TIA/Stroke

A transient episode of neurologic dysfunction due to focal brain, retinal, or spinal cord ischemia without acute infarction.

TIA – Most important predictor of stroke: 15% of patients with stroke report previous TIA.

Temporary reduction/cessation of cerebral blood flow adversely affecting neuronal function

  • Carotid/vertebral atherosclerotic disease
    • Artery-to-artery thromboembolism
    • Low-flow ischemia
  • Small, deep vessel disease associated with hypertension (HTN)
    • Lacunar infarcts
  • Cardiac diseases
    • 1–6% of patients with myocardial infarction (MI) develop stroke.
  • Embolism secondary to the following:
    • Valvular (mitral valve) pathology
    • Mural hypokinesias/akinesias with thrombosis
    • Cardiac arrhythmia (atrial fibrillation accounts for 5–20% incidence)
  • Hypercoagulable states
    • Antiphospholipid antibodies
    • Increased estrogen (e.g., oral contraceptives)
    • Pregnancy and parturition
  • Arteritis
    • Noninfectious necrotizing vasculitis
    • Drugs
    • Irradiation
    • Local trauma
  • Sympathomimetic drugs (e.g., cocaine)
  • Other causes: spontaneous and posttraumatic (e.g., chiropractic manipulation) , arterial dissection

RISK FACTORS

  • HTN
  • Cardiac diseases (atrial fibrillation, MI, valvular disease)
  • Diabetes
  • Hyperlipidemia
  • Atherosclerotic disease (carotid/vertebral stenosis)
  • Cigarette smoking
  • Thrombophilias

 

 

 

  • Emphasis on symptom onset, progression, and recovery
  • Carotid circulation (hemispheric):

 

— monocular visual loss, hemiplegia, hemianesthesia, neglect, aphasia, visual field defects (amaurosis fugax); less often: headaches, seizures, amnesia, confusion

 

  • Vertebrobasilar (brain stem/cerebellar):

 

—– bilateral visual obscuration, diplopia, vertigo, ataxia, facial paresis, Horner syndrome, dysphagia, dysarthria; also headache, nausea, vomiting, ataxia.

 

  • Past medical history, baseline functional status

 

  • ABCD2 or ABCD3-I score: predicts 48-hour CVA risk
    • Score of 0 to 1: 0%; 2 to 3: 1.3%; 4 to 5: 4.1%; 6 to 7: 8.1%
      • Age >65 years: 1 point
      • Blood pressure (BP) 140/90 mm Hg: 1 point
      • Clinical presentation
        • Unilateral weakness: 2 points
        • Speech impaired without weakness: 1 point
      • Duration: 1 to 2 points based on time
      • Diabetes: 1 point
      • Dual TIA(within 7 days preceding): 2 points
      • Imaging (new lesion or carotid stenosis): 2 points

 

DIFFERENTIAL DIAGNOSIS

  • Evolving stroke
  • Migraine (hemiplegic)
  • Focal seizure (Todd paralysis)
  • Bell palsy
  • Neoplasm of brain
  • Subarachnoid hemorrhage
  • Intoxication
  • Glucose or other electrolyte abnormalities
  • Head trauma
  • Central nervous system infection
  • Multiple sclerosis

 

 

Antiplatelet – aspirine 300 mg , dipyridamole , clopidrogrel

BP control

Statin – cholesterol control

AF control – NOAC or warfarin

DM control

Stop smoking – SNAPS

Driving

Clear safety net

 

ABCD2 rule –à admit

Advice drug adverse effect

 

BSL, HBA1c, Digoxin , lipids , LFT, Coagulopathy , ECG, CT, MRI

Echocardiogram (transthoracic and/or transesophageal) if there is suspicion for cardioembolic source, carotid Doppler

CHAD WASH