Stroke and Transient Ischemic Attack - Management and Prevention
Effective Date: April 29, 2009
Summary
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Flow Sheet
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Patient Guide
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Full Guideline in PDF
Recommendations and Topics
Scope
This guideline focuses on the management and prevention of stroke and transient ischemic attack (TIA) in adults in the ambulatory and in-patient settings.
Diagnostic Codes: Stroke-434; TIA-435; Intracerebral hemorrhage-431
It is recognized that there may be obstacles to the application of some of the recommendations supported by the literature. These include rapid access to carotid ultrasound, tissue plasminogen activator (tPA) and computed tomography (CT) scanning, as well as availability of defined stroke units and access to rehabilitation services.
I. Diagnosis: TIA or Stroke
Basic examination of all patients includes a neurological and cardiovascular exam which includes vital signs and carotid auscultation.
A TIA is a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia without evidence of acute infarction.1 Clinical symptoms typically last minutes to one hour (although they can last longer). These symptoms can include motor, sensory, speech/language, vision or cerebellar disturbances.
Differential Diagnosis for suspected TIA: In addition to TIAs, the most important and frequent causes of discrete self-limited attacks include seizures, migraine with aura, syncope and vertigo due to peripheral vestibulopathies. When assessing patient, also look for signs and symptoms of vasculitis, sinusitis, mastoiditis and meningitis for a possible differential diagnosis.
A stroke is defined as the sudden onset of focal neurological deficit resulting from either infarction or hemorrhage within the brain. Symptoms of a stroke are similar to that of TIA, however, are not temporary.
Differential Diagnosis for suspected stroke can include: seizure, migraine, brain tumor, peripheral vertigo, syncope, subdural hematoma, acute confusional state (delirium), vasculitis, drug side effect, transient global amnesia, encephalitis, functional disorder and paroxysmal symptoms of other neurological disorders including MS, upper cord lesions, radiculopathies and acute peripheral neuropathies.
A brief assessment tool for triage purposes is The Cincinnati Stroke Scale (see Appendix B).2
The average risk of stroke after a TIA is up to 3% in the first 2 days, 5% in the first week and up to 12% at 90 days.3 Recent studies have shown that a patient’s 90 day risk can be lowered from 12% to about 2% with timely (<24hr) investigation and aggressive management (see section IV).4
II. Preventing TIA/Stroke in Patients with Atrial Fibrillation
Consider all patients with atrial fibrillation for antithrombotic therapy. The decision to place a patient on long-term anticoagulation must be based on an analysis of risk and benefit, with consideration of patient values and preferences. A predisposition to falls, even when considering potential head trauma, is rarely a contraindication to the use of anticoagulants in the elderly patients with atrial fibrillation.5 Even when taking anticoagulants, the risk of subdural hematoma is so low that persons with an average risk of stroke from atrial fibrillation (5% per year in the absence of anticoagulation) must fall approximately 300 times in a year for the risks of anticoagulation to outweigh its benefits on a statistical basis.5
Establish the risk of stroke in patients with atrial fibrillation using the Cardiac failure, Hypertension, Age, Diabetes, Stroke (CHADS2) Risk Scoring System.6 The score aids in determining best treatment recommendations.
*See Appendix A for specific risks associated with treatment and non-treatment.
In diabetic patients the CHADS2 score may underestimate the risk.7
Combined use of acetylsalicylic acid (ASA) and warfarin is not recommended for stroke prevention.8 Patients with recurrent, nonprovoked episodes of (paroxsymal) atrial fibrillation/atrial flutter and those with sustained atrial fibrillation are considered to have the same risk of stroke.
Recently the oral anticoagulant dabigatran etexilate (Pradax®) has been approved for use in Canada for the prevention of stroke and systemic embolism in patients with nonvalvlular atrial fibrillation. Other similar drugs continue to undergo clinical trials. Due to the increased risk of GI bleeding and the difficulty in reversing the anticoagulant effect with dabigatran, physicians are encouraged to stay abreast of new evidence and exercise caution if using these new agents.
III. Investigations: TIA and Stroke
Consider strokes and emergent TIA’s as medical emergencies and perform investigations and treatment as soon as possible. Immediately send patients suspected of having an acute stroke to an emergency department by ambulance; most will be admitted to hospital for initial care and treatment. Consider patients with an emergent TIA for admission.
The initial investigations for emergent TIAs and a suspected acute stroke are the same. Complete investigations within 24 hours wherever possible.
Complete a carotid ultrasound or other carotid imaging within 24 hours of a carotid territory TIA.9 Carotid territory TIAs include retinal TIAs (transient monocular blindness or amaurosis fugax), hemiplegic TIAs (unilateral, motor or sensory deficits, speech or language problems – dominant hemisphere), neglect syndromes (non-dominant hemisphere) and visual field loss.
Patients diagnosed with a non-emergent TIA may be referred to an internist/neurologist or (if available) a rapid stroke assessment unit. Alternately, a physician may decide to investigate/manage patients diagnosed with a non-emergent TIA as outpatients (see below and/or outpatient TIA order sets).
Diagnostic Tests and Recommended Timing in TIA/Stroke9
**Timing is from time of onset of signs and symptoms of stroke to testing.
Note: Erythrocyte sedimentation rate (ESR), investigations for a hypercoagulable state and transesophageal echocardiography are not recommended as usual care.
IV. Management: TIA and Stroke
For physicians working in emergency departments across British Columbia, a standardized stroke/high risk TIA order set has been developed to guide investigations and treatment options. This includes a tPA order set for appropriate patients. Please see www.phsa.ca/HealthPro/EmergencyServices/ERProtocols/TIAstroke.html. An overview is provided below.
TIA Management Overview (Including Secondary Stroke Prevention)
Emergency Stroke Management Overview
Thrombolytic eligible patients should receive tPA as quickly as possible (within 4.5 hours of clearly defined symptom onset)12 Benefits of tPA are time critical; the earlier the treatment; the better the outcomes.
Acute antiplatelet therapy (for secondary stroke prevention; patient assessed individually)
After intracranial hemorrhage exclusion – for patients not given tPA an immediate one time dose of 160mg ASA is recommended.13
For patients who have been given tPA withhold antiplatelet or anticoagulant therapy for first 24hrs, after which, ASA (50-325mg) should be given daily.
Initial Management:
- Temperature (treat >38°C, as fever may contribute to further brain injury or indicate complication such as pneumonia)
- Initial neurological vital signs (Q4H)
- O2 saturation
- Blood sugar (treat hypo and hyperglycemia)
- BP (treat >220 systolic or >120 diastolic cautiously in first 48hrs; aim for reduction by 10-15% unless otherwise indicated by medical conditions)
- Heart rhythm (to assess for atrial fibrillation)
- Swallowing screen (if fails keep NPO until full swallowing assessment)
Manage stroke patients on an acute stroke or general neurological unit where possible. It is recommended that the core interdisciplinary team (medical, nursing, nutrition, occupational therapy, physiotherapy, social work and speech-language staff) assess patient within 48 hours of admission. This improves quality of life and can help prevent some of the medical complications of stroke.
Neurosurgical referral for consideration of hemicraniectomy is a treatment option in patients < 60 years of age with massive middle cerebral artery infarcts where severe cerebral edema may otherwise lead to fatal brain infarction. Surgery is generally done within the first 48 hours after stroke onset and candidates should be identified within the first 24-36hrs.14
Prevention of medical complications of stroke is an important aspect of patient care. There are multiple complications post-stroke, and the following list addresses some of the most serious or common complications.15 Early mobilization and appropriate positioning within 24 hours are associated with improved outcomes. Assess swallowing and refer to SLP/OT as appropriate.
- Serious cardiac complications - common in the first three months post-stroke16
- Depression – estimated to affect up to 1/3 of patients; assess and treat individually
- Dysphagia/malnutrition/dehydration – optimize positioning (sitting upright in chair unless contraindicated) for meals etc.; consider enteral feeding if no oral intake for >48hrs; there is a reduction in risk of aspiration pneumonia when swallowing is managed early by a speech therapist
- Decubitous ulcer formation – longlasting ulcers can develop rapidly in poorly mobile patients; focus on positional and nutritional support as well as mattress optimization
- Shoulder pain with hemiplegia – Consider referral to physiotherapist and physiatrist
- Venous thromboembolism – As pulmonary embolism accounts for 13-25% of early deaths post-stroke,17 assess patients for prophylaxis with heparin or leg compression.
Preventing a second stroke is vital in patient care. Antiplatelet therapy is indicated for all ischemic stroke patients unless there is an indication for warfarin therapy. ASA, clopidogrel and the combination of extended release dipyridamole plus ASA are all acceptable antiplatelet agents for secondary stroke prevention. Recent evidence demonstrates that clopidogrel and extended release dipyridamole plus ASA have similar efficacy in secondary stroke prevention.18 There is some evidence showing superiority of clopidogrel or dipyridamole plus ASA over ASA.19,20,21 Base the choice of therapy on patient risk, compliance, side effect profile and cost (see Appendix C: Stroke Medication Table).
The long-term use of clopidogrel plus ASA is not recommended for secondary stroke prevention,22,23 unless there is a cardiac indication. Secondary stroke prevention also includes both lifestyle measures and carotid endarterectomy as outlined in the management of TIA (section IV).
For patients who have a stroke while on antiplatelet therapy, investigate the cause to exclude high risk cardiac source and need for carotid endarterectomy and consider a change of antiplatelet therapy.
Achieve target BP (see Hypertension guideline) within 2 to 3 months (for control within 48 hours see section IV – Emergency Stroke Management Overview). The SPARCL trial showed that intensive lipid lowering therapy reduced the incidence of recurrent stroke and reduced overall cardiovascular (CV) events, but did not improve overall survival in a study that included mostly 65 year old men.11
V. Rehabilitation
Assess all persons with stroke for their rehabilitation needs. Have all patients admitted to hospital with an acute stroke assessed by a rehabilitation professional as soon as possible after admission. Have all patients with acute stroke and any residual stroke-related impairments who are not admitted to hospital undergo a comprehensive outpatient assessment for functional impairment, which includes a cognitive evaluation, screening for depression, screening of fitness to drive, as well as functional assessments for potential rehabilitation treatment preferably within 2 weeks.9
Management on a stroke rehabilitation unit improves functional outcomes that are durable for up to one year.9 Components of stroke rehabilitation are summarized below to aid the general practitioner in arranging for these services. For a detailed discussion refer to Teasell et al15 or see the Evidence-Based Review of Stroke Rehabilitation (EBRSR) website at http://www.ebrsr.com.
Referral to an interdisciplinary rehabilitation unit is appropriate when admission criteria are met: medically stable; requires 24/7 nursing care; requires at least two rehab services (physiotherapy (PT), occupational therapy (OT), speech-language pathology (SLP) or neuropsychology); can tolerate >3 hours of activity.
Ataxia, Gait Disturbance, and/or Falls – Mobilize patients within 24 hours, provided that they are alert and hemodynamically stable. Rehabilitation includes lower limb strength training to increase walking distance after stroke. Gait and/or standing post-stroke are improved with gait retraining (including task-specific), balance training, EMG-biofeedback training, and functional electrical stimulation.
Cognitive Dysfunction – Compensatory strategies (reminders, day planners) improve memory outcomes. Consider referral of patients with cognitive deficits either for neuropsychological assessment or to an OT trained in cognitive evaluation. Also, consider referral to driving simulation training/assessment programs.
Community Re-Integration – Referral to community-based support services is associated with increased social activity. Education and information also have a positive benefit.
Dexterity – Consider referral of patients with upper limb weakness or decreased coordination for physical and occupational therapy. Mental practice is associated with improved motor performance and activities of daily living performance.
Driving – Consider referral to driving simulation training/assessment programs.
Dysarthria – Consider referral of patients with impaired articulation for speech assessment and training, which is associated with improved intelligibility and communication.
Dysphasia – Intensive speech and language therapy in the acute phase, especially with severely aphasic patients, showed significant improvement in language outcomes.
Hemianopia – Consider ophthalmologist referral regarding optical prisms for patients with homonymous hemianopia as this improves visual perception scores.
Neglect – Visual scanning techniques and limb activation therapies improve neglect. Consider referral of patients with hemisensory neglect for perceptual retraining by an OT and/or neuropsychologist.
VI. Discharge to Primary Care
Communication to the attending family physician is of utmost importance at the time of hospital discharge after treatment for a TIA or Stroke. It is desirable that a discharge summary (see Appendices D and E) be sent expeditiously to the family physician and that a copy be given to the patient.
VII. Prevention
General Principles of Primary Prevention of Stroke and TIA
Prevention of Cardiovascular disease (CVD) also prevents cerebrovascular disease (see CVD and Hypertension guidelines). Lifestyle factors such as smoking cessation, increased physical activity, dietary modifications, and limited alcohol intake are recommended. Risk assessment with tools based on Framingham (see CVD guideline) and the United Kingdom Prospective Diabetes Study (UKPDS) (see Diabetes guideline) is recommended.
Not recommended: Routine use of carotid ultrasound screening in asymptomatic patients. The selective use of carotid ultrasound in patients with a carotid bruit may be considered in patients who are good surgical candidates. Carotid endarterectomy may be an option in these asymptomatic highly selected patients (carotid stenosis greater than 80%; life expectancy greater than 5 years; perioperative morbidity and mortality expected <3%).24
Rationale
Strokes are major causes of death and disability in BC. There were 8548 first ever stroke events in BC in 2007/8. Approximately 60% of these were acute ischemic, while ~30% were TIAs and ~10% were haemorrhagic events.25 A significant proportion of patients with a stroke survive; rapid assessment and treatment is considered critical to reducing disability and mortality related to stroke.
Prevention of stroke is important and therefore education and use of risk assessment tools such as Framingham and CHADS2 is encouraged. Other preventative strategies can be found in the Cardiovascular Disease, Diabetes, Obesity, and Hypertension guidelines.
Timely investigation and management of TIAs significantly reduces the chance of stroke. This guideline recommends investigation and treatment of stroke and TIAs as soon as possible (within 24-48 hrs), and secondary stroke prevention therapy would ideally be initiated in the same timeframe.
It is acknowledged that outcomes are better for patients managed in an organized stroke unit, and the development of such units is considered ideal. A stroke unit is a specialized geographically defined hospital unit dedicated to the management of stroke patients with care being provided according to a well-defined stroke care pathway. For hospitals with low annual stroke volumes, patients may be cohorted onto an identifiable ward.
References
- Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack--proposal for a new definition. N Engl J Med. 2002; 347:1713.
- Kothari RU, Pangioli A, Liu T et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Acad Emerg Med. 1999;33:373-80.
- Giles MF and Rothwell PM. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 2008;6(12):1063-72.
- Rothwell PM, Giles MF, Marquardt L, et al. Effect of urgent treatment of transient ischemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007;6:953-60.
- Claiborne JS, Rothwell PM, Nguyen-Huynh MN et al. Validation and refinement of scores to predict very early stroke risk after transient ischemic attack. Lancet. 2007;369: 283-292.
- Gage BF, Waterman AD, Shannon W, et al. Validation of Clinical Classification Schemes for Predicting Stroke. JAMA. 2001;285:2864-70.
- Stevens RJ, Kotahri V, Adler A, et al. The UKPDS risk engine: a model for the risk of coronary heart disease in type 2 diabetes (UKPDS 56). Clin Sci. 2001:671-9.
- Hart RG Benavente O and LA Pearce. Increased risk of intracranial hemorrhage when aspirin is combined with warfarin: A meta-analyis and hypothesis. Cerebrovasc Dis. 1999;9:215-217.
- Canadian Stroke Network and the Heart and Stroke Foundation of Canada: Canadian Stroke Strategy. Canadian Best Practice Recommendations for Stroke Care: 2006. Ottawa, 2006. Update 2008.
- Antithrombotic Trialist’s collaboration. Collaborative meta-analysis of randomized trial of antiplatelet therapy for prevention of death, myocardial infarction and stroke in high risk patients. BMJ 2002;324:71-86.
- Amarenco P et al. High dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006;355:549-59.
- Welch KMA, Tilley BC, Marler JR, et al. Tissue plasminogen activator for acute ischemic stroke N Eng J Med. 1995;333:1581-7.
- Adams HP, del Zoppo G, Alberts MJ et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655-711.
- Vahedi K, Hofmeijer J, Juettler E. et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;Mar;6(3):215-22.
- Teasell R, Foley N, Bhogal S, et al. An evidence-based review of stroke rehabilitation. Topics in Stroke Rehabilitation. 2003; 9(4):29-58.
- Prosser J, MacGregor L, Lees KR, et al. Predictors of early cardiac morbidity and mortality after ischemic stroke. Stroke. 2007. 38:2295-302.
- Kelly J, Rudd A, Lewis R, et al. Venous thromboembolism after stroke. Stroke. 2001:32:262-7.
- Diener HC, Sacco R, Yusuf S, et al. Rationale, design and baseline data of a randomized, double-blind, controlled trial comparing two antithrombotic regimens (a fixed-dose combination of extended-release dipyridamole plus ASA with clopidogrel) and telmisartan versus placebo in patients with strokes: the Prevention Regimen for Effectively Avoiding Second Strokes Trial (PRoFESS). Cerebrovasc Dis. 2007;23(5-6):368-80. Epub 2007 Feb 26.
- Diener HC, Darius H, Bertrand-Hardy JM, et al. Cardiac safety in the European Stroke Prevention Study 2 (ESPS2). Int J Clin Pract. 2001 Apr;55(3):162-3.
- The ESPRIT Study Group. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT). Lancet. 2006;367:1665-1673.
- A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet. 1996 Nov 16;348(9038):1329-39.
- Hart RG, Bhatt DL, Hacke W, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of stroke in patients with a history of atrial fibrillation: subgroup analysis of the CHARISMA randomized trial. Cerebrovasc Dis. 2008;25:344-347.
- Diener HC, Bogousslavsky J, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004 Jul364(9431):331-7.
- Goldstein LB, Adama R, Alberts MJ, et al. Primary prevention of ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. 2006;37:1583-1633.
- Krueger, H (H. Krueger & Associates Inc). BC Stroke Strategy. Draft data: Based on Revised Stroke Algorithm as of January 30, 2009. Acute Cerebrovascular Syndrome in B.C. First Ever Stroke Event by Type and Fiscal Year.
- Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA 2006 guideline for the management of atrial fibrillation Circulation 2006;114:700-752.
- Benavente, RG McBride O, Pearce LB. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis Annals of Intern Med. 1999;131:492-501.
- Singer DE, Albers GW, Dalen JE, et al. Antithrombotic Therapy in Atrial fibrillation. Chest 2004;126: 429-456.
- Mant J, Hobbs R, Fletcher K, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomized controlled trial. Lancet 2007;370:493-503.
- Albers GW, Dalen JE, Laupacis A, et al. Antithrombotic therapy for atrial fibrillation. Chest 2001;119:194S-206S.
- Hylek EM, Evans-Molina C, Shea C, et al. Major Hemorrhage and Tolerability of Warfarin in the First year of Therapy Among Elderly Patients With Atrial Fibrillation. Circulation. 2007;2689-2696.
- Canadian Stroke Quality of Care Expert Panel on Stroke Prevention, Canadian Stroke Network, November 2005.
Resources
List of Important Abbreviations
ASA | Acetylsalicylic acid |
CHADS2 | Cardiac failure, Hypertension, Age, Diabetes, Stroke |
CHD | Coronary heart disease |
CVD | Cardiovascular disease |
OT | Occupational therapy |
PT | Physiotherapy |
SLP | Speech-language pathology |
TIA | Transient ischemic attack |
tPA | Tissue plasminogen activator |
UKPDS | United Kingdom Prospective Diabetes Study |
Appendices
Appendix A: Stroke Risk Assessment in Atrial fibrillation: CHADS2 Score
Appendix B: Cincinnati Stroke Scale
Appendix C: Stroke Medication Table
Appendix D: TIA/Stroke Discharge Summary to Family Physicians
Appendix E: TIA Patient Discharge Instruction
Appendix F: A Guide for Patients
This guideline is based on scientific evidence current as of the Effective Date.
This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission.
The principles of the Guidelines and Protocols Advisory Committee are to:
- encourage appropriate responses to common medical situations
- recommend actions that are sufficient and efficient, neither excessive nor deficient
- permit exceptions when justified by clinical circumstances.
Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.
A mobile version of this and other guidelines is also available at www.BCGuidelines.ca
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