Stroke lecture

Question 1

Define a TIA

Answer 1

transient (<24 hrs) neurological dysfunction caused by brain, spoinal cord or retinal ischaemia with no evidence of acute infarction

Question 2

Why is making the diagnosis of a TIA important?

Answer 2

There is a significant risk of stroke in the days after a TIA

Question 3

What is the initial treatment of TIA as a GP or A+E doctor?

Answer 3

Start the patient on high dose aspirin 300mg
Refer to TIA clinic
Change to clopidogrel 75mg OD after 2 weeks (if the have AF, may switch them to a DOAC or warfarin instead of clopidogrel)

Question 4

What tool would you use to calculate the risk of stroke after TIA?

Answer 4

ABCD2 score

Question 5

What are the components of the ABCD2 score?

Answer 5

Age - ≥60yrs (1)
Blood pressure - ≥140/90 (1)
Clinical features of the TIA 
- unilateral weakness (2)
- speech disturbance without weakness (1)
- other symptoms (0)
Duration of symptoms 
≥60 mins (2)
10-59 mins (1)
<10 (0)
Diabetes - Yes (1), no (0)

Question 6

What has now replaced the ABCD2 score?

Answer 6

The new guidance is to aim to see everyone who has had a TIA within 24 hours in a TIA clinic

Question 7

Does everyone in a TIA clinic have a TIA? What are the differentials of a TIA?

Answer 7

No differentials are:

• syncope
• falls
• infection
• functional disorders

Question 8

What are the investigations for a TIA?

Answer 8

Bloods
- FBC for infection
- U+E - of sodium is very low or high, can mimic TIA
- urea - uraemia can make you drowsy
- CRP, ESR
- LFTs and clotting
- TFT
- Haematinics - B12, ferritin
- Lipid profile
ECG - 24 or 72 hours tape - looking for AF
Carotid artery ultrasound
CT head/MRI - MRI gives much more detailed info, eg multiple sclerosis plaques, tumours, often the CT head would have already been done in A+E, so go on to do MRI in TIA clinic
consider echo - if abmormal ECG, or murmur

Question 9

What new guidance is there for management of high risk TIA and mild stroke?

Answer 9

Dual antiplatelet therapy with aspirin and clopidogrel for 10-21 days (not something you would do as a GP or in A+E, but something to consider in the TIA clinic)

Question 10

Define stroke

Answer 10

A clinical syndrome characterised by sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death with no apparent cause other than that of vascular origin

Question 11

What are the two different types of stroke?

Answer 11

Ischaemic (85%)

Haemorrhagic (15%) - includes subarachnoid haemorrhage

Question 12

What are the differentials for a stroke?

Answer 12

Migraine 
subdural haemorrhage 
Cancer 
Infection 
Hypoglycaemia 
Seizure (Todd's seizure)
Posterior reversible encephalopathy syndrome (PRES) - headache, vision changes, seizures, limb weakness  due to a rise in BP 
Functional

Question 13

What are the causes of ischaemic stroke?

Answer 13

artherosclerosis eg of the carotid artery
cardioembolic - eg in AF
dissection - eg carotid artery

Question 14

What investigations would you do for stroke?

Answer 14

Very similar to TIA: 
-Bloods 
- FBC for infection
- U+E - of sodium is very low or high, can mimic TIA 
- urea - uraemia can make you drowsy 
- CRP, ESR 
- LFTs and clotting 
- TFT
- Haematinics - B12, ferritin
- Lipid profile  
-ultrasound scan of carotid artery
ECG- 24/72 hr tape
consider echo - in sb with ischaemic stroke, abmormal ECG, or murmur
CT head or MRI

Question 15

within what time period should a CT head/MRI be done for a pt with a suspected stroke?

Answer 15

Within 1 hr

Question 16

When would an MRI be used in addition to a CT head?

Answer 16

When the symptoms don’t match the findings on the CT head
If the CT head is normal
So whenever there is uncertainty

Question 17

What is the management for an ISCHAEMIC stroke?

Answer 17

Non-pharmacological

• exercise
• good diet, low salt
• stop smoking
• reduce alcohol

Pharmacological
- asprin 300 mg OD for 2 weeks
- change to clopidogrel 75 mg
- if AF, use DOAC or warfarin instead of clopidogrel
(for mild strokes, can use dual antiplatelet with aspirin and clopidogrel for 10-21 days)
- manage BP if >220/110 - use a GTN patch or labetalol
- thrombolysis, Alteplase (give within 4.5 hrs)
- thrombectomy (within 6 hours) - can do outside this timeframe if there is mismatch between deficit (salvageable brain, also called penumbra) and infarct
- carotid endarterectomy (>50% obstruction)
- cholesterol manaegement - reduce cholesterol by 40% start atorvastatin
- long term BP target to be 130/80
- DRIVING

Question 18

How long are you not allowed to drive for after an ischaemic stroke?

Answer 18

1 month
If you have ongoing symptoms after a month (ie further events), then need to see a doctor before starting to drive and may need a driving assessment from an occupational therapist

Question 19

What are the contraindications for thrombolysis?

Answer 19

Major surgery or trauma in the last 3 months
Warfarin or DOAC
Significant head trauma in the last 2 months
Stroke in the last 6 weeks

Question 20

Where must a stroke be for thrombectomy?

Answer 20

Proximal large vessel occlusion (so can’t be an occlusion that is deep seated in the brain)

Question 21

What are the requirements are there for thrombectomy?

Answer 21

1. Proximal large vessel occlusion (so can’t be an occlusion that is deep seated in the brain)
2. Has to be done within 5 hours of symptom onset (takes an hour to complete and not beneficial after 6 hours)
3. causes a disabling neurological deficit

Question 22

What are the causes of a HAEMORRHAGIC stroke?

Answer 22

• hypertension
• Cerebral amyloid angiopathy (CAA)- where amyloid beta peptides are deposited in the small vessels making them friable
• Aneurisms
• AVM
• Trauma
• Antiplatelets and anticoagulants

Question 23

How would you manage a HAEMORRHAGIC stroke?

Answer 23

Reduce blood pressure to 140/80
Reverse anticoagulation
Neurosurgical referral
Insert an external ventricular drain if hydrocephalus develops