Transient Ischemic Attack and Acute Ischemic Stroke

Info

🌱 來自: Huppert’s Notes

Transient Ischemic Attack and Acute Ischemic Stroke🚧 施工中

Transient Ischemic Attack and Acute Ischemic Stroke

Transient ischemic attack (TIA)

•   Definition: Transient neurologic deficit that lasts <24 hr with a normal brain MRI

•   Management: ABCD2 score (Age, BP, Clinical presentation, Duration, DM2) helps risk stratify patients. If score >3, consider hospitalization. Workup same as for stroke (see below).

Acute ischemic stroke

•   Etiology:

-   Thrombotic: Rupture of atherosclerotic plaque

-   Embolic: Cardioembolic event due to atrial fibrillation, cardiac thrombus, aortic atheroma, or paradoxical emboli from an intracardiac shunt

-   Lacunar: Due to lipohyalinosis of small vessels which occurs in the setting of hypertension and/or diabetes

-   Arterial dissection: Arterial wall compromise leading to thrombus formation. Common cause of stroke in young people in the setting of trauma, neck manipulation (e.g., during a chiropractor visit), connective tissue disease

•   Symptoms: See Table 12.4. Symptoms depend on the vascular territory involved and thus which anatomic areas are affected.

TABLE 12.4 • Vascular Territories and Corresponding Symptoms/Deficits If Injury

•   Diagnosis:

-   If concern for a stroke, call a code stroke. If a code stroke is activated, simultaneously:

•   Perform a complete neurologic exam and document any new neurologic deficits

•   Establish the “time last seen normal” (i.e., time when the patient was last seen by another person at their neurologic baseline; not the same as when the patient was found to be symptomatic)

•   Check vital signs and point of care glucose

•   Order CT stroke protocol

•   Review medication list. If the patient is confused, in particular check for administration of any delirium-inducing medications. Determine whether the patient is on any anticoagulants as an inpatient or outpatient

•   Establish whether the patient has a history of stroke (and subsequent deficits) or seizure

•   Determine if the patient underwent any recent invasive procedures/surgeries

-   Imaging:

•   CT stroke protocol (CT brain w/o contrast, CT angiogram head/neck, CT perfusion) to rule out hemorrhage, evaluate for early signs of ischemia, and diagnose large vessel occlusion

•   MRI brain w/o contrast: Ischemia is bright on DWI and dark on ADC sequences

•   Treatment:

-   Tissue plasminogen activator (tPA): If no contraindications for administration and last seen normal time **<**4.5 hours prior

-   Consider thromectomy if large vessel occlusion

•   Work-up: Telemetry/cardiac event monitor, TTE (with bubble if age < 60 yr), carotid ultrasound (for anterior circulation strokes if no CTA neck), fasting lipid panel, HgA1c

•   Secondary prevention:

-   Lifestyle changes (exercise, diet)

-   Management of risk factors (e.g., hypertension, hyperlipidemia, diabetes, smoking cessation)

-   Antiaggregant/anticoagulation:

•   Aspirin

•   If stroke while on aspirin, consider switching to clopidogrel

•   If acute stroke with minor deficits, consider aspirin + clopidogrel (clopidogrel for 21 days per the POINT trial N Eng J Med 2018 or clopidogrel for 3 months per the SAMPRISS N Eng J Med 2015)

•   If atrial fibrillation/valvular disease, recommend anticoagulation