Stroke on the CCFP exam

Approach

• Keep the mimics in mind: low blood sugar, weakness after a seizure, migraine, a tumour, and blood on or around the brain.
• Check a finger-prick glucose on arrival. Correct a low one at once.
• Remember a transient ischemic attack (TIA): stroke symptoms that clear fully. Within 48 hours of onset, it goes to an emergency department with stroke care.
• Brainstem or balance symptoms that come and go can pass for a mimic. They still need urgent vessel imaging.
• A seizure at onset does not by itself rule out clot-dissolving treatment.
• In newborns and children, a seizure is a common first sign of stroke.
• No test should hold up the first brain scan or the treatment decision.

Approach

• History and exam cannot reliably tell a bleed from a clot. A brain scan is required.
• Within 6 hours and a possible treatment candidate: plain CT plus CT angiography of the head and neck, at once.
• Image the vessels from the aortic arch to the top of the head.
• Ask which blood thinner he takes and when he took the last dose. Record both.
• Get an electrocardiogram (ECG) to look for atrial fibrillation. Unless he is unstable, it can wait until after the treatment decision.
• A bleed on a blood thinner: reverse it now, without waiting for labs.
• A large bleed, or one blocking fluid flow in the brain: call neurosurgery. Use the phone or telestroke (a video consult with a stroke specialist) if none is on site.

Approach

• Fix the time last known well. The clock runs from there, not from when symptoms were found.
• Disabling ischemic stroke within 4.5 hours of last known well: offer clot-dissolving treatment (thrombolysis).
• The guideline sets no upper age limit. In one large trial, patients 80 or older did better with treatment.
• Do not wait for blood results or an MRI. Neither should delay the decision.
• Keep blood pressure below 185/110 during treatment and for 24 hours after.
• Aim for a median door-to-needle time of 30 minutes or less, and 60 minutes or less for 90% of patients.
• No stroke expert on site: use telestroke (a video consult with a stroke specialist). A blocked large vessel may also need clot removal by catheter (thrombectomy).

Approach

• Start rehab screening within 48 hours of admission, ideally.
• The core team: a physiatrist (a rehab doctor) or neurologist, nurse, physiotherapist, occupational therapist, speech-language pathologist, social worker and dietitian.
• The patient and family belong on the team. Set goals with them and review the plan at least weekly.
• Add a psychologist, recreation or vocational therapist, or pharmacist as needed.
• Plan for home early: equipment, transport, referrals and follow-up booked before discharge.
• A child needs a team trained in children's stroke, with the parents on it and links to the school.

Approach

• Discuss goals of care: the diagnosis, the likely outcome, the patient's values, and comfort versus prolonging life.
• Find the substitute decision-maker and any wishes the patient stated before.
• Cover breathing machines, tube or intravenous feeding, fluids, and the purpose of each medicine.
• Decide on tube feeding early, with the patient or family and the team.
• Document the plan. Revisit it when the patient's condition changes; wishes can change too.
• After a catastrophic stroke, take a palliative approach. Call palliative care for hard symptoms or family conflict.

Approach

• Screen everyone after a stroke or TIA for thinking changes compared with before.
• An abnormal or unclear screen: refer for a detailed assessment before risky, demanding tasks. A child going back to school may need full neuropsychological testing.
• Screen before discharge from hospital and from rehab, then again at follow-up visits.
• In adults, use a validated tool. The Montreal Cognitive Assessment (MoCA) picks up mild deficits better than the Mini-Mental State Exam.
• Attention, processing speed and planning are hit most often. Test them even if nobody reports a problem.
• Screen for depression, anxiety and apathy too. They affect thinking.
• In children, deficits may only show years later, as demands grow.

Approach

• Be honest and sensitive. Fit what you say to the family's needs and goals.
• Check readiness, health literacy and preferred language before you start.
• Repeat it. Patients keep less than a quarter of what they hear in hospital.
• Say what to expect next and what to watch for.
• A child can grow into a disability. New problems may surface at new stages, so plan long-term follow-up.
• Tell parents the stroke is not their fault. Almost no childhood stroke is preventable.

Approach

• Have a therapist assess his need for a cane, walker, wheelchair or other aid. Reassess as he improves.
• Foot drop: an ankle-foot brace after proper assessment. Check that it helps his walking.
• Arrange a home assessment for changes and equipment that make the home safe.
• Ask whether his wife can meet his needs. Train her, and link her to caregiver support.
• Try a day or weekend visit home before discharge.
• Book referrals and follow-up before he leaves.

Approach

• Screen swallowing before anything by mouth, pills included. A failed screen goes to a speech-language pathologist.
• The diet and fluid texture follow that assessment, not the screen.
• ASA when swallowing is unsafe: 325 mg rectally, or 81 mg by tube. After thrombolysis, wait 24 hours and a scan with no bleed.
• Cannot swallow safely: consider tube feeding, usually within the first 3 to 7 days. Use a tube through the belly wall if it is needed for 4 weeks or more.
• Mouth care at least twice a day, above all with a swallowing problem.
• Leg clots: if the patient cannot move about alone, start leg pumps or heparin from admission. Skip them only if something rules them out.
• Check the skin often in a patient who cannot move.

Approach

• Blood pressure after a stroke or TIA: below 140/90. Start or adjust treatment before hospital discharge.
• First choice: an angiotensin-converting enzyme (ACE) inhibitor with a thiazide-type diuretic. Do not combine an ACE inhibitor with an angiotensin receptor blocker.
• Ischemic stroke or TIA not from the heart: a statin, aiming for LDL below 1.8 mmol/L. Consider adding ezetimibe if it stays above.
• Diabetes: A1c (average blood sugar over 3 months) 7.0% or lower. Off target on standard pills, consider a drug with proven heart benefit.
• Atrial fibrillation: an anticoagulant, not ASA. A direct oral anticoagulant is preferred over warfarin for most patients.
• Do not routinely add ASA to an anticoagulant. Bleeding rises without clear benefit.
• Look for hidden atrial fibrillation: heart monitoring for 24 hours or more. Monitor 2 weeks or more in selected patients 55 or older.

Approach

• Minor stroke (National Institutes of Health Stroke Scale 0 to 3) or high-risk TIA, low bleeding risk: two antiplatelets, short term.
• ASA 162 mg load then 81 mg daily, plus clopidogrel 300 to 600 mg load then 75 mg daily, for 21 days.
• Or ASA plus ticagrelor 180 mg load then 90 mg twice daily, for 30 days.
• Then one antiplatelet for life: ASA 80 to 325 mg, clopidogrel 75 mg, or ASA with extended-release dipyridamole.
• No minor-stroke criteria: one antiplatelet, started within 24 hours of onset.
• No stroke or vascular event yet: ASA is not recommended, even with risk factors. Weigh it with the patient.
• Children: ASA 1 to 5 mg/kg a day, usually no more than 81 mg.