Stroke: Transient Ischaemic Attack

Question 1

Definition

Answer 1

NOT A STROKE
Sudden onset of focal neurological deficit due to temporary focal cerebral ischaemia without acute infarction
< 24 hours = typically 5-15 mins

Question 2

Epidemiology

Answer 2

Males
Black people
Increasing age

Question 3

Risk factors

Answer 3

IHD
Hypertension
Smoking
Diabetes
Hypercholesterolaemia
Atrial fibrillation
Carotid stenosis
Obesity/ Hypercholesterolaemia
VSD

Question 4

Aetiology

Answer 4

Carotid Thromboembolism
- Thrombosis
- Emboli
* usually from carotid artery - listen for a carotid bruit *
Cardio embolism
- Atrial fibrillation
- After an MI
- Valve disease/ prosthetic valve
- Hyper viscosity
- Hyperinflation
- Hyper perfusion

Question 5

Pathophysiology

Answer 5

90% = ICA (anterior circulation)
10% = Vertebral (posterior)

Question 6

Symptoms

Answer 6

CAROTID -
Facial weakness
Limb weakness
Slurred speech
Amaurosis fugax
- Temporal occlusion of retinal artery/ hypoxia
- Unilateral
- “Like curtains descending”
VERTEBROBASILLAR - VerteBrobasiLlar
Vomiting
Loss of balance
Bilateral limb weakness

Question 7

Signs

Answer 7

CAROTID -
Focal neurology
Irregular pulse (AF)
Carotid bruit - carotid artery stenosis
HTN
VERTEBROBASILLAR -
Diplopia
Vertigo
Ataxia

Question 8

ACA signs

Answer 8

Contralateral hemiparesis and sensory loss: weak numb contralateral leg
(Lower > Upper)

Question 9

MCA

Answer 9

Contralateral hemiparesis and sensory loss:
- weak numb contralateral side of body,
- face drooping with forehead spared
- contralateral homonomous hemianopia
- dysphagia (temporal)
- aphasia

Question 10

PCA

Answer 10

• Vision loss = contralateral homonymous hemianopia with macular sparring - occipital cortex affected
• Visual agnosia

Question 11

Vertebral artery

Answer 11

Cerebellar syndrome
Positive Romberg test (sensory + motor ataxia)
Brain stem infarct
CN lesions 3-12

Question 12

Diagnosis

Answer 12

FIRST LINE = Bloods
- Glucose (rule out hypo)
- FBC (polycythaemia)
- ESR (raised in vasculitis)
- Cholesterol
CT scan (rule out haemorrhage)
Carotid artery doppler USS (stenosis or atheroma)
GOLD STANDARD = Clinical judgement - until there is recovery = it is impossible to differentiate from a stroke

Question 13

Risk Score

Answer 13

ABCD2: a risk stratifying tool to determine the risk of future stroke:
Age > 60 (1)
BP > 140/90 (1)
Clinical symptoms:
- unilateral weakness (2)
- slurred speech, no weakness (1)
DMT2 (1)
* Score > 6 refer to neurology asap, risk of stroke in a week -= 35.5% *

Question 14

Treatment

Answer 14

FIRST LINE = 300mg of Aspirin
- 75mg Clopidogrel long term + Atorvastatin 80mg

Question 15

When not to offer aspirin in these circumstances

Answer 15

• Bleeding disorder or taking an anticoagulant: needs immediate admission and assessment
• Taking low-dose aspirin regularly: continue the current dose and arrange a specialist review
• Aspirin is contraindicated: needs specialist advice