Diagnosis

• FAST: Outside hospital Face Arms Speech Test
• ROSIER Recognition of Stroke in Emergency Room
• If Thrombotic
  • Carotid (80%): unilateral motor +/- amourosis fugax
  • Verterobasilar (20%): bi-lateral visual, hemiparesis

Investigation

TIA suspected, conduct assessment ASAP:

• ABCD² score: Age >60 =1; BP >140/90 =1; Clinical Unilateral weakness =2, speech disturbance =1; Duration > 60 min = 2, 10-59 = 1; Diabetes =1

Imaging

• Brain Scan: Diffusion weighted MRI
• TIA suspected but symptoms resolved: specialist review within 1 week before imaging
• TIA + ABCD² > 4: Urgent brain scan if pathology uncertain
• Acute Stroke: Urgent brain scan if on anti-coagulant; known bleeding disorder; GCS < 13; Unexplained fluctuating symptoms; Papilloedema; Severe headache at onset of stroke symptoms
• Carotid Imaging (Doppler) If candidates for carotid endarterectomy, within 1 week

Management

• Transient Ischemic Attack: symptoms signs resolved within 24 hrs
• ABCD² > 4 or < 3 but stroke suspected: 300 mg aspirin loading dose + secondary prevention measures (RCP recommend 75 mg clopidogrel and statin)
• Crescendo TIA (> 2 in a week) treat for high risk stroke

Carotid Endarterectomy

• If stable non disabling stroke or TIA, should undergo surgery within 2 wks if carotid stenosis between 50-99 % as well as receiving best medical treatment
• If < 50% best medical treatment only (BP, Anti-platelet, Cholesterol lowering, lifestyle advice)

Acute Stroke

• Alteplase in conjunction with level 1 & 2 nursing and access to imaging and per marketing authorisation (BNF 2.10.2 states within 4.5 hrs)
• If inter-cerebral haemorrhage excluded by imaging: 300 mg Aspirin PO or rectally if dysphagic, started within 24 hrs and continued for 14 days
• After 14 days definitive anti-thrombotic (e.g. 75 mg Clopidogrel)
• If also in AF treat with 300 mg Aspirin only for 14 days, before considering ant-coagulant
• If already receiving anticoagulants: Prosthetic valves stop and replace with Aspirin 300 mg for 7 days, but if DVT/PE should receive anti-coagulant instead
• If dyspeptic then offer + PPI, intolerant consider alternate anti-platelet
• Treat O2 sats < 94 %, 4 > CBG > 11, hypertensive emergencies
• Swallow test < 24 hrs: if unable to feed orally given NGT +/- bridle or gastrostomy if cannot tolerate
• Hydration and nutrition: BMI + The Malnutrition Universal Screening Tool (MUST)
• Food and fluids should be given in form that reduces risk of aspiration (Pneumonia) ie. thickened
• Mobilise as soon as possible: key concept in initial care

Non Thrombotic Presentations

• Venous Sinus Thrombosis: Anticoagulate INR 2-3
• If Haemorrhagic stroke: Reverse anti-coagulation IV Vit K + Prothrombin Complex (Beriplex)

Surgery

• Neurosurgical treatment may be indicated for a very small number of carefully selected patients
• Previously fit people should be considered for surgical intervention following primary intracranial haemorrhage if they have hydrocephalus

NICE Source: CG68 Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. Summary compiled by Dr D P Sheppard MBBS.