Stroke Medicine

Question 1

Antiplatelet Post Stroke

Answer 1

3weeks DAPT (aspirin and clopidogrel) then mono-therapy.

When?
- as soon as bleed excluded on CTB if no tPA
- CTB 24 hours post tPA then start if no bleed

Question 2

Clopidogrel vs Ticagrelor post stroke

Answer 2

Higher bleeding rates with Ticagrelor.

Clopidogrel is pro-drug activated by CYP2C19, poor metabolisers will benefit from Ticagrelor (often asians).

Question 3

Blood pressure targets in stroke

Answer 3

Acute ischaemic - permissive hypertension to promote perfusion:
- No tPA up to 220/120
- With tPA up to 185/110

For ICH goal is <140

Long term goal is <130 systolic, wait 48-72 hours prior to lowering BP.

Question 4

Lipid Management post stroke

Answer 4

LDL goal < 1.8
High dose statin, then add ezetimibe.

Question 5

Management of carotid stenosis

Answer 5

Asymptomatic - medical management.

Symptomatic:
- >70% CEA
- 50-70%, CEA if male

Aim to do within 2 weeks of event, max 3 months.

Question 6

Management of intracranial atherosclerosis

Answer 6

Intensive medical management. No role for warfarin, no role for stenting.

Question 7

Management of Carotid Dissection

Answer 7

Aspirin mono-therapy.
No role for anticoagulation.
Good prognosis with resolution of dissection in the majority of cases. 50% complete recanalisation, and further 20% haemodynamically significant recanalisation.

Question 8

Indication for closing a PFO in setting of cryptogenic stroke

Answer 8

Only close if age <60 with NO OTHER CAUSE FOUND, and PFO with associated septal aneurysm or moderate-large right to left shunt.

Question 9

Management of CVST:

Answer 9

Anticoagulation:
- start immediately to prevent clot propagation
- usually enoxaparin before starting NOAC
- Provoked 3-6 months
- Unprovoked 6 -12 months
- Thrombophilia - indefinite

May need hemicraniectomy if severe

Major risk factors:
- Pregnancy
- hormone replacement
- Obesity
- Chronic inflammatory conditions
- malignancy