investigations for stroke and tia what, when and where (…and who and why) k. butcher, md, phd,...
TRANSCRIPT
![Page 1: Investigations for Stroke and TIA What, When and Where (…and Who and Why) K. Butcher, MD, PhD, FRCP(C) University of Alberta WMC Health Sciences Centre](https://reader030.vdocuments.us/reader030/viewer/2022032802/56649e115503460f94afcffa/html5/thumbnails/1.jpg)
Investigations for Stroke and TIAWhat, When and Where(…and Who and Why)
K. Butcher, MD, PhD, FRCP(C)University of AlbertaWMC Health Sciences Centre
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Disclosures
Speaker’s Honoraria
Novo Nordisk
Boeringher Ingelheim
Sanofi-Aventis
Servier
Roche
Consultant
Novo Nordisk
Grant-in-AidSalary Award
Grant-in-Aid
Grant-in-AidSalary Award
Grant-in-AidSalary Award
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Learning Objectives
• The requirement for urgent brain imaging in patients with new onset focal neurological deficits.
• The tempo of brain imaging required in patients with suspected TIA versus stroke, and the relationship to treatment decisions.
• The available options for brain as well as intracranial and extracranial vascular imaging. Participants will also appreciate the advantages and disadvantages of each imaging modality.
• Appropriateness and timing of various cardiac investigations, including ECG, Holter monitoring and echocardiography.
• Appropriate blood work to be performed in stroke and TIA patients.
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Outline
1. Acute investigations• Imaging• Laboratory/other
2. Secondary prevention investigations
Tempo of investigations in Stroke and TIA
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Case• 58 year old male with a history of
hypertension and smoking complains of headache to his office co-workers. One minute later, he develops left sided facial droop and falls to his left.
• EMS is called and he is brought to your ED. BP is 190/100, HR is 90 BPM and he is in NSR.
• Investigation of choice?
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Acute CT Scan
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Acute Stroke Treatment: The Need for Speed
Pre-tPA Post-tPA
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Time is Brain
The ATLANTIS, ECASS, AND NINDS rt-PA Study group, 2002
Adjusted odds ratio of stroke recovery
Stroke onset to treatment time [min]
N = 2799
4.5 hoursNNT=14
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ECASS III Results
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Who Needs Imaging?
Patients with Focal CNS
Symptoms and Signs
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Acute Stroke HistoryPrimary goal: Stroke or not stroke?
• Focal neurological deficits– Weakness– Speech problems– Visual symptoms– Headache– Vertigo/Dizziness– never stroke in isolation– Sensory changes
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Imaging Triage: Physical ExamThe NIH Stroke Scale: RAPID and directed examination
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Planning the Tempo of Investigations• Establish true time of onset
• Cardiovascular risk factors:– Previous stroke, ischemic heart disease– Hypertension– Atrial fibrillation– Diabetes– Smoker
• CV medications • Younger patients:
– Mimics: Migraine, epilepsy– Specific mechanism (esp. younger patients): dissection
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Putting Symptoms into Context
Left sided numbness for 1 houra. 23 year old female with history of migraineb. 52 year old male with history of STEMI 6 weeks ago
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IMAGING TEMPO: SUMMARY
FIXED/PERSISTENT CNS DEFICITS
IMAGE IMMEDIATELY
TRANSIENT CNS DEFICITS
IMAGE
WITHIN 24 H
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Investigation and Treatment Strategies
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Alberta Provincial Stroke Strategy: Telstroke Alberta
Wetaskiwin
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Expediting Diagnosis: Tele-Radiology
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Future Directions: Portable CT
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42 year old F, 2.5 hours of non-fluent dysphasia and Right U/E weakness
CT: Early Infarct Sign
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24 hour Follow-up Scan (post r-tPA)
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Alberta Stroke Program Early CT Score (ASPECTS)
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CT: Early Infarct Sign
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Hypo-attenuation: Acute Infarction
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Extensive Hypo-attenuation and Sulcal Effacement
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24 hour Follow-up Scan (post r-tPA)
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Isolated Sulcal Effacement/Swelling
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24 hour Follow-up Scan (post r-tPA)
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Initial Investiagions: ABC’s
• Airway and Breathing: Oxygen Saturation
Keep Sp02 >92%
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Initial Investigations: ABC’sCirculation: 12 lead ECG, cardiac and NIBP
monitor if available
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Frequency of Hypertension in Acute Stroke
Adapted from Leonardi-Bee et al, Stroke: 33, 1315, 2002
Hypertensive
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Laboratory Investigations
• Glucose (critical…why?)• CBC (Platelets >100 for tPA)• INR, PTT (INR < 1.7 for tPA)• Lytes, Cr, BUN
In thrombolysis, the utility of waiting for these labs must be weighed against the time is
brain concept
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Imaging Blood Vessels
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Hyperdense MCA Sign
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Hyperdense Dot Sign
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ADVANCED IMAGING
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CT Angiography
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DWI
CT
T2
Diffusion-Weighted Imaging: DWI
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DWI Evolution: Natural History
24 hours
4 hours
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Time course of DWI Evolution-11 min +11 min 3 hours 24 hours
Hjort et al, Ann. Neurol, 2005
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Value of DWI in Ischemic Stroke
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What is the Ischemic Penumbra?
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Penumbral Imaging: MRI
No Reperfusion
Reperfusion
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Imaging the Penumbra: CT Perfusion
Non-contrast CT Blood FlowCT Angiogram
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Investigations for Secondary Prevention
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TIA Investigation: Is there a rush?
Gladstone D et al. CMAJ. 2004 Mar 30;170(7):1099-104.
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TIA Risk Stratification:ABCD2 Score
A: age > 60 years – 1 point
B: BP (systolic>140mmHg, diastolic>90 mmHg). Either 1 point. (max 1 point)
C: clinical – unilateral weakness =2, speech only = 1
D: Duration, >60 minutes =2, 10-59 =1, <10 =0
D2: Diabetes=1
Rothwell PM, Lancet 2005; 366:29-36, Johnston, SC, Lancet 2007;369:283-292.
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ABCD 2 score: Front-loaded Risks
Score 2-day risk 7day risk 90 day risk
• High risk 6-7 8.1% 11.7% 17.8%
• Moderate risk 4-5 4.1% 5.9% 9.8%
• Low risk 0-3 1.0% 1.2% 3.1%
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What do they Need?
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1. Brain Imaging: CT or MRI
Even brief symptoms cause areas of permanent injury
~50% of all TIA’s are associated with permanent damage, particularly if symptoms last > 1 hour
Kidwell C et al. Stroke 1999; 6:1174-1180.
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A. Doppler/Duplex Ultrasound
• Indications?– Symptoms of anterior
circulation ischemia
• Utility?• Tempo?
2. Carotid Imaging
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B. Cerebral Angiography
Utility?
Indications?
Risks?
Digital Subtraction (Conventional Catheter) Angiography
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C. CT AngiographyIntracranialCT Angiogram
ExtracranialCT Angiogram
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D. MR AngiographyExtracranial Intracranial
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recent stroke, left hemisphere
Indications for Carotid Endarterctomy?
Why does CEA prevent stroke?
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NNT=6
NNT=9
NNT=3
Carotid Endarterectomy Timing
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3. Cardiac Investigations
• Who needs an Echo?• What kind do they
need?
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Echocardiography OptionsTransthoracic Echocardiogram
Transesophageal Echocardiogram
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Echocardiography Summary
TEE
Young patients without stroke risk factors (a
small minority)
TTE
Patients with cardiac disease or other
reasons for investigating
ventricular function
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Higher Yield Cardiac Investigation?
Holter Monitor
12
34
1234567
% of Patients with Paroxysmal Atrial Fibrillation (this changes management!)
Number of Infarcts
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Secondary Prevention Blood Work
• Fasting Glucose—Management?
• Fasting lipids—LDL target?
• Homocysteine?
• Tests of Hypercoagulability?– Reserve for younger patients or those with a
history of recurrent thrombosis– Anticardiolipin and Lupus Anticoagulant are
the higher yield investigations
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Summary• Diagnosis:
– rapid, accurate diagnosis essential ‘Time is Brain’– History and Physical: identify focal neurological
deficits
• Acute Treatment:– Consider thrombolysis– TIA is also a medical emergency and needs to be
investigated urgently