Stroke and TIA Dx and Mx

Question 1

How do you assess the likelihood a TIA is followed by a stroke?

Answer 1

A - Age > 60

B - BP >140/90

C - Clinical features - Other = 0, Speech disturbance =1, unilateral weakness = 2

D - Duration - <10mins = 0, 10-59mins, = 1, >60mins = 2

D - Diabetes

90 day stroke risk:
0-3 = 3.1%
4-5 = 9.8%
6-7 = 17.8%

Question 2

A patient presents with transient neurology and your suspect TIA. How evaluate/Ix?

Answer 2

• Carotid Ax - CT angio or USS
• ECG and Holter
• Ideal CT/MRI brain

Question 3

How do you assess the severity of a stroke?

Answer 3

NIHSS

• 1a. Level of Consciousness
• 1b. LOC questions
• 1c. LOC Commands
• 2. Best Gaze
• 3. Visual
• 4. Facial Palsy
• 5. Motor Arm 5a. L), 5b. R)
• 6. Motor Leg 6a. L), 6b. R)
• 7. Limb Ataxia
• 8. Sensory
• 9. Best Language
• 10. Dysarthria
• 11. Extinction and Inattention

0 - 40 total
Usually avoid Thrombolysis if NIHSS over 25

Question 4

Acute Ischaemic stroke Ix/Mx

Answer 4

• Urgent CT head/Angio/Perfusion - Haemorrhage or not
• Urgent Thrombolysis IV alteplase (0.9mg/kg (max of 90mg)
• – Contraindications via medcalc
• – Within 4.5 hours
• – Within 9 hours if large salvageable penumbra
• —– From last known well or midpoint of sleep
• Endovascular Retrieval
• – Large vessel occlusion in the internal carotid artery, proximal middle cerebral artery (M1 segment), select basilar artery, M2 depending discussion
• – Within 6 hours of onset
• – Within 6-24 hours if large salvageable penumbra
• – Still give thrombolysis prior to as long as doesn’t delay
• Antithrombotic therapy
• – If not for lysis/clot retrieval or haemorrhagic then pt should receive Aspirin ASAP.
• – If lysed then w/h antiplatelets for 24hrs
• – If TIA or minor stroke DAPT should be started within 24 hours and continue for 3 weeks then aspirin alone
• Use O2 only if hypoxic
• Aim BGLs < 10 in 1st 72 hours
• Keep NBM until swallow cleared
• Utilise antipyrexials if febrile
• Admission to stroke unit

Question 5

Acute Haemorrhagic stroke

Answer 5

• Aim SBP 140mmHg
• Reverse anticoagulation if needed
• – Prothrombinex + 5-10mg IV Vitamin K
• Call Neurosurgery ? intervention

Question 6

Secondary Stroke Prevention

Answer 6

• Long term aspirin unless anticoagulated
• – If Lysed then wait 24 hours - Re-CT (no Haemorrhage) then commence
• If AF then preference DOACs - Can delay commencement by up to 2 weeks post event
• High dose Statin
• Carotid Surgery
• – Recent (3/12) non disabling ant circ ischaemic stroke/TIA with 70-99% ipsilateral stenosis (Consider if 50-69% ipsilateral stenosis)
• – Ideally within 2 weeks of stroke
• – Preference endarterectomy over stenting
• BP control SBP < 140
• Cease hormone replacement, if necessary - Non oestrogen
• Lifestyle modification (smoking, weight, exercise, diet, alcohol)

Question 7

Cervical artery dissection - Acute Mx:

Answer 7

Acute ischaemic stroke due to cervical arterial dissection should be treated with antiplatelet therapy

Question 8

Cerebral venous sinus thrombosis Acute Mx:

Answer 8

• Body weight-adjusted subcutaneous low molecular weight heparin or dose-adjusted intravenous heparin, followed by warfarin, regardless of the presence of intracerebral haemorrhage
• Consider Craniotomy if impending herniation

Question 9

PFO on TTE

Answer 9

• If < 60 years and no other likely cause then can close