STROKE

Question 1

Types of strokes

Answer 1

1. Transient ischaemic attack
   (TIA)
   - often described as a “mini-stroke”
2. Ischaemic stroke
3. Intracerebral haemorrhage

Question 2

Initial management of transient ischaemic stroke (TIA)?

Answer 2

1. Immediately give aspirin
   300mg
   - If Cl then alternative antiplatelet e.g. clopidogrel

Question 3

Long term management of TIA

Answer 3

1. For strokes NOT associated with AF:
   Long term treatment with Clopidogrel (unlicensed in TIA)
   - Or Dipyrimadole + Aspirin
   - Or just Dipyrimadole on its own
   - Or Aspirin on its own
   Stroke Associated with AF:
   - Anticoagulants (e.g. Warfarin)
2. Statin after 48 hours after stroke
3. BP meds to get to a target of 130/80mmHg
4. Lifestyle modifications
   - Diet, smoking cessation etc.

Question 4

If clopidogrel is contraindicated in the long term
management of TIA or ischaemic stroke, what else can the patient take?

Answer 4

1. MR Dipyrimadole + Aspirin (in combination)
   - If contraindicated to Clopidogrel ONLY
2. MR Dipyrimadole on its own
   - if contraindicated to Aspirin and Clopidogrel
3. Aspirin on its own
   - If contraindicated to Clopidogrel and MR dipyrimadole

Question 5

When would anticoagulants be recommended for long-term management of TIA or
Ischaemic stroke?

Answer 5

ONLY in patients with stroke associated with AF (or other indications)

Question 6

Initial management of Ischaemic stroke

Answer 6

1. Alteplase within 4.5 hours
2. Aspirin 300mg ASAP or within 24 hours
   - If Cl to aspirin, give Clopidogrel

Question 7

Are anticoagulants recommended in the initial management of an ischaemic stroke?

Answer 7

Not recommended
- However, parenteral anticoagulants may be recommended in patients who are symptomatic of or at high risk of VTE (DVT or PE)
- Warfarin SHOULD NOT be commenced in the acute phase of ischaemic stroke

Question 8

When would Anticoagulants be considered for
someone who had an ischaemic stroke associated with AF?

Answer 8

• They’d usually be considered after a stroke (long term management not initial)
• Therefore these patients should receive aspirin (normally for 2 weeks) before being considered for anticoagulation therapy

Question 9

If a patient is already receiving
anticoagulation for a prosthetic heart valve and they experience an ischaemic stroke, what do you do to their medication if they are at high risk of haemorrhage transformation?

Answer 9

• These patients should have their anticoagulation
  therapy stopped for 7 days and substituted with aspirin

Question 10

Long-term management of Ischaemic stroke
Stroke not associated with AF

Answer 10

1. Long term treatment with Clopidogrel
   - Or Dipyrimadole + Aspirin
   - Or just Dipyrimadole on its own
   - Or Aspirin on its own
2. Statin after 48 hours after stroke
3. Blood pressure
   medications to get to a target of 130/80mmHg
4. Lifestyle modifications
   - e.g. Diet, smoking cessation etc

Question 11

Long-term management of Ischaemic stroke
Stroke Associated with AF:

Answer 11

1. Anticoagulants (e.g. Warfarin)
2. Statin after 48 hours after stroke
3. Blood pressure
   medications to get to a target of 130/80mmHg
4. Lifestyle modifications
   - e.g. Diet, smoking cessation etc

Question 12

Does the serum-cholesterol concentration matter prior to commencing statin in the long term management of TIA or
Ischaemic stroke?

Answer 12

• NO
• You must offer statin irrespective of serum-cholesterol concentration

Question 13

Initial management of
Intracerebral haemorrhage

Answer 13

1. Surgical intervention to remove the haematoma and relieve intracranial pressure
2. BP management

Question 14

Long term management of
Intracerebral haemorrhage

Answer 14

1. Aspirin and Anticoagulants are NOT recommended
   - Specialist advice should be sought for patients with atrial fibrillation and those at a high risk of ischaemic stroke or cardiac ischaemic events
2. Blood pressure should be measured and treatment initiated where appropriate
3. AVOID STATINS