124 Companion Episode: Working Through TIAs and Strokes

Good morning and Merry Christmas and Happy Hanukkah. We are right in the middle of the holiday season, obviously with today being Christmas Eve. What I wanted to do with this particular show, what I want to do with this podcast, is I wanted to start creating these, what I’m going to call companion episodes. I want to work into the system the things I’ve been talking about for so long, the things like being engaged, being active, of participating in your own learning, thinking things through, rebuilding information. This is how we hold onto things. This is how we restructure the material so that our brains can keep it. We are terrible at memorizing lists.

It’s not what we’re good at. Student after student will struggle to memorize a list, spend hours and hours, and become very frustrated because the list they’re trying to memorize, they can’t remember it, or at best they can remember it for a few days or weeks, but then they have to relearn all of it. This is not the way to go about your studying. So a lot of the students I work with are what I always call overstudying, but they’re working on the wrong things. And it’s hard to get that across to people who are putting in the time, putting in the work, putting in the effort, but not seeing the results they want. So I want to start maybe picking that up here in these companion episodes and considering putting together some active, engaged studying. So we’re going to pick up today with TIAs and strokes.

And I’m going to walk you through kind of what I mean. And this will be developing as we go over 2025. But for episode one, I’ve got an outline that I want to stick with that I think you’re going to start to see how things come together.

So let’s start with just looking at TIAs and strokes, right? So initially, one of the key factors, the simplest key factor, is that TIA symptoms fully resolve within 24 hours. Strokes symptoms persist beyond 24 hours, and they may have lasting damage to the brain, right? Where TIAs are transient is kind of the name of it.

Next, you can look at them and look at their headache severity and how they come on. So hemorrhagic stroke, what do we think about when we think about a hemorrhagic stroke in patient presenting? Well, they’re more likely to present with severe headache, vomiting, and rapid decline in their consciousness, in their way of thinking. For an ischemic stroke, you’re usually more focal, neurologic deficits with extreme headaches.

Now, what about TIAs? Similar, may have mild headaches or none, but deficits then resolve quickly. Right? That’s your major difference. So, when we look at hemorrhagic strokes versus… what are they? I’m struggling already.

Hemorrhagic strokes versus ischemic strokes, you’re looking at a severe thunderclap type headaches, vomiting, rapid decline, versus ischemic strokes, which is more, it is a rapid decline, but you get more focal, neurological deficits without those extreme headaches. You can get a headache, but it’s not going to be the same, right? So if you’re trying to figure out how to separate these in a patient who walks through the door, how to separate these on your exams, this is the kind of terminology, the kind of ideas, the picture I want in your head of what to look for.

Now, as far as imaging goes in all of these cases for hemorrhagic stroke, you’re going to get a CT because you’re looking for a hyperdense area for bleeding. That’s what you’re looking for. For an ischemic stroke, you’re going to be looking for that same thing, but you’re looking to not see it, right? You’re looking to not see that brain bleed.

Now, you may also see on a CAT scan an area of low attenuation, and this can take a while to appear, but this is where the tissue is not doing so well, right? An MRI is going to help with this. Now on a TIA, the imaging is going to be normal in most cases. So you’re not going to get a permanent lesion. So that’s going to be your differences there. What about treatments? So we talked a little bit about treatments last week and how to compare and contrast the treatments for these different issues and why we do certain things.

So let’s start with TIAs. TIAs are going to be the patient comes in, either the symptoms are resolving or they have resolved, right? So we’re like, huh, not sure I want to give a TPA, not sure exactly, I’m not seeing anything on the CAT scan. This is going to be short-term antiplatelet therapy often used to prevent stroke reoccurrence. So short-term antiplatelet therapies. Long-term therapy depends on the etiology. So if it’s, whether it’s more cardioembolic or whether we think it’s atherothrombotic.

So whether it’s a coming from the heart tissue, we talked about this last week, right? So I think if it’s non-cardiogenic, we’re going to be doing things like aspirin, clopidogrel, and ticlopidine versus if it’s a cardiogenic clot, we’re going to be doing something more like heparin or coumadin. For an ischemic stroke, you should be able to come up with what is our first term treatment? What is our first line treatment? Well, first line treatment is going to be the IV TPA, right? And what was the window for that? It was under four and a half hours.

And so we’re going to want to do that almost immediately upon realizing we have an ischemic stroke. But before we do that, obviously we have to do a CAT scan to make sure they’re not bleeding. They don’t have any of the contraindications we talked about last week. If it’s a mechanical, I’m sorry, you can go in and take that thrombus out if it’s indicated for large vessel occlusions. And then you’re going to move to that more long-term management things like what we just talked about for TIAs. Hemorrhagic strokes, you want to get the blood pressure under control and lowered in most cases. You want to reverse any anticoagulation going on.

Obviously, they’re bleeding like we talked about before. You want to bring down intracranial pressure. And then you may need to get neurosurgery involved and do something about an aneurysm or that actual bleed.

All right, cool. I wanted to work through that real simple discussion because I think repetition is so important in creating that foundational idea of what different diseases are, how they relate to each other is so very valuable.

All right, let’s jump into some questions here. And I want you to really think these through based on what we covered just now and then last week. So some of this actually, I almost cheated a little bit and gave these away.

So let’s go through a few. What is the time cutoff for symptoms to resolve and still be classified as a TIA? What is the time cutoff for symptoms to resolve and still be classified as a TIA? I’ll give you the answers at the end. Which imaging study is first line to identify an intracranial hemorrhage? Which imaging study is first line to identify an intracranial hemorrhage? List one medication used to lower intracranial pressure in hemorrhagic strokes.

List one medication used to lower intracranial pressure in hemorrhagic stroke. Name the gold standard imaging modality for identifying ischemic stroke. What percentage of strokes are ischemic versus hemorrhagic? Give one example of a potential cause for hemorrhagic stroke. Give one example for a potential cause for a hemorrhagic stroke. Identify one modifiable risk factor for TIA and stroke. Identify one modifiable risk factor for TIA and stroke.

All right, let’s jump into these and see how you did. So number one, what’s the time cut off for symptoms to resolve until we classified as a TIA would be within 24 hours. That one should be pretty straightforward knowledge at this point. Which imaging studies first line to identify intracranial hemorrhage? This one too. Non-contrast CT scan. Should be right on the tip of your tongue.

List one medication used to lower intracranial pressure. This too needs to be like just like three times three is nine. You really have to have this one. Mannitol or hypertonic saline. Name the gold standard imaging modality for identifying ischemic strokes. That’s going to be an MRI. What percentage of strokes are ischemic versus hemorrhagic?

Well, 85% are ischemic and 15% are hemorrhagic. Give one example of a potential cause for hemorrhagic stroke. I just have a rupture of a cerebral aneurysm or an AVM. Identify one modifiable risk factor for TIA and stroke. Hypertension is the one that I have. There are others, obviously, though.

Okay, let’s look at some questions now. And I want to take the questions I just went through and show you how they stack into PANCE-type questions. So I’m going to go through two of these and let’s see how we do. But what this exercise is really for is just to demonstrate to you how the information builds from the simple straightforward question we just did into PANCE style questions. So first one, we have a 68 year old woman who experiences sudden onset of her right arm weakness and difficulty speaking. The symptoms completely resolve within six hours with no residual deficits. Which of the following time frames define the cutoffs for diagnosing a transient ischemic attack rather than a stroke?

Do you see how that builds out of what we just did? So your answer choices are A within 12 hours, B within 24 hours, C within 48 hours, D within 72 hours. This is a really simple, straightforward question with just a lot of words in the vignette, right? But the answer is going to be B within 24 hours, right? It’s a difference between our TIA and our more formal stroke. Question number two. A 60 year old man is brought to the ER with altered mental status and headache described as the worst of his life.

On exam, his blood pressure is 190 over 110 and he shows left-sided weakness. Which initial imaging study is most appropriate to rapidly identify or rule out an intracranial hemorrhage? I also just could have written this as most appropriate for this patient, right? And the answer here choices are A, carotid ultrasound, B, non-contrast CT scan of the head, C, MRI of the brain with contrast, D, CT angiography of the head and neck. And our answer, of course, is going to be B, non-contrast CT scan of the head. Again, the key here is I want you to see how the information builds. They take a very simple idea and turn it into a pretty straightforward question that looks slightly complicated or sounds slightly complicated, but really the reality is it’s no different than that simple question we did earlier.

Now, these are just going to be not pulled from those original questions. I just want to go through two more questions today on this topic, PANCE style questions, and see how we walk through them and look at some of the wrong answers and what’s going on with them. So first, we have a 67-year-old man presents with sudden onset of left-sided weakness and mild headache. By the way, this is a little easier because we’re in strokes, right? So it’s kind of straightforward. It gets harder when we mix all this stuff together. His blood pressure is 190 over 110 on arrival.

A non-contrast CT scan of the head shows no signs of hemorrhage. It has been two hours since symptoms onset. Which of the following is the most appropriate next step in management? Based on everything we said, you should have a pretty good idea in your head of what we want to do. A, give aspirin and observe for 24 hours. B, control blood pressure to less than 185 and administer IV tPA. Proceed with mechanical thrombectomy.

D, perform lumbar puncture to rule out subarachnoid hemorrhage. Well, this should be pretty obvious. You’re not going to need a lumbar puncture. Well, actually, I take that back. If you were to, what would be the conditions in which you’d want a lumbar puncture?

Let’s say it that way. Well, if my patient came in and I had no signs of hemorrhage, that immediately made me think, oh, I don’t need a lumbar puncture. But the reality is the lumbar puncture is when I really think that there’s a subarachnoid or there’s a bleed, but my CT scan didn’t show it, right? That’s when I’m going to do a lumbar puncture. But in this case, I don’t really have that headache and I don’t have the signs I’m looking for to push me to do that lumbar puncture. I’m feeling pretty comfortable that I have a, based on the symptoms, based on the CAT scan, that I’ve got a ischemic stroke going on.

So let’s look at give aspirin and observe for 24 hours. Well, that’s not really going to be our first deal, right? We’re going to want to start, if we think that it is a ischemic stroke, we’re going to start with IV TPA. And there’s only one choice that has that, which is B. So we want to control the blood pressure down to less than 185 naturally and administer IV TPA. We’re not going to do a mechanical thrombectomy at this point based on everything in this question. So our answer here is B.

But again, what I want you to do is just think about how we get there and what the structure is.

All right, let’s go through one more. A 55-year-old woman with a history of atrial fibrillation presents with sudden onset of right-sided arm weakness and speech difficulty that resolved within 30 minutes. A carotid ultrasound shows 65% stenosis in her left internal carotid artery. Non-contrast head CT is unremarkable. Which of the following is the most appropriate next step in this patient’s management? Now this one’s a little tricky. A, begin dual antiplatelet therapy with aspirin and clopidogrel.

B, initiate anticoagulation with heparin, bridging to warfarin. C, schedule a carotid endarterectomy. D, obtain MRI of the brain before initiating therapy. I’m just going to read the stem one more time. A 55-year-old woman with a history of atrial fibrillation presents with a sudden onset of right-sided arm weakness and speech difficulty that resolves within 30 minutes. A carotid ultrasound shows 65% stenosis in her left internal carotid artery. Non-contrast head CT is unremarkable.

Which of the following is the most appropriate in the next step? A, begin dual antiplatelet therapy with aspirin and clopidogrel. B, initiate anticoagulation with heparin bridging to warfarin. C, schedule a carotid endarterectomy. D, obtain MRI of the brain before initiating therapy.

Okay, so what I’m looking at is her symptoms have resolved, right? So she’s getting better. And I have this history of AFib, but I also have this ultrasound showing 65% stenosis of the left carotid artery. I’ve got nothing on this CT. So what do I want to do here? So obtaining an MRI of the brain before initiating therapy, it’s a good thing to do. But we have our CT to rule out the hemorrhage, right?

So there’s not a lot that we’re going to gain right away out of that MRI as far as I can tell. Are we going to do a carotid endarterectomy right away? Well, usually not. This is carotid endarterectomies are usually if we have got greater than 70% stenosis. So maybe, but not really. So really down to our two choices, A and B, which is where everyone gets frustrated, right? Everyone’s like, oh, I can get it down to two and then I’m not sure.

Well, in this case, we’re down to two, right? We either want to start antiplatelet therapy or anticoagulation therapy. So we have to decide. And unfortunately, what you’re looking for is, is this a is this coming from the heart, or is this coming from the blood vessels? Right? That’s really what we’re trying to decide here and how we treat this. So, the problem is is that she has AFib, so it makes it a little bit more complicated.

In this case, we’re going to start with a the dual antiplatelet therapy, because what we have here is it’s not clearly cardioembolic. We don’t know for sure that it’s coming from there. We have another source. So we’re going to start with aspirin and clopidogrel in this case.

Now, as time goes on, we may shift our thinking and move to heparin and warfarin. But in this case, it’s going to be A. And I know that it can be frustrating. I know that’s going to be super frustrating. That’s part of why we’re walking through these.

All right. Fantastic. That was a ton of fun. And I think something I’d be doing with you if I were sitting down to tutor one-on-one is this kind of work, going through test questions, going through how they’re going to be presented based on the information you’ve studied, based on the information you have.

Now, you may have knowledge gaps, but there’s also the piece that says, how do we go through the questions and see what’s going on there? So, that takes us out for TIAs and strokes. We’re going to move on next week through neuro. But I just wanted to say, have a Merry Christmas, Happy Holidays, Happy Hanukkah. One, oh, one more thing before we sign out for today is just that I’ve gotten a couple emails about people who want to sign up for the 33 Days to Pass the PANCE program for one reason or another. I think it’s a fantastic way to learn like the skills we’re talking about today, improve test taking skills, improve reading questions, improve study skills, improve shortening up actually the time you’re studying. Because like we said, most people are over studying, but don’t know how to shorten it up because they’re not heading in the right directions on things.

All of that we cover within that program. Now it’s geared directly for the PANCE, of course, that was the thinking when I created it. But I’ve had a ton of didactic and clinical students go through it and have just so much success that I’ve opened it up to those students in general.

Now, people have been asking me, how do I register? Well, right now you can’t. That’s the thing, right? I don’t open registration until the month before. So the next cohort is going to start February 1st. I will open registration in early January because usually once we, I have to get a few things set up to make it run. And then I also, people get excited and really want to jump in and get started.

I want everyone to start at the same time on the same pace. We do this as a group and that’s a big part of what goes on there. So you can head over to physicianassistantexamreview.com/33. You can look more into the program. But again, you can’t register until the beginning of January. And if you’re on the email list, you’ll certainly see when that happens. But that’s for each of those cohorts throughout the year.

You usually do one in February, in April, in September, and in November. I may change that around a little bit, but that’s where we’re at right now.

All right. So this was a fantastic, I think this was a great, great first attempt at this. I’d love to hear your feedback. Just shoot me an email. Let me know what you think. Something to add, something to remove, and how this works for you moving forward, because that’s really the most important part to me.

All right. Take care. Happy holidays.