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

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1 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 Approach to TIA treatment Prevention of recurrent stroke Primary prevention of stroke Risk factor modification Carotid surgery Patient 1-68 yo man Non-Contrast Head CT HTN, elevated cholesterol, 50 pk-yr smoker Left body weakness/numbness, slurred speech x 60 minutes BP 170/100; P 56; CV exam normal No neglect; left visual field cut present Left body weakness and sensory loss ABIM ReCert Course

2 Q1-What is true about this patient s candidacy for tpa therapy? 1. The patient is within the optimal time frame for TPA therapy 2. A head CT scan is not necessary 3. Treatment with tpa lowers mortality 4. tpa does not increase the risk of intracerebral hemorrhage 5. Hemianopia is a contraindication to tpa 78% 0% 19% 0% 3% Q2-Which statement regarding acute stroke therapy is false? 1. IV tpa can be given up to 4.5 hours after onset of symptoms 2. Time of onset of symptoms is when the patient was last known to be normal 3. Intra-arterial tpa can be given up to 24 hours after onset of symptoms 4. Clot extract < 8 hours onset of symptoms 25% 19% 49% 7% tpa for Acute Stroke-Indications Age > 18 years Onset of symptoms < 4.5 hours; onset is last time patient was known to be normal CT-no hemorrhage CT hypodensity < 1/3 hemisphere Measurable neurologic deficit that is not clearing at the time of the evaluation Acute Stroke-tPA Contraindications Prior 3 months-head trauma, stroke, MI Prior 3 weeks GI/urinary tract hemorrhage BP >185 systolic and > 110 diastolic Plt < 100K, glucose < 50, prior ICH Bleeding, acute trauma, subarach hemorr Major surgery < 14 days, heparin in last 48 hours, INR >1.7 on Coumadin ABIM ReCert Course

3 Acute Stroke-Concurrent Evaluation Noncontrast head CT-mandatory pre-rx Finger stick glucose, oxygen sat Electrolytes, renal function tests, CBC, plt EKG, cardiac enzymes INR, PTT Do not delay tpa treatment unless suspect these values will be abnormal Useful tpa Facts Risk of hemorrhage 5-10x higher in tpa recipients; symptomatic hemorrhage less Only 2-8.5% with acute stroke receive tpa Faster is better-the earlier treatment is started, the better the odds of improvement Original NINDS tpa trial showed 1/3 with improved disability scores at 90 days The Value of Stroke Teams Many judgments in a short time frame Stroke Center Certification Pt care-stroke team, written protocols, EMS, ED, inpatient stroke unit, neurosurgery Support-Director, neuroimaging, laboratory, outcome/quality improvement, CME NINDS-recommends ED MD stroke team head CT tpa < 1 hour Stroke-Two Other Primary Treatments Both require neurointerventional expertise Clot removal up to 8 hours after symptom onset consider when tpa contraindicated Intraarterial tpa given via arterial catheter up to 6 hours after onset of symptoms PROACT studies with urokinase UCSF a study center ABIM ReCert Course

4 Mechanical Embolectomy: Merci Retrieval System Catheter Angiography Pre-Treatment Catheter Angiography Post-Treatment ABIM ReCert Course

5 Acute Stroke Treatment Options hours IV tpa 0-6 hours IA tpa 0-8 hours clot removal-tpa contraindicated > 8 hours-secondary prevention with anticoagulants or antiplatelets Important Stroke Mimics Seizure (postictal state-todd s paresis x hours) Hypoglycemia (focal signs; glucose < 45 mg/dl) Metabolic Encephalopathy Conversion disorder-diagnosis of exclusion Apparent worsening of an old deficit-the deficit associated with a prior stroke looks worse during an acute systemic insult (e.g.-infection) Future Directions How better identify the ischemic penumbra? We assume penumbra has short lifespan Animal models show time dependent growth of ischemic core MR diffusion identifies infarcted tissue CT/MR perfusion identifies ischemic tissue Perfusion/diffusion mismatch = penumbra Patient 2-59 yo woman 30 pack-year smoker with diabetes She has a history of migraine headches 20 minute episode of left face, arm, and leg weakness and numbness Vital signs and physical exam are normal Neurologic examination is normal ABIM ReCert Course

6 Q3-Which is the least likely on the differential diagnosis? Transient Ischemic Attack (TIA) 1. Migraine equivalent 2. Sensory seizure 3. Stroke 4. TIA 53% 30% 9% 8% New definition-neurologic symptoms less than one hour (may persist up to 24 hours), no cerebral infarct on neuroimaging 7 day overall risk of stroke % Classic definition is focal neurologic deficit lasting less than 24 hours 1/3 to 1/2 have evidence of stroke by imaging Treat as for acute stroke Q4-Early treatment of TIA affects future stroke risk. 1. True 2. False 78% 22% 1 2 Future Stroke Risk with TIA ABCD 2 Score Age > 60 years = 1 point BP: SBP > 140 or DBP > 90 = 1 point Clinical: unilateral weakness = 2 points; -Speech disturb without weakness = 1 point Duration > 60 mins = 2 points minutes 1 point Diabetes = 1 point ABIM ReCert Course

7 Stroke Risk: TIA Rx-ABCD 2 Score Risk of stroke at 2 days after symptoms: Score 6-7 points: 8.1% risk (high) Score 4-5 points: 4.1% risk (medium) Score 0-3 points: 1.0% risk (low) Maximum score = 7 points Early Treatment for TIA Treat at time of the symptoms 80% risk reduction resulting from urgent TIA clinics vs. usual primary care visit Short stay (24 hours) treatment 75% discharged on same day Stroke risk reduced 80% from prediction Patient 3-72 yo right-handed man Patient developed right face/arm/leg weakness and numbness two days ago Thought his symptoms would go away; they have improved 50% Risks: Inc cholesterol, tobacco use BP 138/84 HR72 Afebrile CV normal Right hemiparesis and hemisensory loss Q5-Which one of the following statements is true? 1. The patient is a candidate for tpa therapy 2. The patient likely had a small vessel stroke 3. Evidence for possible atrial fibrillation should be collected 4. The patient should receive anticoagulation 3% 5. The patient is at high risk for a poor long term outcome 23% 28% 21% 24% ABIM ReCert Course

8 Typical Large Vessel Stroke Evaluation Brain CT or MRI Echocardiogram-TEE, not TTE EKG, arrhythmia monitoring Carotid evaluation Evaluate and manage stroke risk factors Stroke: Transesophageal vs. Transthoracic Echocardiography 20-50% of large vessel stroke patients may have an embolic source ¾ of embolic sources only seen on TEE TEE better visualizes left atrium, right-toleft shunts, aortic arch 17% of strokes from Afib-accurate number? Atrial Fibrillation Detection EKG detects continuous Afib 48 hour Holter may detect intermittent Afib 30 day monitor may detect 20% more patients with Afib Should a 30 day event monitor be standard? J Stroke Cerebrovasc Dis 18(3), May-Jun 2009 ABIM ReCert Course

9 Stroke-Carotid Evaluation/Rx Endarterectomy has benefit for patients with 70-99% stenosis and ipsilateral symptoms Assumes skillful vascular surgeons Assumes medical Rx available in early 1990s Can use CTA, ultrasound, MRA or angio CTA can also evaluate intracranial vessels Ultrasound common if not using CTA Carotid Endarterectomy vs. Stenting Stenting has role in pts at high surgical risk Conflicting data regarding comparability of stenting vs. endarterectomy Stenting performed by cardiologists, interventional radiologists, vascular surgeons EVA-3S death and stroke rates at 1 and 6 months lower with endarterectomy UCSF Stroke Service Approach Endarterectomy for patients with 70-99% symptomatic lesions Reserve stenting for those at high risk for surgery (post-radiation, restenosis s/p prior TEA, severe CHF, age > 80 years) Use personnel with experience/expertise Q6-Which of the following is not an indication for anticoagulation 1. Atrial fibrillation 2. Left atrial thrombus 3. Patent foramen ovale 4. Carotid artery dissection 5. 90% stenosis of the common carotid artery 0% 0% 26% 38% 36% ABIM ReCert Course

10 Indications for Anticoagulation in Stroke Hypercoagulable states Cardiac thrombus-left atrial or ventricular Patent foramen ovale +/- Low ejection fraction (< 35) +/- Vertebral/carotid dissection +/- Atrial fibrillation Patient 3-72 yo right-handed man Patient developed right face/arm/leg weakness and numbness two days ago Right hemiparesis and hemisensory loss CT confirms non-hemorrhagic stroke EKG, TEE, 48 hour Holter, US negative Q7-What is you first antiplatelet drug of choice? 1. Aspirin 2. Plavix (clopidrogrel) 3. Aggrenox (ASA/dypyridamole) 4. Dipyridamole alone 67% 19% 14% 0% Antiplatelet Therapy for Secondary Prevention of Stroke Aspirin is inexpensive; equally efficacious at low and high dose Plavix is an alternative for those who cannot tolerate aspirin or have failed aspirin Aggrenox is another alternative to aspirin No difference in Plavix vs. Aggrenox; latter with more hemorrhagic events ABIM ReCert Course

11 Supportive Stroke Care Statins after TIA or stroke DVT prophylaxis (Lovenox) Control fever and blood glucose Allow BP to rise (220/110; MAP 130+) Nutritional-swallowing, dehydration PT-subluxation at shoulder in paretic arm Depression; at risk for delerium Approach to Stroke Therapy Candidate for primary treatment?-iv/ia tpa; clot retrieval Inclusion/exclusion criteria; time windows Resources for appropriate administration If not, anticoagulation? Afib, hypercoag, low EF, PFO, cardiac clot, artery dissection If not, candidate for antiplatelet therapy?- ASA, Plavix, Aggrenox Welcome to Lake Tahoe! ABIM ReCert Course

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