Alan Barber. Professor of Clinical Neurology University of Auckland

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Alberta Gilbert
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1 Alan Barber Professor of Clinical Neurology University of Auckland

2 Presented with L numbness & slurred speech 2 episodes; 10 mins & 2 hrs Hypertension Type II DM Examination P 80/min reg, BP 160/95, normal neurology

3 Diagnosed as TIA Discharged from hospital outpatient appointment at stroke clinic

4 Stroke

5 Loss of focal brain (or eye) function Of presumed vascular origin temporary loss of blood flow to brain/eye Symptoms resolve <24 hours Stroke

6 Loss of focal brain (or eye) function Of presumed vascular origin temporary loss of blood flow to brain/eye Symptoms resolve <24 hours A TIA is where stroke symptoms disappear within 24 hours Stroke

8 But

9 But most TIA s last only minutes 60% <1 hour 71% <2 hours 14% 2-24 hours

10 But 1/3 of TIA patients have acute cerebral infarction on MRI scans

11 Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, without evidence of acute infarction

12 Transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, without evidence of acute infarction Tissue based definitions useful infarction distinguishes MI from angina focuses on pathophysiology, not temporal factors

13 An infarction of central nervous system tissue

14 TIAs don t precede cerebral hemorrhage don t cause loss of consciousness

15 TIAs don t precede cerebral hemorrhage don t cause loss of consciousness TIAs almost never cause isolated focal symptoms double vision or dysphagia non-focal symptoms faintness, dizziness, confusion

16 1 in 5 people with stroke had a TIA first

17 1 in 5 people with stroke had a TIA first The risk of stroke following a TIA is high

18 1 in 5 people with stroke had a TIA first The risk of stroke following a TIA is high Strokes after TIA are severe 1 in 5 fatal 2 in 3 survivors disabled

19 1 in 5 people with stroke had a TIA first The risk of stroke following a TIA is high Strokes after TIA are severe 1 in 5 fatal 2 in 3 survivors are disabled Not all TIAs carry the same stroke risk

20 Presented with L numbness & slurred speech 2 episodes; 10 mins & 2 hrs Hypertension Type II DM Examination P 80/min reg, BP 160/95, normal neurology

22 Age 60 1

23 Age 60 1 Blood pressure high 1

24 Age 60 1 Blood pressure high 1 Clinical no weakness 0 speech/no weakness 1 unilateral weakness 2

25 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

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 Presented with L numbness & slurred speech 2 episodes - 1 st 10 mins, 2 nd 2 hrs Hypertension Type II DM Examination normal but BP 160/95 ABCD2 = 6

28 25% 20% Stroke Risk 15% 10% 2-Day Risk 7-Day Risk 30-Day Risk 90-Day Risk 5% 0% ABCD 2 Score

29 ABCD2 score: Proportion of TIAs 34% 45% 21% Stroke risk at 2 days days months

30 As bad or worse than unstable angina Unstable angina 12% 30 day risk of death or MI Lancet 2002;359:189-98

31 80% of strokes after TIA can be prevented start aspirin (or clopidogrel) straight away blood pressure lowering therapy cholesterol lowering therapy stop smoking urgent carotid revascularisation

32 Discharged from hospital no change to usual aspirin outpatient appointment at stroke clinic Represented 4 days later with severe stroke left hemiparesis, sensory loss and neglect

33 Patients who need to be seen urgently ABCD 2 4 ABCD 2 <4 and In atrial fibrillation On an anti-coagulant Crescendo (recurrent TIAs) Patients who don t need to be seen urgently ABCD 2 <4 TIA more than a week ago ABCD 2 no good for posterior circulation

34 Patients who need to be seen urgently ABCD 2 4 ABCD 2 <4 and In atrial fibrillation On an anti-coagulant Crescendo (recurrent TIAs) Patients who don t need to be seen urgently ABCD 2 <4 TIA more than a week ago n

35 Patients who need to be seen urgently ABCD 2 4 ABCD 2 <4 and In atrial fibrillation On an anti-coagulant Crescendo (recurrent TIAs) Patients who don t need to be seen urgently ABCD 2 <4 TIA more than a week ago ABCD 2 no good for posterior circulation

36 Dr Anna Ranta, MD, FRACP on behalf of the FASTEST Trial Team

38 In primary care, an electronic decision support tool Improved guideline adherence Reduced 90 day stroke risk Reduced treatment costs without affecting safety A Ranta Neurology 2015

40 R weakness lasting <10 mins Past history nil / no meds never smoked Diagnosed TIA

41 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

42 R weakness lasting <10 mins Past history nil / no meds never smoked ABCD2 = 2 3% three month stroke risk

43 R weakness lasting <10 mins Past history nil / no meds never smoked ABCD2 = 2 3% three month stroke risk No meds started & referred to outpatients

44 Admitted 3 days later slurred speech R face, arm and leg weakness BP 220/120 L subcortical infarct

45 We recommend sending patients to ED if ABCD 2 4 ABCD 2 <4 and In atrial fibrillation On an anti-coagulant Crescendo (recurrent TIAs)

46 But ABCD 2 = 2 patient still at risk for stroke (1 in 33)

47 But ABCD 2 = 2 patient still at risk for stroke (1 in 33) Before they leave start secondary prevention aspirin or clopidogrel anti-hypertensive lipid lowering therapy

49 Successive days had transient (10-15 mins) right amaurosis fugax left hand weakness one episode of right leg weakness Hypertensive, cholesterol, ex smoker R carotid bruit & normal neuro examination

50 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 10% three month stroke risk

51 Successive days had transient (10-15 mins) right amaurosis fugax left hand weakness one episode of right leg weakness Hypertensive, cholesterol, ex smoker R carotid bruit & normal neuro examination Started aspirin & sent in

52 CT head normal Carotid US >70% right ICA stenosis L ICA occlusion Management iv heparin urgent carotid endarterectomy no further events

53 Send people to ED if recurrent TIAs regardless of ABCD 2 iv heparin often used with crescendo TIAs Urgent carotid US for people with carotid territory TIAs most benefit of carotid revascularisation in 1 st days after a TIA or minor stroke

54 Send people to ED if recurrent TIAs regardless of ABCD 2 iv heparin often used with crescendo TIAs Urgent carotid US for people with carotid territory TIAs most benefit of carotid revascularisation in 1 st days after a TIA or minor stroke What was the cause of right leg weakness?

56 Presented with slurred speech resolved after 1 h very mild L leg weakness (persisting when seen) Background HT dyslipidaemia TIA diagnosed & aspirin started

57 Admitted 3 weeks later headache L leg heavy and dragging Examination mild left arm & leg incoordination

59 It s not a TIA if neurological symptoms & signs when you see them TIA patients need brain imaging

61 Presented with left sided tongue numbness & tingling numbness slowly spread over 10 mins left mouth, face, upper limb & lower limb left upper & lower limbs felt heavy Background Nil Oral contraceptive

62 Examination Alert and oriented left facial, arm & leg sensory loss 4+/5 weakness left upper & lower limbs Investigations ECG normal Bloods normal

64 What s going on?

65 What s going on? Migraine

66 What s going on? Migraine Had low grade left-sided pressure that she hadn t commented on until asked Nothing to suggest previous migraine No family history of migraine Started Amitriptyline increasing to 75 mg at night

67 Tingling is a positive symptom should prompt consideration of migraine or sensory seizures Sensory march of symptoms over minutes typical for migraine Headache in migraine can be subtle

69 Presented with multiple episodes of L arm weakness L face and hand numbness/tingling lasting 20 mins Hypertensive Normal examination Multiple TIAs

70 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 10% three month stroke risk

72 What s going on?

73 What s going on? Subarachnoid blood Sensory seizures Episodes stopped on phenytoin

74 Tingling is a positive symptom should prompt consideration of migraine or sensory seizures

76 Recurrent thunderclap headaches Recurrent episodes of ataxia bilateral LL weakness & sensory loss visual blurring Fluoxetine for depression Daily cannabis use

78 Admission

79 Admission 6 weeks later

80 94% thunderclap headaches 22% cortical SAH 16% TIA 4% stroke 6% intracerebral hemorrhage 3% seizures Ducros A. Brain;2007;130:3091

81 RCVS 37% spontaneous 7% post partum 55% vasoactive substances cannabis 30% SSRI 19% decongestants 12% cocaine 5% Ducros A. Brain;2007;130:3091

83 Presented (while driving) with Left upper limb fat & heavy Had to steer with right hand Then involuntary jerking left arm over 45 mins No alteration of awareness or other symptoms

84 Left parietal infarct at 30 years Left MCA TIA 2008 normal carotid ultrasound scan Smoker Migraine

86 What s going on?

87 What s going on? Focal onset seizures

88 What s going on? Focal onset seizures What do you do?

89 What s going on? Focal onset seizures What do you do? Lamotrigine; increasing to 100 mg BD Driving restriction

91 6x episodes over 4 weeks L upper & lower limb shaking when standing or walking eased if lay down Background R MCA infarct at 34 years Occluded R ICA Hypertensive, elevated lipids, smoker

92 L & R ICA systems separate with no Circle of Willis flow R ICA occluded R CCA stensosed L ICA patent

94 Jerky, coarse, involuntary movements upper +/- lower limbs multiple episodes last < 5 minutes precipitated by rising, exercising, coughing often accompanied by paresis 10% of patients with ICA occlusion Persoon S. Brain;2010;133:915

95 Due to low cerebral blood flow Not recurrent emboli epileptic no change level of consciousness face & trunk spared no Jacksonian march normal EEG Persoon S. Brain;2010;133:915

96 L & R ICA systems separate with no Circle of Willis flow R ICA occluded R CCA stensosed L ICA patent R CCA stented

98 TIAs precede ¼ strokes carry a poor prognosis up to 80% of strokes can be prevented stroke risk can be determined by ABCD2 score

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