Presentation on theme: "Advances in Prevention and Treatment of Stroke 2008"— Presentation transcript:
1 Advances in Prevention and Treatment of Stroke 2008 S. Andrew Josephson, MDDepartment of Neurology, Neurovascular DivisionUniversity of California San FranciscoThe speaker has no disclosures
2 Case 1A 67 year-old woman with a history of HTN presented to the ED after being found at work not moving her right side.Exam shows mutism, R face and arm plegia with decreased sensation in R arm as well as L gaze deviation and R homonymous hemianopsia.Her symptoms began at noon, it is now 4:30 p.m. There are no contraindications to tPA.
3 What treatment should you initiate? IV t-PAIV heparinAntiplateletsMechanical EmbolectomyIntra-arterial t-PA
4 The 2007 Acute Stroke Timeline Time of onset= last time seen normal0-3 Hours IV-tPA0-6 Hours IA-tPA0-8 Hours Mechanical EmbolectomyGreater than 8 hours Anticoagulants or Antiplatelets
5 Case 2A 40 year-old man with no PMH comes to the ED after a 30 minute episode of aphasia and right arm weakness that has since resolved.The patient reports 5 days of neck pain after severe vomiting from a gastroenteritisExam is normal
6 What is the likely etiology of his TIA? Afib-related cardioembolic diseasePFOCarotid artery dissectionSmall vessel diseaseEndocarditis-related septic emboli
7 Differential for Transient Focal Neurologic Deficit The Big Three1. Stroke/TIA2. Seizure3. Complicated Migraine
8 Risk of Future Stroke with TIA: ABCD2 Score 7-day risk overall percentAge>60 =1 pointBlood PressureSBP>140 or DBP>90 =1 pointClinical FeaturesUnilateral weakness =2 pointsSpeech disturbance without weakness =1 pointDuration>60 minutes =2 points10-59 minutes =1 pointDiabetes=1 pointJohnston SC et al: Lancet 369:283, 2007
10 Aggressive Therapy for TIA Two key studies in October 20071. SOS-TIA trial1085 patients with TIA admitted to a 24-hour centerAll treated with standard therapy74 percent discharged on same day, stroke risk reduced 80 percent from ABCD2 prediction2. EXPRESS study80 percent reduction in risk with urgent TIA clinic visit versus usual primary care visit in 1278 patientsLavallee PC et al: Lancet Neurology 6:953, 2007Rothwell PM et al: Lancet 369:Oct 8, 2007
11 Approach to Stroke Treatment Acute Stroke Therapy?Anticoagulants?AntiplateletsNoNo
12 Shrinking Indications for Anticoagulation in Stroke 1. Atrial Fibrillation2. Some other cardioembolic sourcesThrombus seen in heart?EF<35?PFO with associated Atrial Septal Aneurysm3. Vertebral and carotid artery dissection4. Rare hypercoagulable states: APLA
13 Cervical Artery Dissection Vertebral and Carotid ArteriesCommon etiology of stroke in youngPathophysiologyRisk FactorsMost idiopathicVomiting, Coughing, ChiropracticPresentation: Neck Pain, HATx with anticoagulation
14 Case 3A 65 year-old man with a history of DM, HTN presents with 2 days of L sided binocular visual lossExamination shows left-sided homonymous hemianopia and is otherwise unremarkable.The patient is on ASA 81mg daily
16 TEE vs. TTE (Stroke 10/06)231 consecutive TIA and stroke patients of unknown etiology underwent TTE and TEE127 found to have a cardiac cause of emboli, 90 of which (71 percent) only seen on TEE38 of 46 “major risk factors” only found on TEE (most left atrial thrombi)TEE superior to TTE for: LA appendage, R to L shunt, examination of aortic arch
22 Aggrenox vs. Plavix Aggrenox Plavix Headache in first 2 weeks: 30% discontinuePerhaps not compatible with cardiac antiplatelet goals or with unstable anginaCannot be crushed in FTPlavixLess evidence directly from stroke trialsConcerns regarding use with ASAPRoFESS trial results announced May 2008
23 Antiplatelet Options If on no antiplatelet medication ASA or Plavix vs. AggrenoxIf already on ASASwitch to Plavix vs. AggrenoxNote: There is no acute data for AggrenoxIf already on Plavix or Aggrenox???
24 Other Acute Stroke Management Statins for (almost) allSPARCL (NEJM 8/06), 80mg atorvastatin in stroke and TIA if LDL>100Permissive HTNTo at least 220/120 (unless IV t-PA): Mortality and morbidity increases if lower acutelyTight Glucose and Fever controlEnoxaparin for DVT prophylaxisPREVAIL trial (Lancet 2007)
25 Case 4A 68 year-old woman with a history only of HTN presents with daily episodes of right eye blindness that completely resolve after 3 to 15 minutes.Exam is normal including fundoscopy
26 What treatment should you initiate? Aggressive Medical ManagementEndarterectomy (CEA)Carotid Stenting
27 When to Fix the Carotid? NASCET in early 1990s Benefit of endarterectomy in patients with symptoms ipsilateral to 70-99% stenosisComparison: best medical management at the time50-69% symptomatic stenosis revascularization has limited benefit, especially in womenIn stroke management don’t miss carotid disease or atrial fibrillation
28 How to Fix the Carotid? Stenting +/- distal protection SAPPHIRE (NEJM 10/04 and 4/08) in high-risk patientsOther small trials compare with NASCET dataCurrently widely practiced: NeuroIR, vascular surgeons, BodyIR, CardiologistsUnique risks: Hypotension, Bradycardia
29 Randomized Trial Results SPACE Trial (Lancet 10/06)1200 patients with recent stroke/TIA randomized to CEA vs. stentingEVA-3S (NEJM 10/06)527 patients with recent stroke/TIA randomizedBoth failed to demonstrate non-inferiorityIn EVA-3S, stenting associated with significantly more short-term stroke and death
30 My Current ApproachRevascularize all patients with 70-99% symptomatic lesionsRecommend CEA for all unless specific contraindication or extremely high-risk surgical candidatesSpecifics: post-radiation, previous CEA with restenosisHigh risk: age>80, active coronary disease, severe CHFUtilize those surgeons and interventionalists with the most experience
31 Case 5A 54 year-old man with a history of HTN comes to your office concerned as his mother just died after an ischemic stroke. He wants to know what primary preventative interventions can reduce his chances of having a similar event.
33 2006 Primary Prevention Guidelines Risk estimation schemesASA effective only for high-risk men, medium-risk womenTreat vascular risk factorsAnticoagulants for afibCHADS2 score1-2=medium risk3 or higher=high risk
34 Asymptomatic Carotid Stenosis Some benefit for endarterectomy in asymptomatic stenosis>60% or >80% cut-offsMust have a very low perioperative risk of stroke and death to realize benefit (3%)Data much less convincing than symptomatic trialsWhen to screen? Who to screen?
35 Folic Acid Supplementation Really doesn’t work for MI or DementiaMeta-analysis of 8 randomized with stroke as an end-point recently releasedReduced risk of stroke by 18% (RR 0.82)Greater effects seen with>36 months of treatmentDecreased homocysteine by >20 percentNo fortification or little fortification of grainNo history of strokeLancet 369:1876, 2007