This document provides an overview of stroke, including definitions of stroke and transient ischemic attack (TIA), typical presentation of a patient with stroke, relevant history taking and examination, initial investigations and treatment. Key points covered include causes of stroke, risk factors, classification systems, thrombolysis criteria and contraindications, complications, and secondary prevention strategies including for patients with atrial fibrillation.

1. Stroke
Mark Hall
Clinical Teaching Fellow
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2. Objectives
• Revise definitions of stroke and TIA
• Discuss how a patient with a stroke
presents and stroke mimics
• Elicit a relevant history from a patient
with suspected stroke
• Examine a patient with suspected stroke
• Revise initial investigation and treatment
of a patient with suspected stroke
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3. What is a stroke?
“…a clinical syndrome consisting of rapidly
developing clinical signs of focal (or
global in case of coma) disturbance of
cerebral function lasting more than 24
hours or leading to death with no
apparent cause other than a vascular
origin.”
Hatano S. Experience from a multicentre stroke register: a preliminary
report. Bulletin of the World Health Organisation 1976;54(5):541–553.
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4. What is a TIA?
“A transient ischaemic attack (TIA) is
defined as stroke symptoms and signs
that resolve within 24 hours.”
Hatano S. Experience from a multicentre stroke register: a preliminary report.
Bulletin of the World Health Organisation 1976;54(5):541–553.
The National Collaborating Centre for Chronic Conditions National clinical
guideline for diagnosis and initial management of acute stroke and
transient ischaemic attack (TIA). Royal College of Physicians London 2008
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5. Stroke
• Stroke is the third commonest cause of
death and the most frequent cause of
severe adult disability in Scotland
• High mortality (10 - 20% at 30 days)
• 50% of survivors are dependent
• 10% will have a recurrence within 1 year
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6. Stroke - Causes
• Causes of stroke
– Ischaemic (80 %)
• Embolic (AF, embolus from metallic valve, carotid artery
plaque)
• Atherosclerotic
• Prothrombotic state
– Haemorrhagic (10-20 %)
• Hypertension
• Cerebral artery aneurysm
• Over-anticoagulation
• Bleeding diathesis
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7. Stroke – Risk Factors
• Risk factors
– Age
– Smoking
– Family history
– Hypertension
– Diabetes
– Hyperlipidaemia
– AF, prothrombotic state
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8. The Brain
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9. How might a person with a stroke
present?
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10. How might a person with a stroke
present?
• Arm weakness
• Leg weakness
• Facial Droop
• Slurred speech
• Unable to get the right words out
• Uncomprehending
• Falls
• Fractures
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11. History
(who gives the history?)
• Onset
• Symptoms
• Time course
• Risk factors
• Past Medical History
• Medications
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12. Examination
• Pronator drift •Cranial Nerves
• Tone •Gait
• Power •Visual Fields
• Reflexes •Speech
• Coordination •Comprehension
•Swallow
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13. Which Pattern?
Upper Motor Neuron Lower Motor Neuron
• Muscle weakness • Muscle weakness
• Increased Tone • Fasciculations
• Increased Reflexes • Decreased tone
• Up going plantar - • Decreased reflexes
Babinski • Absent Babinski
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15. Clinical assessment
• Hemianopias
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16. • Expressive dysphasia
– ‘telegraphic speech’
• Receptive dysphasia
– Fluent meaningless speech
– Neologisms
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22. Classification of Stroke
• TACS (Total anterior circulation stroke)
– A combination of:
• New higher cerebral dysfunction (eg: dysphasia)
• Homonymous visual field defect
• Motor and / or sensory deficit of (at least 2 of) face / arm / leg
• PACS (partial anterior circulation stroke)
– 2 or 3 of TACS
– OR New higher cerebral dysfunction alone (eg: dysphasia)
– OR motor or sensory deficit more restricted than for LACS
• LACS (Lacunar anterior circulation stroke)
– Pure motor
• Unilateral weakness (2 or 3 of face / arm / leg)
– Pure sensory
• Unilateral sensory disturbance (2 or 3 of face / arm / leg)
– Sensory motor (combination of above)
– Ataxic hemiparesis
• Hemiparesis with ipselateral cerebellar ataxia
• POCS (posterior circulation stroke)
– Cerebellar dysfunction
– Brainstem signs
– Occipital lobe dysfunction
– Bilateral weakness / sensory dysfunction
– Ipselateral CN palsy with contralateral weakness (crossed signs)
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23. Investigations
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24. Investigations
• Bloods
• ECG
• CXR
• CT Brain
• (echocardiogram)
• (carotid doppler)
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26. Current guidance - evaluation
• NIHSS (National Institute of Health Stroke Scale)
– To evaluate neurological status / predict severity of Stroke
– Complete hemiparesis with dysphasia, dysarthria, hemianopia
and sensory loss scores 25+ (often cut off point for
thrombolysis)
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27. Current guidance – Acute Stroke
Care
• NICE pathway - Acute stroke
• SIGN guidance 108
• Perform brain imaging (CT scan) immediately if:
– Indications for thrombolysis
– Possible haemorrhage / RICP
• On anticoagulant treatment
• Known bleeding tendency
• Reduced consciousness (GCS <13)
• Unexplained progressive or fluctuating symptoms
• Papilloedema, neck stiffness or fever
• Severe headache at onset of stroke symptoms
• Brainstem or cerebellar stroke
• Otherwise imaging ASAP (within 24 hours)
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28. Current guidance – Acute Stroke
Care
• Criteria for thrombolysis
– No sign of haemorrhage on immediate brain
imaging
– Definite onset within 4.5 hours
– No contraindications
• These may be relative depending on clinical
picture – discuss with stroke team on call
• Acute stroke unit admission
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29. Contraindications to thrombolysis
• Bleeding
– Known history of or suspected intracranial haemorrhage
– Anticoagulants (except warfarin if INR<1.4)
– Treated with LMW Heparin within last 48 hours & APTT is still raised
– Platelet count of below 100,000/mm3
– Known haemorrhagic diathesis
– Severe liver disease
– GI / Menstrual / urinary bleeding during the last 21 days
– Major surgery or significant trauma in last 14 day
• Physical status
– Seizure at onset of stroke
– BP > 185 mmHg systolic (or diastolic > 110 mmHg)
– BM < 2.8 or > 22 mmol/l
– Bacterial Endocarditis / Pericarditis
– Symptoms rapidly improving before thrombolysis
– NIH Stroke Scale <5 (very minor neurological deficit) or > 25 (very severe)
• Other
– Head injury within the last 3/12
– Other stroke within last 3/12
– History of stroke PLUS diabetes
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30. Stroke mimics
• Seizure
• Hypoglycaemia
• Electrolyte disturbance (Na+, Ca++)
• Subdural haematoma
• Brain tumour
• Lower Motor Neurone Lesion
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31. Treatment-ischaemic/embolic
• Consider thrombolysis
• Aspirin 300mg od for 2 weeks then
clopidogrel 75mg od
• Statin
• Surgery?
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32. Treatment-haemorrhagic
• Reverse anticoagulation
• Surgery is rarely needed
• Usually for hydrocephalus
• Monitor for neurological deterioration
• Re-image
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33. Complications of stroke
• Pressure sores
• Pneumonia (including aspiration)
• DVT / PE
• UTI
• Incontinence
• Depression
• Seizures
• Fatigue
• Spasticity / contractures
• Shoulder pain
• Impact on relationships / driving / work /
independence
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34. Transient Ischaemic Attack
• TIA
– Sudden onset neurological dysfunction lasting < 24
hours
– Often lasts for minutes
– No lasting structural neurological damage
– Aetiology as for stroke
– May predict future stroke
• Scoring scales for likelihood
• Secondary prevention
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35. •
TIA – risk stratification a TIA
ABCD2 algorithm predicts very early risk of stroke following
– A – Age
• >60 =1
– B – Blood pressure
• >140/90 mmHg = 1
– C – Clinical features of the TIA
• Unilateral weakness = 2
• Speech disturbance without weakness = 1
– D1 – Duration of symptoms
• > 60 min = 2
• 10-59 min = 1
• <10 min = 0
– D2 – Diabetes
• Diagnosed with diabetes = 1
• The corresponding 2 day risks for a subsequent stroke are
– ABCD2 scores
• 0-3 = 1% (low risk, Start Aspirin 300mg OD and refer to TIA clinic)
• 4-5 = 4% (High risk, consider admission. Aspirin 300mg OD, urgent TIA
clinic)
• 6-7 = 8% (As above)
pathways forSC et al (2007)learning283-292
Johnston clinical Lancet, 369,

36. TIA - management
• Start Aspirin 300mg OD
• Depending on ABCD2
– Admit to hospital
– Refer to TIA clinic (within 24 hours or 1
week)
• Secondary prevention as per stroke
• Consider Anticoagulation if in AF
– Based on CHADS2VASC score
• Calculates stroke risk for patients with AF
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37. AF – risk stratification
• CHADS2 VASc Score
– Congestive Cardiac Failure = 1
– Hypertension = 1
– Age 65-74 years = 1
– Age > 75 years = 2
– Diabetes = 1
– Stroke / TIA history = 2
– Vascular Disease (PVD or IHD) = 1
– Sex (Female) = 1
– Maximum Score 9 points
• 0 = Low risk, no need to anticoagulant
• 1 = Low – Moderate risk, consider oral anticoagulation or Aspirin
• 2 = High risk, consider oral anticoagulation
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38. Summary
• Act FAST
• Think of thrombolysis early
• Focus on onset (sudden/stuttering)
• Ask about progress
• Ask yourself
– Have they had a stroke?
– If they have had a stroke, why?
• Examine carefully – look for patterns
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39. Summary
• Remember to assess swallow and act
accordingly
• Communication is vital – take time to do it well
• Haemorrhage
– reverse anticoagulation
– think about hydrocephalus
• Infarct
– Aspirin 300mg od for 2 weeks then clopidogrel
75mg od
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40. Further Reading
• Hacke, W., Kaste, M., Bluhmki, E., Brozman, M., Dávalos, A., Guidetti, D., Larrue,
V., Lees, K., Medeghri, Z., Machnig, T., Schneider, D., von Kummer, R., Wahlgren,
N., Toni, D. and the ECASS Investigators (2008) Thrombolysis with Alteplase 3 to
4.5 Hours after Acute Ischemic Stroke. The New England Journal of
Medicine,359(13), 1317-1329.
• SIGN guideline 118 http://www.sign.ac.uk/pdf/sign118.pdf
• SIGN guideline 108 http://www.sign.ac.uk/pdf/sign108.pdf
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