04.08 Neuro

04.08 Neuro [PDF link]: Transient ischaemic attack (TIA), Ischaemic stroke – Thrombolysis, Thrombectomy, Secondary prevention, Strokes according to arterial distribution, Strokes according to Bamford-Oxford classification. Haemorrhagic stroke (intracranial haemorrhage, ICH).

Updated 09/05/2025

External links

• Rosier score for ischaemic stroke: MDCalc

• NIH score for stroke severity (NIHSS): MDCalc / PDF version

• NICE guidance for stroke and TIA diagnosis and initial management: NICE

• NICE CKS for secondary prevention of stroke: NICE

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Extra notes

• Useful article – somewhat of a review on stroke treatment in 2025 which integrates guidance from different sources

• Antiplatelets vs anticoagulants (in the context of stroke)

  • Antiplatelets are used to prevent strokes due to underlying atherosclerosis

    • Atherosclerosis leads to plaque formation, which causes platelet aggregation, leading to platelet-rich thrombi/emboli

    • If atherosclerosis is the main driver of stroke, then antiplatelets should be used

  • Anticoagulants are used to prevent strokes from a cardioembolic source

    • ~25% of strokes are attributable to atrial fibrillation

  • What if both atherosclerosis and AF are present?

    • No firm guidance on this, but long term anticoagulation may be considered

    • In strokes, 2 weeks of antiplatelets should be given before anticoagulation

    • Use of both antiplatelets and anticoagulants at the same is not recommended

• Treatment of non-cardioembolic non-disabling stroke / high risk TIA

  • Recommendations from the ISWP guidelines

    • 21 days dual antiplatelet therapy (DAPT) with aspirin + clopidogrel

    • OR 30 days DAPT with aspirin + ticagrelor

    • After 21/30 days DAPT, lifelong monotherapy with clopidogrel or ticagrelor

    • If DAPT not suitable (eg allergy to aspirin), give loading dose clopidogrel then maintenance dose

  • In NICE guidance, first line treatment is still clopidogrel 75 mg OD (with aspirin/dipyridamole as second line)

    • DAPT only recommended for those with high risk of TIA [not actually defined], or those with intracranial stenosis

    • Treatment options include aspirin + clopidogrel for 90 days, or aspirin + ticagrelor for 30 days

    • Followed by mono therapy with clopidogrel or ticagrelor

Stroke vs Bell’s – if it spares the forehead, we smack the forehead. Helps me remember that if facial weakness spares the forehead, we smack our foreheads cos we’re worried it’s stroke 🤦🏻‍♀️🤦🏻‍♀️🤦🏻‍♀️