Management of Stroke Management of Stroke and Transient Ischaemic and Transient Ischaemic

AttackAttack

Sam ThomsonSam Thomson

Stroke FactsStroke Facts

• In 1999 in England and Wales stroke In 1999 in England and Wales stroke represented 11% (56000) of all deathsrepresented 11% (56000) of all deaths

• In England approx 110000 suffer a 1In England approx 110000 suffer a 1stst or recurrent strokeor recurrent stroke

• 20000 suffer a TIA each year20000 suffer a TIA each year• More than 900000 people in England More than 900000 people in England

living with effects of stroke, half living with effects of stroke, half dependent on others for ADLsdependent on others for ADLs

Case 1Case 1

• Mrs Smith telephones for advice Mrs Smith telephones for advice regarding her 70 yr old husband who regarding her 70 yr old husband who has a dense right sided weakness has a dense right sided weakness which started 30 mins ago. which started 30 mins ago.

• What do you do next?What do you do next?

FASTFAST

• FACE – Has the face fallen on one FACE – Has the face fallen on one side, can they smile?side, can they smile?

• ARMS – Can they raise both arms and ARMS – Can they raise both arms and keep them there?keep them there?

• SPEECH –Is their speech slurred?SPEECH –Is their speech slurred?

• TIME – To call 999. If you see any TIME – To call 999. If you see any single one of these signs.single one of these signs.

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

WHO Definition of StrokeWHO Definition of Stroke

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

TIA DefinitionTIA Definition

• Symptoms of signs of stroke which Symptoms of signs of stroke which resolve within 24 hoursresolve within 24 hours

Pre hospital health professional Pre hospital health professional checklist for recognition of checklist for recognition of strokestroke• Sudden onset of neurological symptoms, Sudden onset of neurological symptoms,

validated tool such as FAST should be validated tool such as FAST should be used to screen for diagnosis of stroke or used to screen for diagnosis of stroke or TIATIA

• Exclude hypoglycaemiaExclude hypoglycaemia

• Those admitted to A&E with suspected Those admitted to A&E with suspected stroke or TIA should have diagnosis stroke or TIA should have diagnosis established with a validated tool, such as established with a validated tool, such as ROSIERROSIER

ROSIER ScaleROSIER Scale

Pre hospital carePre hospital care

• If patient is not hypoxic (sats <95%) If patient is not hypoxic (sats <95%) supplemental Oxygen is not supplemental Oxygen is not recommended.recommended.

• Maintain BM 4-11mmol/lMaintain BM 4-11mmol/l

• BP manipulation not recommended BP manipulation not recommended unless hypertensive emergency (SBP unless hypertensive emergency (SBP >200mmHg)>200mmHg)

Acute care of StrokeAcute care of Stroke

• All with suspected stroke should be All with suspected stroke should be admitted directly to specialist acute stroke admitted directly to specialist acute stroke unitunit

• Brain imaging should be performed Brain imaging should be performed immediately, definitely within 1 hour for immediately, definitely within 1 hour for those who may be candidates for those who may be candidates for thrombolysis, on anticoagulants, thrombolysis, on anticoagulants, depressed LOC, or severe headache at depressed LOC, or severe headache at onset of strokeonset of stroke

Case 2Case 2

• Mr Brown attends to tell you about Mr Brown attends to tell you about an episode at the weekend where an episode at the weekend where the left side of his mouth drooped the left side of his mouth drooped and he had slurred speech. This and he had slurred speech. This resolved after 30 mins.resolved after 30 mins.

• What else would you like to know?What else would you like to know?

ABCD2 ScoreABCD2 Score• Age - >60yrs Age - >60yrs 1 point1 point• Blood Pressure - >140/90mmHgBlood Pressure - >140/90mmHg 1 point1 point• Clinical Features – Clinical Features –

- Unilateral weakness - Unilateral weakness 2 points2 points- Speech disturbance without weakness 1 - Speech disturbance without weakness 1

pointpoint- Other 0 points- Other 0 points

• Diabetic – 1 pointDiabetic – 1 point• Duration - >60 mins Duration - >60 mins 2 points 2 points

10-60 mins 1 point10-60 mins 1 point< 10 mins 0 points< 10 mins 0 points

Case 2 InfoCase 2 Info

• A = 59 yrsA = 59 yrs

• B = 140/80mmHgB = 140/80mmHg

• C = Unilateral weakness C = Unilateral weakness

• D = Not DiabeticD = Not Diabetic

• C = Weakness lasted 30 minsC = Weakness lasted 30 mins

• Total = 3 PointsTotal = 3 Points

Risk Assessment – Low RiskRisk Assessment – Low RiskABCD2 Score <4 should receive:ABCD2 Score <4 should receive:• Immediate Aspirin (150-300mg)Immediate Aspirin (150-300mg)• Specialist assessment as soon as Specialist assessment as soon as

possible, but definitely within 1 week of possible, but definitely within 1 week of onset of symptomsonset of symptoms

• Commencement of secondary Commencement of secondary prevention as soon as diagnosis prevention as soon as diagnosis confirmedconfirmed

• MRI within 1 week of onset of symptoms, MRI within 1 week of onset of symptoms, but after specialist assessmentbut after specialist assessment

What do I do?What do I do?

• Complete and Fax TIA Clinic Referral Complete and Fax TIA Clinic Referral FormForm

• Request relevant blood tests – FBC, Request relevant blood tests – FBC, ESR, TFT, Biochemical Profile, Fasting ESR, TFT, Biochemical Profile, Fasting Lipids and GlucoseLipids and Glucose

• Inform the patient a CT head may be Inform the patient a CT head may be required as part of the assessmentrequired as part of the assessment

• Aspirin 300mg stat, then 75mg odAspirin 300mg stat, then 75mg od

Case 3Case 3

• Mr Brown is now 60 years old and Mr Brown is now 60 years old and has represented as he has had 2 has represented as he has had 2 further episodes of facial weakness in further episodes of facial weakness in the last 2 days.the last 2 days.

• What do you do now?What do you do now?

Case 3 InfoCase 3 Info

• A = 60 yrsA = 60 yrs

• B = 150/80mmHgB = 150/80mmHg

• C = Unilateral weakness C = Unilateral weakness

• D = Not DiabeticD = Not Diabetic

• C = Weakness lasted 30 minsC = Weakness lasted 30 mins

• Total = 5 Points and more than 1 TIA in a Total = 5 Points and more than 1 TIA in a weekweek

Risk Assessment – High RiskRisk Assessment – High Risk

ABCD2 score >/= 4 are at high risk, need:ABCD2 score >/= 4 are at high risk, need:• Immediate Aspirin (150-300mg)Immediate Aspirin (150-300mg)• Specialist assessment with 24 hours of Specialist assessment with 24 hours of

onset of symptomsonset of symptoms• Commencement of secondary prevention Commencement of secondary prevention

as soon as diagnosis confirmedas soon as diagnosis confirmed

• Urgent MRI within 24 hours of onset of Urgent MRI within 24 hours of onset of symptoms (if contraindicated CT)symptoms (if contraindicated CT)

What do I do?What do I do?

• Arrange urgent admission to MAU for Arrange urgent admission to MAU for assessment assessment

• Even if was still scoring 3 points, Even if was still scoring 3 points, would still be classed as high risk as would still be classed as high risk as more than 1 TIA in a week suggests more than 1 TIA in a week suggests increased risk of stroke increased risk of stroke

Carotid ImagingCarotid Imaging• All those who are candidates for carotid All those who are candidates for carotid

intervention should have carotid imagining intervention should have carotid imagining within 1 week of onset of symptomswithin 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 - assessed and referred for carotid endarterectomy within 1 week of onset of endarterectomy within 1 week of onset of symptomssymptoms

- Receive treatment within a maximum of - Receive treatment within a maximum of 2 weeks of onset of symptoms2 weeks of onset of symptoms

• If no critical stenosis, should be no surgery If no critical stenosis, should be no surgery an receive the best medical treatmentan receive the best medical treatment

Medical treatmentMedical treatment

• Control Blood PressureControl Blood Pressure

• Antiplatelets – Aspirin and Antiplatelets – Aspirin and DipyridamoleDipyridamole- If dyspepsia continue Aspirin with PPI- If dyspepsia continue Aspirin with PPI

- If genuine allergy substitute with Clopidogrel - If genuine allergy substitute with Clopidogrel

• Cholesterol reduction through diet Cholesterol reduction through diet and drugsand drugs

• Good Diabetic controlGood Diabetic control

ReferencesReferences

• Stoke – diagnosis and initial Stoke – diagnosis and initial management of acute stroke and TIAmanagement of acute stroke and TIA

• NICE guideline, draft for consultation NICE guideline, draft for consultation Jan 2008Jan 2008