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Stroke- TIA

. Presentations which can mimic TIA or Stroke are described with a focus on recognition and use of assessment tools as FAST and ROSIER ( several other tools also exist ). Management of TIA based on the ABCD risk scoring is shown in greater detail. The reader is advised to consider discussing DVLA guidance and complications of stroke are mentioned ( encountered frequently ). The charity stroke association can be a useful tool in advising patients in a post stroke scenario.

Stroke-Clinical syndrome consisting of rapidly developing clinical signs of focal ( at times global ) disturbance of cerebral function lasting more than 24 hrs or leading to death with no apparent cause other than that of vascular origin

TIA-Acute loss of focal cerebral or ocular function with symptoms lasting less than 24 hrs and which is thought to be due to inadequate cerebral or ocular blood supply as a result of low blood flow , thrombosis or embolism associated with diseases of the blood vessel , heart or blood
 ( Hankey and Warlow 1994 )


Tissue based definition ( event lasting less than 1 hour without cerebral infarction ) on MRI brain scan requires early scanning and is thus limited in generalisability



TIA is associated with a very high risk of stroke
 in the first month after the event and upto 1 year afterwards

Major health problem in UK Most people survive a first stroke but often have significant morbidity In England estimated cost to economy is around £8 billion / year This burden will increase as population demographics change Over 80,000 people in England and Wales are admitted with acute stroke each year Use of term CVA should be abandoned as it implies that the stroke is a chance event for which little can be done Brain attack – an alternative term used to describe the acute presentation of stroke and TIA ( it removes the requirement for a delay of 24 hrs to diagnose stroke )

Risk factors-Smoking Alcohol and drug abuse Physical inactivity poor diet.Hypertension Permanent and Paroxysmal AF 
estimated that AF causes more than 20 % of ischaemic strokes Infective endocarditis Valvular disease Carotid artery disease Congestive cardiac failure Congenital or structural heart disease including patent foramen ovale Age Gender
Men ↑ likely to suffer with stroke at younger age
Women ↑ risk with COCP use , migraine with aura , immediate post-partum period and pre-eclampsia Hyperlipidaemia Diabetes mellitus Sickle cell disease Antiphospholipid syndrome and other hypercoagulable disorders CKD Obstructive sleep apnoea
independent risk factor +
usually associated with other comorbidities

Presentation with sudden onset and cannot be explained by 
another condition such as hypoglycaemia Unilateral weakness or sensory loss Dysphasia Ataxia , vertigo or in-coordination Syncope Amaurosis fugax- sudden transient loss of vision in one eye Homonympus hemianopia Cranial nerve defects

TIA may only last minutes and symptoms often resolve before patient is seen. Collateral history is important. R/O TIA Mimics Migraine aura Seizure Syncope Functional or anxiety related Vestibular disorders Metabolic eg hypoglycaemia Delirium eg sepsis Suspected TIA- all patients
 who have ongoing 
symptoms however mild are considered to have had 
stroke and urgent
 transfer to hospital should
 be arranged Confusion , altered level of consciousness and coma Headache – sudden severe and unusual headache which may be associated with neck stiffness
Sentinel headache(s) may occur in the preceding weeks Weakness – sudden loss of strength in the face or limbs Sensory loss- paraesthesia or numbness Speech problems as dysarthria Visual problems – visual loss or diplopia Dizziness ,vertigo or loss of balance
isolated dizziness usually not a symptom of TIA Nausea and / or vomiting Cranial nerve deficits as
○ unilateral tongue weakness
○ Horner’s syndrome – miosis , ptosis and facial anhidrosis Difficulty with
fine motor co-ordination
gait Neck facial pain ( arterial dissection ) Post circulation stroke – acute vestibular syndrome
○ acute persistent , continuous vertigo or dizziness with nystagmus , nausea or vomiting
○ head motion intolerance and
○ new gait unsteadiness


ABCD2 score-Age – 60 yrs and older ( 1 point )
 Blood pressure 
Systolic >= 140 ( 1 point ) Diastolic >= 90 ( i point )

Clinical features Any unilateral weakness ( 2 points ) Speech impairment without weakness ( 1 point )

Duration
60 minutes or more (2 points )
10-59 minutes ( 1 point )

Diabetes mellitis ( 1 point )

Suspected stroke-Confusion , altered level of consciousness and coma Headache – sudden severe and unusual headache which may be associated with neck stiffness
Sentinel headache(s) may occur in the preceding weeks Weakness – sudden loss of strength in the face or limbs Sensory loss- paraesthesia or numbness Speech problems as dysarthria Visual problems – visual loss or diplopia Dizziness ,vertigo or loss of balance
isolated dizziness usually not a symptom of TIA Nausea and / or vomiting Cranial nerve deficits as
○ unilateral tongue weakness
○ Horner’s syndrome – miosis , ptosis and facial anhidrosis Difficulty with
fine motor co-ordination
gait Neck facial pain ( arterial dissection ) Post circulation stroke – acute vestibular syndrome
○ acute persistent , continuous vertigo or dizziness with nystagmus , nausea or vomiting
○ head motion intolerance and
○ new gait unsteadiness
 Mimics-Seizure Sepsis Toxic/ metabolic Space occupying lesion Syncope Delirium Vestibular Mononeuropathy Functional Dementia Migraine Spinal cord lesions Other

FAST test- Facial asymmetry- 1 pt Arm weakness 1 pt Speech disturbance – 1 pt Time

Some people with stroke with not be identified by FAST test eg

○ sudden onset visual disturbance
○ lateralising cerebral dysfunction Continue to treat as having a suspected stroke if suspected despite a negative FAST test-Emergency hospital admission to stroke unit Explain to the ambulance staff about situation Inform the hospital in advance Do not start antiplatelet treatment until haemorrhagic stroke has been r/o While awaiting transfer
○ monitor ABC
○ give oxygen if saturation < 95 % and no CIs If not admitted ( not beneficial / appropriate )
○ document clearly
○ discuss with specialist team and possible assessment and management at home or as Outpatient within 24 hrs

Complications of stroke-Early period following stroke
○ haemorrhagic transformation of ischaemic stroke
○ cerebral oedema
○ seizures
○ VTE – PE in 13 – 25 % of deaths 
○ cardiac problems
 MI , CCF , AF and arrthymias
○ Infection – aspiration pneumonia , UTI and cellulitis from pressure sores
 Long term

○ Mobility problems
Hemiparesis or hemiplegia ( affects about 80 % of people with stroke )
Ataxia -lack of co-ordinated movement
Falls 
Spasticity and contractures

○ Sensory problems- altered sensation as touch , temp and pain
○ Continence problems
 Urinary and fecal incontinence is common following stroke
○ Pain
○ Fatigue
○ Swallowing hydration nutrition problems
 swallowing impairment common
○ Sexual dysfunction
○ Skin problems – pressure sores
○ Visual problems -altered acuity , hemianopia , diplopia , nystagmus and blurred vision
○ Cognitive problems
○ Emotional and psychological problems
○ Communication problems
○ Difficulties with activities of daily living
○ Loss of income

References

  1.  Diagnosis and management of transient ischaemic attack and ischaemic stroke in the acute phase BMJ 2011 ; 342 :d 1938
  2. National Clinical Guideline Centre (UK). Stroke Rehabilitation: Long Term Rehabilitation After Stroke [Internet]. London: Royal College of Physicians (UK); 2013 May 23. (NICE Clinical Guidelines, No. 162.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK247494/
  3. BCGuideline.ca Stroke and Transient Ischaemic Attack-Acute and Long-Term Management Guideline and Protocol Advisory Committee https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/stroketia_2015_full.pdf
  4. Neurology for General Practitioners -E Book-Roy G Beran
  5. Stroke and transient ischaemic attack in over 16s : diagnosis and initial management : guidance ( CG 68 ) https://www.nice.org.uk/guidance/ng128
  6. Transient Ischaemic attacks: Assessment and Management Australian Family Physician Vol 39 , No 11, November 2010 https://www.racgp.org.au/afpbackissues/2010/201011/201011leung.pdf
  7. Clinical Neurology , 4th Edition Hodder Education December 2011
  8. Stroke and TIA CKS NHS revised March 2017 https://cks.nice.org.uk/stroke-and-tia
  9. Is Transient Ischemic Attack a Medical Emergency ? OHTAC Recommendation Health Technology ( HTA ) database via https://www.crd.york.ac.uk/crdweb/PrintPDF.php?AccessionNumber=32015000483&Copyright=Health+Technology+Assessment+%28HTA%29+database%3Cbr+%2F%3ECopyright+%26copy%3B+2020+Health+Quality+Ontario%3Cbr+%2F%3E
  10. Transient Ischaemic Attack Treatment & Management E Medicine Dec 2016 https://emedicine.medscape.com/article/1910519-overview
  11. Ischaemic Stroke Medscape July 2017
  12. Diagnosis of Acute Stroke Am Fam Physician. 2015 Apr 15 ;91 (8) :528-536
  13. Diagnosis and initial management of transient ischaemic attack Pippa TyrrellSharon Swain and Anthony Rudd the multidisciplinary guideline development group DOI: https://doi.org/10.7861/clinmedicine.10-2-164 

  14. More than half the stroke patients were not given preventative drugs , study finds BMJ 2016 ; 355 :i6105
  15. Royal College of Physicians National clinical guideline for stroke Prepared by the Intercollegiate Stroke Working Party Fifth Edition 2016
  16. https://www.strokeassociation.org/idc/groups/stroke-public/@wcm/@hcm/documents/
downloadable/ucm_309713.pdf
  17. Nadarajan VPerry RJJohnson J, et al
    Transient ischaemic attacks: mimics and chameleons

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