TIA. What it is, What it isn t, What to do about it, and When WM. BLAINE BENDURE, MD, MS BOARD CERTIFIED NEUROLOGIST

Transcription

1 TIA What it is, What it isn t, What to do about it, and When WM. BLAINE BENDURE, MD, MS BOARD CERTIFIED NEUROLOGIST

2 Disclosures I have no financial disclosures.

3 Goals By the end of the talk the audience should be able to: Identify the risk of symptomatic stroke following TIA Understand the new definition for transient ischemic attack (TIA) and small stroke without residual deficit List several common mimickers of TIA Identify the risk factors that make up the ABCD 2 score Name the preferred imaging study for TIA patients

4 There s nothing mini about TIA Overall incidence estimated to be >200,000 cases per year 1 40% of all people who have experienced a TIA go on to have an ischemic stroke later 2 WAE(7 Almost half of all strokes may occur within the first 24 hours after a TIA 3 Within 90 days after a TIA, ~10 to 15 % of people will have a stroke 4 Evaluation and treatment within 24 hours can reduce the risk by approximately 80% 5. 1 Kleindorfer, et al, Stroke, Johnston, et al, JAMA, Rothwell, et al, Neurology, Luengo-Fernandez,et al, Lancet Neurol, Chandratheva, et al, Neurology, 2009

5 Slide 4 WAE(7 may?? or do?? Weedn, Ashley E. (HSC), 5/4/2017

6 The NEW definition of TIA 1960s - A sudden neurologic deficit lasting less than 24 hours 2002 A brief neurologic dysfunction with symptoms typically lasting less than one hour without evidence of acute infarction 2009 A transient episode of neurologic dysfunction caused by focal cerebral, spinal cord, or retinal ischemia, without acute infarction 6 Using the new definition, many patients with classically defined TIA are redefined as having a minor stroke if there is any evidence of acute infarction on MRI 6 Easton, et al, Stroke, 2009

7 Minor strokes have even higher risk A study using classically defined TIA showed patients with infarction on MRI had an in-hospital stroke rate of 19.4%, compared with 1.3% among those without evidence of infarction 7 A study using the new definition of TIA to evaluate patients with symptoms <24 hours also showed increased risk among those with evidence of infarction on MRI 7.1% had a stroke within the next seven days, compared with just 0.4% of patients without evidence of infarction 8 7 Ay, et al, Ann Neurol., Giles, et al, Neurology, 2011

8 Case Example 1 65-year-old man with HTN, HLP, CAD, and previous heavy smoker, presents to the emergency department one hour after having transient speech difficulties with right face and hand weakness that lasted for approximately 20 minutes. The patient had been outside at his ranch for several hours and it was a sunny hot day. Vitals T37.8, BP 100/72, HR 106. On examination appears stated age and in NAD, mouth and skin appear dry. RRR, S1S2, no murmurs. He has a soft bruit over his left carotid. Chest CTAB. Abdomen is soft NTND. Neurological examination is non-focal. CT head Atrophy appropriate for age. Hypodense changes in the supratentorial white matter c/w microvascular ischemic changes, no bleeding, no early signs of infarction, no chronic strokes, significant calcification in the bilateral carotid siphons.

9 Case Example 1 65-year-old man with HTN, HLP, CAD, and previous heavy smoker, presents to the emergency department one hour after having transient speech difficulties with right face and hand weakness that lasted for approximately 20 minutes. The patient had been outside at his ranch for several hours and it was a sunny hot day. Vitals T37.8, BP 100/72, HR 106. On examination appears stated age and in NAD, mouth and skin appear dry. RRR, S1S2, no murmurs. He has a soft bruit over his left carotid. Chest CTAB. Abdomen is soft NTND. Neurological examination is non-focal. CT head Atrophy appropriate for age. Hypodense changes in the supratentorial white matter c/w microvascular ischemic disease, no bleeding, no early signs of infarction, no chronic strokes, significant calcification in the bilateral carotid siphons.

10 Case Example Don t forget to check for volume depletion and listen for a bruit! Carotid stenosis with TIA symptoms is high risk and requires urgent evaluation and intervention Evaluate with CTA or MRA of head and neck when stenosis is suspected

11 Symptomatic carotid stenosis 50% or greater stenosis or occlusion in a symptomrelevant vessel in the intracranial or extracranial circulation puts a patient at high risk for future stroke 9 9 Coutts, et al, Stroke, 2012

12 TIA Mimics Clinical Symptom Odds Ratio of a TIA Mimic Memory loss 9.17 Headache 3.71 Blurred vision 2.48 Unilateral paresis 0.35 Transient monocular blindness 0.15 Diplopia 0.14 Note: The higher the odds ratio is above 1 the more likely the symptom is due to a TIA mimic; the lower the odds ratio is below 1 the more the symptom is due to a TIA or stroke 10 Amort M et al. Cerebrovasc Dis. 2011

13 Other differentials to consider Intracranial hemorrhage Hypoglycemia Migraines Seizure disorder Brain tumor or metastases Multiple sclerosis CNS infection or vasculitis

14 Case Example 2 32-year-old woman with history of smoking (not on oral contraception) is transferred from another ED where she presented with transient difficulty speaking and left facial weakness 45 minutes into symptom onset and resolved 5 minutes after she received IV tpa (NIHSS = 3). She denies any headache symptoms. She had a fight with her boyfriend a few hours prior to the onset of symptoms. Vitals: T36.1, BP 132/80, HR 91. WD/WN woman, appears anxious and tearful, NCAT, RRR, no murmurs, CTAB, neurologic examination nonfocal, face now appears symmetric and speech is fluent. CT head appropriate for age with no evidence of acute abnormalities (of note she has had two previous head CTs and one brain MRI w/o contrast done for left facial weakness and headache that were all unremarkable)

15 Case Example 2 32-year-old woman with history of smoking (not on oral contraception) is transferred from another ED where she presented with transient difficulty speaking and left facial weakness 45 minutes into symptom onset and resolved 5 minutes after she received IV tpa (NIHSS = 3). She denies any headaches symptoms. She had a fight with her boyfriend a few hours prior to the onset of symptoms. Vitals: T36.1, BP 112/80, HR 91. WD/WN woman, appears anxious and tearful, NCAT, RRR, no murmurs, CTAB, neurologic examination nonfocal, face now appears symmetric and speech is fluent. CT head appropriate for age with no evidence of acute (or chronic) abnormalities (of note she has had two previous head CTs and one brain MRI w/o contrast done for left facial weakness and headache that were all unremarkable)

16 ABCD 2 score ABCD 2 Scoring System for Evaluating Stroke Risk After TIA 11 CLINICAL CHARACTERISTICS POINTS Age 60 year 1 Blood pressure: systolic 140 mm Hg or 1 diastolic 90 mm Hg Clinical characteristics Unilateral weakness 2 Speech impairment w/o weakness 1 Diabetes mellitus 1 Duration of TIA symptoms 60 minutes minutes 1 Allows stratification of patients High risk (score 6 or 7) 8.1% 2-day risk of stroke Moderate risk (score 4 or 5) 4.1% 2-day risk of stroke Low risk (score 0 to 3) 1% 2-day risk of stroke). 11 Johnston et al. Lancet 2007

17 ABCD 2 Scores for Case Example 1 and 2 CLINICAL CHARACTERISTICS POINTS Case 1 Case 2 Age 60 year Blood pressure: systolic 140 mm Hg or diastolic 90 mm Hg Clinical characteristics Unilateral weakness Speech impairment w/o weakness Diabetes mellitus Duration of TIA symptoms 60 minutes minutes Total Score = 5 3

18 When to hospitalize for TIA* The 2009 American Heart Association and American Stroke Association (AHA/ASA) guidelines 6 for the definition and evaluation of TIA state that it is reasonable to hospitalize patients with TIA who present within 72 hours of symptom onset and meet any of the following criteria: ABCD 2 score of 3 ABCD 2 score of 0 to 2 and uncertainty that the diagnostic workup can be completed within two days as an outpatient ABCD 2 score of 0 to 2 and other evidence that the event was caused by focal ischemia

19 Hospitalize vs specialty clinic follow up vs discharge with none If all patients are hospitalized who present to the ED then significant time and healthcare dollars will be spent on some patients who actually have TIA mimics Patients with true TIA compete with the patients with TIA mimics for urgent studies possibly creating delays in diagnosis and treatment Patients discharged from the ED without specialty clinic follow up are less likely to receive timely stroke interventions and more likely to have higher rates of stroke/tia or death Kapral et al. Neurology 2016

20 TIA Specialty Clinics Patients determined to have low risk for stroke are discharged from ED to follow up in outpatient TIA clinics within hours Reduces number of patient admissions Saves healthcare dollars Preferred by some patients Several different models with different methods of stratification M3T model, SOS-TIA (Paris model), EXPRESS (Oxford model), Stanford model, Ottawa model, FASTEST (New Zealand model) Despite differences they each reduce stroke rate after TIA Ranta et al. Neurology 2016

21 Initial Evaluation of a Patient with TIA Head imaging is recommended on all TIA patients within 24 hours of the onset of symptoms MRI-DWI is the preferred imaging modality as it has high sensitivity for detecting infarction 6 There may only be partial acceptance of these guidelines 14 In a retrospective study of VA patients diagnosed with TIA/minor stroke only 40% had MRI within 2 days even though there were no predefined radiology protocols and no cost constraints 14 Chaturvedi, et al, Neurology, 2017

22 Immediate treatment in a patient with TIA RRR ARR NNT Antiplatelet therapy 13-28% 1-1.9% HMG-CoA reductase inhibitor Antihypertensive agent Anticoagulant for atrial fibrillation 16% 0.44% % % % 8% 13 Adapted from Ranta et al. Neurology 2016

23 Antiplatelet Therapy for TIA Short term use of dual antiplatelet therapy may be better at lowering risk following TIA/small stroke than aspirin alone (FASTER and CHANCE) Ticagrelor has greater efficacy in ACS compared with clopidogrel (PLATO), but in TIA/stroke it is not better than aspirin alone (SOCRATES) Ticagrelor-aspirin combo may be more beneficial after minor stroke, but with increased minor bleeding (PRINCE) Patients carrying cytochrome CYP2C19*2 or *3 variants, which are more common in the Asian population, have worse results on clopidogrel

24 Antiplatelet Therapy for TIA Triple therapy is not superior to aspirin/dipyridamole or clopidogrel alone and only increases bleeding (TARDIS) The NIH-sponsored Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial is randomly assigning patients to clopidogrel plus aspirin vs aspirin alone starting within 12 hours of a small stroke or TIA

25 In Conclusion TIA offers the greatest opportunity to prevent stroke that physicians will encounter The new tissue-based definition (as opposed to time-based) focuses less on an arbitrary time limit and more on whether there was a vascular event without actual evidence of infarction TIA mimics are common and appropriately stratifying patients is important so that moderate and high risk patients receive timely intervention All TIA patients require a complete investigation into the cause of their symptoms so that they are sent out on the best combination of therapies to lower their risk of stroke

26 Thank you

27 References 1. Kleindorfer et al. Incidence and short-term prognosis of transient ischemic attack in a population-based study. Stroke Apr;36(4): Epub 2005 Feb Rothwell PM, Warlow CP. Timing of TIAs preceding stroke: time window for prevention is very short. Neurology. 2005;64(5): Chandratheva A, Mehta Z, Geraghty OC, Marquardt L, Rothwell PM; Oxford Vascular Study.. Population-based study of risk and predictors of stroke in the first few hours after a TIA. Neurology Jun 2;72(22): doi: /WNL.0b013e3181a826ad. PubMed PMID: ; PubMed Central PMCID: PMC Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA. 2000; 284: Luengo-Fernandez R, Gray AM, Rothwell PM. Effect of urgent treatment for transient ischaemic attack and minor stroke on disability and hospital costs (EXPRESS study): a prospective population-based sequential comparison. Lancet Neurol 2009; 8: Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009; 40: Ay H, Koroshetz WJ, Benner T, et al. Transient ischemic attack with infarction: a unique syndrome? Ann Neurol. 2005;57(5): Giles MF, Albers GW, Amarenco P, et al. Early stroke risk and ABCD 2 score performance in tissue-vs time-defined TIA: a multicenter study. Neurology. 2011;77(13):

28 . References 9. Coutts SB, Modi J, Patel SK, et al. CT/CT angiography and MRI findings predict recurrent stroke after transient ischemic attack and minor stroke: results of the prospective CATCH study. Stroke 2012;43(4): doi: /strokeaha Amort M, Fluri F, Schäfer J, et al. Transient ischemic attack versus transient ischemic attack mimics: frequency, clinical characteristics and outcome. Cerebrovasc Dis. 2011;32(1): Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369: Kapral MK, Hall R, Fang J, Austin PC, Silver FL, Gladstone DJ, Casaubon LK, Stamplecoski M, Tu JV. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology Apr 26;86(17): Ranta A, Barber PA. Transient ischemic attack service provision: A review of available service models. Neurology Mar 8;86(10): Chaturvedi S, Ofner S, Baye F, Myers LJ, Phipps M, Sico JJ, Damush T, Miech E, Reeves M, Johanning J, Williams LS, Arling G, Cheng E, Yu Z, Bravata D. Have clinicians adopted the use of brain MRI for patients with TIA and minor stroke? Neurology Jan 17;88(3):