TIA/Stroke (1) C.L.I.P.S. Why do we care? Stroke is the 5th most common cause of death in the U.S. and 3rd most common cause of death in women. A 2010 study noted that more than half of the 6 million adults with stroke in the U.S were women. Definition: Transient neurologic symptoms without evidence of acute infarction; A lack of evidence of infarction on MRI in pts w/ sxs c/w cerebral ischemia distinguishes TIA from minor stroke Clinical sxs: SUDDEN ONSET unilateral weakness, speech disturbance, or transient monocular blindness or double vision Risk factors: Smoking, obesity, DM, HLD, HTN, Family hx of coagulation disorder, stroke or TIA Sex-specific risk factors: Pregnancy, Pre-E, Gestational DM, use of OCPs or postmenopausal hormones DDx of TIA: Brain tumor, CNS infection, Falls/trauma, Hypoglycemia, Migraines, Multiple sclerosis, Seizure disorder, Subarachnoid hemorrhage, Vertigo Initial assessment for TIA/stroke: BP, HR, O2 sat, POC glucose, EKG Last known well time Neuro exam, NIHSS, STAT Non-contrast Head CT Dial 44 for Stroke Alert Stroke-related hyperglycemia is associated with greater brain injury, poorer functional outcomes and increased mortality. What effect does glycemic control with insulin have on these complications? None. Insulin does not improve mortality rates/neurological outcomes after stroke Updated 4/2018 Muraida

ASA 81mg starting at 12 wks until delivery TIA/Stroke (2) C.L.I.P.S. Inpatient management of TIA/Stroke after admission: If emergent CT Head is performed, obtain MRI too (more sensitive for infarct) Consider Carotid artery U/S vs. MRA Monitor for neurologic complications -Cerebral edema, seizure, intracranial hemorrhage Prevent future ischemic events by initiating: -ASA or Clopidogrel, Statin, BP control (initially allowing permissive HTN to avoid infarction of at-risk tissue) -Management of DM, screening/treatment for depression Consult Speech for swallow assessment, early PT, OT and nutrition. Monitor for inpatient complications: -Pneumonia, UTI, pressure sores, DVT/PE, delirium Assessment of future risk with ABCD2 score: Age > 60 (1) BP: SBP >140 or DBP >90 (1) Clinical presentation -Unilateral weakness (2) -Speech Impairment w/o weakness (1) Diabetes mellitus (1) Duration of TIA ->= 60 minutes (2) -10-59 minutes (1) Risk of stroke at 2 days…1-3 points (1%), 4 or 5 points (4%), 6 or 7 points (8%) Long-term prevention of future stroke: Modifying RF, esp HTN and smoking, incr exercise (DASH, NRT, BMI<30, mod activity >= 30 min daily) Aspirin or Clopidogrel, statins, and CEA for those with carotid artery stenosis >70% What is recommended to prevent stroke in pregnant women with chronic HTN or HTN in prior pregnancy? ASA 81mg starting at 12 wks until delivery Aspirin is reasonable ppx in women with what condition and no contraindication? Diabetes