Nicolas Bianchi M.D. May 15th, 2012

Transcription

1 Nicolas Bianchi M.D. May 15th, 2012

2 New concepts in TIA Differential Diagnosis Stroke Syndromes

3 To learn the new definitions and concepts on TIA as a condition of high risk for stroke. To recognize the major TIA/stroke syndromes and mimics.

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5 200K-500K per year in US. Incidence /1000 per year. The incidence of TIA increases exponentially with age regardless of race and gender. Among patients who present with stroke, the prevalence of prior TIA has been reported to range from 7% to 40%.

6 TIA: sudden, focal neurological deficit of presumed vascular origin lasting less than 24 hours. Reversible ischemic neurological deficit : 1-7 days. Became obsolete in the 1970 s as it was found that they all lead to new infarction.

7 transient ischemic attack (TIA): a brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction DWI+ in 33% of TIA by old definition More than 6 hours = 50% chance of DWI + DWI+ in some cases of less 30 symptoms.

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9 TIA: TRANSIENT episode of neurological dysfunction caused by FOCAL brain, spinal cord, or retinal ischemia, without acute infarction. Ischemic Stroke: an infarction of central nervous system tissue. Maybe symptomatic or silent May be DWI -

10 True TIAs Migraines Seizures Syncope Vertigo Myasthenia Medication Side Effects Drugs Use or Intoxications Paroxysmal Dyskinesia Periodic Paralysis

11 For patients with relatively brief symptom duration (i.e. symptoms that persist several hours but less than a day) who do not receive a detailed diagnostic evaluation, it may be difficult to determine whether stroke or TIA is the most appropriate diagnosis. Analogous to the term Acute Coronary Syndrome used in cardiology

12 Transient Ischemic Attack Generally lasts minutes, not seconds or hours Usually stroke risk factors are present Migraine with Aura Multiple identical events; lasts minutes to hours No permanent signs or corresponding MRI findings Often with nausea, photophobia, phonophobia Headache may or may not be present Partial Seizure Often lasts seconds, followed by postictal state Limb shaking and/or change in mentation

13 Among TIA patients who go to ED: 5% have stroke in next 2 days 10% have stroke in next 3 months 25% have recurrent TIA in next 3 months 2.6% have major CV event in next 3 months Admit patient for rapid etiological evaluation and decrease risk of stroke if proper therapy instituted.

14 4,574 patients from 12 centers. DWI patients (n = 3,206), Recurrent stroke rates at 7 days: DWI: 7.1% (95% confidence interval ) after tissue-positive and 0.4% ( ) after tissue-negative events (p diff<0.0001). CT: 12.8% ( ) and 3.0% ( ), respectively (p diff < ). The ABCD2 score had predictive value in tissue-positive and tissue-negative events (AUC = 0.68 [95% confidence interval ] and 0.73 [ ], respectively; p sig < for both results, p diff = 0.17). Tissue-positive events with low ABCD2 scores and tissuenegative events with high ABCD2 scores had similar stroke risks, especially after a 90-day follow-up.

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17 Predictors of new vascular events included Symptom duration of >1 hour DWI abnormality. Vascular events occurred in 40% of patients with both of these features. Presence of large-vessel occlusive disease.

18 Will allow for rapid thrombolysis in the event a stroke occurs. It permits cardiac monitoring and facilitates rapid diagnostic evaluation: to obtain evidence of a vascular origin for the symptoms either directly (evidence of hypoperfusion and/or acute infarction) or indirectly (identification of a presumptive source such as a large-vessel stenosis). to exclude an alternative non-ischemic origin to ascertain the underlying vascular mechanism of the event which allows selection of the optimal therapy to identify prognostic outcome categories. Rates of adherence to secondary prevention interventions may also be greater after hospitalization.

19 Sudden Focal Neurologic symptom Weakness, Numbness Slurred speech Difficulty speaking or understanding Vertigo, imbalance, difficulty walking, fall Incoordination Impaired vision: amaurosis fugax, Cranial nerve palsies

20 Ischemic stroke Intracerebral hemorrhage Partial seizure with Todd s Paralysis Hypoglycemia Toxic-metabolic insult with old lesion Subdural hematoma Tumor with bleed or seizure Abscess with seizure

21 Ischemic 87% Large Vessel Disease Cardio Embolism Small Vessel Disease Hemodynamic Undetermined Other: dissection Cryptogenic Hemorrhagic 10 % SAH 3%

22 Hemispheric Contralateral Hemiparesis/Heminumbness F/A/T/L Contralateral Visual Field defect Contralateral neglect (Nondominant Cortical) Aphasia (Dominant Cortical) Dysarthria Cerebellar Ipsilateral Ataxia Brainstem Quadriparesis Vertigo Diplopia Dysarthria Dysphagia

23 430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage 432 Other and unspecified intracranial hemorrhage 433 Occlusion and stenosis of precerebral arteries 434 Occlusion of cerebral arteries 435 Transient cerebral ischemia 436 Acute, but ill-defined, cerebrovascular disease 437 Other and ill-defined cerebrovascular disease 438 Late effects of cerebrovascular disease

24 2012 ICD-9-CM Diagnosis Code 435 Transient cerebral ischemia 2012 ICD-9-CM Diagnosis Code Basilar artery syndrome 2012 ICD-9-CM Diagnosis Code Vertebral artery syndrome 2012 ICD-9-CM Diagnosis Code Subclavian steal syndrome 2012 ICD-9-CM Diagnosis Code Vertebrobasilar artery syndrome 2012 ICD-9-CM Diagnosis Code Other specified transient cerebral ischemias 2012 ICD-9-CM Diagnosis Code Unspecified transient cerebral ischemia recurring, transient episodes of neurologic dysfunction caused by cerebral ischemia; onset is usually sudden, often when the patient is active; the attack may last a few seconds to several hours; neurologic symptoms depend on the artery involved. A brief attack (from a few minutes to an hour) of cerebral dysfunction of vascular origin, with no persistent neurological deficit.

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