UNCONTROLLED WHEN PRINTED

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.


References
References

Page contributors:

DefaultDefault Author
St John WA
Want to help improve this article? Visit our Contribute page.

Clinical Resources Website

St John Ambulance Western Australia Ltd (ABN 55 028 468 715) (St John WA) operates ambulance and other pre-hospital clinical services. St John WA’s Clinical Resources, including its Clinical Practice Guidelines (Clinical Resources), are intended for use by credentialed St John WA staff and volunteers when providing clinical care to patients for or on behalf of St John WA, within the St John WA Clinical Governance Framework, and only to the extent of the clinician’s authority to practice.

Other users – Terms of Use

The content of the St John WA Clinical Resources is provided for information purposes only and is not intended to serve as health, medical or treatment advice. Any user of this website agrees to be bound by these Terms of Use in their use of the Clinical Resources.

St John WA does not represent or warrant (whether express, implied, statutory, or otherwise) that the content of the Clinical Resources is accurate, reliable, up-to-date, complete or that the information contained is suitable for your needs or for any particular purpose. You are responsible for assessing whether the information is accurate, reliable, up-to-date, authentic, relevant, or complete and where appropriate, seek independent professional advice.

St John WA expressly prohibits use of these Clinical Resources to guide clinical care of patients by organisations external to St John WA, except where these organisations have been directly engaged by St John WA to provide services. Any use of the Clinical Resources, with St John WA approval, must attribute St John WA as the creator of the Clinical Resources and include the copyright notice and (where reasonably practicable) provide a URL/hyperlink to the St John WA Clinical Resources website. 

No permission or licence is granted to reproduce, make commercial use of, adapt, modify or create derivative works from these Clinical Resources. For permissions beyond the scope of these Terms of Use, including a commercial licence, please contact medservices@stjohnambulance.com.au

Where links are provided to resources on external websites, St John WA:

  • Gives no assurances about the quality, accuracy or relevance of material on any linked site;
  • Accepts no legal responsibility regarding the accuracy and reliability of external material; and
  • Does not endorse any material, associated organisation, product or service on other sites.

Your use of any external website is governed by the terms of that website, including any authorisation, requirement or licence for use of the material on that website.

To the maximum extent permitted by law, St John WA excludes liability (including liability in negligence) for any direct, special, indirect, incidental, consequential, punitive, exemplary or other loss, cost, damage or expense arising out of, or in connection with, use or reliance on the Clinical Resources (including without limitation any interference with or damage to a user’s computer, device, software or data occurring in connection with such use).

Cookies

Please read this cookie policy carefully before using Clinical Resources from St John WA.

The cookies used on this site are small and completely anonymous pieces of information and are stored on your computer or mobile device. The data that the cookies contain identify your user preferences (such as your preferred text size, scope / skill level preference and Colour Assist mode, among other user settings) so that they can be recalled the next time that you visit a page within Clinical Resources. These cookies are necessary to offer you the best and most efficient possible experience when accessing and navigating through our website and using its features. These cookies do not collect or send analytical information back to St John WA.

Clinical Resources does integrate with Google Analytics and any cookies associated with this service enable us (and third-party services) to collect aggregated data for statistical purposes on how our visitors use this website. These cookies do not contain personal information such as names and email addresses and are used to help us improve your user experience of the website.

If you want to restrict or block the cookies that are set by our website, you can do so through your browser setting. Alternatively, you can visit www.internetcookies.com, which contains comprehensive information on how to do this on a wide variety of browsers and devices. You will find general information about cookies and details on how to delete cookies from your device. If you have any questions about this policy or our use of cookies, please contact us.

St John Ambulance Western Australia Ltd © Copyright 2020, All Rights Reserved

Terms of Use | Privacy Policy | Copyright Statement & Disclaimer