Evaluation and Management of TIA and

StrokeClaire J. Creutzfeldt

UW Harborview Stroke CenterJanuary 2013

Outline

1. Some stroke facts2. Approach to evaluation and management of

Stroke3. Acute management of• Ischemic stroke

TIA Present < 4.5 hrs after onset Present > 4.5 hrs after onset

• Hemorrhagic stroke4. Time for questions

Stroke facts(AHA Heart and Stroke Statistical Update 2012)

• ~700,00 strokes each year in the USo a stroke every 45 seconds

• 200,000 of those are recurrent strokes

• Kills >150,000 people/yr in US, 1/16 deaths

• 28% of stroke victims < 65 years old

• 4,500,000+ stroke survivors are alive in US

• leading cause of long-term disability in the US

• 3rd most common cause of death, ranking behind diseases of the heart and cancer

• In developed countries, stroke mortality has been constantly decreasing (5%/year since 1970ies)

4th

Stroke classification

Normal Ischemic Intracerebral Subarachnoid stroke hemorrhage hemorrhage

(80%) (15%) (5%)

“A stroke happens, when…

Mechanisms

Causes of initial event Prevention of recurrent stroke

Large vessel arteriosclerosis Carotid endarterectomy, Antiplatelet

Cardioembolism Anticoagulation Small vessel disease Antiplatelet agent Other Cryptogenic (Antiplatelet

agent)

…blood flow to a part of the brain is interrupted”

EvaluationBASIC STROKE EVALUATION• Thorough H&P• Non-con head CT• Imaging of extracranial arteries• EKG and telemetry• Routine blood studies• (TTE)

COMPREHENSIVE STROKE EVALUATION• MRI• Imaging of intra- and extracranial arteries• TEE• Prolonged cardiac monitoring• U-tox• Blood tests for hypercoagulable state• Genetic tests for rare causes such as CADASIL,

Fabry’s disease, MELAS…

Case 1

• 70 y/o m with h/o diabetes and hypertension presents to clinic and tells you about this episode a couple of days ago where he couldn’t move his entire right side. Symptoms resolved within half an hour.

• BP 165/85, neurologically intact

What is your next step?

Case 1

A. Do a thorough neurological exam. If he really has no residual neurological deficits, no need for imaging

B. Optimize his blood pressure management and have him follow up in a month

C. Refer him to a TIA clinic (urgently), offer him admission to the hospital OR get an expedited workup yourself consisting of MRI brain, vascular imaging, EKG, Echocardiogram and blood work.

D. Educate him about the difference between TIA and stroke and have him follow up in a month

E. Add Clopidogrel to his daily baby Aspirin and have him follow up in a month

post-TIA Stroke RiskJAMA 2000;284:2901-2906

1707 TIA patientsStroke event rates:•10.5% at 90 days• 5.3% at 2 days

ABCD2 score for TIA Risk Stratification

5 Factors Points

Age > 60 1

BP > 140/90 on first assessment after TIA

1

Clinical features unilateral weakness speech impairment without

weakness

21

Duration of TIA ≥60 minutes 10–59 minutes

21

Diabetes 1

Lancet 2007; 369: 283–92

ABCD2 score

Lancet 2007; 369: 283–92

Early TIA management

• Our system: offer admission to all• Others: TIA clinic• Treat:

– Risk factors– Antithrombotics– CEA

• Testing– Brain imaging (CT or MRI)– Vascular imaging – Cardiac evaluation (Echo, EKG)– blood work including basics + lipids, HbA1c, others

Case 2

70 y/o m with h/o diabetes and hypertension presents to the ER with sudden onset R-sided numbness and weakness.

• BP 165/85, awake and able to walk

What is your next step?

Case 2

A. Refer him to a TIA clinic (urgently), offer him admission to the hospital OR get an expedited workup yourself consisting of brain and vascular imaging, EKG, Echocardiogram and blood work.

B. Admit him to the stroke unit, add Clopidogrel to his daily baby Aspirin and order an MRI brain

C. Thorough H&P with time of onset and NIHSS followed by stat lab draw, EKG, head CT

Additional History I

• Symptoms started one hour ago • EKG: normal• NIHSS 11

What medication would you want to use acutely?

IV tPA for Acute Ischemic StrokeIndividual Patient Data Meta-analysis

Lancet 2004; 363: 768-74

tPA inclusion/exclusion criteria

IN: >18yrs, ischemic stroke w/in 3*hrs

EX: * symptoms minor or rapidly improving* seizure at stroke onset* stroke or head trauma w/in 3 months* major surgery w/in 2 weeks* h/o ICH* sustained BP >185/110 (aggressive tx

necessary)* GI or UT hemorrhage w/in 21 days* arterial puncture at noncompressible site

w/in 7d* INR >1.7, platelets <100,000, glucose <50

or >400

][

Lancet 2004; 363: 768-74

3-4.5 hrs

Additional warnings for patients treated between 3 -4.5 hours

• Age > 80

• History of prior stroke AND diabetes

• Any anticoagulant use prior to admission (even if INR <1.7)

• Severe Stroke (NIHSS >25)

• CT findings involving more than 1/3 of the MCA territoryNEJM 2008;359:1317-29.

Additional History II

• Symptoms started 5 hours ago • EKG: normal• Symptoms: stable or progressing

What treatment might you consider acutely?

Mechanical thrombectomy

• a word of caution:• MERCI clot retriever, PENUMBRA• FDA clearance was based on single-group,

nonrandomized trials comparing device treatment with historical controls from PROACT II

• effective recanalization but no better outcome• these devices were not approved as clinically

effective treatments for acute stroke but were cleared for use as devices to remove thrombus in acute stroke

• look for results of MR Rescue and IMS-3 next week! Circulation. 2011;123:2591-2601

MR Rescue and IMS-3: http://clinicaltrials.gov/

Additional History III

• Patient woke up with symptoms, last seen normal > 15 hours ago

• EKG: normal• Symptoms: stable or progressing

Early supportive care

• Reverse ischemia (enhance perfusion)– Antithrombotic Medications – Blood Pressure– Interventions

• Limit injury (neuroprotection)– Glycemia (aggressively normalize)– Core body temperature

• Avoid infections

– Glutamate antagonists– Free radical scavengers

• High quality care– Joint Commission Stroke Centers

• Stroke units• Performance measures

Aspirin

RR = 1.0

Aspirin better Placebo better

0.8795% CI

0.81 to 0.94

Risk significantly reduced by 13%

Doses ranged from 30 to 1500 mg per day

Risk of stroke, MI, or vascular death

BMJ. 2002; 324: 71–86

other antiplatelet agents

NEJM 2008;359:1287-9

$1.20/month

$149.70/month$157.20/month

Blood Pressure Management after acute ischemic stroke

• Treatment threshold– tPA ineligible: 220/120 (unless other end organ damage)– tPA eligible: 185/110 (can treat pre-tPA)

• Preferred Meds– Labetalol iv– Nicardipine drip

Intervention after stroke or TIA- when and what -

• Severe carotid stenosis (70-99%)

• Moderate stenosis (50-69%)

• Stenosis < 50%

• Angioplasty/stenting vs. surgery

• Carotid occlusion

• Asymptomatic carotid artery stenosis

NEJM 2010;363:11–23

Case 3

70 y/o m comes to your clinic as a hospital follow up after an ischemic stroke.

PMH: Diabetes, borderline hypertension, smokingExam today: BP 135/69, mild right-sided weakness

and occasional word finding difficulties.He also seems withdrawn and depressed.

Medications: ASA 81, Niacin, HCTZ 25, Insulin sq

What is your next step?

Case 3

A. Change Niacin to a Statin

B. Change HCTZ to Chlorthalidone

C. Educate patient on life-style change, diet and smoking cessation

D. Consider an SSRI

E. All of the above

Case 4

A 65 y/o woman with known hypertension had complained to her husband about a severe headache shortly before she collapsed.

In the ER, she has decreased LOC, right-sided hemiparesis and aphasia.

Initial BP is 230/120

Case 4 - CT

Case 4

What is the most likely etiology of her hemorrhage?

A. Cerebral amyloid angiopathy

B. Hypertension

C. Ischemic stroke turned hemorrhagic

AmyloidAngiopathyICH

HypertensiveICH

Intraparenchymal hemorrhage

Goals of ICH therapy

• Prevent hematoma enlargement • Blood pressure treatment

• Hemostatic agents

• Surgery

• Limit injury (neuroprotection)– Reduce Raised ICP

– Glycemic control

– Temperature

• Prevent Complications– Swallow screening, DVT prophylaxis, Seizure

prophylaxis

Hematoma Expansion

Stroke 2007;38;2001-2023;Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

Prevent hematoma enlargement/Reduce ICP Blood pressure treatment (goals, agents)Hemostatic agentsSurgery

Stroke complications

Semin Neurol. 2010

thank you