• Sudden onset
• Focal neurological deficit
• Vascular cause
• Lasting >24 hrs
• But note most TIAs are <15 mins
• So if it's >15 mins, can presume it's a stroke

Screening tools

• FAST for stroke
  
• But only 80% of strokes are FAST +ve
• ROSIER for stroke
• ABCD2 for patients with suspected TIA

ROSIER

• Questions:
  
• Has there been loss of consciousness or syncope?
• Yes -1
• Has there been seizure activity?
• Yes -1
• Is there a NEW ACUTE onset (or on awakening from sleep) of:
• Asymmetric facial weakness
• Yes +1
• Asymmetric arm weakness
• Yes +1
• Asymmetric leg weakness
• Yes +1
• Speech disturbance
• Yes +1
• Visual field defect
• Yes +1
• Stroke is likely if total scores are > 0
• Scores of </= 0 have a low possibility of stroke but not completely excluded

Swallow screen

• Give teaspoon of water to drink
• Listen to voice to check for aspiration
• Repeat x3
  

ABCD2

• Age
  
• >60 => 1 point
• Blood pressure
•  >140/90mmHg => 1 point
• Clinical features (max. score 2 points)
  
• Unilateral weakness => 2 points
• Speech disturbance without weakness => 1 point
• Duration
• > 60 mins => 2 points
• 10 – 60 mins => 1 point
• < 10 mins => 0 points
• Diabetes
• 1 point

• >4 => Likely TIA
  
• High risk patients (six to seven points) have an 8.1% two-day recurrent stroke risk
• Any patient with more than one episode in the last week is at a greater than 30% risk of stroke within a week
  

• Time cutoff now 4.5 hrs
• Done in 10% of ischaemic strokes
• Outcomes:
• 1/8 are cured
• 1/3 are improved
• 1/18 get worse
• Haemorrhagic transformation
  

• NO role in haemorrhagic stroke
• 2 (rare) indications:
• Malignant MCA syndrome
• => Decompression (craniectomy)
• If age <60, early (<48hrs), no significant comorbidities
• Large cerebellar infarct
  

• BAD
• 40% 1 year mortality
• High risk of early progression
• Reverse anticoagulation
• Vit K
• FFP

• Cortical features indicated large rather than small artery
• Treat fever aggressively
  
• Reduces cerebral O2 demand
• DVT prophylaxis
• TED stockings don't work
• LMW heparin might work
• HYDRATION and MOBILISATION definitely work
• Lose 2E6 brain cells per minute
• Stroke 1 month mortality:
• 25% in 2000
• 8% now at SGH
• 6% now in Germany
• Treat SBP >200 mm Hg
• Use IV LABETALOL
• Mixed alpha/beta adrenergic antagonist
• Fast onset (10-15 mins)
• BP target post-stroke: <130/80
• Avoid statins after haemorrhagic stroke unless strongly indicated
• Particularly if they have inadequately controlled hypertension
• Small increased risk of further haemorrhagic stroke
• May be offset by benefit (ischaemic stroke/CHD)
• But seek advice!