2. Charles Ashton Medical Director

3. Topics/Order of the day 1  What Works ?  Clinical features of TIA inc the difference between Carotid and Vertebral territories  When is a TIA not a TIA  TIA management and Stroke prevention (BP Antiplatelet, Statin, Carotid surgery and AF  Thrombolysis and Stroke units  The place of Neurosurgery

4. Topics/Order of the day 2  Imaging  Carotid Surgery  AF and CHADS 2 score  Cost /Commissioning issues  New advances  Take Home Messages  MCQ

5. Stroke Treatments/Prevention  Thrombolysis  Acute Stroke Units  Anticoagulation  Antiplatelets  Antihypertensives  Statins  Smoking Cessation  Closing PFO’s  Carotid Endarterectomy  Exercise, weight, alcohol

6. Acute Stroke Units  Reduce Mortality by 28% (Langhorne 1993)  Work by Improved general care  ? Reduce damage at ischaemic penumbra

7. Thrombolysis  IV recombinant Tissue Plasminogen Activator (TPA)  Haemorrhage must be excluded  Little or no benefit after 4.5 hours  NNT at 1 hour 4 and at 3 hours 16  Causes up to 5% deaths due to IC bleeds  No Mortality benefits  Reduce Disability and proportion patients with No disability from about 35% to 27%  Works best in moderately severe strokes

8. Contraindications  Any evidence of intracerebral haemorrhage  Severe Hypertension (>180 systolic or >100 diastolic)  Siezures  History of AVM  Recent Surgery  Stroke within 3 months

9. Contraindications 2  Patients older than 80 years  All patients taking oral anticoagulants are excluded regardless of international normalized ratio (INR)  Patients with baseline National Institutes of Health Stroke Scale score ≥25  Patients with a history of both prior stroke and diabetes

11. Intracerebral Bleed

12. Middle Cerebral Infarct

13. Neurosurgery  Very rarely required  Massive infarction of a cerebral hemisphere may need decompression  Occasionally intracerebral haemorrhage with mid line shift (little evidence)  Hydrocephalus

14. Anterior Cerebral Artery  Signs and Symptoms:  Weakness (may be mono paresis)  Extra pyramidal symptoms (tremor)  Apraxia  Sensory loss in same distribution as weakness  Mood/personality changes  Incontinence  Aphasia

15. Middle Cerebral Artery Infarction  Symptoms and Signs Dysphasia (if Left hemisphere involvement)Dysphasia  Dyslexia  Dysgraphia  Contralateral Hemiparesis or HemiplegiaHemiparesisHemiplegia  Contralateral hemisensory disturbance  Rapid progression in Decreased Level of ConsciousnessDecreased Level of Consciousness  Vomiting Vomiting  Homonymous Hemianopia  Denial or lack of recognition of paralyzed extremity  Eyes look toward lesion  Inability to turn eyes toward the affected side

16. Posterior Cerebral Artery Central  Signs and Symptoms: Central Thalamic or subthalamic nuclei involvement  Diffuse sensory loss  Mild HemiparesisHemiparesis  Intention Tremor Intention Tremor  Cerebral peduncle involvement  Contralateral HemiplegiaHemiplegia  Oculomotor Nerve deficit Oculomotor Nerve  Brainstem involvement  Pupillary dysfunction Pupil  Nystagmus Nystagmus  Loss of conjugate gaze

17. Posterior Cerebral Artery (Peripheral)  Signs and Symptoms: Peripheral Visual Changes  Homonymous hemianopia  Cortical blindness  Lack of depth perception  Failure to see objects not centered in visual field  Visual hallucinations  Memory deficits  Perseveration  Dyslexia

19. Plaque Ulceration

20. Express Study  After minor Stoke or TIA 10% one week risk of recurrent stroke  Early intervention reduced risk by 80 %  The most effective single intervention was carotid endarterectomy which reduced risk by 75% on its own Early use of Existing Preventive Strategies for Stroke

21. Predicted effect of treatment Based on RCTs of long-term treatment Most patients Relative Risk Reduction Aspirin 20% Statin 20% Blood pressure lowering 30% Some patients Warfarin 50% Carotid Endarterectomy 75% (Aspirin + Clopidogrel ?) Total >80%

22. CHADS 2 Score for AF d the CHADS2 score system Congestive heart failure Hypertension Age > 75 years Diabetes Stroke –previous history of stroke or TIA  Presence of any of the above adds 1 to the score except for previous history of stroke which adds 2

23. ABCD Score Used to predict the risk of stroke during the first seven days after a TIA. Researchers found there to be over 30% risk of stroke in TIA patients with an 'ABCD score' of six, as compared to no strokes in those with a low ABCD score.

24. ABCD Score A Age of patient Age >/= 60 1 Age < 60 - 0 B Blood pressure at SBP > 140 or DBP >/= 90 - 1 Assessment Other - 0 C Clinical Features Unilateral weakness - 2 presented with Speech disturbance (no weakness) - 1 Other 0 D Duration of TIA >/= 60 minutes - 2 symptoms 10-59 minutes 1 <10 minutes 0 ________ TOTAL 6

27. What is a TIA ?  Transient – full recovery in 24 hours  Brain infarction occurs after 1 hour  Loss of function  Corresponds to a vascular territory  Lobes have mixed vascular territories

28. When you don’t know when it begins and ends When it lasts more than 24 hours When there is no focal neurological deficit When the main symptom is LOC although this can be a part of posterior circulation TIA’s When a patient with a Stroke gets tired When is a TIA not a TIA ?

29. Carotid TIA  Limb weakness  Dysphasia  Amaurosis Fugax Mono Ocular Blindness  NOT loss of consciousness  NOT sensory loss

31. Vertebral TIA  Dysarthria  Sensory Changes  Hemianopia  Vertigo  LOC  Dysphagia  Nystagmus  Nausea and Vomiting  Needs to have 2 or more of the above  More like to have cardiac source

32. Pure Sensory TIA’s  Pure or predominantly sensory transient ischaemic attacks are uncommon  Angiography demonstrates focal stenoses in the proximal portion of the posterior cerebral artery (PCA).  ps-TIAs strongly suggest the presence of PCA disease.  Repeated compromise of small vessels supplying the posterior-lateral part of the thalamus

33. Investigations  FBC – Thrombocythaemia Polycythaemia  U&E LFT’s  ECG – AF  Dopplers, MRA, DSA  CT scan – will be normal  Diffusion weighted MRI abnormal early on  Transthoracic Echo Transoesophageal Echo  Bubble contrast echo for PFO  24 hour tape (occasionally)

34. Imaging in TIA  CT should be normal  Standard MRI should be normal  Diffusion weighted MRI will confirm diagnosis (if done early)  Exclusion of Carotid stenosis > 75 % most important

36. Bubble Contrast Echo

37. Antiplatelet Therapy (NICE 2011)  TIA 1 st line Clopidogrel 75mg (indefinite) 2 nd line Aspirin 75mg (indefinite)  Stroke (after 2/52 300mg od Aspirin) 1 st line Clopidogrel 75mg (indefinite) 2 nd line Aspirin and Dyridamole SR

38. PFO Closure Device

39. Statins  Relatively disappointing for Stroke prevention  No evidence of benefit older than 80 (Prosper Study)  Otherwise follow NICE targets of 4mmol/l TC and 2mmol/l LDL if obtainable with generic Statin if not the old targets of 5mmol/l TC and 3mmol/l LDL

40. The Future  Immediate DWI MRI  Endovascular photoacoustic recanalization  Intra arterial thrombolysis  Mechanical clot removal  Factor Xa inhibitors Dibagitran etc

41. Payment by Results ? How are outpatients costs worked out ?

42. Take Home Points  TIA diagnosis is clinical (take a good history)  Around 50 % of referrals to TIA clinics aren’t TIA  The concept of Acute brain attack  Most of the secondary prevention can be done in general practice ASAP  Carotid endarterectomy for >75% stenosis is very important  We don’t anticoagulate enough AF patients