Stroke/TIA

Question 1

Stroke/TIA - PRICMCP?

Answer 1

P: weakness, numbness, speech, vision, duration (stroke if >24h). Bleeding (N+V+headache) or Ischaemic. Duration of symptoms. Residual symptoms. Ask - was this a convincing dx of TIA? Neck pain (dissection)

R: HTN**, lipids, DM, FH, smoking, AF. Thrombophilia (e.g. APS), vasculitis.

I: MRI/CTA/CTB demonstrated stroke or patient does not know

C: injury (fall), residual deficits/disability, increased level of care, recurrence.

M: thrombolysis (clot buster via drip?), thrombectomy, anticoagulation, rehab.

C: ongoing disability vs. asymptomatic.

P: understanding of risk factors and chance of recurrence, adherence.

Question 2

Stroke/TIA examination (5)

Answer 2

Full CNS/PN exam, including speech (+higher function if time).

1. Residual deficit
2. Carotid bruit
3. Cardiac murmur
4. BP
5. Mobility

Question 3

How would you investigate this patient with suspected TIA?

Answer 3

T: NIHSS score, CTB (rule out ICH), CTA (?ECR - anterior circulation infarct, vasculitis, intracranial stenosis), CT perfusion study (to estimate size of the infarct, size of tissue that is critically hypoperfused/salvageable - for thrombolysis)

Exclude alternative diagnosis + causative conditions - FBC (anaemia), ESR (GCA), Glucose (hypoglycaemia), Lipids (RF for stroke), ECG + Holter (IHD, arrhythmia, HB, AF…etc), TFT (if in AF), urine for glucose/protein. Also brain imaging to rule out SOL. If young patient: thrombophilia, APS abs, ANA

Source: Carotid dopplers (in ACA + MCA territory), TTE (LV size - a predictor of embolic risk)/TOE (bubble study ?PFO)

Treatment baseline: PLT (DAPT), Hb, renal function (NOAC), INR (warfarin)

Screen complications:

Question 4

Features of TACI (total anterior circulation infarcts)? (4)

Answer 4

= large cortical stroke affecting both MCA and ACA. Typically proximal MCA or ICA (much worse clinically)

All 3 of below must be present

1. Homonymous hemianopia
2. Contralateral hemiplegia (upper>lower limbs) +/- Hemisensory loss
3. Higher center involvement (Global dysphagia, visuospatial disorder)

Question 5

Clinical features of PACI (partial anterior circulation stroke)?

Answer 5

Is a less severe form of TACI, where only part of anterior circulation (i.e. ICA - MCA/ACA) has been affected.

2/3 of below must be fulfilled.

1. Homonymous hemianopia
2. Contralateral hemiplegia (upper>lower limbs) +/- Hemisensory loss
3. Higher center involvement (Global dysphagia, visuospatial disorder)

Can be further classified to superior MCA, inferior MCA, proximal ACA infarct.

Question 6

What are 3 sub-types of PACI and what are their clinical features?

Answer 6

1. Superior MCA: contralateral hemiplegia + hemisensory + conjugate gaze paresis with forced gaze towards the lesion + broca’s (if left sided stroke)
2. Inferior MCA: contralateral hemianopia +visuo-spatial intention, receptive dysphasia
3. Proximal ACA: contralateral lower limb > upper limb + primitive reflexes + frontal signs

Question 7

Clinical features of POCI (posterior circulation infarct) - 5

Answer 7

One of the following need to be present.

Involves cerebellum/brainstem/visual cortex.

1. CN palsy + Contralateral motor/sensory deficit
2. Bilateral motor/sensory deficit
3. Conjugate gaze paresis (e.g. horizontal)
4. Cerebellar dysfunction
5. Isolated homonymous hemianopia

Question 8

Clinical features of LACI (lacunar syndrome)?

Answer 8

= subcortical stroke that occurs from small vessel disease. There is no loss of higher centre (e.g. dysphasia)

One of the

1. Pure motor
2. Pure sensory
3. Pure sensory/motor
4. Hemiparesis
5. Ataxia
6. Dysarthria

Question 9

Management of TIA? (5)

Answer 9

TIAs go home In C-A-B.

Treat as medical emergency - high-risk of stroke (10%)

Investigate for the cause: carotid USS, TTE, ECG, CTB (exclude bleeding)

• If symptomatic 70-99% need revascularization with CEA (some evidence for stent if younger). If asymptomatic, medical Mx (aspirin, statin, BP meds)

Cholesterol: smoking cessation, the Mediterranean diet (mixed-nuts) → biggest benefit in stroke reduction, Statin

Antithrombotic: if NIHSS > 5 → Aspirin, if ≤5 → DAPT (aspirin + clopidogrel) for 3 weeks (reduces risk of recurrent stroke + small inc in mod-sev bleeding risk). Loading dose for both.

BP-lowering: salt restriction, exercise, weight loss, anti-hypertensives

Driving (i.e. they go home in a CAB): NO driving for 2 weeks

Question 10

If patient is already on aspirin (or plavix) and they have a TIA (no AF). How would you treat?

Answer 10

DAPT for 1st 3 weeks (i.e. treat as high-risk TIA).

Question 11

Patient with AF and they have a TIA. How would you manage?

1. NOAC
2. Warfarin

Answer 11

1. Continue NOAC. Check compliance. Investigate for the mechanism of TIA → may be reasonable to add single antiplatelet, if the mechanism is due to atherosclerosis than to cardioembolism.
2. Warfarin - check level. If therapeutic + still had TIA → as above. If subtherapeutic, consider bridging Heparin.

Question 12

What is ABCD2 score?

Answer 12

Age (≥60 = 1, <60 = 0)

BP (1 point for systolic ≥140 or diastolic ≥90)

Clinical features (unilateral weakness = 2; speech only = 1, other = 0)

Duration (≥60min = 2, 10-59 min = 1; <10min = 0)

Diabetes (1 for yes)

High-risk of stroke if ≥4 points.

Question 13

Contraindications to thrombolysis for acute ischaemic stroke presenting <4.5h? (5)

Answer 13

ICH/GI/GU bleeding last 3 months

Active bleeding

BP > 185 or diastolic 110 (persistent)

INR > 1.7 (with current anticoagulation use) or deranged APTT/PT/TT/Xa assay in the context of current anticoagulation (last dose <48h)

PLT <100

Question 14

What is your approach to anti-thrombotic therapy in acute, ischaemic stroke (non-thrombolysis/ECR eligible)?. Patient is currently not on antiplatelet or anticoagulation.

Answer 14

1. Assess the severity of stroke - it is a severe stroke if NIHSS ≥4.
2. For minor stroke (NIHSS <4) → DAPT for 3 weeks (with loading doses). Only continue further for a total of 90 days if stroke was caused by intracranial large artery atherosclerosis.
3. For major stroke (NIHSS ≥4) → Aspirin only (given haemorrhagic risk?)

Question 15

What is your approach to anti-thrombotic therapy in acute, ischaemic stroke (non-thrombolysis/ECR eligible)?. Patient is currently on a single antiplatelet.

Answer 15

1. Assess the severity of stroke - it is a severe stroke if NIHSS ≥4.
2. For minor stroke (NIHSS <4) → Switch to DAPT for 3 weeks (with loading doses). Only continue further for a total of 90 days if stroke was caused by intracranial large artery atherosclerosis.
3. For major stroke (NIHSS ≥4) → continue existing antiplatelet therapy only.

Question 16

Acute ischaemic stroke in a patient on long-term anticoagulation. Therapeutic and adherent. What is your approach?

Answer 16

1. Cease anticoagulation for assessment for eligibility for thrombolysis or thrombectomy. if eligible, WH for at least 24 hours post thrombolysis.

If not eligible then, the next approach is depending on a) size of the infarct, b) evidence of hemorrhagic transformation or other significant bleeding complications.

2. Big infarct (seek expert) but no symptomatic haemorrhagic transformation → Start Aspirin, cease anticoagulation for 1-2 weeks → resume anticoagulation + stop aspirin if patient is stable (imaging + clinical)
3. Small infarct, no transformation → recommence anticoagulation when patient stable (can be as early as 24-48 hours)

Question 17

What is a large infarct? (3)

Answer 17

Involve ≥1/3rd of MCA territory or

≥ half of PCA territory or

NIHSS >15

Question 18

Management of haemorrhagic transformation of the ischaemic infarct?

Answer 18

WH all anticoagulant and antiplatelet therapy for 1-2 weeks (or until patient is stable), at which point can be restarted as indicated.

Asymptomatic haemorrhagic transformation - speak to experts but generally, it is reasonable to continue Aspirin especially if haemorrhage is petechial (scattered/puncuate). If patient had not been started on antiplatelet yet, it is reasonable to wait until the patient’s neurologic condition stabilise.

no DAPT, including petechial or parenchymal haemorrhage.

Question 19

Patient with new ischaemic stroke with new-onset AF (not previously on anticoagulation) - what is your approach in managing acute-anthrombotic therapy? (initial + long-term). Discuss different scenarios.

Answer 19

Initial approach is the same. if patient is not eligible for TPA or ECR, start antiplatelet ASAP while evaluation for underlying mechanism is on the way.

• Aspirin for NIHSS ≥4, DAPT for NIHSS <4.

If a cardioembolic source is found, in context of new AF - next question is a) is there a large infarct, b) persistent HTN (≥185/110), c) symptomatic haemorrhagic transformation or other major bleeding events.

1. If large infarct or persistent HTN → Aspirin monotherapy → reassess in 1-2 weeks → if stable, switch to long-term oral anticoagulant.
2. If major bleeding / symptomatic haemorrhagic transformation → W/H antithrombotic therapy until stabilised → switch to long-term OA.
3. If non-of them present → switch to OA as soon as patient is stable (usually in 24-48 hours after admission for minor stroke)

Question 20

New stroke (ischaemic) Mx. Patient is found to have carotid artery stenosis (symptomatic - 70-99%). Anti-thrombotic agent choice depending on planned CEA or CAS?

Answer 20

CEA: Aspirin monotherapy before and after.

CAS: DAPT prior to and continued after CAS for 30 days then single-agent.

Question 21

What is your approach in assessing this patient for possible thrombectomy for acute ischaemic stroke? Do you know any criteria that would suggest the ECR would be beneficial for this patient? (4)

Answer 21

Criteria:

1. Anterior circulation infarct (specifically, large artery occlusion in the proximal anterior circulation)
2. Within 6 hours - whether or not thrombolysis was given or not.
   * However, up to 24 hours is considered for ECR (so must discuss with neuro) if treatment can be started in 24 hours and patient has disproportionally severe deficit compared with volume of infarct (i.e. clinical-core mismatch*
3. CT+Perfusion suggest small infarct core
4. Persistent, disabling neurological deficit

Question 22

Indication for Hemicraniectomy in stroke? Would you recommend it to this patient?

Answer 22

<10% of ischaemic strokes are malignant - i.e. due to space-occupying cerebral oedema → herniation of temporal lobe to brainstem (mortality 80%).

Usually from proximal MCA infarct.

Hemicraniectomy reduces mortality but patients are left with major disability - so discussion must be made with family for ?conservative Mx.

Indication: <60y, infarct involving >50% of MCA territory + dec LOC (hence high risk of developing malignant oedema).

Question 23

How would you manage BP in this acute stroke patient?

Answer 23

Ischaemic: One must balance the risk between haemorrhagic risk from HTN vs. hypoperfusion from too aggressive BP lowering.

Generally, reduce BP cautiously, aim 10-20% if BP >220/120

For ICH: aim <180.

Question 24

In which situations would you recommend warfarin instead of NOAC in patient with new AF and had a stroke as a choice of long-term secondary prevention? (3)

Answer 24

1. Rheumatic heart disease
2. Mechanical prosthetic valve
3. Cardiac source of emboli (e.g. LV thrombus)