Makindo Medical Notes

Introduction 🧠

This page summarises the acute presentation and treatment of stroke and TIA. It blends UK guideline recommendations with concise teaching notes for bedside practice. Full details are available in the Stroke Guidelines 2023.

3.1 Pre-hospital Care 🚑

95% of strokes present outside hospital. Rapid recognition and transfer to a hyperacute stroke service is vital. Ambulance teams screen with stroke tools and alert hospitals.

Letter	Description	Year
A	Check capillary glucose and use a validated stroke/TIA tool; transfer positives urgently to a hyperacute service.	2016
B	If suspicion remains despite negative tool, manage as stroke until excluded.	2016
C	Minimise call-to-hospital time; send a pre-alert.	2016
D	Secure airway if at risk with suction, positioning and adjuncts.	2016
E	Keep patients NBM until dysphagia screening.	2016
F	Suspected TIA: give aspirin 300 mg immediately and arrange specialist review within 24h.	2016
G	Monitor for AF and arrhythmias.	2016

Teaching Pearls 🎓

• Always exclude hypoglycaemia before labelling “stroke”.
• Stroke mimics: seizure, migraine, hypoglycaemia, sepsis.
• “Time is brain” — every 15 min delay = more neurons lost.

3.2 TIA & Minor Stroke — Assessment ⚕️

TIAs are “mini-strokes” with high early recurrence risk. Specialist assessment must be urgent.

Letter	Description	Year
A	Suspected TIA: give aspirin 300 mg immediately and assess within 24h.	2023
B	Do not use ABCD2 or similar to triage urgency.	2023
C	For symptoms >1 week ago: specialist review within 7 days.	2016
D	Educate patients/carers on stroke recognition and emergency response.	2016
E	Specialist assessment before brain imaging decisions, except urgent CT if anticoagulated or bleeding disorder.	2023
F	MRI is the preferred imaging for TIA.	2023
G	If MRI delayed >7 days, use MRI SWI/T2* to exclude haemorrhage.	2023

Teaching Pearls 🎓

• Never delay aspirin while waiting for a clinic slot.
• ABCD2 has poor predictive value — not recommended anymore.
• Consider mimics: seizure, migraine, hypoglycaemia, MS relapse.

3.3 TIA & Minor Stroke — Treatment & Prevention 💊

Secondary prevention must start immediately. Risk of recurrence is highest in the first few days.

Letter	Description	Year
A	Offer lifestyle change, antiplatelet/anticoagulant therapy, statins, BP-lowering therapy.	2023
B	Dual antiplatelet (aspirin+clopidogrel or ticagrelor+aspirin) for 21–30 days, then monotherapy.	2023
C	Start high-intensity statin (e.g. atorvastatin 20–80 mg) immediately.	2023
D	AF with TIA/minor stroke: anticoagulate once bleed excluded.	2016
E	Carotid imaging within 24h if intervention considered.	2023
F	Report carotid stenosis using NASCET method.	2016
G	Severe carotid stenosis (50–99%): urgent endarterectomy <7 days.	2016
H	<50% stenosis: no intervention, optimise medical therapy.	2016

Teaching Pearls 🎓

• Dual antiplatelet is short-term only — to reduce early recurrence.
• Statins should be started immediately, not delayed until follow-up.
• Carotid surgery works best when done early (<7 days).

3.4 Acute Stroke Imaging 🩻

Brain imaging guides reperfusion treatment. Speed matters: door-to-scan within 1 hour is national standard.

Letter	Description	Year
A	Admit suspected stroke patients directly to a hyperacute stroke unit for urgent assessment.	2016
B	Brain imaging within 1 hour of arrival.	2023
C	Interpretation for reperfusion should be by trained clinicians only.	2023
D	Potential thrombectomy candidates need immediate CT angiogram (arch → vertex).	2023
E	Late presenters or wake-up strokes: use CT/MR perfusion or MRI DWI–FLAIR mismatch.	2023
F	MRI with stroke sequences (DWI, SWI/T2*) when diagnosis uncertain.	2023

Teaching Pearls 🎓

• Target: CT head within 1 hour of arrival.
• Exclude bleed before giving thrombolysis.
• Always think: “Is this patient a thrombectomy candidate?”

3.5 Ischaemic Stroke Management 💉

Thrombolysis and thrombectomy save brain tissue — but only if delivered quickly and safely.

Letter	Description	Year
A	Thrombolyse (alteplase or tenecteplase) if onset <4.5h, any age/severity.	2023
B	Consider thrombolysis 4.5–9h or wake-up strokes if perfusion mismatch present.	2023
C	BP must be <185/110 before thrombolysis.	2016
D	Thrombolysis only in organised stroke centres with trained staff and protocols.	2016
F	Eligible thrombectomy patients should also receive thrombolysis (unless contraindicated).	2023
G	Anterior circulation large-vessel stroke: thrombectomy + thrombolysis within 6h (NIHSS ≥6, mRS 0–2).	2023
I	Thrombectomy up to 24h if perfusion mismatch present.	2023
N	Consider decompressive hemicraniectomy in malignant MCA infarction.	2016

Teaching Pearls 🎓

• “Time is brain” → push for CT, thrombolysis, and thrombectomy pathways.
• Do not forget BP control before thrombolysis.
• Thrombectomy eligibility = big vessel + disabling deficit + salvageable brain.

3.6 Intracerebral Haemorrhage (ICH) 💥

About 1 in 10 acute strokes are ICH. Reversal of anticoagulants and early BP lowering are critical.

Letter	Description	Year
A	Warfarin ICH: reverse with PCC + IV vitamin K.	2016
B	DOAC ICH: reverse with idarucizumab (dabigatran) or PCC ± andexanet alfa for Xa inhibitors.	2023
C	BP 150–220: lower to 130–139 within 1h and maintain for 7 days (unless contraindicated).	2023
D	Admit to hyperacute stroke unit; repeat imaging if deterioration.	2023
E	Consider neurosurgical drain for hydrocephalus.	2016

Teaching Pearls 🎓

• Always ask: “On anticoagulants?” — reversal may be lifesaving.
• Aggressive BP lowering reduces haematoma expansion.
• Monitor closely — deterioration → repeat CT immediately.

3.7 Subarachnoid Haemorrhage (SAH) 🩸

SAH is a neurosurgical emergency. Sudden “thunderclap” headache is the red flag.

Letter	Description	Year
A	Thunderclap headache: CT brain ± CTA immediately; if negative, LP at 12h for xanthochromia.	2016
B	Refer to neuroscience centre; give nimodipine 60mg 4-hourly.	2016
C	Treat aneurysm (endovascular or clipping) within 48h of ictus if fit.	2016

Teaching Pearls 🎓

• “Worst headache of life” = exclude SAH until proven otherwise.
• Nimodipine reduces vasospasm risk — don’t omit it.
• Discuss early with neurosurgery, even if CT is negative but suspicion remains.

3.8 Cervical Artery Dissection 🩻

Carotid/vertebral dissections cause stroke in younger adults. Often present with neck pain + neuro deficit.

Letter	Description	Year
A	Investigate with CT or MR angiography.	2016
B	Eligible patients can still receive thrombolysis.	2016
C	Treat with anticoagulant or antiplatelet for at least 3 months.	2016
D	DOAC or warfarin acceptable for 3 months.	2023
E	Consider 21 days of dual antiplatelet before monotherapy.	2023

Teaching Pearls 🎓

• Think dissection in young stroke with neck pain or trauma.
• Carotid bruit + Horner’s syndrome = classic but rare triad.

3.9 Cerebral Venous Thrombosis (CVT) 🧵

CVT is rare but treatable. Headache ± seizures or focal deficits are typical.

Letter	Description	Year
A	Investigate with CT/MR venography.	2016
B	Full-dose anticoagulation even if haemorrhagic venous infarct present.	2016
C	Anticoagulate ischaemic stroke with DVT/PE unless contraindicated.	2016

Teaching Pearls 🎓

• Do not be afraid to anticoagulate even with venous haemorrhage.
• Consider prothrombotic states (e.g., OCP, pregnancy, thrombophilia).

3.10 Acute Stroke Care 🛏️

Hyperacute stroke units save lives. Protocols maintain physiological stability and prevent complications.

Letter	Description	Year
A	Admit to hyperacute stroke unit with trained staff and protocols.	2016
B	Monitor: consciousness, glucose, BP, O₂ sats, hydration, temperature, rhythm.	2016
C	Give oxygen only if sats <95%.	2016
D	Assess hydration within 4h and maintain normal fluid balance.	2016
E	Screen swallow within 4h before giving food/fluid/meds orally.	2016
F	If dysphagic: consider NG tube feeding within 24h, refer dietitian.	2023
H	Maintain glucose 5–15 mmol/L, avoid hypo.	2016

Teaching Pearls 🎓

• First swallow screen within 4h — don’t miss aspiration risk.
• Fever, hypo, dehydration all worsen stroke outcome.

3.11 Positioning 🪑

Correct positioning reduces aspiration, pressure sores and shoulder pain.

Letter	Description	Year
A	Specialist positioning assessment within 4h of arrival.	2016
B	Patients may sit up or lie flat — whichever is comfortable in first 24h.	2023
D	Position to minimise aspiration, respiratory complications, pressure injury.	2016

3.12 Early Mobilisation 🚶

Mobilisation helps recovery but very early/forced mobilisation may be harmful.

Letter	Description	Year
A	Assess mobility within 24h by trained staff.	2016
B	If stable, encourage frequent short mobilisations between 24–48h after onset.	2016

3.13 DVT & PE Prevention 🦵

Stroke patients are highly VTE-prone, especially with immobility and hemiplegia.

Letter	Description	Year
A	Offer intermittent pneumatic compression within 3 days of admission for 30 days or until mobile.	2016
B	Do not use LMWH or stockings routinely for DVT prevention.	2016
C	Anticoagulate ischaemic stroke patients with symptomatic DVT/PE if no contraindication.	2016
D	ICH patients with DVT/PE: consider vena caval filter.	2016

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End of Summary. For full recommendations see UK Stroke Guidelines.