Stroke and TIAupdate

Roser Icart Palau

Stroke Physician

Royal London Hospital

Barts Health NHS Trust

November 2014

Stroke update Relevance

Recognizing stroke

Stroke scales

Investigations

Treatment

Secondary prevention

Is stroke relevant? 174-216 people per 100,000 have a stroke in the UK….

Worldwide in 2010

16.9 million people with first ever stroke

5.9 million deaths

33 million stroke survivors

102 million Disability Adjusted Life Years lost due to

stroke

Feigin V et al. The Lancet, 2014: 383;245 - 255

Is stroke relevant? 174-216 people per 100,000 have a stroke in the UK….

Worldwide in 2010

16.9 million people with first ever stroke

5.9 million deaths

33 million stroke survivors

102 million Disability Adjusted Life Years lost due to

stroke

Feigin V et al. The Lancet, 2014: 383;245 - 255

1 every 5 minutes

Stroke recognition Definition:

Rapid loss of partial brain function due to disturbances in the blood

supply to the brain.

Multiple classifications

Clinical presentation

Localized

Onset: sudden and >

Type: “negative” (loss of function

rather than “positive”)

Stroke recognition tools FAST

20% False +

>50%: Sepsis – Seizures – Metabolic - SOL

Pitfall: Posterior Circulation Strokes

ROSIER

Recognition of Stroke in Emergency Room Scale

sensitivity of 93% , specificity of 83% , PPV 94%

Nor AM, et al. Stroke 2004;35:1355–9Harbison J, et al. Stroke 2003;34:71–6

Nor, et al. Lancet Neurol 2005; 4:727-34Jackson A, R J Med Sci, 2008; 177:188-92

ROSIER Score

Loss of

consciousness

-1

Convulsive fits -1

Face weakness 1

Arm weakness 1

Leg weakness 1

Speech disturbance 1

Visual field deficit 1

InvestigationsDiagnosis / Aetiology

CT Head

InvestigationsDiagnosis / Aetiology

MRI Head

InvestigationsDiagnosis / Aetiology

CT Angiogram MRA Dopplers

InvestigationsDiagnosis / Aetiology

Holter

Echocardio

Bubble-echo

TOE

Lipid profile

(random cholesterol)

TFTs

HbA1c

Thrombophilia

Autoimmunity

InvestigationsDiagnosis / Aetiology

Gozalet et al, AJNR, 2006 27:728-735

CT / MRI - Perfusion

Treatment – Acute Thrombolysis

Intravenous alteplase (rt-PA)

Ischaemic strokes + within window + No contraindications

Licence: < 80 years old >80: OK

4.5 hours from onset up to 6h

Lees et al, Lancet 2010; 375: 1695 – 1703.

IST3. Lancet, 2012; 379: 2352-62

Cochrane review, July 2014

ICH 1% to 5%M incr with longer times to treat.

ICH 1% to 8%M at 1/52: 7% vs 11%

6/52: 27% vs 27%

Treatment – Acute Thrombolysis

.

Aspirin

Reduction in: death

(12%) non-fatal recurrent stroke

IST. Lancet, 1997. 31;349:1569-81.

Treatment – Acute Thrombolysis

.

Aspirin

.

Stroke Units

Reduction in mortality: at 4 months ~ 30%,

at 5 years ~ 40%

In haemorrhagic strokes… As well

Langhorne et al, Lancet, Lancet. 1993;14;342 :395-8

Jorgensen et al, Stroke, 1999; 30: 930-933

Langhorne et al. Stroke. 2013: 44;3044-9

Surgical Treatments Neurosurgical intervention

Decompressive hemicraniectomy

External Ventricular Drain

Haematoma evacuation

Carotid endarterectomy

Symptomatic Internal Carotid Artery Stenosis

> 50% (NASCET)

Treatment at discharge Early Support Discharge

Transfers: independent or Assist of 1 … 40%

Improves: death and disability

extended activities of daily life

satisfaction

Secondary prevention

Antiplatelet treatment: Clopidogrel 75mg o.d.

Anticoagulation in AF

Of CV risk factors, aiming for:

BP < 130/80

Cholesterol <4 mmol/LLanghorne et al, Lancet. 2005 ;5-11;365(9458):501-6.

New Treatments New combinations

Dual – Triple antiplatelet therapy

New agents

Desmoteplase - Tenecteplase - Argatroban

Tranexamic Ac

L-Dopa

Interventional approach

Intra arterial tPa

Mechanical clot removal

NeuroprotectionSolitaire device

TIA Definition

Mimics

Risk Assessment

Management

Pathway

TIA - Definition Stroke < 24h

Golden rule:

Is the patient symptomatic at the time of the

assessment?

Yes: Stroke

No: TIA

Minor strokes

Diagnosis: Clinical

MRI

TIA mimics

Nadarajan V, et al. Pract Neurol 2014;14:23–31.

60 %

TIA mimics

Nadarajan V, et al. Pract Neurol 2014;14:23–31.

TIA Risk assessment for stroke

ABCD2

Age ≥ 60 1

BP systolic ≥ 140 mmHg and/or diastolic ≥ 90

mmHg

1

Unilateral weakness (with or without speech

impairment)

or

Speech impairment alone

2

1

Duration ≥ 60 minutes

or

Duration 10 – 59 minutes

2

1

Diabetes 1

Total:

ABCD2

score

2-day

risk of

stroke

7-day risk of

stroke% of

patients

0 - 3 1 % 1.2% 21 %

4 - 5 4.1 % 5.9% 45 %

6 - 7 8.1 % 11.7% 34 % Johnston et al. Lancet 2007;369:283-92.

High

•ABCD2 score ≥ 4

•more than 1 TIA in 7 days

•atrial fibrillation

•on anticoagulation

Low

•ABCD2 score ≤ 3

•Patients that present late

(more than 1 week after their

last symptom) independently

of their score.

TIA management Specialist assessment after risk assessment

High risk TIAs

Low risk TIAs

Treatment

Antiplatelets: Aspirin or Clopidogrel

(loading 300 followed by 75mg)

or LMWH

Address CV risk factors

Advice

Not to drive for a month

Re-symptomatic - 911

24 h

7 days

Summary Relevant

Symptoms: localized + sudden onset + negative

Mimics

TIA: risk assessment

Investigations

Treatment: Stroke Units – Aspirin – Thrombolysis

Rehabilitation

Secondary prevention

Thanks

roser.icartpalau@bartshealth.nhs.uk