Stroke and TIA

Quick Overview

Stroke is a medical emergency requiring immediate recognition and time-critical intervention. TIA (transient ischaemic attack) presents with stroke symptoms resolving within 24 hours. NICE NG128 emphasises hyperacute thrombolysis (<4.5h) and thrombectomy (<6h, up to 24h in selected cases) for ischaemic stroke, alongside urgent secondary prevention to reduce recurrence risk (80% within 7 days post-TIA).

Core Facts & Concepts

Time-Critical Thresholds 🚨

• Thrombolysis (IV alteplase): Within 4.5 hours of symptom onset (NICE NG128)
• Thrombectomy: Within 6 hours (up to 24 hours if advanced imaging shows salvageable penumbra)
• Brain imaging: Immediate non-contrast CT head within 1 hour of hospital arrival
• Door-to-needle time: Target <60 minutes for thrombolysis

ROSIER Score (Recognition of Stroke in Emergency Room) - Score ≥1 suggests stroke:

• Loss of consciousness/syncope: -1
• Seizure activity: -1
• Asymmetric facial weakness: +1
• Asymmetric arm weakness: +1
• Asymmetric leg weakness: +1
• Speech disturbance: +1
• Visual field defect: +1

ABCD² Score (TIA stroke risk stratification):

• Score ≥4: High risk (4% stroke within 48h) - admit
• Score <4: Specialist assessment within 24 hours

Stroke Subtypes 📊

• Ischaemic: 85% (atherothrombotic, cardioembolic, lacunar, cryptogenic)
• Haemorrhagic: 15% (intracerebral haemorrhage, subarachnoid haemorrhage)

Problem-Solving Approach

Hyperacute Stroke Management (Step-by-Step):

1. Immediate assessment: ABCDE, blood glucose (exclude hypoglycaemia mimicking stroke)
2. Activate stroke pathway: Door-to-scan <1 hour
3. CT head (non-contrast): Exclude haemorrhage, assess early ischaemic changes
4. Thrombolysis eligibility (if <4.5h):
   • 🚩 Contraindications: Recent surgery/trauma, active bleeding, BP >185/110 mmHg, previous ICH
5. Thrombectomy consideration: Large vessel occlusion on CT angiography
6. Admit to stroke unit: Reduces mortality by 18% and disability by 29%

Acute Management Priorities:

• Maintain BP <185/110 mmHg pre-thrombolysis (permissive hypertension otherwise)
• Aspirin 300mg after haemorrhage excluded (continue 14 days, then switch to secondary prevention)
• Swallow assessment before oral intake (aspirin PR/NG if unsafe swallow)
• Monitor for complications: cerebral oedema, haemorrhagic transformation

Analysis Framework

Secondary Prevention (NICE NG128):

⭐ Clinical Pearl: Start DOAC for AF at 2 weeks post-ischaemic stroke (earlier if small infarct, later if large)

Carotid Stenosis Management:

• Symptomatic ≥50% stenosis: Carotid endarterectomy within 2 weeks of TIA/non-disabling stroke
• Asymptomatic ≥70%: Consider endarterectomy (individualised decision)

Visual Aid

Key Discriminators:

Key Points Summary

✓ Thrombolysis window: <4.5 hours | Thrombectomy: <6h (up to 24h with imaging selection)

✓ CT head within 1 hour of arrival - exclude haemorrhage before aspirin/thrombolysis

✓ ROSIER ≥1 suggests stroke | ABCD² ≥4 = high-risk TIA requiring admission

✓ Secondary prevention: Clopidogrel 75mg OD (non-AF) | DOAC at 2 weeks (AF-related)

✓ Aspirin 300mg for 14 days acutely, then switch to clopidogrel (ischaemic stroke)

✓ Carotid endarterectomy within 2 weeks for symptomatic ≥50% stenosis

✓ 🚩 Don't miss: Hypoglycaemia mimicking stroke - check BM immediately