Transient Ischemic Attack & Stroke

Etiology  Classified as ischemic (75% of which embolic, 25% are thrombotic) or haemorrhagic
 Embolic:
 Cardioembolic
 AF
 Dilated cardiomyopathy
 Mural thrombus
 Bacterial endocarditis
 Prosthetic valve thrombosis  paradoxical embolus i.e. from venous to arterial circulation (ASD, PFO)
 Artery to artery – i.e. thrombus formation on atherosclerotic plaques embolises to intracranial arteries
 Aortic arch
 Carotid bifurcation
 Carotid or vertebral artery dissection
 Thrombotic: Acute thrombosis of large to medium vessels due to atherosclerotic disease
 Small vessel stroke (Lacunar stroke – atherothrombotic or lipohyalonotic occlusion of small penetrating arteries at subcortical
location e.g. basal ganglia, thalamus, internal capsule)
 Most commonly due to HTN/DM
 Miscellaneous causes
 Hypercoagulable disorders
 Giant cell arteritis – temporal arteritis, Takayasu arteritis
 Wegener’s granulomatosis
 Sickle cell disease
 Venous sinus thrombosis
 Infective vasculitis – neurovascular syphilis, bacterial and fungal meningitis, tuberculous meningitis
 Moyamoya disease
 Drug related

Clinical Haemorrhagic Thrombotic ischemic Embolic ischemic

features
Onset Sudden Gradual (Stuttering course) Sudden
Conscious Often decreased Often normal Often normal
level
Headache + +/- Usu. -
N/v ++ Usu. - Usu. -
PMHx HTN Similar factors for CAD AF
On anticoagulants
Coagulopathies
Vitals Usu. severe HTN Mod. to normal BP Variable BP
Clinical Stroke syndromes by vascular territory
manifestation Artery Deficits
ICA  Amaurosis fugax (transient monocular blindness)
Opthalmic  Due to cholesterol emboli called Hollenhorst plaques lodged in retinal artery
ACA Hemiplegia (leg > arm)
Abulia – inability to act decisively
Urinary incontinence
Primitive reflexes

MCA Hemiplegia (face/arm>leg)

Hemianesthesia
Homonymous hemianopia
Apahsia – If dominant hemisphere affected (superior division  expressive apahsia; inferior division 
receptive aphasia) and If non-dominant hemisphere affected apraxia and neglect
PCA Macular-sparing homonymous hemianopia
Alexia w/o agraphia (?), Thalamic sx w contralateral hemisensory disturbance
Vertebral, Wallenberg syndrome –
PICA Numbness of ipsilateral face and contralateral limbs, diplopia, dysarthria, ipsilateral Horner’s
Basilar Pupillary changes (midbrain stroke – dilated, pontine stroke – pinpoint)
Long tract signs – quadriplegia, sensory loss,
Cranial nerve abnormalities
Cerebellar dysfunction
Top of basilar stroke  locked in syndrome
Cerebellar Vertigo, Nausea/vomiting
Diplopia, Nystagmus
Dysarthria
Ipsilateral limb ataxia
 Lacunar 5 major syndromes:
(arterioles) 1. Pure hemiplegia
2. Pure hemianesthesia
3. Ataxic hemiparesis
4. Dysarthria + clumsy hand
5. Mixed sensorimotor

Physical Exam  Cardio: murmurs, carotid bruits

 Neuro: Cranial nerves exam , offer cerebellar and UL and LL neuro exam
 NIH stroke scale
Transient  Sudden deficit due to cerebral ischemia
Ishcemic Attack  < 24 hr, though most resolve within 1 hr
 TIAs generally have negative sensation e.g. loss of sensation or power and they rarely cause positive symptoms e.g. tingling,
aura, twitching of muscles
 The ABCD2 score is a clinical score to predict stroke risk within the 1st 2 days folllowing a TIA
A – Age > 60y/o (+1)
B – BP > 140/90 (+1)
C – Clinical features unilateral weakness (+2), speech impairment w/o weakness (+1)
D – Duration of symptoms 60min or more (+2), 10 – 59 min (+1)
D – DM (+1)
 The risk of a subsequent stroke falls to 2% by 1 week
Management
1. CBG – This is the only assessment that should precede the initiation of IV rtpa
2. Thrombolysis with rTPA – 0.9mg/kg max dose 90mg, with 10% given as a bolus dose over 1 min, remaining given over 60 min
 Recommended for selected patients with 3 – 4.5 hours of stroke symptom onset
 Absolute contraindications:
 Time of onset > 3 – 4.5hrs
 Acute intracranial haemorrhage or Previous intracranial haemorrhage or Subarachnoid Haemorrhage
 Within the last 3 months: Ischemic stroke, head trauma, intracranial or spinal surgery
 BP > 185/110
 GI/GU bleed in last 3 weeks
 Coagulopathy – INR > 1.7, Platelets < 100,000
 Treatment dose LMWH within 24 hours or DOAC use within last 48 hours
 Glucose < 50mg/dL
 Non-compressible arterial puncture within the last 1 week
 Relative contraindications:
 Minor deficits – Non-disabling
 Seizure at onset
 MI within last 3 months – consider initial tPA for concurrent MI
 Pregnancy
 Stroke mimics

3. 12-lead ECG and cardiac enzymes should not delay the administration of IV rtpa, FBC, RP, PT/PTT
4. Stat non-contrast CT brain – very sensitive in detecting acute cerebral haemorrhages but relatively insensitive to acute ischemia, particularly whenL
 Area of stroke is < 5mm in diameter or
 Located in the region of the brainstem or
 If stroke < 12 hours old
5. KIV MRI Brain
6. Preferably CT brain angiogram Head and Neck if no CI and endovascular intervention indicated
Mgt of Ischemic stroke
1.
2. Aspirin 300mg – start within 24 – 48 hrs
3. Endovascular thrombectomy – if anterior circulation proximal cutoff (mostly MCA) and within 6hrs of symptom onset
Workup to  Cardiac: Holter to assess for AF
assess  Extracranial vessel imaging: Carotid u/s and Doppler
modifiable risk  Lipids, HbA1c, TSH, homocysteine
factors
Secondary 1. Antiplatelet therapy
stroke 
prevention 2. Anticoagulation therapy for patients with cardioembolic stroke secondary to atrial fibrillation
 Dabigatran vs Warfarin: Comparable efficacy but warfarin has an increased bleeding risk

3. Blood pressure control
4. Surgical endarterectomy for severe carotid artery stenosis has successfully reduced the long-term risk of stroke in both symptomatic
and asymptomatic patients