Cryptogenic Strokes: Evaluation and Management

Size: px
Start display at page:

Download "Cryptogenic Strokes: Evaluation and Management"

Transcription

1 Cryptogenic Strokes: Evaluation and Management 77 yo man with hypertension and hyperlipidemia developed onset of left hemiparesis and right gaze preference, last seen normal at 10:00 AM Brought to ZSFG by ambulance J. Claude Hemphill III, MD, MAS Kenneth Rainin Chair in Neurocritical Care Professor of Neurology and Neurological Surgery University of California, San Francisco Chief of Neurology, San Francisco General Hospital Past-President, Neurocritical Care Society UCSF Disclosures Research Support: NIH/NINDS; Cerebrotech Medical Stock (options): Ornim NEUROCRITICAL CARE PROGRAM Non-contrast head CT negative Given IV t-pa with door-toneedle time 16 minutes Stroke CT then completed Right middle cerebral artery occlusion endovascular embolectomy - TICI 3 flow at 2 hours 15 minutes after last known well time Page 1

2 Cryptogenic Stroke Over next 4 days, recovered well and remained with only left lower visual field deficit and mild gait instability Symptomatic cerebral infarct for which no probable cause is identified after adequate diagnostic evaluation Workup 3 days of telemetry no arrhythmias Transthoracic echo mild diastolic dysfunction, borderline enlarged atrium Glucose normal LDL 117 Carotid imaging with CTA and angio without stenosis ~40% of strokes in 1970s ~15% of strokes in advanced stroke centers currently Diagnosis cryptogenic stroke Saver NEJM 2016 Frequency of Stroke by Etiologic Subtype Discharged to rehabilitation on ASA High-dose statin ACE inhibitor 84% Thrombotic Also sent with Zio patch Zio patch showed 3 self-limited runs of paroxysmal atrial fibrillation Embolic 53% 31% Hemorrhagic 16% Diagnosis cardioembolic stroke 10% 6% Page 2 Ischemic Intracerebral Subarachnoid

3 Imaging of Ischemic Stroke Ischemic Stroke Subtypes - Localization Large Vessel Qureshi NEJM 2001 Small Vessel Lacunar MCA ACA PCA Basilar Ischemic Stroke Causes Large Vessel Embolic» Cardiac (e.g. atrial fibrillation)» Artery-to-Artery (e.g. carotid stenosis)» Aortic Arch Thrombotic» Atherosclerotic stenosis» Hypercoaguable state Small vessel Microthrombosis in chronically damaged penetrating artery Hypertension or diabetes in most cases Distinction between ischemic stroke risk factors and causes Hart Lancet Neurology 2014 Page 3

4 What s a Good Stroke Workup? Reason - acute treatment or stroke cause? Large vessel versus small vessel? Age of patient? Vascular risk factors? Usual start BP, ECG, CBC, Chem7 Lipid panel, glucose, Hgb A1C, tox screen Carotid imaging for anterior circulation stroke (CTA, ultrasound, MRA) Transthoracic echo if not lacunar Hart Lancet Neurology 2014 Cryptogenic Stroke So let s treat it WARSS randomized trial Warfarin-aspirin recurrent stroke study 2206 patients with ischemic stroke No high-grade carotid stenosis (with planned surgery) or inferred cardioembolic source (mostly atrial fibrillation) Randomized to» ASA 325 mg daily or» Warfarin for INR % of patients classified as cryptogenic 56% small vessel disease Mohr NEJM 2001 Mohr NEJM 2001 Page 4

5 Cryptogenic Stroke Intracranial stenosis WASID randomized trial 50-99% stenosis No difference in ASA and warfarin ~22% event rate in 1.8 years So when is it a cryptogenic stroke? Doesn t this just mean we have not looked hard enough or smart enough? What are stroke causes that we used to call cryptogenic? And what can we do about them? Many are known stroke causes that we just not had the technology to sufficiently evaluate (or not have sufficiently appreciated) Chimowitz NEJM 2005 and 2011 Patent Foramen Ovale(?) SAMMPRIS randomized trial 70-99% stenosis Intracranial stenting worse than medical therapy Vasculitis - Angiography Found in ~50% of cryptogenic stroke patients and ~25% of healthy people PICSS study (substudy of WASID) No difference in time to event between warfarin and ASA Three randomized trials of PFO closure negative for ischemic stroke reduction But if you find a DVT, a right-to-left shunt, and a PFO you may have a cause Classic finding is sausaging of small-medium arteries Angiography may be normal Is abnormal angiogram diagnostic? Homma Circulation 2002 Saver NEJM 2016 Page 5

6 Moya-Moya LICA RICA Other Causes Obliterative arteropathy with b/l distal intracranial ICA occlusions or highgrade stenoses Hypercoaguable States Cancer Antiphospholipid antibody syndrome Usually diagnosed angiographically ( vague or hazy puff of smoke ) Genetic Conditions Not restricted to Asians CADASIL Fabry s disease MRI/MRA by be strongly suggestive LICA lenticulostriate puff of smoke Migraine-associated stroke Non-inflammatory with intimal thickening and smooth muscle proliferation Undiagnosed Atrial Fibrillation CRYSTAL AF Study As little as a single 1-hour episode of atrial fibrillation during 2 years of monitoring doubles stroke risk ~15% of acute stroke patients have atrial fibrillation at stroke onset Randomized study (n=441) of patients with cryptogenic stroke or TIA Insertable cardiac monitor (ICM) versus conventional follow-up Additional ~13% are diagnosed based on inpatient telemetry or 24 hour holter At 6 months Numerous studies have shown detection of paroxysmal atrial fibrillation with prolonged monitoring How long to monitor? ICM group afib 8.9% Conventional F/U afib 1.4% Mean time in afib was 4.3 minutes in a day 2-4 weeks? 2-4 years? Saver NEJM 2016 Sanna NEJM 2014 Page 6

7 Sanna NEJM 2014 Sanna NEJM 2014 How About a New Cause of Stroke ESUS (embolic stroke of undetermined source) Definition - a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic source with a clear indication for anticoagulation Proposed as term to replace (most) cryptogenic stroke a therapeutically relevant entity (??) Hart Lancet Neurology 2014 Hart Lancet Neurology 2014 Page 7

8 Hart Lancet Neurology 2014 Hart Lancet Neurology 2014 Proposed Workup Algorithm for Ischemic Stroke Saver NEJM 2016 Page 8

9 Cryptogenic Stroke Despite an extensive workup, a significant % of patients will not have an identified cause of ischemic stroke Workup is not just inpatient anymore If your rate is >15% you aren t looking hard enough Recurrent annual stroke rate in true cryptogenic stroke is ~3-6% Aggressive treatment of vascular risk factors is always part of the intervention Antiplatelet agents as first-line antithrombotic ESUS (embolic stroke of undetermined source) may become an actual diagnosis with a defined treatment Clinical trials ongoing Page 9

Cryptogenic Stroke: What Don t We Know. Siddharth Sehgal, MD Medical Director, TMH Stroke Center Tallahassee Memorial Healthcare

Cryptogenic Stroke: What Don t We Know. Siddharth Sehgal, MD Medical Director, TMH Stroke Center Tallahassee Memorial Healthcare Cryptogenic Stroke: What Don t We Know Siddharth Sehgal, MD Medical Director, TMH Stroke Center Tallahassee Memorial Healthcare Financial Disclosures None Objectives Principles of diagnostic evaluation

More information

Management and Investigation of Ischemic Stroke By Etiology

Management and Investigation of Ischemic Stroke By Etiology Management and Investigation of Ischemic Stroke By Etiology Andrew M. Demchuk MD FRCPC Director, Calgary Stroke Program Deputy Dept Head, Clinical Neurosciences Heart and Stroke Foundation Chair in Stroke

More information

True cryptogenic stroke

True cryptogenic stroke True cryptogenic stroke Arne Lindgren, MD, PhD Dept of Clinical Sciences Lund, Neurology, Lund University Dept of Neurology and Rehabilitation Medicine Skåne University Hospital Lund, Sweden Disclosures

More information

Patent Foramen Ovale and Cryptogenic Stroke: Do We Finally Have Closure? Christopher Streib, MD, MS

Patent Foramen Ovale and Cryptogenic Stroke: Do We Finally Have Closure? Christopher Streib, MD, MS Patent Foramen Ovale and Cryptogenic Stroke: Do We Finally Have Closure? Christopher Streib, MD, MS 11-8-18 Outline 1. Background 2. Anatomy of patent foramen ovale (PFO) 3. Relationship between PFO and

More information

Management of intracranial atherosclerotic stenosis (ICAS)/intracranial atherosclerosis

Management of intracranial atherosclerotic stenosis (ICAS)/intracranial atherosclerosis Management of intracranial atherosclerotic stenosis (ICAS)/intracranial atherosclerosis Tim Mikesell, D.O. Oct 22, 2016 Stroke facts Despite progress in decreasing stroke incidence and mortality, stroke

More information

PFO Management update

PFO Management update PFO Management update May 12, 2017 Peter Casterella, MD Swedish Heart and Vascular 1 PFO Update 2017: Objectives Review recently released late outcomes of RESPECT trial and subsequent FDA approval of PFO

More information

How Can We Properly Manage Patients With Stroke of Undetermined Origin?

How Can We Properly Manage Patients With Stroke of Undetermined Origin? How Can We Properly Manage Patients With Stroke of Undetermined Origin? : Spotlight on Embolic Stroke of Undetermined Source (ESUS) MI SUN OH Department of Neurology, Hallym University Scared Heart Hospital,

More information

2015 Update in Diagnosis and Management of Stroke

2015 Update in Diagnosis and Management of Stroke 2015 Update in Diagnosis and Management of Stroke S. Andrew Josephson MD Carmen Castro Franceschi and Gladyne K. Mitchell Neurohospitalist Distinguished Professor Senior Executive Vice Chair, Department

More information

Stroke Topics. Advances in the Prevention and Treatment of Stroke. Non-Contrast Head CT. Patient 1-68 yo man

Stroke Topics. Advances in the Prevention and Treatment of Stroke. Non-Contrast Head CT. Patient 1-68 yo man Stroke Topics Advances in the Prevention and Treatment of Stroke August 10, 2009 John W. Engstrom, M.D. Professor of Neurology Acute treatment options for ischemic stroke tpa, clot retraction, future directions

More information

MEET 2007: Evaluation and treatment of the stroke and TIA patient for the non-neurointerventionist. neurointerventionist

MEET 2007: Evaluation and treatment of the stroke and TIA patient for the non-neurointerventionist. neurointerventionist MEET 2007: Evaluation and treatment of the stroke and TIA patient for the non-neurointerventionist neurointerventionist Steve Ramee, MD Ochsner Medical Center New Orleans DISCLOSURE Nothing Nothing to

More information

DEBATE: PFO MANAGEMENT TO CLOSE OR NOT TO CLOSE. Matthew Starr, MD Stroke Attending

DEBATE: PFO MANAGEMENT TO CLOSE OR NOT TO CLOSE. Matthew Starr, MD Stroke Attending DEBATE: PFO MANAGEMENT TO CLOSE OR NOT TO CLOSE Matthew Starr, MD Stroke Attending DISCLOSURES None DEBATE Should PFO be closed? * * Sometimes yes THE CASE AGAINST PFO CLOSURE 1. Did the PFO cause the

More information

Disclosures. CREST Trial: Summary. Lecture Outline 4/16/2015. Cervical Atherosclerotic Disease

Disclosures. CREST Trial: Summary. Lecture Outline 4/16/2015. Cervical Atherosclerotic Disease Disclosures Your Patient Has Carotid Bulb Stenosis and a Tandem Intracranial Stenosis: How Do SAMMPRIS and Other Evidence Inform Your Treatment? UCSF Vascular Symposium 2015 Steven W. Hetts, MD Associate

More information

Advances in Prevention and Treatment of Stroke: What Every Primary Care Physician Needs to Know. Case 1 4/5/11. What treatment should you initiate?

Advances in Prevention and Treatment of Stroke: What Every Primary Care Physician Needs to Know. Case 1 4/5/11. What treatment should you initiate? Advances in Prevention and Treatment of Stroke: What Every Primary Care Physician Needs to Know S. Andrew Josephson, MD Director, Neurohospitalist Program Medical Director, Inpatient Neurology University

More information

Alan Barber. Professor of Clinical Neurology University of Auckland

Alan Barber. Professor of Clinical Neurology University of Auckland Alan Barber Professor of Clinical Neurology University of Auckland Presented with Non-fluent dysphasia R facial weakness Background Ischaemic heart disease Hypertension Hyperlipidemia L MCA branch

More information

What the general cardiologist should know about arrhythmia Stroke prevention in AF" Peter Ammann Kantonsspital St. Gallen

What the general cardiologist should know about arrhythmia Stroke prevention in AF Peter Ammann Kantonsspital St. Gallen What the general cardiologist should know about arrhythmia Stroke prevention in AF" Peter Ammann Kantonsspital St. Gallen What the cardiologist should know about arrhythmia and stroke are there real low

More information

CEREBRO VASCULAR ACCIDENTS

CEREBRO VASCULAR ACCIDENTS CEREBRO VASCULAR S MICHAEL OPONG-KUSI, DO MBA MORTON CLINIC, TULSA, OK, USA 8/9/2012 1 Cerebrovascular Accident Third Leading cause of deaths (USA) 750,000 strokes in USA per year. 150,000 deaths in USA

More information

APPENDIX A NORTH AMERICAN SYMPTOMATIC CAROTID ENDARTERECTOMY TRIAL

APPENDIX A NORTH AMERICAN SYMPTOMATIC CAROTID ENDARTERECTOMY TRIAL APPENDIX A Primary Findings From Selected Recent National Institute of Neurological Disorders and Stroke-Sponsored Clinical Trials That Have shaped Modern Stroke Prevention Philip B. Gorelick 178 NORTH

More information

Speakers. 2015, American Heart Association 1

Speakers. 2015, American Heart Association 1 Speakers Lee Schwamm, MD, FAHA Executive Vice Chairman of Neurology, Massachusetts General Hospital Director, Stroke Service and Medical Director, MGH TeleHealth, Massachusetts General Hospital Director,

More information

[(PHY-3a) Initials of MD reviewing films] [(PHY-3b) Initials of 2 nd opinion MD]

[(PHY-3a) Initials of MD reviewing films] [(PHY-3b) Initials of 2 nd opinion MD] 2015 PHYSICIAN SIGN-OFF (1) STUDY NO (PHY-1) CASE, PER PHYSICIAN REVIEW 1=yes 2=no [strictly meets case definition] (PHY-1a) CASE, IN PHYSICIAN S OPINION 1=yes 2=no (PHY-2) (PHY-3) [based on all available

More information

2018 Update in Diagnosis and Management of Stroke

2018 Update in Diagnosis and Management of Stroke 2018 Update in Diagnosis and Management of Stroke S. Andrew Josephson MD Carmen Castro Franceschi and Gladyne K. Mitchell Neurohospitalist Distinguished Professor Chair, Department of Neurology Director,

More information

Stroke Case Studies. Dr Stuti Joshi Neurology Advanced Trainee Telestroke fellow

Stroke Case Studies. Dr Stuti Joshi Neurology Advanced Trainee Telestroke fellow Stroke Case Studies Dr Stuti Joshi Neurology Advanced Trainee Telestroke fellow Case 1 64 year old female with dysphasia and right arm weakness 3 hours prior CT head: dense M1 sign. No established ischaemia

More information

2/7/

2/7/ Disclosure Intracranial Atherosclerosis an update None Mai N. Nguyen-Huynh, MD, MAS Assistant Professor of Neurology UCSF Neurovascular Service February 7, 2009 Case #1 60 y.o. Chinese-speaking speaking

More information

Stroke/TIA. Tom Bedwell

Stroke/TIA. Tom Bedwell Stroke/TIA Tom Bedwell tab1g11@soton.ac.uk The Plan Definitions Anatomy Recap Aetiology Pathology Syndromes Brocas / Wernickes Investigations Management Prevention & Prognosis TIAs Key Definitions Transient

More information

Karl Meisel, MD MA Director of Stroke Clinic University of California San Francisco

Karl Meisel, MD MA Director of Stroke Clinic University of California San Francisco Karl Meisel, MD MA Director of Stroke Clinic University of California San Francisco I have no financial disclosures 1 Hospital Management Thrombolytic and Thrombectomy Blood pressure Stroke in the Young

More information

Alan Barber. Professor of Clinical Neurology University of Auckland

Alan Barber. Professor of Clinical Neurology University of Auckland Alan Barber Professor of Clinical Neurology University of Auckland Presented with L numbness & slurred speech 2 episodes; 10 mins & 2 hrs Hypertension Type II DM Examination pulse 80/min reg, BP 160/95

More information

Sixth Annual Intensive Update in Neurology 9/15-16/2016. W Tom Kushner DO Swedish Stroke Clinic Neurohospitalist

Sixth Annual Intensive Update in Neurology 9/15-16/2016. W Tom Kushner DO Swedish Stroke Clinic Neurohospitalist W Tom Kushner DO Swedish Stroke Clinic Neurohospitalist 1 One Strategy for cryptogenic stroke: ESUS Positively defined criteria FDA allows clinical trials NOACs have lower risk profile Another strategy

More information

How to Evaluate Patients with Cryptogenic Stroke

How to Evaluate Patients with Cryptogenic Stroke How to Evaluate Patients with Cryptogenic Stroke Jeffrey Saver, MD Professor of Neurology Director, How to Evaluate Patients with Cryptogenic Stroke Disclosure Scientific Consultant, Unpaid Trialist: AGA

More information

Direct oral anticoagulants for Embolic Strokes of Undetermined Source? George Ntaios University of Thessaly, Larissa/Greece

Direct oral anticoagulants for Embolic Strokes of Undetermined Source? George Ntaios University of Thessaly, Larissa/Greece Direct oral anticoagulants for Embolic Strokes of Undetermined Source? George Ntaios University of Thessaly, Larissa/Greece Disclosures Scholarships: European Stroke Organization; Hellenic Society of Atherosclerosis.

More information

TIA: Updates and Management 2008

TIA: Updates and Management 2008 TIA: Updates and Management 2008 S. Andrew Josephson, MD Department of Neurology, Neurovascular Division University of California San Francisco Commonly Held TIA Misconceptions TIA is easy to diagnose

More information

Supplementary webappendix

Supplementary webappendix Supplementary webappendix This webappendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Hart RG, Diener H-C, Coutts SB, et al,

More information

/ / / / / / Hospital Abstraction: Stroke/TIA. Participant ID: Hospital Code: Multi-Ethnic Study of Atherosclerosis

/ / / / / / Hospital Abstraction: Stroke/TIA. Participant ID: Hospital Code: Multi-Ethnic Study of Atherosclerosis Multi-Ethnic Study of Atherosclerosis Participant ID: Hospital Code: Hospital Abstraction: Stroke/TIA History and Hospital Record 1. Was the participant hospitalized as an immediate consequence of this

More information

Vivek R. Deshmukh, MD Director, Cerebrovascular and Endovascular Neurosurgery Chairman, Department of Neurosurgery Providence Brain and Spine

Vivek R. Deshmukh, MD Director, Cerebrovascular and Endovascular Neurosurgery Chairman, Department of Neurosurgery Providence Brain and Spine Vivek R. Deshmukh, MD Director, Cerebrovascular and Endovascular Neurosurgery Chairman, Department of Neurosurgery Providence Brain and Spine Institute The Oregon Clinic Disclosure I declare that neither

More information

2017 Cardiovascular Symposium CRYPTOGENIC STROKE: A CARDIOVASCULAR PERSPECTIVE DR. WILLIAM DIXON AND DR. VENKATA BAVAKATI SOUTHERN MEDICAL GROUP, P.A.

2017 Cardiovascular Symposium CRYPTOGENIC STROKE: A CARDIOVASCULAR PERSPECTIVE DR. WILLIAM DIXON AND DR. VENKATA BAVAKATI SOUTHERN MEDICAL GROUP, P.A. CRYPTOGENIC STROKE: 2017 Cardiovascular Symposium A CARDIOVASCULAR PERSPECTIVE DR. WILLIAM DIXON AND DR. VENKATA BAVAKATI SOUTHERN MEDICAL GROUP, P.A. CRYPTOGENIC STROKE CRYPTOGENIC: OF OBSCURE OR UNKNOWN

More information

2014 Update in Diagnosis and Management of Stroke

2014 Update in Diagnosis and Management of Stroke 2014 Update in Diagnosis and Management of Stroke S. Andrew Josephson MD Carmen Castro Franceschi and Gladyne K. Mitchell Neurohospitalist Distinguished Professor Acting Chairman, Department of Neurology

More information

Practical Considerations in the Early Treatment of Acute Stroke

Practical Considerations in the Early Treatment of Acute Stroke Practical Considerations in the Early Treatment of Acute Stroke Matthew E. Fink, MD Neurologist-in-Chief Weill Cornell Medical College New York-Presbyterian Hospital mfink@med.cornell.edu Disclosures Consultant

More information

Intracranial Atherosclerosis in Asians

Intracranial Atherosclerosis in Asians Intracranial Atherosclerosis in Asians Anthony S. Kim, MD Assistant Clinical Professor of Neurology UCSF Neurovascular Service February 27, 2010 Disclosures Research Support National Institutes of Health

More information

Cryptogenic Stroke: The role of silent Atrial Fibrillation

Cryptogenic Stroke: The role of silent Atrial Fibrillation Cryptogenic Stroke: The role of silent Atrial Fibrillation PD Dr. med. Martin A. Ritter Westfälische Wilhelms-Universität Münster Germany ritterm@uni-muenster.de 1 Turin, 25.10.2014 Agenda 1. What is a

More information

Cryptogenic Stroke: A logical approach to a common clinical problem

Cryptogenic Stroke: A logical approach to a common clinical problem Cryptogenic Stroke: A logical approach to a common clinical problem Alphonse M. Ambrosia, DO, FACC Interventional Cardiologist CardioVascular Associates of Mesa Mesa, Arizona Speakers Bureau Boston Scientific

More information

Canadian Best Practice Recommendations for Stroke Care. (Updated 2008) Section # 3 Section # 3 Hyperacute Stroke Management

Canadian Best Practice Recommendations for Stroke Care. (Updated 2008) Section # 3 Section # 3 Hyperacute Stroke Management Canadian Best Practice Recommendations for Stroke Care (Updated 2008) Section # 3 Section # 3 Hyperacute Stroke Management Reorganization of Recommendations 2008 2006 RECOMMENDATIONS: 2008 RECOMMENDATIONS:

More information

Cryptogenic Stroke: Finding Light in the Darkness

Cryptogenic Stroke: Finding Light in the Darkness Cryptogenic Stroke: Finding Light in the Darkness Scott E. Kasner, MD Professor of Neurology Director, Comprehensive Stroke Center Disclosures WL Gore PI for Gore REDUCE Trial Medtronic DSMB for CRYSTAL

More information

Permanent foramen ovale: when to close?

Permanent foramen ovale: when to close? Permanent foramen ovale: when to close? Pierre Amarenco INSERM U-698 and Denis Diderot University - Paris VII Department of Neurology and Stroke Center Bichat hospital, Paris, France PFO - Pathology TEE

More information

TIA triage in Not all that glitters is gold

TIA triage in Not all that glitters is gold TIA triage in 2016 Not all that glitters is gold Disclosures No industry related disclosures Expert witness work Overview Definition Implications Guidelines, secondary prevention Implementation of guidelines

More information

Antithrombotic Summit Basel 2012 Basel, 26. April Peter T. Buser Klinik Kardiologie Unviersitätsspital Basel

Antithrombotic Summit Basel 2012 Basel, 26. April Peter T. Buser Klinik Kardiologie Unviersitätsspital Basel Antithrombotic Summit Basel 2012 Basel, 26. April 2012 Peter T. Buser Klinik Kardiologie Unviersitätsspital Basel Background stroke = third-leading cause of death among adults 1/5 of stroke survivors require

More information

TRAUMATIC CAROTID &VERTEBRAL ARTERY INJURIES

TRAUMATIC CAROTID &VERTEBRAL ARTERY INJURIES TRAUMATIC CAROTID &VERTEBRAL ARTERY INJURIES ALBERTO MAUD, MD ASSOCIATE PROFESSOR TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER EL PASO PAUL L. FOSTER SCHOOL OF MEDICINE 18TH ANNUAL RIO GRANDE TRAUMA 2017

More information

Cerebrovascular Disease. RTC Conference Resident Presenter: Dr. Christina Bailey Faculty: Dr. Jeff Dattilo October 2, 2009

Cerebrovascular Disease. RTC Conference Resident Presenter: Dr. Christina Bailey Faculty: Dr. Jeff Dattilo October 2, 2009 Cerebrovascular Disease RTC Conference Resident Presenter: Dr. Christina Bailey Faculty: Dr. Jeff Dattilo October 2, 2009 Cerebrovascular Disease Stroke is the 3 rd leading cause of death and the leading

More information

TIA AND STROKE. Topics/Order of the day 1. Topics/Order of the day 2 01/08/2012

TIA AND STROKE. Topics/Order of the day 1. Topics/Order of the day 2 01/08/2012 Charles Ashton Medical Director TIA AND STROKE Topics/Order of the day 1 What Works? Clinical features of TIA inc the difference between Carotid and Vertebral territories When is a TIA not a TIA TIA management

More information

DIFFERENT STROKES FOR DIFFERENT FOLKS!!

DIFFERENT STROKES FOR DIFFERENT FOLKS!! DIFFERENT STROKES FOR DIFFERENT FOLKS!! Identifying Stroke Subtypes SWAROOP PAWAR M.D., MPH. Vascular Neurologist UMG Neuroscience Associates Greenville Health System None Disclosures Outline Stroke, TIA

More information

Slide 1. Slide 2 Conflict of Interest Disclosure. Slide 3 Stroke Facts. The Treatment of Intracranial Stenosis. Disclosure

Slide 1. Slide 2 Conflict of Interest Disclosure. Slide 3 Stroke Facts. The Treatment of Intracranial Stenosis. Disclosure Slide 1 The Treatment of Intracranial Stenosis Helmi Lutsep, MD Vice Chair and Dixon Term Professor, Department of Neurology, Oregon Health & Science University Chief of Neurology, VA Portland Health Care

More information

Carotid Revascularization

Carotid Revascularization Options for Carotid Disease Carotid Revascularization Wayne Causey, MD 2 nd Year Vascular Surgery Fellow Best medical therapy, Carotid Endarterectomy, and Carotid Stenting Who benefits from best medical

More information

The Epidemiology of Stroke and Vascular Risk Factors in Cognitive Aging

The Epidemiology of Stroke and Vascular Risk Factors in Cognitive Aging The Epidemiology of Stroke and Vascular Risk Factors in Cognitive Aging REBECCA F. GOTTESMAN, MD PHD ASSOCIATE PROFESSOR OF NEUROLOGY AND EPIDEMIOLOGY JOHNS HOPKINS UNIVERSITY OCTOBER 20, 2014 Outline

More information

Stroke Update. Claire J. Creutzfeldt, MD January 12, 2018

Stroke Update. Claire J. Creutzfeldt, MD January 12, 2018 Stroke Update Claire J. Creutzfeldt, MD January 12, 2018 Disclosures None relevant to this presentation I receive funding from the NINDS What s new in stroke? A new model for cardioembolic stroke: atrial

More information

Is Stroke a Paradoxical Embolism in Patients with Patent Foramen Ovale?

Is Stroke a Paradoxical Embolism in Patients with Patent Foramen Ovale? ORIGINAL ARTICLE Is Stroke a Paradoxical Embolism in Patients with Patent Foramen Ovale? Masahiro YASAKA, Ryoichi OTSUBO, Hiroshi OE and Kazuo MINEMATSU Abstract Objective Purpose was to assess the stroke

More information

11/27/2017 DISCLOSURE CRYPTOGENIC STROKE CLINICAL PATHWAYS. No Relevant Financial Disclosures Sub-Investigator LEARNING OBJECTIVES

11/27/2017 DISCLOSURE CRYPTOGENIC STROKE CLINICAL PATHWAYS. No Relevant Financial Disclosures Sub-Investigator LEARNING OBJECTIVES CRYPTOGENIC STROKE CLINICAL PATHWAYS Michelle Lee Kearney, ACNP-BC NP, Stroke Program St Thomas Health Nashville, TN DISCLOSURE No Relevant Financial Disclosures Sub-Investigator Stroke-AF Trial (Medtronic)

More information

Ischemic stroke: management, prevention and follow up. Amit Kansara MD Providence Stroke Center Providence Brain and Spine Institute

Ischemic stroke: management, prevention and follow up. Amit Kansara MD Providence Stroke Center Providence Brain and Spine Institute Ischemic stroke: management, prevention and follow up Amit Kansara MD Providence Stroke Center Providence Brain and Spine Institute Quotes Benjamin Franklin: All would live long, but none would be old.

More information

Thrombolysis-WAKE UP Intra-arterial interventions DEFUSE 3 Haemorrhagic Stroke - TICH 2 Secondary Prevention CROMIS 2 Secondary Prevention NAVIGATE

Thrombolysis-WAKE UP Intra-arterial interventions DEFUSE 3 Haemorrhagic Stroke - TICH 2 Secondary Prevention CROMIS 2 Secondary Prevention NAVIGATE Thrombolysis-WAKE UP Intra-arterial interventions DEFUSE 3 Haemorrhagic Stroke - TICH 2 Secondary Prevention CROMIS 2 Secondary Prevention NAVIGATE ESUS Progression of haematoma Anticoagulation Large ICH

More information

5/2/2016. Outpatient Stroke Management Sheila Smith MD May 5, 2016

5/2/2016. Outpatient Stroke Management Sheila Smith MD May 5, 2016 Outpatient Stroke Management Sheila Smith MD May 5, 2016 1 Management of Outpatient Stroke Objectives Review blood pressure management post stroke Review antithrombotic therapy Review statin therapy Discuss

More information

PATENT FORAMEN OVALE: UPDATE IN MANAGEMENT OF RECURRENT STROKE KATRINE ZHIROFF, MD, FACC, FSCAI LOS ANGELES CARDIOLOGY ASSOCIATES

PATENT FORAMEN OVALE: UPDATE IN MANAGEMENT OF RECURRENT STROKE KATRINE ZHIROFF, MD, FACC, FSCAI LOS ANGELES CARDIOLOGY ASSOCIATES PATENT FORAMEN OVALE: UPDATE IN MANAGEMENT OF RECURRENT STROKE KATRINE ZHIROFF, MD, FACC, FSCAI LOS ANGELES CARDIOLOGY ASSOCIATES OBJECTIVES Review social burden and epidemiology of stroke Gender disparities

More information

ACUTE ISCHEMIC STROKE. Current Treatment Approaches for Acute Ischemic Stroke

ACUTE ISCHEMIC STROKE. Current Treatment Approaches for Acute Ischemic Stroke ACUTE ISCHEMIC STROKE Current Treatment Approaches for Acute Ischemic Stroke EARLY MANAGEMENT OF ACUTE ISCHEMIC STROKE Rapid identification of a stroke Immediate EMS transport to nearest stroke center

More information

Secondary Stroke Prevention: A Precautionary Tale

Secondary Stroke Prevention: A Precautionary Tale Secondary Stroke Prevention: A Precautionary Tale Kirsten George-Phillips, BSP Clinical Practice Leader, AHS Clinical Pharmacist, AHS Owen Stroke Prevention Clinic Learning Objectives! Examine literature

More information

Symptoms of small vessel strokes. Small Vessel stroke. What is this? Treatment. Large Vessel stroke 6/1/2018

Symptoms of small vessel strokes. Small Vessel stroke. What is this? Treatment. Large Vessel stroke 6/1/2018 Stroke Stroke Megan Stevens MD Vascular Neurology SUDDEN Maximal at onset Lateralized weakness, lateralized numbness, vision loss (one eye or portion of field in both eyes), double vision, slurred speech,

More information

Patent Foramen Ovale: Diagnosis and Treatment

Patent Foramen Ovale: Diagnosis and Treatment Patent Foramen Ovale: Diagnosis and Treatment Anthony DeMaria Judy and Jack White Chair in Cardiology University of California, San Diego At one time or another a Grantee, Sponsored Speaker or Ad-hoc Consultant

More information

Guiding Secondary Stroke Prevention through Evaluation of Ischemic Stroke Etiology

Guiding Secondary Stroke Prevention through Evaluation of Ischemic Stroke Etiology Guiding Secondary Stroke Prevention through Evaluation of Ischemic Stroke Etiology Ann M. Leonhardt Caprio, MS, RN, ANP-BC Program Coordinator Comprehensive Stroke Center, Strong Memorial Hospital Clinical

More information

Management of Atrial Fibrillation. Leon Ptaszek, MD, PhD, FACC, FHRS 25 March 2018

Management of Atrial Fibrillation. Leon Ptaszek, MD, PhD, FACC, FHRS 25 March 2018 Management of Atrial Fibrillation Leon Ptaszek, MD, PhD, FACC, FHRS 25 March 2018 Disclosures Speaker: St. Jude Medical, Biotronik Consultant: St. Jude Medical, World Care Clinical Objectives Recognize

More information

CLINICAL FEATURES THAT SUPPORT ATHEROSCLEROTIC STROKE 1. cerebral cortical impairment (aphasia, neglect, restricted motor involvement, etc.) or brain stem or cerebellar dysfunction 2. lacunar clinical

More information

Embolic Stroke of Undetermined Source (ESUS) Lee Birnbaum, MD, MS Depts of Neurology and Neurosurgery UTHSCSA

Embolic Stroke of Undetermined Source (ESUS) Lee Birnbaum, MD, MS Depts of Neurology and Neurosurgery UTHSCSA Embolic Stroke of Undetermined Source (ESUS) Lee Birnbaum, MD, MS Depts of Neurology and Neurosurgery UTHSCSA Disclosures UTHSCSA Site-PI for NAVIGATE ESUS Industry sponsored by Bayer New Approach rivaroxaban

More information

Vessel Wall Imaging of Intracranial Arterial Disease Commercial Interests

Vessel Wall Imaging of Intracranial Arterial Disease Commercial Interests Vessel Wall Imaging of Intracranial Arterial Disease Commercial Interests Disclosures No relevant commercial interests Off Label / Investigational Use No off label / investigational use Daniel Mandell,

More information

CVA Updates Karen Greenberg, DO, FACOEP. Director Neurologic Emergency Department Crozer Chester Medical Center

CVA Updates Karen Greenberg, DO, FACOEP. Director Neurologic Emergency Department Crozer Chester Medical Center CVA Updates 2018 Karen Greenberg, DO, FACOEP Director Neurologic Emergency Department Crozer Chester Medical Center Disclosure I have the following financial relationship with the manufacturer of any commercial

More information

Shawke A. Soueidan, MD. Riverside Neurology & Sleep Specialists

Shawke A. Soueidan, MD. Riverside Neurology & Sleep Specialists Shawke A. Soueidan, MD Riverside Neurology & Sleep Specialists 757-221-0110 Epidemiology of stroke 2018 Affects nearly 800,000 people in the US annually Approximately 600000 first-ever strokes and 185000

More information

Endovascular Treatment of Ischemic Stroke

Endovascular Treatment of Ischemic Stroke Endovascular Treatment of Ischemic Stroke William Thorell, MD Associate Professor Neurosurgery UNMC Co-Director Stroke and Neurovascular Center Nebraska Medicine Overview Definitions of terms Review basic

More information

INSTITUTE OF NEUROSURGERY & DEPARTMENT OF PICU

INSTITUTE OF NEUROSURGERY & DEPARTMENT OF PICU CEREBRAL BYPASS An Innovative Treatment for Arteritis INSTITUTE OF NEUROSURGERY & DEPARTMENT OF PICU CASE 1 q 1 year old girl -recurrent seizure, right side limb weakness, excessive cry and irritability.

More information

Carotid Artery Revascularization: Current Strategies. Shonda Banegas, D.O. Vascular Surgery Carondelet Heart and Vascular Institute September 6, 2014

Carotid Artery Revascularization: Current Strategies. Shonda Banegas, D.O. Vascular Surgery Carondelet Heart and Vascular Institute September 6, 2014 Carotid Artery Revascularization: Current Strategies Shonda Banegas, D.O. Vascular Surgery Carondelet Heart and Vascular Institute September 6, 2014 Disclosures None 1 Stroke in 2014 Stroke kills almost

More information

KEEPING YOUR PATIENT OUT OF THE HOSPITAL BY PREVENTING A SECOND STROKE

KEEPING YOUR PATIENT OUT OF THE HOSPITAL BY PREVENTING A SECOND STROKE KEEPING YOUR PATIENT OUT OF THE HOSPITAL BY PREVENTING A SECOND STROKE Dr. Grant Stotts Staff Neurologist, Ottawa Hospital Director, Ottawa Stroke Program Medical Director, Champlain Regional Stroke Program

More information

Stroke Update. Lacunar 19% Thromboembolic 6% SAH 13% ICH 13% Unknown 32% Hemorrhagic 26% Ischemic 71% Other 3% Cardioembolic 14%

Stroke Update. Lacunar 19% Thromboembolic 6% SAH 13% ICH 13% Unknown 32% Hemorrhagic 26% Ischemic 71% Other 3% Cardioembolic 14% Stroke Update Michel Torbey, MD, MPH, FAHA, FNCS Medical Director, Neurovascular Stroke Center Professor Department of Neurology and Neurosurgery The Ohio State University Wexner Medical Center Objectives

More information

Antithrombotic therapy in patients with transient ischemic attack / stroke (acute phase <48h)

Antithrombotic therapy in patients with transient ischemic attack / stroke (acute phase <48h) Antithrombotic therapy in patients with transient ischemic attack / stroke (acute phase

More information

Variables in Riksstroke - TIA

Variables in Riksstroke - TIA Variables in Riksstroke - TIA The TIA registration started 2010 for patients treated in hospital and 2015 it was 67 of 72 hospitals are registrating TIA On the www.riksstroke.org/forms/ you find the Riksstroke

More information

Document Title: The Management of Acute Ischemic Stroke & TIA

Document Title: The Management of Acute Ischemic Stroke & TIA Project: Ghana Emergency Medicine Collaborative Document Title: The Management of Acute Ischemic Stroke & TIA Author(s): Rashmi U. Kothari, M.D. (KCMS/MSU), 2012 License: Unless otherwise noted, this material

More information

PFO- To Close for Comfort. By: Vincent J.Caracciolo, MD FACC

PFO- To Close for Comfort. By: Vincent J.Caracciolo, MD FACC PFO- To Close for Comfort By: Vincent J.Caracciolo, MD FACC PATENT FORAMEN OVALE PFO- congenital lesion that frequently persists into adulthood ( 25-30%)- autopsy and TEE studies. PFO prevalence higher

More information

CLOSE. Closure of Patent Foramen Ovale, Oral anticoagulants or Antiplatelet Therapy to Prevent Stroke Recurrence

CLOSE. Closure of Patent Foramen Ovale, Oral anticoagulants or Antiplatelet Therapy to Prevent Stroke Recurrence CLOSE Closure of Patent Foramen Ovale, Oral anticoagulants or Antiplatelet Therapy to Prevent Stroke Recurrence Guillaume TURC, MD, PhD Paris Descartes University Sainte-Anne hospital Paris, France On

More information

Comparison of Five Major Recent Endovascular Treatment Trials

Comparison of Five Major Recent Endovascular Treatment Trials Comparison of Five Major Recent Endovascular Treatment Trials Sample size 500 # sites 70 (100 planned) 316 (500 planned) 196 (833 estimated) 206 (690 planned) 16 10 22 39 4 Treatment contrasts Baseline

More information

Why Treat Patent Forman Ovale

Why Treat Patent Forman Ovale Why Treat Patent Forman Ovale Clifford J Kavinsky, MD, PHD Professor of Medicine and pediatrics Associate Director, Center for Congenital and Structural Heart Disease Rush University Medical Center Conclusions

More information

Brain Attack. Strategies in the Management of Acute Ischemic Stroke: Neuroscience Clerkship. Case Medical Center

Brain Attack. Strategies in the Management of Acute Ischemic Stroke: Neuroscience Clerkship. Case Medical Center Brain Attack Strategies in the Management of Acute Ischemic Stroke: Neuroscience Clerkship Stroke is a common and devastating disorder Third leading antecedent of death in American men, and second among

More information

NIH Public Access Author Manuscript J Stroke Cerebrovasc Dis. Author manuscript; available in PMC 2008 September 1.

NIH Public Access Author Manuscript J Stroke Cerebrovasc Dis. Author manuscript; available in PMC 2008 September 1. NIH Public Access Author Manuscript Published in final edited form as: J Stroke Cerebrovasc Dis. 2007 ; 16(5): 216 219. Echocardiography in Patients with Symptomatic Intracranial Stenosis Scott E. Kasner,

More information

KEEPING YOUR PATIENT OUT OF THE HOSPITAL BY PREVENTING A SECOND STROKE OR TIA December 8, 2017

KEEPING YOUR PATIENT OUT OF THE HOSPITAL BY PREVENTING A SECOND STROKE OR TIA December 8, 2017 KEEPING YOUR PATIENT OUT OF THE HOSPITAL BY PREVENTING A SECOND STROKE OR TIA December 8, 2017 1 Faculty Disclosure Faculty: Grant Stotts MD, FRCPC Assistant Professor, uottawa Brain and Mind Institute

More information

Current Clinical Trials for Stroke Survivors in NJ and Philadelphia Areas

Current Clinical Trials for Stroke Survivors in NJ and Philadelphia Areas Current Clinical Trials for Survivors in NJ and Philadelphia Areas For more information go to https://clinicaltrials.gov/ and search for the title in search box Condition / Disease 1. Spatial Neglect and

More information

Direct Oral Anticoagulants Beyond Atrial Fibrillation and Venous thrombosis

Direct Oral Anticoagulants Beyond Atrial Fibrillation and Venous thrombosis Direct Oral Anticoagulants Beyond Atrial Fibrillation and Venous thrombosis Robert D. McBane II Gonda Vascular Center 2018 MFMER 3755772-1 Disclosures Bristol-Myers Squibb Research Grant Apixaban in Cancer

More information

Non-commercial use only

Non-commercial use only Italian Journal of Medicine 2016; volume 10:202-206 Embolic stroke of undetermined source: a retrospective analysis from an Italian Stroke Unit Marco Masina, 1 Annalena Cicognani, 1 Carla Lofiego, 2 Simona

More information

collaterals offset ischemia

collaterals offset ischemia Imaging of Intracranial Stenosis objectives & next steps collaterals offset ischemia systematic evaluation of collaterals hemodynamic impact, not % stenosis develop fractional flow measures collateral

More information

Index. cardiology.theclinics.com. Note: Page numbers of article titles are in boldface type.

Index. cardiology.theclinics.com. Note: Page numbers of article titles are in boldface type. Index Note: Page numbers of article titles are in boldface type. A Acute ischemic stroke TOAST classification of, 270 Acute myocardial infarction (AMI) cardioembolic stroke following, 207 208 noncardioembolic

More information

Carotid Artery Stenting

Carotid Artery Stenting Carotid Artery Stenting JESSICA MITCHELL, ACNP CENTRAL ILLINOIS RADIOLOGICAL ASSOCIATES External Carotid Artery (ECA) can easily be identified from Internal Carotid Artery (ICA) by noticing the branches.

More information

Case 1 5/26/2017 ENDOVASCULAR MECHANICAL THROMBECTOMY IN PATIENTS WITH ACUTE ISCHEMIC STROKE

Case 1 5/26/2017 ENDOVASCULAR MECHANICAL THROMBECTOMY IN PATIENTS WITH ACUTE ISCHEMIC STROKE ENDOVASCULAR MECHANICAL THROMBECTOMY IN PATIENTS WITH ACUTE ISCHEMIC STROKE Rhonda Whiteman Racing Against the Clock Workshop June 1, 2017 Objectives To discuss the hyperacute ischemic stroke management

More information

New Trials in Progress: ACT 1. Jon Matsumura, MD Cannes, France June 28, 2008

New Trials in Progress: ACT 1. Jon Matsumura, MD Cannes, France June 28, 2008 New Trials in Progress: ACT 1 Jon Matsumura, MD Cannes, France June 28, 2008 Faculty Disclosure I disclose the following financial relationships: Consultant, CAS training director, and/or research grants

More information

2018 Early Management of Acute Ischemic Stroke Guidelines Update

2018 Early Management of Acute Ischemic Stroke Guidelines Update 2018 Early Management of Acute Ischemic Stroke Guidelines Update Brandi Bowman, PhC, Pharm.D. April 17, 2018 Pharmacist Objectives Describe the recommendations for emergency medical services and hospital

More information

Basilar artery stenosis with bilateral cerebellar strokes on coumadin

Basilar artery stenosis with bilateral cerebellar strokes on coumadin Qaisar A. Shah, MD Patient Profile 68 years old female with a history of; Basilar artery stenosis with bilateral cerebellar strokes on coumadin Diabetes mellitus Hyperlipidemia Hypertension She developed

More information

Advances in Neuro-Endovascular Care for Acute Stroke

Advances in Neuro-Endovascular Care for Acute Stroke Advances in Neuro-Endovascular Care for Acute Stroke Ciarán J. Powers, MD, PhD, FAANS Associate Professor Program Director Department of Neurological Surgery Surgical Director Comprehensive Stroke Center

More information

Secondary Stroke Prevention

Secondary Stroke Prevention Secondary Stroke Prevention Acute stroke conference, Sunnybrook Estates January 20, 2011 Rick Swartz HBSc, MD, PhD, FRCPC Assistant Professor, Department of Medicine, Divisions of Neurology and Obstetrical

More information

ACUTE STROKE TREATMENT IN LARGE NIHSS PATIENTS. Justin Nolte, MD Assistant Profession Marshall University School of Medicine

ACUTE STROKE TREATMENT IN LARGE NIHSS PATIENTS. Justin Nolte, MD Assistant Profession Marshall University School of Medicine ACUTE STROKE TREATMENT IN LARGE NIHSS PATIENTS Justin Nolte, MD Assistant Profession Marshall University School of Medicine History of Presenting Illness 64 yo wf with PMHx of COPD, HTN, HLP who was in

More information

Previous studies of patients enrolled in carotid stenosis

Previous studies of patients enrolled in carotid stenosis Causes and Severity of Ischemic Stroke in Patients With Symptomatic Intracranial Arterial Stenosis Bolanle M. Famakin, MD; Marc I. Chimowitz, MBChB; Michael J. Lynn, MS; Barney J. Stern, MD; Mary G. George,

More information

Recanalization of Chronic Carotid Artery Occlusion Objective Improvement Of Cerebral Perfusion

Recanalization of Chronic Carotid Artery Occlusion Objective Improvement Of Cerebral Perfusion Recanalization of Chronic Carotid Artery Occlusion Objective Improvement Of Cerebral Perfusion Paul Hsien-Li Kao, MD Assistant Professor National Taiwan University Medical School and Hospital ICA stenting

More information

I, (Issam Moussa) DO NOT have a financial interest/arrangement t/ t or affiliation with one or more organizations that could be perceived as a real

I, (Issam Moussa) DO NOT have a financial interest/arrangement t/ t or affiliation with one or more organizations that could be perceived as a real PFO Closure: Where We Are Going to after CLOSURE I Study? Issam D. Moussa, MD Professor of Medicine Chair, Division of Cardiovascular Diseases Mayo Clinic Jacksonville, Florida Disclosure Statement of

More information