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Management of Stroke and Transient Ischaemic Attack

Management of Stroke and Transient Ischaemic Attack. Sam Thomson. Stroke Facts. In 1999 in England and Wales stroke represented 11% (56000) of all deaths In England approx 110000 suffer a 1 st or recurrent stroke 20000 suffer a TIA each year

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Management of Stroke and Transient Ischaemic Attack

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  1. Management of Stroke and Transient Ischaemic Attack Sam Thomson

  2. Stroke Facts • In 1999 in England and Wales stroke represented 11% (56000) of all deaths • In England approx 110000 suffer a 1st or recurrent stroke • 20000 suffer a TIA each year • More than 900000 people in England living with effects of stroke, half dependent on others for ADLs

  3. Case 1 • Mrs Smith telephones for advice regarding her 70 yr old husband who has a dense right sided weakness which started 30 mins ago. • What do you do next?

  4. FAST • FACE – Has the face fallen on one side, can they smile? • ARMS – Can they raise both arms and keep them there? • SPEECH –Is their speech slurred? • TIME – To call 999. If you see any single one of these signs.

  5. Call an ambulance, as until proven otherwise he has had a stroke and may be a candidate for thrombolysis

  6. WHO Definition of Stroke • A clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting >24 hours or leading to death with no apparent cause other than a vascular origin

  7. TIA Definition • Symptoms of signs of stroke which resolve within 24 hours

  8. Pre hospital health professional checklist for recognition of stroke • Sudden onset of neurological symptoms, validated tool such as FAST should be used to screen for diagnosis of stroke or TIA • Exclude hypoglycaemia • Those admitted to A&E with suspected stroke or TIA should have diagnosis established with a validated tool, such as ROSIER

  9. ROSIER Scale

  10. Pre hospital care • If patient is not hypoxic (sats <95%) supplemental Oxygen is not recommended. • Maintain BM 4-11mmol/l • BP manipulation not recommended unless hypertensive emergency (SBP >200mmHg)

  11. Acute care of Stroke • All with suspected stroke should be admitted directly to specialist acute stroke unit • Brain imaging should be performed immediately, definitely within 1 hour for those who may be candidates for thrombolysis, on anticoagulants, depressed LOC, or severe headache at onset of stroke

  12. Case 2 • Mr Brown attends to tell you about an episode at the weekend where the left side of his mouth drooped and he had slurred speech. This resolved after 30 mins. • What else would you like to know?

  13. ABCD2 Score • Age - >60yrs 1 point • Blood Pressure - >140/90mmHg 1 point • Clinical Features – - Unilateral weakness 2 points - Speech disturbance without weakness 1 point - Other 0 points • Diabetic – 1 point • Duration - >60 mins 2 points 10-60 mins 1 point < 10 mins 0 points

  14. Case 2 Info • A = 59 yrs • B = 140/80mmHg • C = Unilateral weakness • D = Not Diabetic • C = Weakness lasted 30 mins • Total = 3 Points

  15. Risk Assessment – Low Risk ABCD2 Score <4 should receive: • Immediate Aspirin (150-300mg) • Specialist assessment as soon as possible, but definitely within 1 week of onset of symptoms • Commencement of secondary prevention as soon as diagnosis confirmed • MRI within 1 week of onset of symptoms, but after specialist assessment

  16. What do I do? • Complete and Fax TIA Clinic Referral Form • Request relevant blood tests – FBC, ESR, TFT, Biochemical Profile, Fasting Lipids and Glucose • Inform the patient a CT head may be required as part of the assessment • Aspirin 300mg stat, then 75mg od

  17. Case 3 • Mr Brown is now 60 years old and has represented as he has had 2 further episodes of facial weakness in the last 2 days. • What do you do now?

  18. Case 3 Info • A = 60 yrs • B = 150/80mmHg • C = Unilateral weakness • D = Not Diabetic • C = Weakness lasted 30 mins • Total = 5 Points and more than 1 TIA in a week

  19. Risk Assessment – High Risk ABCD2 score >/= 4 are at high risk, need: • Immediate Aspirin (150-300mg) • Specialist assessment with 24 hours of onset of symptoms • Commencement of secondary prevention as soon as diagnosis confirmed • Urgent MRI within 24 hours of onset of symptoms (if contraindicated CT)

  20. What do I do? • Arrange urgent admission to MAU for assessment • Even if was still scoring 3 points, would still be classed as high risk as more than 1 TIA in a week suggests increased risk of stroke

  21. Carotid Imaging • All those who are candidates for carotid intervention should have carotid imagining within 1 week of onset of symptoms • If stenosis at critical levels, should be: - assessed and referred for carotid endarterectomy within 1 week of onset of symptoms - Receive treatment within a maximum of 2 weeks of onset of symptoms • If no critical stenosis, should be no surgery an receive the best medical treatment

  22. Medical treatment • Control Blood Pressure • Antiplatelets – Aspirin and Dipyridamole - If dyspepsia continue Aspirin with PPI - If genuine allergy substitute with Clopidogrel • Cholesterol reduction through diet and drugs • Good Diabetic control

  23. References • Stoke – diagnosis and initial management of acute stroke and TIA • NICE guideline, draft for consultation Jan 2008

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