Stroke and TIA Management

Question 1

What to include in history

Answer 1

Exact onset or when last well
Any change or progression in symptoms
Risk factors - smoking, HTN, CVD, AF

Question 2

What to include in exam

Answer 2

Full neuro

Systemic - pulse (AF), heart sounds, carotid bruits, bruising/bleeding

Risk Factor signs - xanthelasma, corneal arcus

Question 3

What is the management of stroke

Answer 3

CT head within 1 hour to exclude intracranial bleed

Thrombolysis (Alteplase) IF <4.5 hours (+ no CI)

if not:

Aspirin 300mg PO/PR OD for 2 weeks
OR Clopidogrel 300mg PO STAT then 75mg OD

Consider mechanical thrombectomy
Transfer to stroke ward

SALT assessment
Nutritional optimisation 
Early mobilisation 
Treat infections and protect pressure areas
Long-term drugs 
MDT rehab 
Consider carotid endarterectomy 

NB - acute severe HTN is only treated in haemorrhagic strokes or to allow thrombolysis

Question 4

What is the management of TIA

Answer 4

Aspirin 300mg PO/PR OD for 2 weeks
OR clopidogrel 300mg STAT then 75mg PO OD

UNLESS already on anti-platelet drug then continue or in AF then start anticoagulation

Specialist review within 24 hours

• Carotid endarterectomy if: as per NASCET or ECST criteria
• Long-term drugs
• Other Ix - ECG, 24H tape, ECHO, vasculitis screen, thrombophilia screen

Question 5

Long-Term drugs for stroke and TIA

Answer 5

Antihypertensives
Clopidogrel 75mg OD (or anti-coag if in AF - but wait 2 weeks after stroke)
Statin - but wait 48 hours after stroke

Question 6

DVLA advice for stroke / TIA

Answer 6

No driving within 4 weeks

Need to tell DVLA if

• HGV driver
• still having sx after 4 weeks
• complications - seizures, neurosurgery, crescendo TIA