Management and Investigation of Ischemic Stroke By Etiology
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1 Management and Investigation of Ischemic Stroke By Etiology Andrew M. Demchuk MD FRCPC Director, Calgary Stroke Program Deputy Dept Head, Clinical Neurosciences Heart and Stroke Foundation Chair in Stroke Research Professor Depts Clinical Neurosciences and Radiology Hotchkiss Brain Institute University of Calgary
2 Recurrent Stroke Rates
3 Stroke Care Continuum Primary Prevention Stroke Onset EMS Transport ED Time Stroke Team Assessment Imaging Acute Treatment Reintegration Rehabilitation Clinical Worsening/ Complication Prevention Admission Secondary Prevention 3
4 Standard Workup for Ischemic Stroke
5 Ischemic stroke?/esus Cardioembolic Large artery Small vessel Other
6 Ischemic stroke?/esus Cardioembolic Large artery Small vessel Other
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8 Vascular imaging Important in young stroke too!
9 Ischemic stroke Cardioembolic Large artery Small vessel Other/?
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11 Atherosclerosis affects multiple vascular beds Large Artery Cerebrovascular disease Coronary artery disease
12 Transcranial Doppler Emboli Detection
13 Two Carotid Revascularization Options >50% symptomatic ICA stenosis CEA CAS vs
14 NNT 3-7
15 Up to 5% in first 5 days
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17 CAS vs CEA trials
18 Better worse CAS vs CEA trials CEA better CAS better CAS better
19 Intracranial (medium sized) atherosclerosis MCA stenosis
20 Intracranial stenting not safe ASA+clopidogrel X 1 month; high dose statins; exercise program
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22 Large Artery Atherosclerosis and dual antiplatelets
23 Large Artery Athero Stroke benefits from statins NNT 20
24 Ischemic stroke Cardioembolic Large artery Small vessel Other/?
25 DWI MRI Single penetrating infarct
26 Hypertensive arteriolosclerosis Multiple lumena (*) Patent arteriole Segmental arteriolar occlusion * * * * Glomeruloid arteriole Lacune Smooth muscle hyperplasia smooth muscle cell loss tunica media Inward disease causes lacunar stroke
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31 Hypertensive arteriolosclerosis Hemosiderin Outward disease causes ICH
32 High dose Atorvastatin use in arteriolosclerosis increased ICH Neurology 2008;70: fold increase in ICH with high dose atorvastatin!
33 Key Messages: Tailored Secondary Prevention Stroke or TIA determine etiology then focus treatment Other/unusual Management varies widely by etiology Dissections and arteriopathies most common Large artery atherosclerosis (CT-angio or MRA) short course of ASA/clopidogrel at least high dose statins; treat to target LDL<2 revascularization if >50% cervical ICA stenosis and early after event Intracranial stenosis stenting not safe Small vessel disease (arteriolosclerosis) (MRI) Aggressive blood pressure control to target most NB- lower better Avoid high dose statins Single antiplatelets long term
34 Case 1 Age 45, no afib, no cerebrovascular risk factors moderate sized cortical stroke- minimal deficits CTA head/neck normal Echo normal TEE normal
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36 No Cause Found Common Especially in Young Stroke
37 PFO stroke eligible
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42 Case 1b Age 45, no afib, no cerebrovascular risk factors moderate sized L cortical stroke- minimal deficits CTA head/neck left cervical carotid web TTE normal
43 8.9% carotid web young cryptogenic stroke 1.9% carotid web age matched controls
44 Web Its Not So Cryptogenic Anymore
45 Case 1c Age 45, no afib, no cerebrovascular risk factors moderate sized cortical stroke- minimal deficits CTA head/neck normal TTE small PFO TEE PFO confirmed
46
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48 GORE
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50 Very Clear Benefit in Stroke Prevention With PFO Closure Overall
51 Who Should Get PFO Closure? Younger patients more benefit
52 Who Should Get PFO Closure? Moderate/large shunts more benefit Large shunts more strokes with medical mgmt
53 Who Should Get PFO Closure? Only Antiplt group benefited from closure AC vs AP
54 Who Should Get PFO Closure? Very high D Dimer predicts high stroke risk <700 >700
55 Role for Anticoagulation in PFO stroke?
56 Role for Anticoagulation in PFO stroke in elderly? Only Antiplt group benefited from closure
57 TCD Bubble Study Best To Evaluate Shunt Size
58 Its Not So Cryptogenic Anymore Web PFO
59 PFO Closure Pathway ESUS TCD bubble: moderate/large shunt <60 years old Requires anticoagulation AC stopped Arrange TEE for PFO characteristics 3 month followup with family to confirm interest in closure Referral to structural heart clinic for interventional cardiology decision on closure
60 Case 2 Age 69, no known afib, stomach cancer moderate cortical stroke CTA head/neck normal Echo normal TEE normal What test should you order?
61
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63 Very Elevated D-dimer > 2 microg/ml = cancer
64 D-dimer falls further with LMWH than with warfarin
65 Its Not So Cryptogenic Anymore Web PFO Cancer Associated Thrombosis
66 Case 3 Age 77, no known afib, cerebrovascular risk factors Prior cortical infarct moderate cortical stroke CTA head/neck normal Echo left atrium mild enlargement Holter 1003 APBs/24h
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71 Yield of Prolonged Rhythm Monitoring
72 Case 3 Age 77, no known afib, cerebrovascular risk factors Prior cortical infarct moderate cortical stroke CTA head/neck normal Echo left atrium mild enlargement Holter 1003 APBs/24h 28 day monitor: several <1 minute runs of atrial fibrillation
73 >24h duration SCAF
74 Its Not So Cryptogenic Anymore Web PFO Cancer covert AF Associated Thrombosis
75 Case 4 Age 77, no known afib, coronary artery disease Prior cortical infarct moderate cortical stroke Echo: moderate LV dysfunction with Apical and lateral hypokinesis
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78 Largest stroke prevention effect if prior stroke Outcome Rivaroxaban plus Aspirin (N=9152) Aspirin (N=9126) Rivaroxaban plus Aspirin vs. Aspirin N Pts %/yr N Pts %/yr HR (95% CI) P P inter Stroke 0.40 No Previous Stroke Previous Stroke ( ) 0.42 ( ) Ischemic or uncertain stroke 0.28 No Previous Stroke Previous Stroke ( ) 0.33 ( ) Previous stroke ARR = 2.7% NNT =
79 Cryptogenic/ESUS Strokes Many Considerations Summary Web PFO Cancer covert AF minor cardiac Associated Thrombosis
80 Cardioembolic Stroke has worst outcome
81 Echo yields warfarin indicated etiologies
82 Atrial Fibrillation Atrial fibrillation (AF) is the most common heart rhythm disturbance It is estimated that 1 in 4 individuals aged 40 will develop AF in their lifetime AF=atrial fibrillation Normal rhythm AF Lloyd-Jones DM, et al. Circulation 2004;110:
83 Stroke Outcome in Patients with AF Effect of first ischemic stroke in patients with AF (n=597) 60% 50% 60% 40% Percent of patients 30% 20% 10% 0% -10% Disabling 20% Fatal 1. Gladstone DJ et al. Stroke 2009; 40:
84 Atrial fibrillation can produce large emboli
85 Anticoagulation in Atrial Fibrillation Thromboembolic Risk Reduction
86 Direct oral anticoagulants (DOACs) Apixaban Edoxaban Dabigatran
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91 GI Bleeding Common Early - Unmasks GI Cancer Recommend occult blood testing, Hb test: 2-4 weeks early after initiation***
92 Case 5 Age 71 male, afib embolic stroke on warfarin INR 2.5; GFR >60
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94 Dabigatran 150 bid best to prevent stroke
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97 Case 6 Age 71 male, afib, mechanical aortic valve embolic stroke on warfarin INR 2.5; GFR >60
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99 Case 7 Age 75 female, afib, Htn, smoker, Needs carotid stenting for symptomatic ICA stenosis
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102 Triple tx Very low dose Riva +DAPT WOEST like Riva 15+P2Y 12
103 Very low dose Riva +DAPT
104 Case 8 Age 79 male, afib for 15 years on warfarin stable INRs brief episode of numbness to left hand
105 Stable on warfarin
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108 Case 9 Age 82 female, afib for 5 years independent,well, GI bleed 10 years ago TIA (aphasia X 5 minutes)
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110 Apixaban safe in the elderly
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114 Apixaban dosing
115 Edoxaban safe in the elderly % dose reduced over 75 yrs old
116 Case 10 Age 90 female, afib for 20 years, suffers cortical infarct,moderate dementia nursing home, very limited quality of life
117 Afib OAC choices after stroke Characteristic Choice High-risk for stroke Dabigatran 150 GERD sx, prior MI/CAD, low GFR Mechanical valve Coronary/carotid stenting Stable on warfarin Elderly Very frail/dependent/poor QOL Riva or Apixa Warfarin +/- ASA NO MORE TRIPLE TX Warfarin + clopidogrel 2.5 bid Riva + DAPT 15 Riva + clopidogrel Continue warfarin esp if questionable new event Apixaban/Edoxaban Consider no treatment
118 Thank-you for your attention! me if you need anything:
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