CVA

• Sudden onset of rapidly developing focal or global neurological disturbance which lasts >24 hours or leads to death

FAST pneumonic for signs of stroke

• Facial weakness (can they smile, has their mouth or eye drooped?)

• Arm weakness - can they raise both arms?

• Speech problems – can they speak clearly, can they understand what you're saying?

• Time – it's time to call 999 immediately if you see any of these symptoms

Management

• Acute stroke: urgently admit for further management & CT scan within 24 hrs.

• High BP should not normally be lowered in the acute phase.

• Aspirin 300mg ASAP to all those presenting with acute stroke once haemorrhage has been excluded (by CT scan)

• Patients with disabling ischaemic stroke who are in AF should be treated with aspirin 300 mg for the first 2 weeks before anticoagulation treatment with warfarin or a direct oral anticoagulant (DOAC) is considered.

• Thrombolysis e.g. Alteplase should be started within 4.5 hours of onset of stroke symptoms after exclusion of intracranial haemorrhage - clear time of onset is essential (not if symptoms on waking from sleep as impossible to ascertain the time of onset). Contraindications for alteplase include a stroke in the last 3M or a convulsion-accompanying stroke.

Transient Ischaemic Attack (TIA)

• <24 hrs neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without evidence of acute infarction

• Immediate aspirin (300 mg) to people with suspected TIA. Secondary prevention is recommended in addition to aspirin, as soon as possible after the diagnosis is confirmed.

• Following TIA, risk of stroke is approximately 7x greater than the risk in the general population, especially in the first few weeks. Patients should be assessed and investigated in a specialist clinic within 7 days.

• Current guidance no longer recommends the use of scoring systems, such as ABCD2, to assess risk of subsequent stroke for people who have had a suspected or confirmed TIA: NICE. Stroke and Transient Attack in over 16s: diagnosis and initial management (NG 128, 2019)

Resources

• Stroke and Transient Ischaemic Attack in over 16s: diagnosis and initial management (NG 128, 2019)

• National Clinical Guideline for Stroke. (RCGP, 2016)

• Stroke and TIA (CKS)

• Cerebrovascular disease (NHS Choices)

• Stroke (NHS Choices)​

• Transient Ischaemic Attack (NHS Choices)

Subarachnoid haemorrhage

• Subarachnoid haemorrhage (NHS Choices), Brain aneurysm (NHS Choices)

Vascular dementia

• Vascular dementia (NHS Choices)​