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Stroke: management in general practice

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The management of stroke is a major component of the Quality Outcomes Framework reflecting the fact that it is a common and important disorder managed in primary care. This assessment resource, composed of 10 clinically-rich questions, assesses your knowledge of common issues related to the recognition and management of cerebrovascular disease. Complete the questions to obtain a certificate for 1 hr of continuous professional development to add into your portfolio.

On completion of this resource, the user should be able to:

Understand the investigations used in the management of patients with cerebrovascular disease

Recognise the varied presentations associated with stroke

Understand the approach to managing stroke in primary care

The management of stroke is a major component of the Quality Outcomes Framework reflecting the fact that it is a common yet important disorder managed in primary care. This assessment resource composed of 10 clinically-rich questions, assesses your knowledge of common issues on the recognition and management of cerebrovascular disease. Complete the questions to obtain a certificate for 1 hr of continuous professional development to add into your portfolio.

Cardiovascular disease

A 72 year old man has a left sided stroke due to ischaemic cerebral infarction. Which of the following risk factors is most likely to be contributory?

The most important contributory risk factor to stroke from those suggested is hypertension. Other risk factors include increasing age, diabetes, smoking, atrial fibrillation as well as carotid arterial disease.
Atrial fibrillation is a major risk factor for stroke. Patients with atrial fibrillation can be further risk assessed using a prediction tool called the CHADS2 score. The CHADS2 score consists of the following criteria:

 - Hypertension (consistently above 140/90) - 1 point

 - Previous stroke, TIA or thromboembolism - 2 points

The score then produced can help determine which thromboprophylaxis a patient receives. A score of 1 would suggest no treatment or aspirin. A score of 2 would suggest aspirin or warfarin therapy. A score above 2 and the patient should be on warfarin rather than aspirin.

Question 1

A 65 year old woman comes to clinic. She has otherwise been well but on this occasion informs you that she has had a couple of episodes of loss of vision in the right eye. She informs you that its like a curtain coming down, with vision completely hazy and dark in that eye for about 10 minutes or so. She has a history of hypertension and diabetes. What is the diagnosis?

This problem of sudden loss of vision in an eye, typically described as 'a curtain coming down' is called amaurosis fugax and is due to an occlusion of the optic artery with embolism or clot. This is a type of TIA and needs to be taken seriously, if a full blown stroke is to be avoided.

The risk of a further stroke can be assessed using the ABCD2 scoring system:

Blood pressure above 140 systolic or 90 diastolic - (1 point)

Clinical features: unilateral weakness (2 points), speech disturbance without weakness (1 point)

Duration of symptoms: over 60 min (2 points), 10-59min (1 point)

A score of 4 or above suggests a high risk of an early stroke

Question 2

An 85 year old male has a stroke with a left sided hemiparesis. Which of the following findings on clinical examination are significant in terms of his stroke risk?

The risk factors for stroke include hypertension, smoking, diabetes, increasing age and atrial fibrillation. The irregularly irregular pulse suggests atrial fibrillation. This results in pooling of blood within the atria with the potential for small clots to develop and hence embolise, particularly to the carotid circulation. Oral anticoagulation with aspirin or warfarin is often used in the reduction of systemic emboli with atrial fibrillation.
Warfarin works by inhibiting vitamin k dependent coagulation factors. It is monitored in patients using the international normalised ratio (INR) to ensure they take enough of the drug to have a therapeutic effect, but as little as possible to reduce potential side effects.

Question 3

A 56 year old man has developed numerous episodes of weakness in the left hand lasting a few minutes. His blood pressure has been 132/76 mmHg and he has a regular pulse of 68bpm. He is a smoker of 20 cigarettes per day but has since tried to stop. Which test do you think would be most valuable in this patient?

This patient has a history suggestive of carotid territory TIAs with weakness in his left hand/arm. We are told that the pulse is regular and that he has a normal blood pressure so an ECG would not be expected to add anything diagnostic. Epidemiological data indicates that there is no direct relationship between cholesterol concentrations and stroke. This contrasts with coronary artery disease where the correlation is strong. In stroke hypertension is far more important. However, carotid dopplers may reveal stenosis (narrowing of the the lumen) of the carotid artery (on the right as his symptoms are left sided). If arteries are more than 50% stenosed, consideration should be given to carotid endarterectomy.
A carotid doppler is a non invasive radiological investigation using sound waves. It is used to assess the blood flow through the large arteries in the neck which supply the brain with oxygen, the carotid arteries. The results of the doppler is used to assess the risk of a patient having a stroke and can help determine which intervention is appropriate.

Question 4

A 72 year old male with diabetes and hypertension is taken to hospital with right sided weakness and inability to speak which developed suddenly. He was found to be hypertensive and has been treated with ramipril 10mg daily and also is discharged from hospital on clopidogrel 75mg daily. He has made a good functional recovery and attends clinic to check on his blood pressure. In this patient, to which target blood pressure would you aim?

The most appropriate approach to the management of hypertension in stroke is to aim for a blood pressure <140/85 mmHg with a target of <130/80 mmHg in patients with diabetes. All patients with a previous stroke or TIA should be considered for treatment with and ACE inhibitor with or without a thiazide diuretic, regardless of blood pressure, unless contraindicated.

Question 5

A 72 year old man has recently been discharged from hospital following admission with a transient ischaemic attack which resulted in him having a left hemiparesis from which he recovered within 12 hrs. He has made a full recovery and has been treated with aspirin and ramipril. However, he enquires as to when he might return to driving?

The patient should inform both DVLA and the insurance company after a stroke or TIA. The guidance suggests that patients should not drive for one month following stroke or TIA providing that the doctor has passed them fit to drive after this month.

Question 6

A 76 year old man has a left sided stroke from which he makes a good recovery. His blood pressure was high and is treated with amlodipine and ramipril. He is also treated with aspirin 75mg daily. His cholesterol concentration is also measured and reveals:

Which of the following would be the most appropriate management for his further management?

This man who has treated hypertension, has had a stroke and irrespective of the cholesterol concentration, should receive a statin as this is associated with further risk reduction. Although cholesterol concentrations are not themselves related to stroke, studies reveal that statin treatment is associated with reduction in stroke risk hence their inclusion on guidance.

Question 7

A 65 year old woman has presented with a sudden onset of visual loss in the right eye, which resolved 12 hours after the onset. All other investigations have been shown to be normal except that she has been noted to have atrial fibrillation. Which is the best option for stroke prevention for this woman?

This woman has had a TIA, manifested by amaurosis fugax, and has atrial fibrillation. The most appropriate approach to managing this would be anticoagulation with warfarin. This would reduce the stroke risk through reduction in the development of emboli within the atria associated with the AF. Overall, anticoagulation with warfarin reduces the risk of stroke by about 2/3.

Question 8

A 65 year old woman attends clinic as she developed a loss of vision in the right eye which was like a curtain coming across her eye. The episode lasted approximately 15 minutes before resolving entirely and occurred about 36 hrs ago. She has no other past medical history of note, drinks modestly but smokes 10 cigarettes per day. On examination, she has a blood pressure of 136/78 mmHg and a pulse of 82 bpm regular. Which treatment should be given to this patient at this stage?

This woman has had amaurosis fugax - a transient ischaemic. According to NICE guidance, the patient should be treated immediately with aspirin 300mg daily. The aspirin should be continued for 14 days then reduced to 75mg daily. If the patient is intolerant or allergic to aspirin an alternative should be used, such as clopidogrel.
Aspirin is another example of a drug used for stroke prevention causing a 12% reduction in the risk of serious vascular events. Aspirin is an analgesic (pain killer) with antiplatelet properties. It is used in lower doses for stroke prevention than when used as a conventional pain killer.

Question 9

A 78 year old man has been admitted to hospital with an acute stroke which resulted in left sided weakness. He has made a good recovery but has found problems with the aspirin medication that he has been taking. It has caused him some heartburn and also he has developed an itchy rash with it. He is currently taking aspirin 300mg daily. What can be done?

In patients who are intolerant of aspirin therapy, then guidance suggests switching to an alternative preparation such as clopidogrel.
After a stroke aspirin should be dosed at 75mg daily, as this patient has experienced adverse effects from this drug then clopidogrel is a good alternative, also taken at 75mg daily. Clopidogrel has a similar antiplatelet effect to aspirin.

Stroke: management in general practice

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