Stroke and Transient Ischemic Attack (TIA) may present with similar symptoms. These symptoms depend on the artery where the lesion is located. The difference between a stroke and is that TIA is temporary and remits within minutes to hours. The management of ischemic and hemorrhagic stroke is different. However, the two cannot be distinguished based on symptoms. Hence the best initial test is a non-contrast CT of the head to distinguish.
Up to 15% of patients with TIA will go on to have a stroke within 90 days. Most have a stroke within 48 hours. 15 million people have a stroke every year. 80-90% are ischemic while 10-20% are haemorrhagic.
Location of stroke and presentation
| Location | Presentation |
|---|---|
| Middle cerebral artery (50%) | Facial and upper extremity weakness/numbness, aphasia (left MCA), dysarthria, dysphagia, contralateral homonymous hemianopsia, hemineglect (right MCA) |
| Anterior cerebral artery | Lower extremity weakness/numbness, urinary incontinence, primitive reflexes, rigidity, gait apraxia |
| Posterior cerebral artery | Prosopagnosia, macular-sparing homonymous hemianopsia, alexia, visual hallucinations, sensory loss, CN III palsy, motor deficits |
| Internal carotid artery | Similar to MCA stroke, monocular blindness, amaurosis fugax if the ophthalmic artery is affected |
| Lacunar stroke | Pure motor or pure sensory, “clumsy hand”” |
- Risk factors for stroke
- Hypertension (#1 risk factor, RR = 3 – 5)
- Heart disease (RR = 2 – 4)
- Atrial fibrillation (RR = 5 – 18)
- Diabetes mellitus (RR = 1.5 – 3)
- Smoking (RR = 1.5 – 3)
- Alcohol use (RR = 1 – 4)
- Older age
- Family History of Stroke
- Past History of Stroke
- Dyslipidemia
- Signs and symptoms
- Facial drooping
- One-sided weakness of the arm or leg
- Verbal deficit: slurring, dysarthria, aphasia, verbal agnosia
- Altered level of consciousness
- Investigations
- Non-contrast CT: to distinguish ischemic from hemorrhagic stroke. Repeat in 3 days.
- Blood Glucose: exclude hypoglycemia
- Coagulation profile: for PT and INR
- Electrocardiogram: for A-fib
- Echocardiogram: for thrombi
- Carotid Doppler: for blockage
- Lipid panel: for LDL
- Complete blood count: for platelets
- Emergency Treatment
- Secure Airway
- Supplemental Oxygen if SpO2 < 94%
- Control Blood Pressure immediately if > 220 mmHg systolic (can use Labetalol)
- Treat hypoglycemia if < 4.4 mmol/L
- Antipyretics (Acetaminophen) if Temperature is > 38 C
- Admit to the ICU
- Treatment of Ischemic Stroke
- tPA: onset within the past 3 hours or 4.5 hours in patients < 80 without a history of stroke and not on anticoagulants
- Mechanical thrombectomy: onset more than 4.5 hours ago
- Treatment of haemorrhagic stroke
- Surgical evacuation
- Reduce SBP < 160 mmHg (Nicardipine is commonly used)
- Reverse anticoagulation. Administer FFP if the patient is on Warfarin
- Monitor for Seizures (up to 28%)
- Discharge medication
- Daily anti-platelet therapy (Aspirin, Clopidogrel)
- Lipid control (Artovastatin)
- Antihypertensive medications to control blood pressure
- Manage any other underlying cause
- Contraindications for tPA
- Previous stroke or serious head injury in last 3 months
- BP > 185/110 despite treatment
- Recent invasive surgical procedure in the last 2 weeks
- Gastrointestinal or Genitourinary bleed in the past 21 days
- Platelet < 10,000/mm3
- INR > 1.7
- Increased PTT if heparin was given in the preceding 48 hours
- Coma or Stupor
- How can you tell whether to start anticoagulation for patients with suspected A-Fib?
- CHA2DS2-VASC Score can be used to assess the risk for stroke
- CHF sx (1)
- Hypertension (1)
- Age > 75 years (2)
- Diabetes mellitus (1)
- Stroke/TIA (2)
- Vascular disease (1)
- Age 65-74 (1)
- Sex female (1)
- If ≥ 2 (men) or ≥ 3 (women) start anticoagulation (DOACs- Rivaroxaban, Apixaban)
- CHA2DS2-VASC Score can be used to assess the risk for stroke
