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Introduction

Cerebrovascular accident (CVA) and Transient Ischaemic Attacks (TIA) both occur when the blood supply to the brain is interrupted. The difference occurs in the definition of the timing; a stroke produces symptoms that last for at least 24 hours, whereas symptoms produced by a TIA are transient (less than 24 hours), usually resolving fully within 30 minutes.

Symptoms

  • Weakness
    • Onset and duration of weakness?
    • Location of the weakness? (e.g. lower limb, upper limb, face)
    • Severity of the weakness? (e.g. subtle, struggling with holding a cup, completely flaccid)
    • Mobility: Is the patient still able to independently mobilise?
    • Is the weakness getting worse or better?
  • Sensory disturbance
    • Onset and duration of sensory disturbance?
    • Location of the sensory disturbance?
    • Severity of sensory disturbance? (e.g. completely numb, tingling, feeling slightly different)
  • Visual disturbance
    • Onset and duration of visual disturbance?
    • Type of visual disturbance? (e.g. vertigo/heminopia/quadrantopia/amaurosis fugax)
  • Co-ordination problems
    • Does the patient feel their balance is poor?
    • Are they bumping into walls and door frames? (also consider visual field loss)
    • Does the patient think any of their limbs feels more clumsy?
    • Is the patient experiencing vertigo? (room spinning around them)
  • Speech disturbance
    • Clarify type of speech disturbance: 
    • Expressive dysphasia “I knew what I wanted to say, but I couldn’t get it out”
    • Receptive dysphasia “I wasn’t able to understand anyone, they were speaking jibberish”
    • Dysarthria “My speech was really slurred, it sounded like I was drunk”
  • Swallowing problems (dysphagia)
    • Has the patient has noticed any problems swallowing fluids or food? (e.g. coughing/choking)
    • Dysphagia is common in stroke and if not recognised can lead to aspiration pneumonia and choking
  • Headache
    • Has the patient experienced headache during this episode?
    • Did the headache start before or after the onset of other symptoms?
    • Clarify the type of headache: 
    • Thunderclap – subarachnoid haemorrhage
    • Unilateral – consider migraine (hemiplegic migraine is a stroke mimic)
    • Generalised headache worse when lying down – consider raised intracranial pressure (e.g. haemorrhagic stroke)
  • Nausea/vomiting
    • In the context of stroke consider either raised intracranial pressure (e.g. haemorrhagic stroke) or posterior circulation ischaemic stroke (POCS)
  • Reduced level of consciousness
    • Consider raised intracranial pressure (e.g. haemorrhagic stroke or malignant middle cerebral artery syndrome)
    • Consider seizures which can occur in the context of haemorrhagic strokes and ischaemic strokes
  • Pain (if pain is a symptom, clarify the details of the pain using SOCRATES)
    • Site: Where is the pain?
    • Onset: When did it start? / Sudden or gradual?
    • Character:  Sharp / dull ache / burning
    • Radiation: Does the pain move anywhere else?
    • Associations: Are there any other symptoms associated with the pain?
    • Time course: Worsening / improving / fluctuating / time of day dependent
    • Exacerbating/Relieving factors: Anything make the pain better or worse?
    • Severity: On a scale of 0-10, how severe is the pain?

Information Needed:

  • History of presenting complaint
    • Due to the nature of TIAs and strokes, it may be useful to first ask some orientation questions, such as the patient’s age, the month and what they believe your job role to be. This can enable you to quickly establish if the patient is orientated and help gauge how reliable the history is likely to be.
  • Onset of symptom(s):
    • When did the symptom start? (date and time)
    • Was the onset acute or gradual?
    • It is essential to get an accurate onset time of symptoms: 
    • This can help differentiate between TIA and stroke as discussed above
    • If the patient is having an ischaemic stroke then this information is key in deciding if they are within the therapeutic window for thrombolysis
  • Duration of symptom(s): minutes/hours/days/weeks/months/years
  • Severity:
    • Weakness: Try to clarify how weak (e.g. subtle, moderate, complete paralysis)
    • Sensory disturbance: Was the arm completely numb or did it just feel different to normal?
    • Visual disturbance: How much of the vision was affected? Was vision blurred or completely lost?
    • Expressive dysphasia: Was the patient able to speak at all?
    • Receptive dysphasia: Was the patient able to understand any communication?
    • Dysarthria: Was the patient’s speech mildly slurred or incomprehensible?
    • Course: Is the symptom worsening, improving, or continuing to fluctuate?
    • Intermittent or continuous: Is the symptom always present or does it come and go?
    • Precipitating factors: Was there any obvious triggers for the symptom?
    • Relieving factors: Does anything appear to improve the symptom?
    • Associated features: Are there other symptoms that appear associated? (e.g. headache/nausea/vomiting/neck stiffness)
  • Previous episodes:
    • Has the patient experienced this symptom previously?
    • How many previous episodes?
    • What frequency?
  • Ask the patient what their dominant hand is (useful to know before clinical examination)
  • Ask about any recent head or neck trauma (important if considering intracranial bleeding or carotid dissection)

Major stroke risk factors

  • Ischaemic heart disease
  • Hypertension
  • Atrial fibrillation
  • Hypercholesterolaemia
  • Diabetes
  • Previous stroke or TIA
  • Smoking
  • Excessive alcohol intake
  • Family history of stroke in first-degree relatives
  • Antiplatelet or anticoagulant medication:
    • Aspirin
    • Clopidogrel
    • Warfarin
    • Apixaban
    • Rivaroxaban
    • Dabigatran
  • Other regular medications:
    • Antihypertensives
    • Cholesterol-lowering agents (e.g. statins)
    • Combined oral contraceptive pill

Assessment

Perform FAST (Face / Arms / Speech / Time) examination.

Terminology used in RACE:

  • Asomatognosia: Loss of awareness of body part
  • Anosognosia: Not aware of impaired ability.
  • Paretic limb: Affected limb

Transient Ischaemic Attack

All patients with suspected transient ischaemic attack (TIA), i.e. focal neurological symptoms due to focal ischaemia that have fully resolved, should have urgent clinical assessment. (Lavallee et al. 2007 [25]; Rothwell et al. 2007 [26]) (Refer to the 'Practical Information' section for further useful information)

Patients with symptoms that are present or fluctuating at time of initial assessment should be treated as having a stroke and be immediately referred for emergency department and stroke specialist assessment, investigation and reperfusion therapy where appropriate. (Lavallee et al 2007 [25]; Rothwell et al. 2007 [26])

In pre-hospital settings, high risk indicators (e.g. crescendo TIA, current or suspected AF, current use of anticoagulants, carotid stenosis or high ABCD2 score) can be used to identify patients for urgent specialist assessment. (Lavallee et al. 2007 [25]; Rothwell et al. 2007 [26])

Improved Stroke patient outcomes rely on:

  • Rapid on-scene assessments
  • Early ED, ASC or ANU notification
  • Urgent transportation
  • Information gathering, inclusive of time of onset/last seen well and next of kin details

Intracranial / Intracerebral Haemorrhage

Intracranial (within the skull but outside of the brain tissue) haemorrhage:

The brain has three membranes layers (called meninges) that lay between the bony skull and the actual brain tissue. The purpose of the meninges is to cover and protect the brain. Bleeding can occur anywhere between these three membranes. The three membranes are called the dura mater, arachnoid, and pia mater.

  • Epidural haemorrhage: Occurs between the skull bone and the outermost membrane layer, the dura mater
  • Subdural haemorrhage: Occurs between the dura mater and the arachnoid membrane
  • Subarachnoid haemorrhage: Occurs between the arachnoid membrane and the pia mater

Intracerebral haemorrhage (haemorrhagic stroke) and/or intraventicular haemorrhage:

  • Intracerebral haemorrhage occurs in the lobes, pons and cerebellum of the brain (bleeding anywhere within the brain tissue itself, including the brainstem).
  • Intraventricular haemorrhage occurs in the ventricles, which are specific areas of the brain (cavities) where cerebrospinal fluid is produced.


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