months and annually - reviewing health, social care needs, RF, secondary prevention

Follow-up <72hrs of admission with stroke rehabilitation team/stroke specialist
Depression screen essential

Question 10

Advice to give RE driving and returning to work

Answer 10

Driving - their responsibility to contact DVLA, on the road assessment, blue badge permits

Return to work - assessment with rehab team, specialist job centre if more profoundly disabled

Question 11

Long term management for Stroke/TIA WITHOUT AF

Answer 11

Clopidogrel, 75mg, PO

Alternatives:
Dipyridamole 200mg BD
Aspirin 75mg OD

Question 12

Long term management for Stroke/TIA WITH AF

Answer 12

Dose adjusted warfarin or DOAC
Target INR of 2.5 (2.0-3.0)

Assessment of bleeding risk - HAS-BLED score

Question 13

Other long term drugs to consider after stroke/TIA

Answer 13

Anti-lipid - High intensity statin - Atorvastatin 20-80mg

Anti-hypertensive meds - target SBP <130