Stroke/TIA

Question 1

A 70 year old man with type II diabetes presents complaining of an episode of facial asymmetry and weakness which lasted 5 minutes. How would you assess and manage him?

Answer 1

Impression
Concerned about stroke/TIA given acute onset weakness. Unlikely to be other less acute causes of facial weakness such as Bell’s palsy or hornets syndrome.

Goals:

• Conduct thorough assessment of patient
• Activate stroke pathway and conduct appropriate investigations
• implement appropriate emergent and ongoing management of stroke and future stroke risk

Question 2

Stroke/TIA - Assessment

Answer 2

Assessment
Begin with A to E assessment as presenting sx are concerning for stroke/TIA and patient at increased risk of subsequent cerebrovascular accident.
A - patent, maintaining
B - RR, sats. Supplemental as req.
C - BP maintenance (10mmHg lower than presentation), bloods (FBC, coags, UEC, lipid panel, VBG)
D - GCS. Imaging stroke protocol; CTB non-con +/- CT angio +/- CT perfusion. Then subsequent definitive management
E - Secondary surveys
F - Fluid balance. Monitoring

Question 3

Stroke/TIA - History

Answer 3

History

• PC: stroke sx - FAST (weakness, dysphagia, dysarthria, aphasia, sensory changes, visual changes), timing, onset,
• PMHx: cardiovascular disease, previous stroke,
• FamHx: cardiovascular disease and stroke
• Medications: Anticoagulants
• SNAP
• ABCD^2 score: assess risk of stroke after TIA

Question 4

Stroke/TIA - Examination

Answer 4

Examination

• General observation + vitals
• Neurological examination: weakness, sensory changes, visual changes
• cardiovascular examination: bruits, murmurs (causes of stroke)

Question 5

Stroke/TIA - Investigations

Answer 5

Investigations
- Key/diagnostic: CTB package

• ABCD^2 score - risk of stroke in future
• Bedside: vitals, VBG, ECG
• Bloods: Coags, FBC, UEC, BSL, lipid panel
• Imaging: as above. Consider MRI-B +/- other contrast protocols to inform emergent management

Question 6

Stroke/TIA - Management

Answer 6

Management
- Initially would manage according ABCDE assessment as above. Important to stabilise the patient and initiate diagnostic imaging to confirm/rule-out stroke as a cause of the presentation in a timely fashion.

Definitive (Ischaemic)

• Thrombolysis (if not contraindicated)
• Thrombectomy (if available and in

Definitive (Haemorrhagic)

• CCBs (prevent vasospasm and compunded ischaemic stroke)
• thrombolysis withheld

Supportive

• Fluids/electrolyte replacement
• BP support
• DVT prophylaxis
• telemetry (if indicated)
• analgesia

Ongoing
- manage cardiovascular disease risk factors with pharmacological and non-pharmacological strategies