Alan Barber. Professor of Clinical Neurology University of Auckland

Transcription

1 Alan Barber Professor of Clinical Neurology University of Auckland

2 Presented with Non-fluent dysphasia R facial weakness Background Ischaemic heart disease Hypertension Hyperlipidemia

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7 L MCA branch territory infarct due to large artery disease

8 L MCA branch territory infarct due to large artery disease What secondary vascular prevention measures are required?

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10 All people with ischemic stroke or TIA unless patient needs to be anti-coagulated Clopidogrel alone Low dose aspirin plus dipyridamole Aspirin alone if can t tolerate A+D or C

11 RRR ARR NNT A vs placebo 13% 1% 100 A+D vs A alone 18% C vs A 10% A+D vs C alone no difference A A+D C Aspirin Aspirin plus Dipyridamole Clopidogrel

12 All patients Ischemic stroke or TIA Intracerebral hemorrhage Regardless if normotensive or hypertensive

13 RRR ARR NNT Stroke/TIA 31% 2% 45

14 Statins All patients after ischemic stroke or TIA Not routinely with intracerebral hemorrhage

15 RRR ARR NNT Statins vs placebo 16% 2.2% 45* * Over 5 years (SPARCL trial)

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18 After non-disabling stroke 70-99% ICA stenosis NNT = 6 to prevent stroke/surgical death

19 After non-disabling stroke 70-99% ICA stenosis NNT = 6 to prevent stroke/surgical death 50-69% ICA stenosis in selected patients NNT = 14 to prevent stroke/surgical death

20 After non-disabling stroke 70-99% ICA stenosis NNT = 6 to prevent stroke/surgical death 50-69% ICA stenosis in selected patients NNT = 14 to prevent stroke/surgical death Benefit of surgery halved if delay >2 weeks halved again if delay > 4 weeks

21 Asymptomatic carotid stenosis? Probably no benefit for surgery Compared with aggressive medical management anti-platelets, statins, anti-hypertensive therapy

22 Results from studies don t justify routine stenting for carotid artery stenosis Large learning curve stenting strokes occur on day 1

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25 L weakness lasting <10 mins Past history nil no meds never smoked Diagnosed TIA

26 Age 60 1 Blood pressure high 1 Clinical no weakness 0 speech/no weakness 1 unilateral weakness 2 Duration <10 mins mins 1 1 hour 2 Diabetes 1

27 3% three month stroke risk Age 60 1 Blood pressure high 1 Clinical no weakness 0 speech/no weakness 1 unilateral weakness 2 Duration <10 mins mins 1 1 hour 2 Diabetes 1

28 Started aspirin plus clopidogrel statin anti-hypertensive agent

29 Started aspirin plus clopidogrel statin anti-hypertensive agent ECG normal CT normal CT angiogram normal (incl neck vessels)

30 For TIA & minor stroke aspirin plus clopidogrel

31 For TIA & minor stroke aspirin plus clopidogrel continued for 3 weeks then aspirin stopped

32 For TIA & minor stroke aspirin plus clopidogrel continued for 3 weeks then aspirin stopped We don t use aspirin plus clopidogrel in other stroke patients or for longer duration as increases brain hemorrhage risk

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34 2x episodes L weakness & sensory loss 2-10 mins Background Hypertension T2DM Ex-smoker

35 5. 5 hours

36 Further 5x episodes over 3 days addition of clopidogrel to aspirin i.v. heparin to anti-platelet therapy reduction of anti-hypertensive therapy

37 Further 5x episodes over 3 days addition of clopidogrel to aspirin i.v. heparin to anti-platelet therapy reduction of anti-hypertensive therapy Day 4 had stroke left with L weakness & sensory loss

38 5. 5 hours 4 days

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40 Crescendo episodes of ischemia usually restricted to internal capsule face, arm & leg symptoms Stenosis single penetrating vessel Resistant to therapy 42% go on to lacunar infarction Donnan GA. Neurology;1993;43:957

41 Patients with multiple TIAs need to be seen in ED regardless of ABCD 2 score

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43 Presented with right posterior occipital/cervical pain dizziness double vision slurred speech unsteadiness No known vascular risks

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45 MR angiogram

46 MRI/A acute right thalamic infarction right vertebral artery dissection iv heparin followed by Warfarin for 3/12

47 Consider arterial dissection with neck pain

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49 4 days L anterior neck & peri-auricular pain Slow onset & mild severity Patient noted partial L ptosis

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51 Present with ipsilateral neck pain Horner s syndrome Lower cranial nerve palsies in 12% particularly hypoglossal Hemispheric stroke or TIA

52 Consider dissection with neck pain May present without stroke Horners, hypoglossal nerve palsy with carotid dissection Treat with anti-thrombotic therapy If no stroke Aspirin plus clopidogrel for 3 months If stroke or recurrent TIAs iv. heparin followed by warfarin

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54 Woke slurred speech & L facial droop Stepwise deterioration L lower limb weakness L hand weakness

55 Background Paroxysmal Afib/Aflutter 2010 ablation procedure & warfarin stopped irregular palpitations for 4 weeks Hypertension Increased BMI Impaired glucose tolerance

56 Examination Pulse 72/min irreg irreg (Afib/flutter on ECG) Mild L weakness

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58 Treated with iv heparin because of the stepwise deterioration What oral anti-thrombotic agent?

59 All strokes/year RRR Placebo 12% Aspirin 10% 14% Warfarin 4% 66% EAFT Lancet 1993; 342:1255

60 In 2006 in Auckland only 20% of stroke patients with known AF were taking Warfarin Somerfield J. Stroke 2006;37:1217

61 In 2006 in Auckland only 20% of stroke patients with known AF were taking Warfarin In 2010 in Northland only 31% of stroke patients with known AF were taking Warfarin Bang & McGrath NZMJ 124;28

62 Even if treated with Warfarin INR only therapeutic 1/2-2/3 of time

63 Even if treated with Warfarin INR only therapeutic 1/2-2/3 of time In Auckland 2006 only 15% stroke patients on Warfarin had INR 2-3

64 Even if treated with Warfarin INR only therapeutic 1/2-2/3 of time In Auckland 2006 only 15% stroke patients on Warfarin had INR 2-3 In Northland 2010 only 8% stroke patients on Warfarin had INR 2-3

65 Even if treated with Warfarin INR only therapeutic 1/2-2/3 of time In Auckland 2006 only 15% stroke patients on Warfarin had INR 2-3 In Northland 2010 only 8% stroke patients on Warfarin had INR % risk of major bleeds per year 10% in 1 st year if 80 years

66 Rivaroxaban Apixaban Warfarin Dabigatran

67 patients 71 years, CHADS 2 =2.1 Randomized to Warfarin (open label) Dabigatran 110 mg bd or 150 mg bd Non-inferiority study NEJM 2009; 361:1139

68 Warfarin %/year Dabi 110 %/year Dabi 150 %/year Ischemic stroke * Death * * = superior to warfarin NEJM 2009; 361:1139

69 Warfarin %/year Dabi 110 %/year Dabi 150 %/year Major bleeding * 3.1 ns Gastrointestinal ns 1.5** Intracranial bleeding * 0.3* * superior to warfarin ** inferior to warfarin

70 Discuss risk-benefits with patients Know in advance when to start what dose to use elderly/renal impairment what to do if patient comes in bleeding

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74 Sudden onset weakness intrinsic hand muscles finger flexors and extensors otherwise normal

75 Sudden onset weakness intrinsic hand muscles finger flexors and extensors otherwise normal Background hypertension ECG & 24 hour ECG monitoring normal

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77 What s going on?

78 What s going on? cortical hand

79 What s going on? cortical hand Paroxysmal atrial fibrillation

80 Stroke risk just as great as permanent AF patients need to be anti-coagulated unless contraindication

81 More common than realized In ischemic stroke with no clear cause Non-invasive ambulatory ECG, by 30 days AF in 16% vs 3% Implantable cardiac monitors, by 6 months AF in 9% vs 1% in controls

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83 Presented with R homonymous hemianopia R upper limb sensory loss Left MCA TIA 2008 normal carotid ultrasound scan Smoker Migraine

84 Presented with R homonymous hemianopia R upper limb sensory loss Left MCA TIA 2008 normal carotid ultrasound scan Smoker Migraine PFO & atrial septal aneurysm on echo

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87 PFOs associated with increased stroke risk L parietal infarct at 30 years PFO & smoking only risk factors Should the PFO be closed?

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89 CLOSURE 1 study 909 stroke & TIA patients no difference in stroke/tia/death at 2 yrs 3% major complications & 6% post-procedure AF N Eng J Med 2012; 366:991

90 CLOSURE 1 study 909 stroke & TIA patients no difference in stroke/tia/death at 2 yrs 3% major complications & 6% post-procedure AF RESPECT study 980 stroke patients 25 strokes (2.5%) over 8 years 9 strokes closed vs 16 medical p=0.08 N Eng J Med 2012; 366:991

91 CLOSURE 1 study 909 stroke & TIA patients no difference in stroke/tia/death at 2 yrs 3% major complications & 6% post-procedure AF RESPECT study 980 stroke patients 25 strokes (2.5%) over 8 years 9 strokes closed vs 16 medical p=0.08 Not clinically meaningful differences N Eng J Med 2012; 366:991