25
Stroke and TIA update Roser Icart Palau Stroke Physician Royal London Hospital Barts Health NHS Trust November 2014
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
