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TheMostCommonQuestionsAboutStrokeandTIA
SharonPoisson,MDMASUniversityofColorado,DenverAssociateProfessorofNeurology
Disclosures
• NIHU54granttostudyischemicstrokeinchildrenandyoungadults
• Nootherdisclosures
LearningObjectives• Uponcompletionofthisprogram,theparticipantshouldbe
ableto:– Identifyhighrisktransientischemicattacks,understandwhatstudiesareneedtobedoneurgently,andunderstandearlymanagementdecisionsneededforsecondarystrokeprevention.
– Outlinerecentadvancesintheacutetreatmentofischemicstrokewithinterventionaltreatments,andunderstandthesignsoflargevesselocclusionswhichhelptoidentifycandidatesforinterventionaltreatment.
– Applytheguidelinesaswellasexpertopinionindeterminingwhatantithrombotictreatmentisappropriatefordifferenttypesofpatientswithstroke,andtounderstandtheappropriatetimingofstartingantithrombotictreatments.
Consult#1• 68 year old man with DM, HTN, h/o CAD • Admitted for hypertensive urgency, spent a day in the
MICU, and is now on the floor. – BP on admission was in the 190s/110s, and has now improved
to the160s/90s. • He reports a couple of episodes in the 2 days prior to
admission:– RUE numbness and clumsiness, dizziness – All of the episodes lasted <5 min.
• He now has no neurologic symptoms and normal exam.• Getting ready for discharge when he gave this history
Consult#1
• “Myquestionsforyou”:– CouldtheseepisodeshavebeenTIAs?– WhatdoIneedtodonow?– Canhegohome?
TransientIschemicAttack
• What is a TIA?– Episode of temporary, focal cerebral dysfunction due
to vascular disease– Classic definition <24 hours– Reality, most <10 minutes
• Why should I care?– High risk of stroke following TIA
• 7 days: ~ 8%• 30 days: ~ 10%• 90 days: 10-20% (average 11%)
– Risk within 90 days after stroke: 2-7% (avg 4%)
Stroke 2014; 45(7): 2160-236
HowdoIknowifitisaTIA?
• Manymimics– Migraine– Changesinelectrolytes– Peripheralnerveproblems– Hypotensive/Hypertensiveepisodes– Functionaldisorders– Nonspecificsymptoms– difficulttodefine
RiskStratificationbyClinicalFeatures
• ClinicalfeaturesarethemostextensivelyvalidatedpredictorsofoutcomeafterTIA
• ABCD2 Score– Finalscore=0-7Clinical Feature Values Points
Age ≥ 60 1Blood Pressure ≥140/90 1Clinical Symptoms Unilateral Weakness 2
Speech disturbance without Weakness
1
Duration ≥60 minutes 210-59 minutes 1
Diabetes Yes - historical 1
ABCD2 Score
SCJohnstonetal.,Lancet2007369:283
ABCD2andRiskCategories
RiskGroup ABCD2
ScoreRiskofStroke
2days 7days 90daysLow 0-3 1% 1.2% 9.8%
Moderate 4-5 4.1% 5.9% 9.8%High 6-7 8.1% 11.7% 17.8%
SomefindingsthatABCD2 isaccurateatpredictingseverestroke,butlessaccurateinpredictingANYsubsequentstroke
WhatdoIdonow?
• ABCD2 =5(age,BP,weakness,DM)• WhatamImostworriedabout?• Whatwillchangemanagementorpredicthigherrisk?
• Whatistheetiology?
RiskStratificationbyEtiology
• Meta-analysis:riskofrecurrentstrokebysubtypeusingTOAST
• N=1709patientswithstroke
• Largearteryatherosclerosishadthehighestearlyriskofrecurrence
Lovettetal.,Neurology200462:569
LAA
ManagementofTIA
• Evaluatefortheetiology• Treattheunderlyingetiology• Secondarystrokeprophylaxis
– Antiplateletoranticoagulant– BPcontrol– DMcontrol– Statinforatheroscleroticrisk
Consult#2• 68 year old man with DM, HTN, h/o CAD • Admitted for hypertensive urgency, spent a day in the
MICU, and is now on the floor. – BP on admission was in the 190s/110s, and has now improved
to the160s/90s. • He reports a couple of episodes in the 2 days prior to
admission:– RUE numbness and clumsiness, dizziness – All of the episodes lasted <5 min.
• He now has no neurologic symptoms and normal exam.• Getting ready for discharge when he gave this history• We did a TIA workup…
Consult#2- workup
• Patienthasbeenontelemetryfor24hours– Noarrhythmias
• Lipidpanelchecked:LDL120• HemoglobinA1c5.9• MRIdonewithnoacuteinfarctseen• MRAheadandneck…
RiskStratificationbyEtiology
• Meta-analysis:riskofrecurrentstrokebysubtypeusingTOAST
• N=1709patientswithstroke
• Largearteryatherosclerosishadthehighestearlyriskofrecurrence
Lovettetal.,Neurology200462:569
LAA
TIA&CarotidDisease• SubgroupanalysisofNASCET• SubjectswithhemisphericTIAandseverecarotidstenosistreatedmedically– 1-monthstrokeriskof22%(2xthatofallcauseTIA)
• CombinedsubgroupanalysisofNASCETandECSTinpatientswithhemisphericTIAandseverecarotidstenosis:– 15.4%ARRofipsilateralstrokewithin5years– Bestoutcomeswinterventionwithin2weeks
Rothwell et al, Lancet 2004; 363
Consult#3
• 37yearoldman,previouslyhealthy– Wasatworkat08:15andtalkingonthephonewhenhesuddenlyhadnonsensicalandslurredspeech
– Co-workerfoundthepatientontheground30minuteslaterandcalledEMS
– BroughttotheED,wherehewasawake,alertbutconfused,perseverating,aggitated
– Noweaknessorotherfocalneurologicsymptomsnoted
– Headlacerationthatrequired3stitchesinED
Consult#3
• Noncontrast HeadCTdoneandwasnormal• Patientwasadmittedtomedicineforconcernfortoxicityversuspost-concussivesyndrome
• Nosignificantfindingsontox screen,basiclabs
• At5pm,hiswifenoticedsomedroopingofhisleftface
• MRIbraindone
DWI ADC
NowWhat??
• ShouldIcallastrokealert?
• Isthereanyacutestroketreatmentthatheisacandidatefor?
• Whatisthewindowforacutetreatment??
tPA for Ischemic Stroke
• Only FDA approved medication for treatment of arterial ischemic stroke– Up to 3 hours from last known normal
• Not approved, but standard practice to use up to 4.5 hours
• As time progresses, chance of benefit decreases, and risk of hemorrhage increases
NEJM (333):597-602.NEJM. (359):1317-1329
Benefits of Thrombolysis
tPA forCerebralIschemiawithin3hoursofonset–changesinoutcomeduetotreatment
Stroke 2010: 41; 300-306
Normal or Nearly NormalBetterNo Major ChangeWorseSeverely Disabled or Dead
Final Outcome:
EarlyCourse:NoearlyworseningEarlyworseningwhemorrhage
WhatistheEvidenceforInterventionalTreatment??
Five New Trials in 2015:
Allmulticenterrandomizedtrialsinadults,assessingthrombectomy and/orintra-arterialthrombolytics intheanteriorcirculation(ICA,M1,M2)comparedwithstandardtreatment
Study NOnsettoGroin
Puncturewindow
NIHSSlimits
MedianNIHSS
%treatedwithIVtPA
Medianonsettogroin
puncturetime
mRS0-2at90-days
(endovascularvscontrol)
Mortalityat90days
(endovascularvscontrol)
Mr.CLEAN 500 6h ≥2 18 89% 260m(4h20m)
33%vs19%(RR1.7)
21%vs22%(RR1.0)
ESCAPE 316 12h(84%in<6h) ≥6 17 76% 200m
(3h20m)53%vs29%(RR1.8)
10%vs19%(RR0.5)
EXTEND-IA 70 6h Nolimits 15 100% 210m(3h30m)
71%vs40%(RR1.8)
9%vs20%(RR0.4)
SWIFT-PRIME 196 6h ≥6 17 100% 224m
(3h44m)60%vs35%(RR1.7)
9%vs12%(RR0.7)
REVASCAT 206 8h(90%in<6h)
≥6 17 73% 269m(4h29m)
44%vs28%(RR1.6)
18%vs16%(RR1.2)
NumberNeededtoTreat
RevisionofAHAGuidelines
• StillgiveIVtpa• IAthrombectomy recommendedwithin6hourwindowforICAandMCAclots• Stronglyrecommendnoninvasivevascularimagingtoscreenpatients• Usestentretrievers
– Aspirationthrombectomy alsohashighrecanalizationrates– THERAPYtrialstoppedearly
• Goodtrendsandconfidenceintervals• Notagooddirectcomparison
• Useaballoonguidecatheter(ordistalaspirationcatheter)alongwithastentretriever
NewTrialAnnounced…• May2017– EuropeanStrokeOrganizationConference,Prague– DAWNtrialresultspresented(notyetpublished)
• Patientswithstrokeandlargevesselocclusionbetween6-24hourspostonsetofsymptoms
• Smallcoreinfarctvolumeonimaging,largepenumbra• 73%relativeriskreductionindependencyofADLs
HowDoWeKnowWhoisaCandidate?
• Thekeyisrecognitionofpossiblelargevesselocclusion
StrokePatternsCOMMON STROKEPATTERNS
AnteriorCirculation
ACAOcclusion
• Contralateralhemiparesis:Legweakness>Arm• Contralateral sensoryloss:Leg>arm• Confusion,personalitychanges
MCAocclusion: • Contralateralhemiparesis:Armandfaceweakness>Leg• Contralateralsensoryloss: Arm/face>leg• Aphasia (usuallyleftbrain)• Spatialneglect (usuallyrightbrain)• Homonymoushemianopiaonoppositesideoftheinfarct• Gazedeviationtowardssideofstroke
PosteriorCirculation
PCA occlusion: • Homonymoushemianopiaonoppositesideoftheinfarct• Contralateralsensoryloss• Possibleaphasia• Disconjugate gaze(uncommon)
Vertebro-basilarocclusion:
• ataxia,vertigo,diplopia,dysarthria,hiccups,nausea,vomiting• disconjugate gaze• crossedsigns• decreasedLOC
WhoShouldWeConsiderforIntervention?
• Inpatients,atleastoutto12hoursfromlasttimeknownnormal,evaluateforcorticalsigns– Aphasia– Neglect– HomonymousHemianopsia– GazeDeviation
• Rapidimagingevaluationwithvesselimaging(CTAorMRA)andevaluationofsizeofstroke(CTperfusionorMRI)
Consult#3• Oncompleteneurologicalexam,pt intubated,agitated,mildLfacialdroop,gazepreferencetoR,Lsidedneglect,nolimbweakness
Consult#3
• Post-thrombectomy,patientdidwell,withimprovementinspeech,neglect
• Returnedhomewithoutpatienttherapies
Consult#4
Consult#4:65yearoldmanwithrightface/arm/legweakness
• Admittedforpneumonia• Post-surgically,hada45minuteepisodeofRface/arm/legweakness
• Nowneurologicallynormal• Previouslyonnomedications
• 7599patientswithstroke/TIAwithin3months,andanothervascularriskfactor
• RandomizedtoPlavixvs Plavix/ASA75mg
ASAplusClopidogrel?MATCHtrial
• 15,603patientswithcardiovasculardiseaseormultiplevascularriskfactors
• RandomizedtoASAalonevs ASA/Plavix• After2years,nobenefitinpreventionofMI/stroke/ordeathduetoCVcauses
• IncreasedbleedingriskinsubgroupwithhistoryofstrokeonASA/Plavix
ASA/Plavix- CHARISMA
• EffectivenessofASA/Plavixvs ASAinpatientswithTIAorminorstrokewithin24hours
• Trialclosedearlyduetopoorrecruitment– Alsostudyingstatins,andpt’s withprioruseofstatinwereexcluded,SPARCLpublished
• 392patientsenrolled– ARRof4.4%in90-dayriskofstrokeinASA/Plavixgroup(9.5%vs 5.1%)
– ARRof5.5%in90-dayriskofstroke/MI/vasc deathinASA/plavix group11.6%vs 6.1%)
– Underpoweredduetopoorenrollmentandfactorialdesign
ASA/Plavix- FASTER
• US/internationalandChineseversionsofsimilartrials
• ASAversusPlavix+ASA inpatientswithhighriskTIAandminorstrokeacutelyandfor90days
• POINTcurrentlyenrolling
POINT…CHANCE
• ResultspresentedatISC2013– notyetpublished
• 5170ChinesepatientswithminorstrokeorTIA
• ASAgroupwith11.7%outcomestroke,8.2%inASA/Plavixgroup(HR0.68,CI0.57-0.81)
• Changein“standardofcare”?
CHANCE
Whendoweusedualantiplatelettherapy?
• Intracranialstenosis:SAMMPRIStrial– 70-99%stenosis– TIAorstroke
• Randomizedtostentingvsaggressivemedicalmanagement– ASA+plavix for2months– Rosuvastatin– Oneanti-HTNmedwasgivenforfree
Chimowitz MI. Stenting versus Aggressive Medical Therapy for Intracranial Stenosis. NEJM 2011;365:993-1003.
Thetrialstops…Early.
• Becausemedicalmanagementwins!– 30-daystrokeordeath
• Stenting:14.7%• MedicalManagement:5.8%
Questions
• Whatistheguidelinerecommendedtimelineforinterventionaltreatmentofacutestroke?a.0-4.5hoursafteranyacuteischemicstrokeb.0-6hoursafteranteriorcirculationlargevesselocclusionc.0-6hoursafteranylargevesselocclusiond.0-24hoursafteranteriorcirculationlargevesselocclusion
Questions
• Whatistheguidelinerecommendedtimelineforinterventionaltreatmentofacutestroke?a.0-4.5hoursafteranyacuteischemicstrokeb.0-6hoursafteranteriorcirculationlargevesselocclusionc.0-6hoursafteranylargevesselocclusiond.0-24hoursafteranteriorcirculationlargevesselocclusion
Question#2
• WhatisthemostcriticalstudynecessaryafterTIAtodeterminetheetiologyandsecondarystrokeprevention?a. ABCD2scoreb. Telemetryc. Lipidpaneld. Vesselimagingofthebraine. Vesselimagingoftheneck
Question#2
• WhatisthemostcriticalstudynecessaryafterTIAtodeterminetheetiologyandsecondarystrokeprevention?a. ABCD2scoreb. Telemetryc. Lipidpaneld. Vesselimagingofthebraine. Vesselimagingoftheneck
Question#3
• Inwhichscenarioshoulddualantiplatelettherapybeconsideredforsecondarystrokeprevention?a. First3monthsafterTIAwithABCD2score=2b. First3monthsafterstrokewithNIHSS=10c. Symptomaticseverecervicalcarotidstenosisd. Alloftheabovee. Noneoftheabove
Question#3
• Inwhichscenarioshoulddualantiplatelettherapybeconsideredforsecondarystrokeprevention?a. First3monthsafterTIAwithABCD2score=2b. First3monthsafterstrokewithNIHSS=10c. Symptomaticseverecervicalcarotidstenosisd. Alloftheabovee. Noneoftheabove
Questions??