How to approach a patient with suspected TIA/ Stroke in ED

How to approach a patient with suspected TIA/ Stroke in ED

We know that 10-15% of patient with TIA end up having stroke with up to 50% of these occurring within 48 hours of presentation. 

Time constraint approach

Within 10-15 minutes or less:

• Give Triage Priority with suspected symptoms
• Check vital signs including Bedside glucose determination to rapidly rule out and treat hypoglycemia « 2.8mmoI/L

• Two large caliber(16 gauge or larger) I.V Cannula
• ECG and Cardiac monitoring (look for:::
• A fib (ask about TIA symptoms before thinking to cardiovert patient)
• Crochetage sign (notch in apex of R wave) seen in II, III, aVF is highly specific sign of the presence of a PFO or ASD
• Complete history taking and document time patient last known well 
• Complete neurological examination to exclude other differential
• Complete lab works including CBC, coagulation profile, LFT, U/E & cardiac markers
• NPO

Diagnosis of TIA/Stroke pearls::

• TIA may present with negative symptoms (lack of function), loss of sensory, motor, vision, speech. Common Differentials like Migraine may present with positive symptoms like pain, scotomas, etc.
• Examination of eyes is very important, give regard ti visual field deficits, look for retinal pathology, patients having retinal TIAs need to be worked up same as stroke
• Early signs of stroke on plain CT head (not contraindications to lytic): blurring in basal ganglia, internal capsule or insula; loss of the grey-white junction clarity, sulcal effacement (gyri edema), hyperdense MCA sign has a large differential so exercise caution in ruling in stroke based solely on hyperdense MCA sign 

Within 25 to 30 Min:

• Activate Stoke Team (if available in hospital) and document the time
• Urgent Non Contrast CT Brain
• Chest X ray
• Within 24 hours CT or MRI and vascular imaging (CTA or MRA) from aortic arch to vertex

Within 60min or less:

• Aspirin 324 mg PO (if no hemorrhage in CT brain)
• Labetalol 20mg I.V. 
• If blood pressure above 220/120
• Blood pressure above 185/110 & the patient is eligible for IV tPA (see down)
• Hypertensive Encephalopathy
• Aortic Dissection or MI


• If Hemorrhagic Stroke:
• ED MD secondary survey 
• BP control
• Consider PT/PTT reversal
• Consult Neurosurgery
• NIHSS

• If Ischemic Stroke & within the eligibility: (4.5 hours window) 
• IV tPA (within 60 min) from ERarrival if:
• No contraindications of tPA and within tPA window (4.5 hours) from last well known
• Obtain pre and post tPA NIHSS
• Admit to ICU for 24 hours after tPA infusion.

RISK STRATIFICATION SCORING::

Risk 
stratification 
is 
essential:
 CHADS 
Score 
(CHF,
HTN,
Age>75,
DM,
previous
Stroke)
≥2
 should
 get
 warfarin 
given 
the 
benefits
–
70% 
risk 
reduction 
in 
embolic 
events
–
and 
the 
risks
–
moderate
 bleeds
(10‐12%),
or 
severe
 bleeds
(2‐3%) 
requiring 
hospitalization, 
transfusion, 
or
 causing 
ICH.

Remember
 that 
older 
age 
means 
higher 
risk 
for 
embolic 
event, So older patient will actually get more benefit from warfarin.

INCLUSION & EXCLUSION CRITERIA FOR THROMBOLYTIC THERAPY: 

Administration of Thrombolytic Therapy

Inclusion Criteria: 
Patients presenting within 3 hours of symptoms onset or last seen normal

• Diagnosis of an ischemic stroke causing measurable neurological deficit
• Onset of symptoms is known and is within (3 - 4.5 hours) of the beginning of treatment
• The patient is 18 years age or older

Exclusion Criteria:
Patients presenting within 3 hours

• Significant head trauma or prior stroke within past 3 months
• Symptoms suggest subarachnoid hemorrhage
• Arterial puncture at a non-compressible site in the previous 7 days
• History of previous intracranial hemorrhage
• Intracranial neoplasm, arteriovenous malformation or aneurysm
• Recent intracranial or intraspinal surgery
• Elevated blood pressure that remains higher than 185 mm HG systolic or above 110 diastolic
• Active internal bleeding
• Acute bleeding diathesis, including:
- Platelet count below 100,000/mm3
- Heparin received within last 48 hours that leads to an elevated aPIT
- Current use of Warfarin with INR above 1.7 or PT longer than 15 seconds
- Current use of direct thrombin inhibitors or direct factor with elevated sensitive laboratory tests (such as aPIT)
- INR, platelet count and ecarin clotting time; IT or approximate factor Xa activity assays)
• Blood glucose less than 50 mg/dL
• CT-proven area of multilobar infarct larger than 1/3 total cerebral hemisphere

Relative Exclusion Criteria:
Patients presenting within 3 hours

• Minor or rapidly improving stroke symptoms
• Pregnancy
• Seizure at the onset with postictal residual neurologic impairments
• Major surgery or serious trauma within previous 14 days
• Recent gastrointestinal or urinary tract bleeding in the past 21 days
• Acute MI in the past 3 months.

Inclusion Criteria:
Patients presenting 3 to 4.5 hours from symptoms onset or last seen normal

• Diagnosis of an ischemic stroke causing a measurable neurologic deficit

Relative Exclusion Criteria:
Patients presenting 3 to 4.5 hours from symptoms onset or last seen normal

• Age above 80 years
• Severe stroke with NIHSS score of more than 25
• Patients taking an oral anticoagulant regardless of INR
• Patients with history of both diabetes and prior ischemic stroke

NIH STROKE SCALE SCORING

Disclaimer::
This approach doesn't replace the medical guidelines in any way. Please follow your local guidelines accordingly.