Assessment and investigation of stroke and transient ischaemic attack

Abstract

▶ There are now several evidence based guidelines for the management of patients with stroke ▶ The concept of a "brain attack" will need to be developed for patients with persisting symptoms who are seen < 24 hours from onset ▶ Overall about 95% of ischaemic events are caused by either atherothromboembolism, cardiogenic embolism or intracranial small vessel disease ▶ Absolute proof of the stroke mechanism in an individual patient will rarely be available as many patients have multiple potential mechanisms ▶ Carotid duplex is an appropriate examination in patients with clinico-radiological evidence of carotid territory ischaemia who would accept, and be accepted for, carotid endarterectomy or angioplasty if an appropriate lesion was detected ▶ Transcranial Doppler has the potential to provide a non-invasive, repeatable, and relatively inexpensive bedside examination which can give information about intracranial stenoses or occlusions, vasospasm, asymptomatic embolism, paradoxical embolisation, and the cerebrovascular reserve ▶ Routine echocardiography in the absence of other pointers to cardiac disease is not justified because of the very low yield of information that would change clinical management.