Strokes and TIA

Question 1

What are TIAs?

Answer 1

brief episodes of neurological dysfunction resulting from focal cerebral ischemia not associated with permanent cerebral infarction

Question 2

A TIA is a …

Answer 2

warning sign

Question 3

8-12% of those with TIA develop a stroke at …

Answer 3

7 days

Question 4

11-15% of those with TIA develop a stroke at …

Answer 4

one month

Question 5

TIA epidemiology

Answer 5

46,000 TIA every year in the UK
15% of strokes are preceded by a TIA
Risk of stroke following a TIA:
5% - 48 hours
8% - one week
12% - one month
17% - three months

Question 6

Risk of stroke following a TIA:
...% - 48 hours
8% - one week
...% - one month
17% - three months

Answer 6

5% - 48 hours
8% - one week
12% - one month
17% - three months

Question 7

The ABCD (2) score

Answer 7

Age >60 years (1)
Blood pressure SBP>140, DBP>90 (1)
Clinical features uni. Weakness (2), speech dis (1)
Duration >60min (2), 10-59 min (1)
Diabetes - yes (1)
Total = 7
0-3 = low risk seen within a week, 4-7 = high risk seen within 24 hours
Now abandoned - low/high risk does not make a difference now

Question 8

What to do ? (TIA - ABCD (2))

Answer 8

Aspirin 300mg immediately
Specialist assessment within 24 hours
2ry prevention measures introduced
Crescendo TIA (2 or > in a week) = high risk

Question 9

Stroke

Answer 9

common and devastating condition
Every 5 minutes in the UK someone has a stroke
High mortality
High morbidity

Question 10

Stroke annual incidence in the UK

Answer 10

100,000 first strokes
30,000 recurrent strokes
500,000 stroke victims in community
third most common cause of death
most common cause of long-term disability

Question 11

Definition of stroke

Answer 11

A clinical syndrome characterised by rapidly developing symptoms and/or signs of focal, and at times global, loss of cerebral function with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.

Question 12

Risk factors of stroke (1)

Answer 12

Non modifiable:
Age 
Male sex
Family hx
Previous stroke
Ethnic origin

Question 13

Risk factors of stroke (2)

Answer 13

Modifiable:
Hypertension
Diabetes Mellitus
Atrial Fibrillation
High cholesterol
Carotid stenosis
Thrombotic tendency
Transient ischaemic attacks (TIA)
Smoking

Question 14

Pathophysiology of Stroke (1)

Answer 14

Ischaemia from atherothrombotic occlusion or embolism (85%)
Left atrium in patients with atrial fibrillation
Left ventricle in patients with myocardial infarction or heart failure

Question 15

Symptoms of Stroke

Answer 15

hemiparesis/monoparesis
hemisensory loss
hemianopia
hemineglect
dysphagia
squint/double vision
vertigo
balance and coordination problems
altered consciousness
dizziness
'confusion'
'off legs'
headache
vomiting

Question 16

Signs of stroke on clinical examination

Answer 16

Conscious level 
Neurological signs
Blood pressure
Heart rate and rhythm
Peripheral pulses

Question 17

Pathological causes of stroke

Answer 17

Cerebral infarct (80%)
Intracerebral haemorrhage (105)

Question 18

Cerebral circulation

Answer 18

Total anterior circulation syndrome
Partial anterior circulation syndrome
Lacunar syndrome
Posterior circulation syndrome

Question 19

Symptoms and signs of stroke depend on …

Answer 19

vascular territory involved - OCSP classification

Question 20

Anterior circulation strokes

Answer 20

Unilateral weakness, unilateral sensory loss or inattention, isolated dysarthria, dysphagia, vision: h. hemianopia, m. blindness, v. inattention

Question 21

Total Anterior Circulation (TAC)

Answer 21

All of the following: motor or sensory cortical hemianopia

60% dead at 1 year

Question 22

Lacunar strokes

Answer 22

Motor or sensory signs only
10% dead at 1 year
25% dependant at 1 year

Question 23

Investigations - Stroke

Answer 23

CT scan head/MRI
ECG
CXR
FBC, ESR, clotting, electrolytes and creatinine, fasting glucose and lipids, urinalysis

Question 24

Investigations - Stroke (2)

Answer 24

Carotid doppler
Echocardiography - bubble contrast-echo
Thrombophilia screen
Vasculitic screen

Question 25

Management of stroke - where?

Answer 25

an acute stroke unity
with recovery different needs of care
stroke units offer

Question 26

Management of stroke - medical treatment

Answer 26

Aspirin 300mg daily for at least 2 weeks
IV fluids - 2L N/S per 24hrs
O2 2l via nasal cannulae

Question 27

Thrombolysis

Answer 27

Atleplase up to 6 hours from onset of stroke increases significantly the chance of a near complete recovery (IST3 findings) and no upper age limit
Followed by thrombectomy

Question 28

Neurosurgery

Answer 28

Large cerebellar infarct or bleed
Acute hydrocephalus
Iv mannitol
Craniectomy

Question 29

Reversal of anticoagulation

Answer 29

Primary intracerebral haemorrhage
Fresh frozen plasma
Vitamin K

Question 30

Early complications of stroke

Answer 30

Hyperglycaemia BM>12
Hypertension
Fever
Infarct extension or rebleeding
Cerebral oedema, herniation

Question 31

Late complications of stroke

Answer 31

Aspiration pneumonia
UTI
DVT
PE
Incontinence
Pressure sores
Depression/anxiety
Seizures
Pain

Question 32

Rehab - stroke

Answer 32

to restore function and reduce the effect of stroke on patients and carers - should start early

Question 33

MDT - stroke

Answer 33

Doctor 
Nurse
Physio
Occupational therapist
Speech and language
Social worker
dietician
more...

Question 34

Summary of stroke

Answer 34

major cause of death and disability
Incidence increases with age
Hx and exam are key to classification
Understand and use OCSP
Stroke units reduce mortality and dependency
MDT care is critical to success
Research is needed (relevant and meaningful)