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

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. 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? What do you do next?

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

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

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 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

TIA Definition Symptoms of signs of stroke which resolve within 24 hours Symptoms of signs of stroke which resolve within 24 hours

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 Sudden onset of neurological symptoms, validated tool such as FAST should be used to screen for diagnosis of stroke or TIA Exclude hypoglycaemia Exclude hypoglycaemia Those admitted to A&E with suspected stroke or TIA should have diagnosis established with a validated tool, such as ROSIER Those admitted to A&E with suspected stroke or TIA should have diagnosis established with a validated tool, such as ROSIER

ROSIER Scale

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

Acute care of Stroke All with suspected stroke should be admitted directly to specialist acute stroke unit 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 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

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. 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? What else would you like to know?

ABCD2 Score Age - >60yrs 1 point Age - >60yrs 1 point Blood Pressure - >140/90mmHg1 point Blood Pressure - >140/90mmHg1 point Clinical Features – Clinical Features – - Unilateral weakness 2 points - Speech disturbance without weakness 1 point - Other 0 points Diabetic – 1 point Diabetic – 1 point Duration - >60 mins 2 points Duration - >60 mins 2 points mins 1 point mins 1 point < 10 mins 0 points

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

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

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

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. 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? What do you do now?

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

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

What do I do? Arrange urgent admission to MAU for assessment 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 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

Carotid Imaging All those who are candidates for carotid intervention should have carotid imagining within 1 week of onset of symptoms 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: 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 If no critical stenosis, should be no surgery an receive the best medical treatment

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

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