Stroke and Transient Ischemic Attack (TIA)

• Stroke is a sudden focal disturbance of central nervous system function.
• It is primarily caused by cerebral infarction (ischemic stroke, ~85% of strokes) or intracerebral hemorrhage.
• Subarachnoid hemorrhage often presents as a sudden, severe headache, potentially with impaired consciousness or focal neurological findings.

Transient Ischemic Attack (TIA)

• TIA involves temporary stroke-like symptoms without lasting deficits.
• TIAs indicate a future stroke risk in up to one-third of individuals.
• TIAs are an emergency, requiring immediate treatment to prevent future strokes.

Stroke Warning Signs (F.A.S.T.)

• Face: Drooping?
• Arms: Can both be raised?
• Speech: Slurred or jumbled?
• Time: Call 911 immediately, it's time to get help right away.

Goals of Stroke Therapy

• Minimize brain damage.
• Prevent complications from stroke-related deficits such as pneumonia or venous thromboembolism.
• Reduce the risk of stroke recurrence.
• Restore function and minimize long-term disability.

Stroke Investigations

• Stroke evaluation is time-critical.
• Thrombolytic drugs or endovascular thrombectomy are effective within the first hours of symptom onset for ischemic strokes.
• Diagnose with clinical history, physical exam, imaging, and ancillary investigations.
• Rule out stroke mimics such as subdural hematoma, Todd's paralysis, brain abscess, herpes simplex encephalitis, hypoglycemia, brain tumor, multiple sclerosis, migraine, or conversion disorder.

History Assessment

• Note the time the patient was last seen well and the time of symptom onset (including if symptoms appeared upon waking).
• Document symptoms at onset and any neurological worsening or improvement.
• Record medications, especially the last dose of anticoagulants or antiplatelet drugs, as well as medications suggesting other relevant conditions (anticonvulsants, diabetes meds, chemotherapy, steroids).
• Ask about antecedent trauma, illness, or previous neurovascular events.
• Check for vascular comorbidity like angina, MI, heart failure, peripheral and renal vascular disease, or atrial fibrillation.
• Determine vascular disease risk factors: hypertension, smoking, diabetes mellitus, dyslipidemia, excessive alcohol, high BMI, low exercise, migraine with aura, obstructive sleep apnea, family history of vascular disease/hemostatic disorders.
• Evaluate pre-stroke cognitive and functional status, place of residence, occupation, and social supports.

Physical Examination

• Rapidly evaluate airway, breathing, and circulation, including vital signs and blood pressure.
• Localize the lesion and determine stroke severity using the NIHSS (National Institutes of Health Stroke Scale).
• Assess comorbid conditions and determine the possible cause of the stroke.

Emergency Laboratory and Radiological Tests

• Conduct CBC, INR, PTT, glucose (to rule out hypoglycemia), electrolytes, urea, creatinine, liver function tests, albumin, and TSH.
• Perform immediate neurovascular imaging to confirm diagnosis and treatment plan.
• Urgent noncontrast CT head and CT angiography (CTA) of head and neck are preferred in the hyperacute phase.
• Noncontrast CT can show changes from ischemic strokes, hemorrhagic strokes, or mimics like tumors.
• CTA can reveal intracranial occlusions or stenosis; multiphase CTA provides information on collateral circulation.
• CTA of the neck may show occlusion/stenosis in carotid, vertebral, or basilar arteries, vascular dissection, or fibromuscular dysplasia.
• Carotid stenosis patients may benefit from revascularization therapy after TIA or non-disabling stroke.
• CT perfusion can improve diagnostic yield for small ischemic strokes, rule out mimics, and aid in treatment decisions.
• MRI brain is occasionally used for extended-window thrombolysis decisions, but access is limited.
• Carotid dopplers are useful for screening carotid stenosis if CTA is unavailable.
• ECG can detect atrial fibrillation, MI, and left ventricular hypertrophy.

Other Investigations (If Indicated)

• Chest X-ray (for heart disease, lung cancer).
• Prolonged ECG monitoring (minimum 24h Holter, 2-week recommended) and echocardiography.

Stroke Unit Care

• Admission to a specialized stroke unit is recommended.
• Key aspects include monitoring, supportive care, and rehabilitation.

Monitoring

• Continuous cardiac monitoring is vital in the initial 24 hours.

Supportive Care

• Manage hypertension, hypotension, fever, and hyperglycemia.
• Avoid and manage fever as independently associated with poor outcomes.
• Treat body temperature ≥38°C with acetaminophen 650 mg PO or PR Q4H.
• O2 via nasal prongs or face mask to keep O2 saturation >90%.
• After alteplase infusion, continue IV normal saline (with or without KCl).

Interventions to Avoid

• Delay placement of nasogastric tubes, indwelling catheters, or intra-arterial pressure catheters.

Medications to Avoid

• No anticoagulant or antiplatelet drugs for 24 hours and until repeat CT scan rules out hemorrhagic transformation.
• CT brain scan after 24 hours

Anticoagulant Therapy

• Routine systemic anticoagulation is not recommended immediately after acute ischemic stroke.
• Special circumstances where anticoagulation is indicated include venous infarcts from cerebral venous sinus thrombosis or carotid artery free floating thrombus.
• Immediate anticoagulation in patients with atrial fibrillation reduces early recurrent ischemic stroke, but increases bleeding risk.
• Most physicians use ASA for patients with AF and ischemic stroke until an oral anticoagulant is started.
• For patients with AF or other cardioembolic stroke causes, long-term anticoagulation with apixaban, dabigatran, edoxaban, or rivaroxaban is preferred over warfarin due to reduced bleeding risk, no need for INR monitoring, and fewer drug interactions.
• If anticoagulation is not possible, use enteric-coated ASA 80–325 mg daily.
• Oral anticoagulant choice should consider age, renal function, health factors, drug interactions, adherence, and patient preferences.
• Dabigatran and rivaroxaban are contraindicated if ClCr < 30 mL/min.