Stroke lecture Flashcards
Define a TIA
transient (<24 hrs) neurological dysfunction caused by brain, spoinal cord or retinal ischaemia with no evidence of acute infarction
Why is making the diagnosis of a TIA important?
There is a significant risk of stroke in the days after a TIA
What is the initial treatment of TIA as a GP or A+E doctor?
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)
What tool would you use to calculate the risk of stroke after TIA?
ABCD2 score
What are the components of the ABCD2 score?
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)
What has now replaced the ABCD2 score?
The new guidance is to aim to see everyone who has had a TIA within 24 hours in a TIA clinic
Does everyone in a TIA clinic have a TIA? What are the differentials of a TIA?
No differentials are:
- syncope
- falls
- infection
- functional disorders
What are the investigations for a 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
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
What new guidance is there for management of high risk TIA and mild stroke?
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)
Define stroke
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
What are the two different types of stroke?
Ischaemic (85%)
Haemorrhagic (15%) - includes subarachnoid haemorrhage
What are the differentials for a stroke?
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
What are the causes of ischaemic stroke?
artherosclerosis eg of the carotid artery
cardioembolic - eg in AF
dissection - eg carotid artery
What investigations would you do for stroke?
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
within what time period should a CT head/MRI be done for a pt with a suspected stroke?
Within 1 hr
When would an MRI be used in addition to a CT head?
When the symptoms don’t match the findings on the CT head
If the CT head is normal
So whenever there is uncertainty
What is the management for an ISCHAEMIC stroke?
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
How long are you not allowed to drive for after an ischaemic stroke?
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
What are the contraindications for thrombolysis?
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
Where must a stroke be for thrombectomy?
Proximal large vessel occlusion (so can’t be an occlusion that is deep seated in the brain)
What are the requirements are there for thrombectomy?
- Proximal large vessel occlusion (so can’t be an occlusion that is deep seated in the brain)
- Has to be done within 5 hours of symptom onset (takes an hour to complete and not beneficial after 6 hours)
- causes a disabling neurological deficit
What are the causes of a HAEMORRHAGIC stroke?
- hypertension
- Cerebral amyloid angiopathy (CAA)- where amyloid beta peptides are deposited in the small vessels making them friable
- Aneurisms
- AVM
- Trauma
- Antiplatelets and anticoagulants
How would you manage a HAEMORRHAGIC stroke?
Reduce blood pressure to 140/80
Reverse anticoagulation
Neurosurgical referral
Insert an external ventricular drain if hydrocephalus develops
