Tranaient ischemic attack

• Patients who had a sudden onset transient episode of neurological dysfunction caused by focal cerebral ischaemia of brain, retina and spinal cord are deemed to have a transient ischemic attack (TIA).
• MRI brain with DWI is sensitive in detecting minor infarcts that may mimic clinical TIA.

Antithrombotic therapy in TIA

• Calculate ABCD2 score:
  • If ABCD2 < 4, start Clopidogrel alone for low risk TIA.
  • If ABCD2 >= 4, start dual antiplatelet therapy (Aspirin and Clopidogrel) for high risk TIA.
• Aspirin loading dose of 300 mg is given and continued as 75 mg daily.
• Clopidogrel loading dose of 300 mg is given and continued as 75 mg daily.
• If dual antiplatelets are started they are continued for 3 weeks and then converted to a single antiplatelet.
• A proton pump inhibitor should be co-prescribed with dual antiplatelets therapy to reduce the risk of gastrointestinal bleeding.
• If the patient is already on anticoagulation for an appropriate indication, continue anticoagulation.
• If there is any new indication for anticoagulation (atrial fibrillation, ventricular thrombus, mechanical heart valve, and treatment of venous thromboembolism), start anticoagulation.

Statin therapy in TIA

• A high intensity stating should be started immediately; Atorvastatin 40 – 80 mg daily.

Other management in TIA

• Elevated blood pressure should be corrected gradually, aiming for a goal of ≤140/90 mmHg.
• Diabetics should achieve glycaemic control at earliest possible and should maintain HbA1C ≦7.0%
• Patients with carotid territory TIA should be screened for a carotid source of thromboembolism and patients with symptomatic, carotid stenosis between 50 – 99% should be offered carotid endarterectomy as early as possible, not later than 2 weeks after the onset of symptoms.
• Patients who are unsuitable for open surgery (e.g. inaccessible carotid bifurcation, re-stenosis following endarterectomy, radiotherapy associated carotid stenosis) should be considered for carotid angioplasty and stenting.
• Patient should be screened for a cardiac source of thromboembolism and if found, should be recommended anticoagulation treatment if the benefit outweighs the risk of major haemorrhage.
• A healthy lifestyle such as adequate physical activity, weight loss if overweight, screening and treatment for sleep apnoea, nutritional counselling, smoking cessation, and abstinence of alcohol consumption should be promoted.

Acute stroke

Stabilization

• Airway
  • Assess for airway patency.
  • Suctioning, positioning, airway support and ventilatory assistance.
• Breathing
  • Give oxygen in SpO2 < 94%.
• Circulation
  • Peripheral IV access should be established

Assessment

• Take a quick history
  • Time of onset of symptoms
  • Rapidity of onset of symptoms (sudden or gradual)
• Focused examination
  • Face, arm and leg weakness
  • Impairment of speech/ mental status/ higher cortical function/ vision
• Stroke severity assessment using the National Institute of Health Stroke Scale (NIHSS)
• Assess for swallowing
• Check CBS and send blood for FBC, INE and APTT

Imaging

• Patients who are stable are immediately sent to CT room for NCCT brain.

Acute ischaemic stroke (AIS)

Intravenous thrombolysis and mechanical thrombectomy

• Assess for the eligibility of intravenous thrombolysis
  • If age 18 – 80 years, within 4.5 hours, and if > 80 years, within 3 hours preferably
  • Exclude the contraindication for intravenous thrombolysis
• If eligible, intravenous thrombolysis can be done with either Alteplase or Tenectaplase.
  • Alteplase (rtPA) 0.9mg/ kg (max 90 mg). 10% of the calculated dose is to be given as an IV bolus over 1 minute and the remainder as an infusion over 1 hour.
  • Tenecteplase 0.25 mg/ Kg (max 25mg) IV bolus over 5 seconds.
• Patients suspected to have large vessel occlusion with NIHSS > 6 who are potentially eligible for endovascular treatment, should undergo CTA.
• Endovascular treatment is recommended within 6 hours of stroke onset in patients with proximal intracranial large vessel occlusions confirmed on CTA.

Antithrombotic treatment of AIS

• If the the patient is eligible for intravenous thrombolysis or mechanical thrombectomy, withold antiplatelets and anticoagulants for at least 24 hours after intravenous thrombolysis.
• Patients who received thrombolysis should be commenced on a single antiplatelet agent 24 hours after thrombolysis.
• If the patient is not eligible for intravenous thrombolysis or mechanical thrombectomy, start antiplatelet therapy as soon as possible using NIHSS score to guide antiplatelet selection.
  • If NIHSS =< 5, start dual antiplatelet therapy.
  • If NIHSS > 5, start Aspirin alone
• If dual antiplatelets are started they are continued for 3 weeks and convert to a single antiplatelet.

Management of blood pressure in AIS

• Correction of hypotension and hypovolemia is recommended to maintain adequate systemic and cerebral perfusion.
• In patients eligible for thrombolysis, the blood pressure (BP) should be <180/105 mmHg prior to and for 24 hours after following thrombolysis. If the BP is >185/ 110, it should be reduced using intravenous antihypertensives (preferably, labetalol; alternatives – hydralazine or sodium nitroprusside).
• In patients not eligible for thrombolysis, the BP should be reduced only if it exceeds 220/ 120 mmHg or in the presence of a hypertensive emergency. BP reduction should be gradual (not exceeding a reduction of >15% in the first 24 hours).

Temperature management

• If hyperthermic, treat with an antipyretic and manage the source of hyperthermia.

Glycaemic control

• Maintain plasma glucose between 140 – 180 mg/dL.

Screening for dysphagia

• Patients should be screened using a validated swallowing screening tool for swallowing difficulties to determine the aspiration risk prior to allowing the oral intake of food, fluids or medication as soon as possible, at least within first 24 hours after admission. Patient should not be given anything orally until the swallowing assessment is carried out.
• Patients who have dysphagia should have a nasogastric tube inserted to allow hydration and nutrition.
• A patient’s clinical status can change in the first few hours following the stroke; therefore, patients should be closely monitored for changes in swallowing ability following initial screening.
• If the inability to swallow safely persists for more than 2 weeks, a percutaneous gastrotomy tube should be considered.

Guidance on urinary catheterization

• The use of chronic indwelling urethral catheters should generally be avoided due to the risk of urinary tract infections.
• Insertion of an indwelling urethral catheter could be considered for patients undergoing EVT but should not delay achieving reperfusion. The need for retaining the catheter should be reconsidered after the end of the EVT procedure, and it should be discontinued as soon as the patient can be expected to resume voiding on their own.
• Insertion of an indwelling urethral catheter is not routinely needed prior to intravenous thrombolysis unless the patient is acutely retaining urine and is unable to void. If inserted for patient-specific reasons, it should not delay acute treatment.
• If used, indwelling catheters should be assessed daily and removed as soon as possible.
• Fluid status and urinary retention should be assessed as part of vital sign assessments.

Prophylaxis for deep vein thrombosis (DVT)

• In addition to maintaining good hydration and treatment with aspirin, intermittent pneumatic compression is recommended to prevent DVT for immobile patients with AIS, unless contraindicated.

Screening for depression

• Depression is not uncommon following a stroke. Antidepressants are recommended for depression following stroke.

Decompressive hemicraniectomy

• Decompressive hemicraniectomy carried out within 48 hours of symptom onset reduces mortality and disability in patients presenting with a middle cerebral artery (MCA) infarction fulfilling all the following criteria:
  • Pre-stroke modified Rankin scale score < 2
  • Clinical deficit indicating the infarction is in the MCA territory
  • NIHSS score >15
  • A decrease in the level of consciousness to a score of 1 or more on item 1a of the NIHSS
  • CT brain showing an infarct of at least 50% of the MCA territory

Rehabilitation

• Patients should receive multidisciplinary team stroke rehabilitation at an intensity that the patient can tolerate and benefit from.

References

1. UpToDate. Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack. Updated Jan 2024.
2. National Guidelines for Management of Stroke in Sri Lanka. Ministry of Health of Sri Lanka. 2023.