Stroke and TIA Evaluations in Neurologically Underserved Regions - PowerPoint Presentation

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Stroke and TIA Evaluations in Neurologically Underserved Regions

Ganesh Asaithambi, MD

John

Nasseff

Neuroscience Specialty Clinic

11/8/18

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Disclosures

No relevant financial or competing interests

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Objectives

Discuss current burden of stroke and TIA

Review acute evaluations for patients presenting with acute stroke symptoms

Identify methods of evaluation for stroke and TIA patients for secondary prevention

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What is a stroke?

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What is a transient ischemic attack (TIA)?

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Background

795,000 people in US have a stroke each yearA stroke occurs every 40 seconds in the USEvery 4 minutes a stroke-related death occursWomen between ages of 45-54 are twice as likely to have and die from a stroke than breast cancerFifth leading cause of death in USLeading cause of disability

Benjamin EJ et al. Circulation 2018;137:e67-e492.

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Ischemic Stroke (

87%)

Hemorrhagic Stroke (

13%)

Large Vessel Disease

Cardioembolism

Small

vessel disease

Cryptogenic

Intracerebral

Hemorrhage

Subarachnoid

Hemorrhage

The Basics: Types of Stroke

Benjamin EJ et al. Circulation 2018;137:e67-e492.

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Stroke in Minnesota (2016)

~2.5% of adults in Minnesota reported ever having had a stroke in their lifetimeMore than 100,000 peopleMore than 5% of all deaths in Minnesota are due to stroke (2,197 deaths in 2016)Fifth-leading cause of death in the stateMore than 11,000 hospitalizations for acute stroke eventsRanked 11th lowest for overall stroke mortality among states and District of ColumbiaFrom 2010-2016, stroke death rate is 26% higher in African-Americans and Asians compared to whites

Minnesota Department of Health

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System of Stroke Care in Minnesota

As July 1, 2018 – 115 stroke hospitals91% of MN residents live within 30 minutes of a designated stroke center!

Minnesota Department of Health

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Transient Ischemic Attacks (TIAs)

“Warning strokes” that can happen before a major stroke~5 million Americans will experience a TIAAlmost 10 times more likely to have a strokeGet a good history, rule out possible mimicsSeizureHypo/hyperglycemiaMigraineConversion disorder/reactionHypertensive encephalopathyDrug toxicity

Benjamin EJ et al. Circulation 2018;137:e67-e492.

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TIA Workup: Inpatient vs Outpatient

ABCD2 score (0-7)Age ≥ 60 years (1)Blood pressure (1)Systolic ≥ 140 mmHgDiastolic ≥ 90 mmHgClinical featuresUnilateral weakness (2)Speech impairment without weakness (1)Duration≥ 60 minutes (2)10-59 minutes (1)Presence of diabetes mellitus (1)

Johnston SC et al. Lancet 2007;369:283-292.

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TIA Workup: Inpatient vs Outpatient

ABCD2 score2-Day risk (%)7-Day risk (%)90-Day risk (%)0-31.01.23.14-54.15.99.8≥68.111.717.8

Johnston SC et al. Lancet 2007;369:283-292.

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But first…

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IV alteplase is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (Class I Recommendation, Level of Evidence A)IV alteplase should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke (Class I Recommendation, Level of Evidence B)Patients should receive mechanical thrombectomy …within 6 hours of symptom onset (Class I Recommendation, Level of Evidence A) if eligibleIf eligible patients can receive mechanical thrombectomyBetween 6 and 16 hours of symptom onset (Class I Recommendation, Level of Evidence A)Between 16 and 24 hours of symptom onset (Class I Recommendation, Level of Evidence B-R)

Acute Ischemic Stroke Treatment Options

Powers WJ et al. Stroke 2018;49:e46-e110

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Acute Ischemic Stroke Treatment Options

Because time from onset of symptoms to treatment has such a powerful impact on outcomes, treatment with IV alteplase should not be delayed to monitor for further improvement (Class III Recommendation, Level of Evidence C-EO)

Powers WJ et al. Stroke 2018;49:e46-e110

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Rural-Urban Inequity in IV alteplase

From 2012-2017:

103 rural hospitalsIV alteplase use increased from 12.9% to 15.9% of all stroke patients (p=0.0013)

Gonzales S et al. Neurology 2017;88:441-448

Tsai AW et al.

Stroke. 2018;49:AWP276

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Work Up for the Stroke/TIA Patient

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Cranial Imaging

Computed tomography (CT) headHemorrhage?Can be negative in the first few hours with increased sensitivity several hours laterEarly CT signs of ischemia confers worse prognosis

Wardlaw JM et al. Radiology 2005;235:444-453.

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Cranial Imaging

Magnetic Resonance Imaging (MRI)

More sensitive that CT

Not as generalizable

Do you need to transfer the patient?

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Vessel Imaging

Carotid

Dopplers

MRA/CTA

Extra- and intracranial vasculature

Digital subtracted angiography

Gold standard

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Cardiac Imaging

Transthoracic Echocardiography“Widely available” Transesophageal EchocardiographyAortic arch atherosclerosisPatent foramen ovale and/or atrial septum aneurysmIntracardiac tumorEndocarditis Left atrial appendage thrombus

3%

Christiansen ME et al. Neurologist 2018;23:30-33.

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Arterial occlusion – why not?When compared to aspirin or placeboNo evidence in superior prevention of stroke within 14 daysNo significant difference in long-term outcome or independenceHigh risk of intracranial bleeding within 7 daysNo variation across etiologies of strokeNot recommended for treatment of patients with AIS (Class III Recommendation, Level of Evidence A)

Immediate Anticoagulation

Berge E et al. Lancet 2000;355:1205-1210.

TOAST Investigators. JAMA 1998;274:702-710.

Bath PM et al. Lancet 2001;358:702-710.

Powers WJ et al. Stroke

2018;49:e46-e110

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FDA approval for secondary prevention of stroke/TIAAspirin (Class I; Level of Evidence A)Aspirin/dipyridamole (Class I; Level of Evidence B)Clopidogrel (Class IIa; Level of Evidence B)

Antiplatelets for Noncardioembolic Strokes

Kernan

et al. Stroke 2014;45:2160-2236.

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Not beneficial in secondary risk prevention for non-acute events (if initiated within 3 or 6 months of stroke)May be of benefit if started acutely (within 24 hours) for severe TIA or minor stroke21 days within Chinese population90 days in a more generalizable populationIntracranial severe stenosis (70-99%)3 month therapyAggressive medical managementNo net benefit when used > 1 year

Dual Antiplatelet (aspirin/clopidogrel)

Diener

HC et al. Lancet 2004;364:331-337.

Cote R et al. Neurology 2014;82:382-389.

Wang Y et al. N

Engl

J Med 2013;369:11-19.

Chimowitz

M et al. N

Engl

J Med 2011;365:993-1003.

Zaidat

OO et al. JAMA 2015;313:1240-1248.

Lee M et al. Ann Intern Med 2013;159:463-470.

Johnston SC et al. N

Engl

J Med 2018;379:215-225.

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WarfarinAtrial fibrillation (Class I; Level of Evidence A)Mechanical aortic or mitral valve (Class I; Level of Evidence B/C)Intracardiac thrombus (Class I; Level of Evidence C)Left ventricular assist device (Class IIa; Level of Evidence C)Cardiomyopathy with ejection fraction < 35% (Class IIb; Level of Evidence B)Rheumatic mitral valve disease (Class IIb; Level of Evidence C)

Long-term Anticoagulation

Kernan

et al. Stroke 2014;45:2160-2236.

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Direct Oral Anticoagulants

Nonvalvular

atrial fibrillation

Apixaban

Rivaroxaban

Dabigatran

Edoxaban

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Current duration of outpatient monitoring is undeterminedAt least 24 hours upon admission for strokeExternal monitors7-, 14-, 28-, and 30-day monitorsInsertable monitorsUp to 3 years

Outpatient Arrhythmia Monitoring

Jauch

E et al. Stroke 2013;44:870-947.

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Proportion of Cardiovascular Disease Risks by Age

Asberg

S et al. Stroke 2014;41:1338-1342.

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Lipid Management

High dose atorvastatinPrior stroke or TIAReduction in recurrent stroke completed with placebo

SPARCL Investigators. N

Engl

J Med 2006;355:549-559.

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Blood Pressure Control

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“Basic Work Up”

CT head

Carotid

Dopplers

TTE

Lipids

Hemoglobin A1c

Screening labs (PT/INR)

Electrocardiogram

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Conclusions

Not all patients need to be transferred to a “larger” hospital for stroke/TIA work up

Confer with a neurologist when you can

Strokes are not all the same

Patients presenting with acute stroke symptoms to the emergency department should still be considered for acute stroke treatments