Suspected Stroke and TIAs

 

Stroke is a clinical syndrome characterised by sudden onset of rapidly developing focal or global neurological disturbance which lasts more than 24 hours or leads to death.  Stroke can be categorised as ischaemic stroke, haemorrhagic stroke or silent stroke.  Ischaemic stroke is defined as neurological dysfunction due to ischaemia and death of brain, spinal cord, or retinal tissue following vascular occlusion or stenosis.  Haemorrhagic stroke is neurological dysfunction caused by a focal collection of blood from rupture of a blood vessel within the brain (intracerebral haemorrhagic stroke) or between the surface of the brain and the arachnoid tissues covering the brain (subarachnoid haemorrhagic stroke).  Silent stroke is identified as radiological or pathological evidence of an infarction without an attributable history of acute neurological dysfunction

A Transient ischaemic attack (TIA) is a transient (less than 24 hours) neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction.  The incidence of first-ever TIA in the UK is approximately 50/100,000 people per year

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Clinical features of stroke and TIA

Suspect a TIA if:

  • The person presents with sudden onset, focal neurological deficit which has completely resolved within 24 hours of onset and cannot be explained by another condition such as hypoglycaemia. Most TIAs are thought to resolve within 1 or 2 hours but can persist for up to 24 hours. Focal neurological deficits may include:
    • Unilateral weakness or sensory loss
    • Dysphasia
    • Ataxia, vertigo, or incoordination
    • Syncope
    • Sudden transient loss of vision in one eye (amaurosis fugax)
    • Homonymous hemianopia
    • Cranial nerve defects

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Suspect stroke if:

  • The person presents with sudden onset, focal neurological deficit which is ongoing or has persisted for longer than 24 hours and cannot be explained by another condition such as hypoglycaemia. The clinical features of stroke vary depending on causative mechanism and the area of the brain affected and may include:
    • Confusion, altered level of consciousness and coma
    • Headache – sudden, severe and unusual headache which may be associated with neck stiffness. Sentinel headache(s) may occur in the preceding weeks
    • Weakness − sudden loss of strength in the face or limbs
    • Sensory loss – paraesthesia or numbness
    • Speech problems such as dysarthria
    • Visual problems – visual loss or diplopia
    • Dizziness, vertigo or loss of balance — isolated dizziness is not usually a symptom of TIA
    • Nausea and/or vomiting
    • Specific cranial nerve deficits such as unilateral tongue weakness or Horner’s syndrome (miosis, ptosis, and facial anhidrosis)
    • Difficulty with fine motor co-ordination and gait
    • Neck or facial pain (associated with arterial dissection)

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Assessment in primary care of stroke and TIA

If stroke is suspected, clinical assessment in primary care should be as brief as possible to prevent delay in admission and treatment

  • Take a focused history asking the person and, if possible, a witness about:
    • Clinical features  including focal neurological deficits and associated symptoms such as headache, vomiting or decreased level of consciousness
    • Time of onset, activity at onset and progression of symptoms
    • Risk factors  such as cardiovascular disease (including myocardial infarction, atrial fibrillation, valvular disease, carotid stenosis, congestive heart failure, and hypertension), diabetes mellitus, hyperlipidaemia, smoking, pregnancy, recent trauma, illness or surgery, alcohol misuse and drug abuse
    • Features that may indicate an alternative diagnosis such as migraine, giant cell arteritis, preceding trauma or seizures
    • Past medical history of miscarriage or thromboembolic events suggesting inherited or acquired thrombophilia
    • Family history of stroke — family history of stroke, especially at a young age, may indicate familial hyperlipidaemia or hypercoagulability
    • Current medications such as anticoagulants

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  • Examine the person to assess:
    • Airway, breathing and circulation (ABC)
    • Vital signs including blood pressure, heart rate, oxygen saturation, and temperature
    • The cardiovascular system — look for signs of heart failure, arrhythmias (such as atrial fibrillation), murmurs, valvular heart disease, endocarditis
    • The neurological system — look for clinical signs of stroke or TIA such as unilateral weakness, visual or speech disturbance, ataxia, and nystagmus
    • The Face Arm Speech Test (FAST test) can be used for rapid assessment — it is positive if one or more of new facial weakness (asymmetry such as the mouth or eye drooping), arm weakness, or speech difficulty (such as slurring or difficulty in finding names for commonplace objects) are present
    • Carry out fundoscopy to identify intraocular haemorrhage (present in one in seven people with aneurysmal SAH)
    • General health — look for signs of trauma, coagulopathy and other risk factors

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  • Carry out appropriate investigations where this does not cause delay in transport to hospital:
    • Check blood glucose with glucometer to rule out hypoglycaemia (blood glucose less than 3.3 mmol/L)
    • Electrocardiogram (ECG) to exclude arrhythmias

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If a TIA is suspected, use the ABCD² score to estimate the risk of stroke after a suspected transient ischemic attack (TIA).  Please also refer to the EKHUFT TIA Clinic Referral Form for information

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Management of suspected acute stroke

  1. Arrange immediate emergency admission to an acute stroke facility for anyone with:
    1. Persisting neurological symptoms suspected of having acute stroke or emergent TIA
    2. Resolved neurological symptoms who has a bleeding disorder or is taking an anticoagulant — haemorrhage must be excluded
  2. Inform the hospital in advance of arrival — include details of time of onset, symptom evolution, current condition and medications (especially anticoagulants)
  3. Do not start antiplatelet treatment until haemorrhagic stroke has been ruled out by a brain scan
  4. While awaiting transfer:
    1. Monitor and manage any deterioration in clinical condition (airway, breathing and circulation [ABCs])
    2. Give supplemental oxygen to people with acute stroke if oxygen saturations are less than 95% and there are no contraindications
  5. Admission may not be appropriate/beneficial in a small number of people with a severe comorbidity. If after discussion with the person and their family/carer, a decision is made not to admit:
    1. Clearly document the reasons for this and
    2. Discuss with the specialist team possible assessment and management at home or as an out-patient within 24 hours

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Management of suspected TIA

If the person has had a suspected TIA within the last week:

  1. Give aspirin 300 mg immediately (with proton pump inhibitor cover where appropriate) and arrange urgent assessment (within 24 hours) by a specialist stroke physician unless:
    1. They have a bleeding disorder or are taking an anticoagulant as haemorrhage requires exclusion — arrange immediate admission for urgent assessment and imaging
    2. They are taking low-dose aspirin regularly — continue the current dose of aspirin until reviewed by a specialist
    3. Aspirin is contraindicated — discuss management urgently with the specialist team
  2. Be aware that a person may have ongoing focal neurological deficits despite a negative FAST test and such people must be managed as acute stroke rather than TIA
  3. Discuss the need for admission or observation urgently with a stroke specialist if the person:
    1. Has had more than one suspected TIA (sometimes known as crescendo TIA)
    2. Has a suspected cardioembolic source or severe carotid stenosis
    3. May be unable to attend for urgent review or lacks a reliable observer at home to contact emergency services if further symptoms occur

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If the person has had a suspected TIA which occurred more than a week previously:

  1. Refer for specialist assessment as soon as possible within 7 days
  2. Assess for atrial fibrillation and other arrhythmias

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Give all people with suspected TIA and their family/carers information on the recognition of stroke and TIA and advise them to call 999 immediately if symptoms occur

Advise the person not to drive until they have been seen by a specialist

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Click here to access the EKHUFT TIA Clinic Referral Form.  Referrals should be emailed to ekh-tr.TIA-Referrals@nhs.net

Use the FAST Test for a quick assessment for someone you suspect might be having a stroke:

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Use the ABCD² score to estimate the risk of stroke after a suspected transient ischemic attack (TIA).  Alternatively, refer to the table below:

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Electrocardiogram

An electrocardiogram (ECG) can usually be undertaken in primary care.  If your practice does not offer ECGs, please request an ECG from East Kent Hospitals

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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