Stroke TIA

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Stroke / TIA

• Rich Derby, LtCol, USAF
• MGMC Family Practice Program

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Objective

• Review evaluation management of Stroke/TIA
  using current AHA/ASA guidelines
• Primary Prevention
• Acute Stroke / TIA
• Post-stroke / TIA history

Focus Scenarios
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Primary Prevention

• 55 year old black male for routine physical
• PMHx Hypertension, Tobacco use
• Meds HCTZ
• FHx Mother had stroke in 60s
• Data 132/88 BP, BMI 27
  TC 213/LDL 145/HDL
  37 - EKG normal
• What are your Interventions for Primary
  Stroke Prevention?

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To answer this question you need to be
aware of

• Stroke risk factors
• Modifiable
• Non-modifiable
• How risk factors quantify into actual stroke risk
• Use of stroke risk assessment tool
• What interventions lower risk

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Modifiable risks

• Cardiovascular Disease
• Hypertension
• CAD/CHF
• Diabetes
• Dyslipidemia
• High total Cholesterol
• and/or Low HDL
• Atrial Fibrillation
• Asymptomatic Carotid Artery Stenosis

• Cigarette smoking
• Sickle Cell Disease
• Dietary Factors
• Obesity
• Physical Activity
• Hormone Replacement Therapy

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Less Well-Documented or Potentially Modifiable
Risk Factors

• Metabolic syndrome
• Alcohol abuse
• Hyperhomocysteinemia
• Drug abuse
• Hypercoagulability
• Oral contraceptive use
• Inflammatory processes
• Periodontal disease, C pneumoniae,
  Cytomegalovirus, H pylori CagA seropositivity,
  Acute infection, elevated hs-CRP
• Migraine
• Sleep disordered breathing

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Non-modifiable risks

• AGE Doubling of stroke rate
  each 10 years
  after age 55
• White Black
• Men Women Men Women
• 4554 1.4 0.8 2.1 2.5
• 5564 2.6 1.6 4.9 4.6
• 6574 6.7 4.2 10.4 9.8
• 7584 11.8 11.3 23.3 13.5
• 85 16.8 16.5 24.7 21.8
  Prevalence (per 100,000)

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Non-modifiable risks
Prevalence (Per 100,000)

• RACE
• Blacks 233
• Hispanics 196
• Whites 93
• SEX
• Men 174
• Women 122

FAMILY Hx (Relative Risk) Paternal
2.4 Maternal 1.4
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Equating risk factors with
actual risk

• Patients should have stroke risk assessment
  (Class I, Level A)
• Risk assessment tools should be considered
  (Class IIa, Level B)
• Helps identify individuals who could benefit from
  therapeutic interventions and who may not be
  treated on the basis of any 1 risk factor
  

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Modified Framingham
Stroke Risk Profile (men)

Points _ 0 1 2
3 4 5 6 7
8 9 10__

• Age 5456 5759 6062 6365
  6668 6972 7375 7678 7981
  8284 85
• SBP 97105 106115 116125
  126135 136145 146155 156165 166175
  176185 186195 196205
• (Untreated)
• SBP 97105 106112 113117
  118123 124129 130135 136142 143150
  151161 162176 177205
• (Treated)
• Diabetes No Yes
• Cigarette No
  Yes
• CVD No
  Yes
• A Fib No
  Yes
• LVH on No
  Yes
• EKG

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10-Year Probability,
Modified Framingham Stroke Risk Score
10-Year Probability,

• Points Men Women
• 1 3 1
• 2 3 1
• 3 4 2
• 4 4 2
• 5 5 2
• 6 5 3
• 7 6 4
• 8 7 4
• 9 8 5
• 10 10 6
• 11 11 8
• 12 13 9
• 13 15 11
• 14 17 13
• 15 20 16

Points Men Women 16 22
19 17 26 23 18 29 27 19 33
32 20 37 37 21 42 43 22 47
50 23 52 57 24 57 64 25
63 71 26 68 78 27 74 84 28
79 29 84 30 88
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Risk Factor High Risk
Caution Low Risk Blood Pressure
gt 140/90 120-139/80-89
lt120/80
or
I dont know Cholesterol gt 240
200-239
lt200
or I dont
know Diabetes Yes
Borderline
No Smoking I still
smoke Atrial Fibrillation I have an irregular
I dont know My heartbeat is
heartbeat

regular Diet I am
overweight I am slightly
My weight is
overweight
healthy Exercise
I am a couch potato I exercise sometimes I
exercise regularly I have stroke in
Yes not sure
no My family Score (each box1)
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TO REDUCE YOUR RISK FOR STROKE 1. Know your
blood pressure. If high, work with your doctor to
lower it. 2. Find out from your doctor if you
have atrial fibrillation. 3. If you smoke,
stop. 4. If you drink alcohol, do so in
moderation. 5. Find out if you have high
cholesterol. If so, work with your doctor to
control it. 6. If you are diabetic, follow your
doctor's recommendations carefully to control
your diabetes. 7. Include exercise in the
activities you enjoy in your daily routine. 8.
Enjoy a lower sodium (salt), lower fat diet. 9.
Ask your doctor how you can lower your risk of
stroke. 10. KNOW THE SYMPTOMS OF STROKE. If you
have any stroke symptoms, seek immediate medical
attention. Symptoms include Sudden numbness or
weakness of face, arm or leg - especially on one
side of the body. Sudden confusion, trouble
speaking or understanding. Sudden trouble
seeing in one or both eyes. Sudden trouble
walking, dizziness, loss of balance or
coordination. Sudden severe headache with no
known cause.
If your RED score is 3 or more,
please ask your doctor about stroke
prevention right away If your yellow
score is 4-6, youre off to a good start.
Keep working on it! If your green
score is 6-8, congratulations! Youre
doing very well at controlling your
risk for stroke!
If you have experienced any of these symptoms,
you may have had a TIA or a stroke call 911
immediately! 1-800-STROKES 1-800-787-6537www.strok
e.org
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Risk assessment tool pitfalls

• Each tool has limitations
• Do not account for all risk factors
• Need to be validated against different
  ethnic/race groups
• Have not yet been shown to improve stroke
  prevention programs

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Interventions of worth(Class I, Level A B)
Assume recommendations from established guidelines

• HTN (JNC-7) regular screening (more frequent in
  minorities) appropriate management
• Diabetes BP lt 130/80, statin use for LDLlt 100
• Dislipidemia (NCEP III)
• Physical Inactivity increase physical activity
• Obesity weight reduction
• Diet lower sodium / increase potassium / DASH
  diet
• Smoking Cessation

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Atrial Fibrillation

• Warfarin anticoagulation (Class I, Level A)
• Valvular heart disease
• Normal valves but high stroke risk (gt4 annually)
• Intermediate risk for stroke no warfarin
  contraindication

• Aspirin (Class I, Level A)
• Low stroke risk
• Intermediate risk

CHADS 2 Risk Assessment Tool useful
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(No Transcript)
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Asymptomatic Carotid Stenosis

• Screen for additional risk factors and manage
  aggressively (Class I, Level C)
• Aspirin recommended (Class I, Level B)
• Prophylactic Endarterectomy (Class I, level A)
• In selected pts with high-grade (60-99)
  stenosis
• If Surgeon has 3 morbidity/mortality rates

• 5-10 (men women) gt 65 have carotid
  stenosis gt 50
• 1 with carotid stenosis gt 80
• General population screening not
  cost-effective
• Angioplasty/stenting alternative being studied

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Aspirin alone?

• Not recommended for primary prevention in men
  (Class III, Level A)
• Recommended for patients with 10-year risk of
  cardiovascular events gt6 (or 5-year gt 3)
  (Class I, Level A)
• May be useful among women whose risk is
  sufficiently high for benefits to outweigh risks
  (Class IIa, Level B)

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Summary - Primary Prevention

• Know stroke risk factors how to quantify into a
  patients individual risk
• Manage modifiable risks aggressively
• BP, Lipids, Tob use, Wt, Diet
• Warfarin vs. aspirin in Atrial Fib based on risk
• Consider endarterctomy in asymptomatic carotid
  stenosis 60-90

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Our case

• Risk Factors
• Male, 55 y/o , black, FHx
• HTN, Tobacco use, LDL gt 130
• Risk Assessment
• 7 10-year risk of stroke by
  Modified Framingham Stroke Risk Score
• 23 10-year risk of cardiovascular event by
  NCEP III risk assessment tool
• Interventions
• Aspirin, Diet, Exercise, Tob cessation, better BP
  control and LDL lt100, consider carotid
  exam/imaging

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Acute Stroke / TIA

• See same patient in ER next day
• Slurring speech, trouble finding words
• Drowsy
• Unable to move rt arm/leg effectively
• What are your Evaluation and Management Plans for
  Acute Stroke / TIA?

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Brain Attack!

• Stroke
• A sudden focal neurological deficit or acute
  neurological impairment caused by the
  interruption of blood flow to a specific region
  of the brain

• 700,000 suffer a new or repeat stroke in U.S.
  each year
• Third leading cause of death in the US (gt
  150,000 yearly)

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Ischemic Stroke85 of all strokes

• KEY POINTS
• Evaluate appropriateness
• of thrombolytic therapy
• - 3 hour window
• - Non-contrast CT
• negative for bleed
• - No contraindications

• Cause
• Thrombotic (atherosclerosis)
• Embolic (A fib, prosthetic valve)
• Vasoconstriction (eclampsia)
• Manifestation
• Occlusion of artery to specific area of brain
  causes specific neurologic syndrome
• middle cerebral artery contralateral hemiplegia,
  hemianesthesia, homonymous hemianopia

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Hemorrhagic stroke15 of all stroke

• Cause
• Primary (70-90)
• - Hypertension, amyloid angiopathy
• Secondary (10-30)
• - Vascular malformation (aneurysm, avm), tumor,
  thrombolytic agents,
• Manifestation
• Rupture of blood vessel with surrounding tissue
  damage
• - symptoms of increased ICP (severe
  headache, nausea/vomitting, altered mental
  status/coma)

• KEY POINTS
• - Non-contrast CT positive for bleed
• - 50 mortality (80 of survivors with
  permanent disability)
• - ICP monitoring
• - Neurosurgical intervention

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Acute Management

• Medical Stabilization
• Focused history
• Neurologic assessment
• Brain Imaging
• Negative CT Evaluate for thrombolytics

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Medical Stabilization

• Airway and Breathing
• Protect from aspiration and hypoxemia
• Vitals / O2
• IV access (isotonic fluids only)
• Labs
• Glucose, electrolytes
• Consider cardiac markers, tox screen, coags
• EKG
• Order Non-Contrast Head CT
• Neurological Assessment

First 10 Minutes!
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History / Exam

• History focus points
• Onset and scenario
• Significant comorbidities and medications
• Review contraindication list for thrombolytics

• Exam focus points
• Neurological Stroke Scale
• NIH Stroke Scale
• Canadian neurologic scale
• Obtain CT !

Within 25 Minutes!
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NIH Stroke Scale
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CT Read within 45 min

• Hemorrhagic

• Ischemic

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Hemorrhagic stroke (ICH)

• Neurosurgery consult
• Manage ICP
• Mannitol
• Surgical decompression
• ICU
• Mangage comorbidities
• Delineate cause
• Speech/OT/PT c/s

• Blood Pressure
• 90 have acutely elevated BP (usually gt160/90)
• Goal of MAP lt130
• Safe to reduce by 20 in controlled fashion
• Labetolol, esmolol, nitroprusside

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Ischemic Stroke

• Is this a candidate for tPA Thrombolysis?
• gt18 years old
• lt 3 hours onset symptoms
• Measurable neurologic deficit dx as ischemic
  stroke
• No contraindications
• Review Checklist
• If appropriate candidate then tPA is indicated
  (Class I, Level A)

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Thrombolytic Criteria
Diagnosis of ischemic stroke causing measurable
neurologic deficitNeurologic signs should not be
clearing spontaneouslyNeurologic signs should
not be minor and isolatedCaution should be
exercised in treating a patient with major
deficitsSymptoms of stroke should not suggest
subarachnoid hemorrhageOnset of symptoms less
than 3 hours before beginning treatmentNo head
trauma or prior stroke in previous 3 monthsNo
myocardial infarction in the previous 3 monthsNo
gastrointestinal or urinary tract hemorrhage in
previous 21 daysNo major surgery in the previous
14 daysNo arterial puncture at a noncompressible
site in the previous 7 daysNo history of
previous intracranial hemorrhageBlood pressure
not elevated (systolic lt185 mm Hg and diastolic
lt110 mm Hg)No evidence of active bleeding or
acute trauma (fracture) on examinationNot taking
an oral anticoagulant, or if anticoagulant being
taken, INR is 1.7 or lessIf receiving heparin in
previous 48 hours, aPTT must be in normal
rangePlatelet count equal to or greater than
100,000 mm3 Blood glucose concentration equal to
or greater than 50 mg/dL (2.7 mmol/L)No seizure
with postictal residual neurologic impairmentsCT
does not show a multilobar infarction
(hypodensity gt1/3 cerebral hemisphere) Patient or
family members understand the potential risks and
benefits from treatment
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Meets Thrombolytic Criteria

• tPA only FDA approved agent for ischemic stroke
• Consent patient
• Risk
• - ICH rate of 6 (up to 15 if guidelines not
  followed)
• Benefit
• - improved 24 hour recovery ( mean 8 vs 12 on
  NIHSS)
• - improved 3 month recovery (30 improvement)
• - death/severe disability reduction (4
  reduction)
• - 11-13 absolute increase in patients with
  excellent outcomes

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tPA Therapy

• 0.9mg/kg tPA IV 10 bolus rest over 60 min
• Monitor for ICH
• No anticoagulants or antiplatlets for 24 hours
• Manage comorbidities
• Delineate Cause
• Speech/OT/PT c/s

• Blood Pressure
• Pretreatment goal SBPlt185 DBPlt110
• Labetalol, esmolol, Nitropaste, Nicardipine
  infusion, Nitroprusside
• During/Post-treatment
• Maintain at or below goal in controlled fashion

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Ischemic stroke but not tPA candidate

• Blood Pressure
• Benign neglect up to 220/120
• If greater 220/120
• 10-15 reduction
• Labetelol, esmolol, nitroprusside, nicardinpine

• Neuro status monitoring
• Aspirin (Class I, Level A)
• Manage co-morbidities
• Delineate cause
• Speech/OT/PT c/s

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TIA

• Focal neurologic deficit that resolves completely
  and spontaneously within 24 hours
• Often occur as heralding sign to acute stroke
  within 48 hours up to 5 of TIA patients
• 5-10 of patients with TIA will have stroke
  within 90 days (up to 20 for those with carotid
  artery disease)

Warrants more aggressive evaluation management
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TIAInitial Evaluation

• Predicting impending stroke
• Age 60 1
• Blood pressure
  (systolic gt140 mmHg and/or diastolic
  90 mmHg 1)
• Clinical features
  (unilateral
  weakness 2, isolated speech disturbance 1,
  other 0)
• Duration of symptoms in minutes
  ( 60 2, 10 to 59 1,
  lt10 0)

• Chance of stroke within 7 days
• Score
• 6 24 - 31
• 5 12
• 4 1 - 9
• lt 3 0

A simple score (ABCD) to identify individuals at
high early risk of stroke after transient
ischaemic attack. Rothwell PM et al. Lancet
2005 Jul 2366(9479)29-36.
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TIAInitial Evaluation

• Consider hospitalization
  
• (especially for higher risk patients)
• Relevant medical assessment
• Focus on Cardiac Risk Factors, Carotid dz,
  embolic dz
• Neurologic assessment (timing, degree,
  resolution)
• Brain imaging
• Carotid imaging (within 48hrs)
• Cardiac assessment (holter, echo, TEE)

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TIA Management

• Manage comorbidities aggressively
• BP lt130/85
• LDL lt100
• FBS lt 126
• Discontinue Tobacco, excessive EtOH
• Physical activity (30-60min 3-4 x wk)
• Discontinue HRT
• Utilize antithrombotic agents

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TIA Antithrombotic Therapy

• Cardioembolic source (Atrial Fibrillation)
• Warfarin INR goal 2.5
• Atherothrombotic source (Class IIa, Level A)
• ASA (50-325mg) qd
• Ext Release Dipyridamole (200mg)ASA (25mg) bid
• best outcomes in studies thus far
• Clopidogrel (75mg) qd

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Summary - Acute Stroke / TIA

• Assess for thrombolysis
• lt 3 hours - ischemic stroke - no
  contraindications
• Measurable neuro deficit scoring and Head CT
  vital components of initial assessment
• Blood pressure management of acute stroke depends
  on scenario (ischemic/hemorrhagic/use of tPA)
• TIA is more concerning than previously thought
• Evaluate for more aggressive management

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Secondary Prevention of Stroke / TIA

• Modify Vascular Risks
• Antihypertensive treatment per JNC VII (Class I,
  A)
• Tight control in diabetics (A1C lt 7) (Class I,
  A)
• Lipids
• LDL lt100 (lt70 in very high risk) (Class I, A)
• If normal TC may still rx with statin (Class IIa,
  B)
• High TG, Low HDL Niacin or Gemfibrazil (Class
  IIb, B)

• Modify Behavioral Risks
• Smoking STOP (Class I, C)
• EtOH Stop if heavy drinker lt 2 daily otherwise
• Obesity get to BMI of 18-25 (Class IIb, C)
• Physical Activity increase to 30min most days
  of week (Class IIb, C)

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Secondary Prevention

• Carotid disease and history of stroke / TIA
• 70-99 stenosis (Class I, level A)
• CEA with surgeon who has lt 6 complication rate
• 50-69 stenosis (Class I, level A)
• CEA depending on patient risks (age, gender,
  comorbidities)
• Less than 50 stenosis (Class III, level A)
• CEA not recommended
• gt70 stenosis with high surgical risks (class
  IIb, level B)
• May consider carotid artery stenting

Primary prevention recall Asymptomatic Patient
without stroke/TIA History Prophylactic
Endarterectomy ( (Class I, level A)
- In selected pts with high-grade (60-99)
stenosis - If Surgeon has 3 morbidity/mortality
rates
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Secondary Prevention

• Cardioembolic risks
• Atrial Fibrillation
• Warfarin for target INR 2.5
  Aspirin if unable to
  use Warfarin (Class I, level A)
• Valvular heart disease
• Warfarin or aspirin depending on type of valvular
  disease
• MI with LV mural thrombus
• Warfarin 3 months to 1 year
• Cardiomyopathy
• Warfarin or antiplatelet therapy

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Antithrombotic Therapy for Noncardioembolic
Stroke or TIA

• Antiplatelet better than anticoagulation (Class
  I, level A)
• Acceptable antiplatelet agents (Class IIa, level
  A)
• Aspirin (50-325mg) daily
• Aspirin and extended-release dipyridamole
• Clopidogrel
• Aspirin and extended-release dipyridamole
  suggested instead of aspirin alone (Class IIa,
  level A)
• Aspirin and Clopidogrel not recommended due to
  increased hemorrhage risk (Class III, level A)

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Summary Secondary prevention

• Manage behaviors diseases that elevate vascular
  risk
• (HTN, Lipids, DM, Tob, Obesity, Activity level)
• Carotid endarterectomy may be indicated in
  patients with stenosis 50-99
• Generally warfarin for cardioembolic risk
  patients
• Antiplatelet therapy (non-cardioembolic
  stroke/TIA)
• Aspirin extended-release dipyridamole preferred
• Aspirin Clopidogrel NOT RECOMMENDED

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Questions