Stroke Overview

Early evaluation and treatment are of utmost importance in acute stroke, as it is a time-sensitive diagnosis. A possible stroke patient should be evaluated within 10 minutes of arrival to the emergency department; some warning signs for stroke include facial drooping, arm or other extremity weakness, and speech difficulties. A CT scan without contrast should be performed within 25 minutes and should be looked at within 45 minutes. tPA can be administered up to 4.5 hours after symptom onset, though only in patients who do not have any absolute exclusions such as previous intracranial hemorrhage or stroke within the last 3 months. tPA can have very harmful effects (the most feared outcome being symptomatic intracerebral hemorrhage) and is only administered if the benefits outweigh the risks. If the time of symptom onset is unknown, this often disqualifies a patient for tPA administration (such as a patient who awoke with symptoms) due to increased risk for serious, critical complications.

TIA or Stroke?

The definition of a TIA is now tissue-based, not time-based: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction

Examples of TIA mimics that require exclusion

• hypoglycaemia
• intracranial haemorrhage
  • all patients on anticoagulants or with similar risk factors should be admitted for urgent imaging to exclude haemorrhage

If a patient presents more than 7 days ago they should be seen by a stroke specialist clinician as soon as possible within 7 days.

The

ABCD2 prognostic score

has previously been used to risk stratify patients who present with a suspected TIA. However, data from studies have suggested it performs poorly and it is therefore no longer recommended.

Patients with suspected TIA should be assessed by a stroke specialist clinician before a decision on brain imaging

NICE

• NICE recommend that CT brains should not be done 'unless there is clinical suspicion of an alternative diagnosis that CT could detect'
  • an example exception would be when there is a concern about haemorrhage as the patient is taking anticoagulants
• MRI (including diffusion-weighted and blood-sensitive sequences)is preferred to determine the territory of ischaemia, or to detect haemorrhage or alternative pathologies
  • it should be done on the same day as the specialist assessment if possible

Management of TIA

It should be remembered that patients who've had a TIA are at high risk of further vascular events, particularly in the first few days. This section covers management following a diagnosis, i.e. after being seen by a stroke specialist clinician.

Medication

Immediate antithrombotic therapy:

[REF](https://www.strokeguideline.org/chapter/acute-care/?</td><td>gl=1*blvbdc*</td><td>up*MQ..%3C/td%3E%3Ctd%3EgaNDIwODM5NTIwLjE3MTQ3MzkxOTE.%3C/td%3E%3Ctd%3Ega%3C/td%3E%3Ctd%3EEE3BZMVLRTMTcxNDczOTE5MC4xLjEuMTcxNDczOTM0OC4wLjAuMA..#161:~:text=B-,Patients%20with%20TIA%20or%20minor%20ischaemic%20stroke,-should%20be%20given)