Effective Date: April 1, 2015
This guideline provides recommendations for the acute and long-term management of stroke and transient ischemic attack (TIA) in adults aged ≥ 19 years, in the primary care setting. This includes secondary stroke/TIA prevention and medications.
This guideline is part of the BCGuidelines.ca - Stroke and Atrial Fibrillation series. The series includes three other guidelines: Atrial Fibrillation – Diagnosis and Management; Use of Non-Vitamin K Antagonist Oral Anticoagulants (NOAC) in Atrial Fibrillation; and Warfarin Therapy Management.
A transient ischemic attack (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 up to 24 hours). These symptoms can include motor, sensory, speech/language, vision or cerebellar disturbances. A TIA can be seen along the same pathophysiological process as a stroke. Even with the resolution of symptoms, an infarct may have occurred and should be treated as a continuum of the same disease process as a stroke.
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, they are not temporary.
Strokes are a major cause of death and disability in BC. Approximately 4900 incident cases of stroke are hospitalized in BC each year with a 13% mortality rate for all prevalent cases.2 About 80% of strokes are ischemic/thrombotic and 20% are hemorrhagic.3 A significant proportion of patients with a stroke survive; rapid assessment and treatment are considered critical to reducing disability and mortality related to stroke.
The major treatable risk factors for cerebrovascular atherosclerotic disease are similar to those for coronary atherosclerosis.4
Table 1: Risk factors for stroke or TIA
Individuals with atrial fibrillation have a 3 to 5 times greater risk for ischemic stroke.5 It is estimated that more than 20% of all strokes are caused by atrial fibrillation.3 Further information about atrial fibrillation and stroke risk can be found in BCGuidelines.ca - Atrial Fibrillation – Diagnosis and Management.
Primary prevention of cardiovascular disease also reduces incidence of cerebrovascular disease (see BCGuidelines.ca - Cardiovascular Disease - Primary Prevention and Hypertension - Diagnosis and Management guidelines).
Key features of a stroke/TIA are: 1) sudden onset; and 2) focal neurological deficits associated with a specific cerebral vascular territory. For example:6
History is critical in differentiating diagnoses when first presenting. Patients with TIA will have complete resolution of symptoms and signs while stroke patients may have persistent symptoms.
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 the patient, look for signs and symptoms of vasculitis, sinusitis, mastoiditis and meningitis for a possible differential diagnosis or possible alternate etiology.
Differential Diagnosis for Suspected Stroke: This includes seizures, tumours, abscesses, arteriovenous malformations, subdural hematomas, demyelination, focal encephalitis, vasculitis, Bell's palsy, plexopathies, mononeuropathies and upper cord lesions.
Basic examination of all patients includes a neurological and cardiovascular exam, with vital signs and carotid auscultation. Glucometer check should be done. A brief assessment tool for triage purposes can be found in Appendix A: Cincinnati Stroke Scale.7
Timing: Strokes and emergent TIAs are medical emergencies and patients should be immediately sent to an emergency department. See definition of emergent TIAs in Table 2. Investigation and treatment of strokes or TIAs should begin as soon as possible, preferably within 24 hours. Contact information for stroke/TIA assessment clinics throughout BC are listed in the Resources below.
Investigations for urgent cases are recommended within 7 days, and within one month for semi-urgent cases.
Table 2. TIA urgency classification
Rationale for Urgency of Assessment: TIA patients are at high risk for stroke. Timely investigation and management of TIAs significantly reduces the chance of stroke. 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.8 A patient’s 90 day risk can be lowered from 12% to about 2% with timely (< 24 hour) investigation and aggressive management.9
The ABCD2 score with vascular imaging is available to assess the short term stroke risk after presenting with TIA.10 The score predicts the risk of stroke within 2 days after a TIA, but also predicts stroke risk within 90 days.11 See Appendix B - ABCD2: To Assess 2-Day Stroke Risk After a TIA.
The initial investigations for emergent TIA and a suspected acute stroke are the same (see Table 3). Patients diagnosed with a non-emergent TIA may be referred to an internist/neurologist or a rapid stroke assessment unit. Alternately, a physician may decide to investigate/manage patients diagnosed with a non-emergent TIA as outpatients.
Table 3. Diagnostic tests for stroke/TIA6
For an emergent TIA, computed tomography angiography (CTA) from arch to vertex (where available) is preferred over carotid ultrasound in those with no contraindication of CTA. The utility of CTA in emergent TIA or minor stroke is twofold: 1) to image the carotid artery to rule out carotid stenosis as an underlying cause of ischemic stroke; and 2) to help predict risk of recurrence.12 Patients with CT/CTA abnormalities including acute ischemia, intracranial/extracranial occlusion, or stenosis ≥50% are at increased risk of early recurrent stroke.
Once diagnosed (see Table 3 above for investigations), determine eligibility for tissue plasminogen activator (tPA) therapy immediately (see Table 4 for criteria). Thrombolytic eligible patients should receive tPA as quickly as possible (within 4.5 hours of clearly defined symptom onset). Benefits of tPA are time critical; the earlier the treatment, the better the outcomes. At the present time there is a lack of evidence in using other thrombolytic agents for stroke. If tPA is not available, consult a stroke neurologist.
Table 4: Criteria for tissue plasminogen activator (tPA) therapy
Once the patient’s eligibility for tPA therapy has been determined, proceed with management recommendations listed in Table 5.
Table 5: Management recommendations for all stroke/TIA, including tPA and non-tPA candidates
Manage stroke patients on an acute stroke or general neurological unit where possible. Patients who have received tPA should be monitored in an intensive care unit. It is recommended that the core interdisciplinary team (e.g., 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.13
There are multiple possible complications post-stroke.14 Early mobilization and appropriate positioning during the first 24 hours are associated with improved outcomes. Some of the most serious or common complications are:
Serious cardiac complications: Common in the first three months post-stroke.15
Depression: Estimated to affect up to 1/3 of patients; assess and treat individually. Refer to BCGuidelines.ca - Major Depressive Disorder in Adults - Diagnosis and Management for more information.
Dysphagia/malnutrition/dehydration: Optimize positioning for meals (e.g., sitting upright in chair unless contraindicated); consider enteral feeding if no oral intake for > 48 hours. There is a reduction in risk of aspiration pneumonia when swallowing is managed early by a speech therapist.
Decubitus ulcer formation: Long lasting ulcers can develop rapidly in poorly mobilized patients; focus on positioning and nutritional support as well as mattress optimization.
Shoulder pain with hemiplegia: Consider referral to physiotherapist and physiatrist.
Venous thromboembolism: Pulmonary embolism accounts for 13-25% of early deaths post-stroke.16 Assess patients for prophylaxis with anticoagulant and/or leg compression with pneumatic compression devices. Graduated compression stockings are contraindicated.
Malignant middle cerebral artery (MCA) syndrome: Consider neurosurgical referral for possible hemicraniectomy in patients < 60 years of age with massive MCA infarcts where severe cerebral edema may otherwise lead to fatal brain infarction. Surgery is generally done within the first 48 hours after stroke onset. Candidates should be identified within the first 24 - 36 hours.
Provide stroke education and follow up information to the patient (refer to Patient Information section). Communication with the patient’s family physician is of utmost importance at the time of hospital discharge after treatment for a stroke/TIA. It is desirable that a discharge summary be sent expeditiously to the family physician and that a copy is given to the patient.
Preventing a second stroke is vital in patient care. Ischemic stroke is not a single disease. It can be due to number of different stroke mechanisms and each has its natural history and treatment strategy. Investigations identify the underlying cause of the ischemic stroke in an individual patient and help provide appropriate secondary prevention.
Carotid Endarterectomy: Recommended in patients with internal carotid artery stenosis > 70%, with symptoms in carotid territory, a surgical risk < 6%, and life expectancy exceeding 5 years. In these patients, it is recommended that surgery be offered within 2 weeks of the TIA. Patients with carotid stenosis of 50 - 70% can be evaluated for surgery on an individual basis. Carotid stenting is an option in high risk surgical patients.
Anticoagulation: For appropriate patients with atrial fibrillation or another high risk cardiac source, anticoagulants are recommended. Details on anticoagulant management can be found within BCGuidelines.ca - Atrial Fibrillation – Diagnosis and Management; Use of Non-Vitamin K Antagonist Oral Anticoagulants (NOAC) in Atrial Fibrillation; and Warfarin Therapy Management. The timing of initiation of anticoagulation in patients who had an atrial fibrillation related stroke is determined by clinical judgment on a case by case basis, with consideration of risk of hemorrhagic transformation and risk of recurrent stroke.
Antiplatelet Therapy: 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.17 There is some evidence showing superiority of clopidogrel or dipyridamole plus ASA over ASA.18-20 Base the choice of therapy on patient risk, compliance, side effect profile and cost (see Appendix C: Prescription Medication Table for Stroke and Transient Ischemic Attack).
The long-term use of clopidogrel plus ASA is not recommended for secondary stroke prevention unless there is a cardiac indication.21,22
For patients who have a stroke while on antiplatelet therapy, investigate the cause to exclude high risk cardiac source or need for carotid endarterectomy. Consider a change of antiplatelet therapy.
Hypertension: Treatment of hypertension with antihypertensive drugs is associated with reduction in recurrent strokes.23,24 There is no clear target blood pressure, but benefit can be achieved with a reduction of 10/5 mmHg.23 BCGuidelines.ca – Hypertension - Diagnosis and Management guidelines suggest blood pressure readings of < 140/90 as recommended for all patients at high risk for ischemic cardiovascular disease (for acute control see Table 4). Lifestyle modifications associated with blood pressure reduction should be included as part of an antihypertensive regimen.
Dyslipidemia: There is insufficient evidence to recommend for or against statin therapy in the acute phase (first 48 hours) of TIA or stroke management. The benefit of statins for secondary prevention of strokes has been demonstrated in systematic reviews and randomized controlled trials.25,26 Consider prescribing a statin for patients who have had a stroke or TIA in order to achieve a reduction in low-density lipoprotein cholesterol (LDL-C). No clear target level of total or LDL-C is currently available for stroke/TIA patients,27 but LDL-C of ≤ 2.0 mmol/L, or ≥ 50% reduction has been suggested for high risk cardiovascular disease patients.28
Diabetes: Diabetes is a clear risk factor for first stroke but data are less conclusive about recurrent stroke.29 Refer to BCGuidelines.ca - Diabetes Care for information on management of diabetes.
Lifestyle: Smoking cessation, limited alcohol consumption, weight control, regular aerobic physical activity, and a diet rich in fruits, vegetables, and low-fat dairy products are recommended.11 Refer to BCGuidelines.ca – Lifestyle & Self-Management Supplement for more information (In Progress).
Stroke Education: Provide stroke education and follow up information to every patient. (Refer to Patient Information section.)
Assess the patient for their rehabilitation needs:
Management on a stroke rehabilitation unit improves functional outcomes (durable for up to 1 year).14 Referral to an stroke rehabilitation unit is appropriate when these admission criteria are met: medically stable; requires 24/7 nursing care; requires at least two rehab services (e.g., physiotherapy (PT), occupational therapy (OT), speech-language pathology (SLP) or neuropsychology); can tolerate > 3 hours of activity.
Components of stroke rehabilitation are summarized below to aid the family physician in arranging these services. For a detailed discussion see the Evidence-Based Review of Stroke Rehabilitation (EBRSR), website: www.ebrsr.com.
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, electromyography (EMG)-biofeedback training, and functional electrical stimulation.
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.
Cognitive Dysfunction: Compensatory strategies (e.g., 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 or assessment programs.
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.
Dysarthria and Dysphasia: Consider referral of patients with impaired speech for assessment and training. Intensive speech and language therapy in the acute phase, especially with severely aphasic patients, showed significant improvement in language outcomes.
Hemianopsia: Consider ophthalmologist referral regarding optical prisms for patients with homonymous hemianopsia as this improves visual perception scores.
Community Re-Integration: Referral to community-based support services is associated with increased social activity. Education and information also have a positive benefit.
Stroke/TIA Assessment Clinics
Diagnostic Codes: Stroke 434; TIA 435; Intracerebral hemorrhage 431
The following documents accompany this guideline:
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:
Contact InformationGuidelines and Protocols Advisory Committee E-mail: hlth.guidelines@gov.bc.ca Web site: www.BCGuidelines.ca |
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 problem. 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.