1. Evaluation and Management of TIA and Stroke
Claire J. Creutzfeldt
UW Harborview Stroke Center
January 2013

2. Outline Some stroke facts
Approach to evaluation and management of Stroke
Acute management of
Ischemic stroke
 TIA
Present < 4.5 hrs after onset
Present > 4.5 hrs after onset
Hemorrhagic stroke
4. Time for questions

3. Stroke facts (AHA Heart and Stroke Statistical Update 2012)
~700,00 strokes each year in the US
a stroke every 45 seconds
200,000 of those are recurrent strokes
Kills >150,000 people/yr in US, 1/16 deaths
28% of stroke victims < 65 years old
4,500,000+ stroke survivors are alive in US
leading cause of long-term disability in the US
3rd most common cause of death, ranking behind diseases of the heart and cancer
In developed countries, stroke mortality has been constantly decreasing (5%/year since 1970ies)
4th

4. Stroke classification
Normal Ischemic Intracerebral Subarachnoid stroke hemorrhage hemorrhage (80%) (15%) (5%)

5. Mechanisms “A stroke happens, when…
…blood flow to a part of the brain is interrupted”
Causes of initial event Prevention of recurrent stroke
Large vessel arteriosclerosis Carotid endarterectomy, Antiplatelet
Cardioembolism Anticoagulation
Small vessel disease Antiplatelet agent
Other
Cryptogenic (Antiplatelet agent)

6. Evaluation BASIC STROKE EVALUATION Thorough H&P Non-con head CT
Imaging of extracranial arteries
EKG and telemetry
Routine blood studies
(TTE)
COMPREHENSIVE STROKE EVALUATION
MRI
Imaging of intra- and extracranial arteries
TEE
Prolonged cardiac monitoring
U-tox
Blood tests for hypercoagulable state
Genetic tests for rare causes such as CADASIL, Fabry’s disease, MELAS…

7. Case 1
70 y/o m with h/o diabetes and hypertension presents to clinic and tells you about this episode a couple of days ago where he couldn’t move his entire right side. Symptoms resolved within half an hour.
BP 165/85, neurologically intact
 What is your next step?

8. Case 1
Do a thorough neurological exam. If he really has no residual neurological deficits, no need for imaging
Optimize his blood pressure management and have him follow up in a month
Refer him to a TIA clinic (urgently), offer him admission to the hospital OR get an expedited workup yourself consisting of MRI brain, vascular imaging, EKG, Echocardiogram and blood work.
Educate him about the difference between TIA and stroke and have him follow up in a month
Add Clopidogrel to his daily baby Aspirin and have him follow up in a month

9. post-TIA Stroke Risk JAMA 2000;284:2901-2906
1707 TIA patients
Stroke event rates:
10.5% at 90 days
5.3% at 2 days

10. ABCD2 score for TIA Risk Stratification
5 Factors
Points
Age > 60 1
BP > 140/90 on first assessment after TIA
Clinical features
unilateral weakness
speech impairment without weakness 2
Duration of TIA
≥60 minutes
10–59 minutes
Diabetes
Lancet 2007; 369: 283–92

11. ABCD2 score
Lancet 2007; 369: 283–92

12. Early TIA management Our system: offer admission to all
Others: TIA clinic
Treat:
Risk factors
Antithrombotics
CEA
Testing
Brain imaging (CT or MRI)
Vascular imaging
Cardiac evaluation (Echo, EKG)
blood work including basics + lipids, HbA1c, others

13. Case 2
70 y/o m with h/o diabetes and hypertension presents to the ER with sudden onset R-sided numbness and weakness.
BP 165/85, awake and able to walk
 What is your next step?

14. Case 2
Refer him to a TIA clinic (urgently), offer him admission to the hospital OR get an expedited workup yourself consisting of brain and vascular imaging, EKG, Echocardiogram and blood work.
Admit him to the stroke unit, add Clopidogrel to his daily baby Aspirin and order an MRI brain
Thorough H&P with time of onset and NIHSS followed by stat lab draw, EKG, head CT

15. What medication would you want to use acutely?
Additional History I
Symptoms started one hour ago
EKG: normal
NIHSS 11
What medication would you want to use acutely? 14 25

16. IV tPA for Acute Ischemic Stroke Individual Patient Data Meta-analysis
Lancet 2004; 363:

17. tPA inclusion/exclusion criteria
IN: >18yrs, ischemic stroke w/in 3*hrs EX: * symptoms minor or rapidly improving * seizure at stroke onset * stroke or head trauma w/in 3 months * major surgery w/in 2 weeks * h/o ICH * sustained BP >185/110 (aggressive tx necessary) * GI or UT hemorrhage w/in 21 days * arterial puncture at noncompressible site w/in 7d * INR >1.7, platelets <100,000, glucose <50 or >400 ] [
Lancet 2004; 363:

18. 3-4.5 hrs
Additional warnings for patients treated between hours
Age > 80
History of prior stroke AND diabetes
Any anticoagulant use prior to admission (even if INR <1.7)
Severe Stroke (NIHSS >25)
CT findings involving more than 1/3 of the MCA territory
NEJM 2008;359:

19. What treatment might you consider acutely?
Additional History II
Symptoms started 5 hours ago
EKG: normal
Symptoms: stable or progressing
What treatment might you consider acutely? 14 25

21. Mechanical thrombectomy
a word of caution:
MERCI clot retriever, PENUMBRA
FDA clearance was based on single-group, nonrandomized trials comparing device treatment with historical controls from PROACT II
effective recanalization but no better outcome
these devices were not approved as clinically effective treatments for acute stroke but were cleared for use as devices to remove thrombus in acute stroke
look for results of MR Rescue and IMS-3 next week!
Circulation. 2011;123:
MR Rescue and IMS-3: 14 25

22. Additional History III
Patient woke up with symptoms, last seen normal > 15 hours ago
EKG: normal
Symptoms: stable or progressing 14 25

24. Early supportive care Reverse ischemia (enhance perfusion)
Antithrombotic Medications
Blood Pressure
Interventions
Limit injury (neuroprotection)
Glycemia (aggressively normalize)
Core body temperature
Avoid infections
Glutamate antagonists
Free radical scavengers
High quality care
Joint Commission Stroke Centers
Stroke units
Performance measures

25. Aspirin Risk of stroke, MI, or vascular death
Aspirin better
Placebo better
0.87
95% CI
0.81 to 0.94
RR = 1.0
Risk significantly reduced by 13%
Doses ranged from 30 to 1500 mg per day
BMJ. 2002; 324: 71–86

26. other antiplatelet agents
$1.20/month
$149.70/month
$157.20/month
NEJM 2008;359:1287-9

27. Blood Pressure Management after acute ischemic stroke
Treatment threshold
tPA ineligible: 220/120 (unless other end organ damage)
tPA eligible: 185/110 (can treat pre-tPA)
Preferred Meds
Labetalol iv
Nicardipine drip

28. Intervention after stroke or TIA - when and what -
Severe carotid stenosis (70-99%)
Moderate stenosis (50-69%)
Stenosis < 50%
Angioplasty/stenting vs. surgery
Carotid occlusion
Asymptomatic carotid artery stenosis
NEJM 2010;363:11–23

29. Case 3
70 y/o m comes to your clinic as a hospital follow up after an ischemic stroke.
PMH: Diabetes, borderline hypertension, smoking
Exam today: BP 135/69, mild right-sided weakness and occasional word finding difficulties. He also seems withdrawn and depressed.
Medications: ASA 81, Niacin, HCTZ 25, Insulin sq
 What is your next step?

30. Case 3 Change Niacin to a Statin Change HCTZ to Chlorthalidone
Educate patient on life-style change, diet and smoking cessation
Consider an SSRI
All of the above

31. Case 4
A 65 y/o woman with known hypertension had complained to her husband about a severe headache shortly before she collapsed. In the ER, she has decreased LOC, right-sided hemiparesis and aphasia. Initial BP is 230/120

32. Case 4 - CT

33. Case 4 What is the most likely etiology of her hemorrhage?
Cerebral amyloid angiopathy
Hypertension
Ischemic stroke turned hemorrhagic

34. Intraparenchymal hemorrhage
Amyloid
Angiopathy
ICH
Hypertensive
ICH

35. Goals of ICH therapy Prevent hematoma enlargement
Blood pressure treatment
Hemostatic agents
Surgery
Limit injury (neuroprotection)
Reduce Raised ICP
Glycemic control
Temperature
Prevent Complications
Swallow screening, DVT prophylaxis, Seizure prophylaxis

36. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage
Hematoma Expansion
Although intracerebral hemorrhage (ICH) was once considered to be a monophasic event that stopped quickly, serial computed tomography (CT) scans have shown that the progression of hematomas expand over time.
Many hemorrhages continue to grow and expand several hours after symptom onset.1-3 Brott and colleagues reported that hematoma expanded in 26% of patients within 1 hour after the initial CT scan and in another 12% within 20 hours.1 A recent meta-analysis by Davis et al that included patients with spontaneous ICH who underwent CT within 3 hours of onset and 24-hour follow-up showed an even higher rate: 73% of patients exhibited some degree of hematoma growth over the first 24 hours; 38% had significant (>33%) expansion over this period.3
Hematoma growth is an independent determinant of both mortality and functional outcome after ICH.4 Predictors of hemorrhage expansion include initial hematoma volume, early presentation, irregular shape, liver disease, hypertension, hyperglycemia, alcohol use, and hypofibrinogenima.4-6
Prevent hematoma enlargement/Reduce ICP
Blood pressure treatment (goals, agents)
Hemostatic agents
Surgery
Stroke 2007;38; ;
Guidelines for the Management of Spontaneous Intracerebral Hemorrhage
Brott T, Broderick J, Kothari R, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke. 1997;28:1-5.
Kazui S, Naritomi H, Yamamoto H, Sawada T, Yamaguchi T. Enlargement of spontaneous intracerebral hemorrhage. Incidence and time course. Stroke. 1996;27:
Davis SM, Broderick J, Hennerici M, et al, for the Recombinant Activated Factor VII Intracerebral Hemorrhage Trial Investigators. Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage. Neurology. 2006;66:
NINDS ICH Workshop Participants. Priorities for clinical research in intracerebral hemorrhage: report from a National Institute of Neurological Disorders and Stroke workshop. Stroke. 2005;36:e23-41.
Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Tanaka R. Multivariate analysis of predictors of hematoma enlargement in spontaneous intracerebral hemorrhage. Stroke. 1998;29:
Kazui S, Minematsu K, Yamamoto H, Sawada T, Yamaguchi T. Predisposing factors to enlargement of spontaneous intracerebral hematoma. Stroke. 1997;28:

37. Stroke complications
Semin Neurol. 2010

38. thank you