Tia

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TIAs - TIAs - size of the problemsize of the problemTIAs - TIAs - size of the problemsize of the problem

Incidence of new cases 42/100,000/yrIncidence of new cases 42/100,000/yr

of which carotid TIAs is 34/100,000of which carotid TIAs is 34/100,000

Incidence of first ever stroke 200/100,000/yrIncidence of first ever stroke 200/100,000/yr

The incidence of new strokes 240/100,000/yrThe incidence of new strokes 240/100,000/yr

TIAsTIAs

Slides on TIAsSlides on TIAsSlides on TIAsSlides on TIAs

Use and amend these slides for your Use and amend these slides for your lecture needs. These slides are for lecture needs. These slides are for

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any medical opinion.any medical opinion.

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CBF ml/100g/minCBF ml/100g/min

NormalNormal

OligaemicOligaemic

Electrocortical function Electrocortical function affectedaffected

Electrical failureElectrical failureIonic pump failureIonic pump failureCell deathCell death

3535

2020

1515

1010

6060

Thresholds of cerebral ischaemiaThresholds of cerebral ischaemiaThresholds of cerebral ischaemiaThresholds of cerebral ischaemia

TIAsTIAsTIAsTIAs

Catchment pop. of 250,000 Catchment pop. of 250,000

there will be there will be

100 new TIAs per year100 new TIAs per year

up to another 170 'unknown to GP'up to another 170 'unknown to GP'

TIAsTIAs

TIAs - TIAs - key questionskey questionsTIAs - TIAs - key questionskey questions

Is history consistent with TIA ?Is history consistent with TIA ?

Is TIA carotid or vertebrobasilar ?Is TIA carotid or vertebrobasilar ?

Is TIA haemodynamic or embolic ?Is TIA haemodynamic or embolic ?

What are p/ts risk factors for TIA ?What are p/ts risk factors for TIA ?

What are appropriate investigations & Rx ?What are appropriate investigations & Rx ?

TIAsTIAs

TIAsTIAsTIAsTIAs

Risk of strokeRisk of stroke

AetiologyAetiology

DiagnosisDiagnosis

Assessment and investigationsAssessment and investigations

Risk factors Risk factors

TreatmentTreatmentTIAsTIAs

TIATIATIATIA

50% of TIAs go unreported50% of TIAs go unreported

6-12% develop a stroke in the first year6-12% develop a stroke in the first year

then risk CVA about 5% annuallythen risk CVA about 5% annually

risk stroke highest first few weeksrisk stroke highest first few weeks

only 15% CVAs have h/o TIAonly 15% CVAs have h/o TIA

TIAsTIAs

TIATIATIATIA

Risk death 6.3 - 8% per yr - RR x1.4Risk death 6.3 - 8% per yr - RR x1.4

25% of deaths stroke, 45% cardiac25% of deaths stroke, 45% cardiac

Only 5-10% of TIA’s suitable for arterectomyOnly 5-10% of TIA’s suitable for arterectomy

Aspirin may lead to 4% reduction strokes/yr - reduce Aspirin may lead to 4% reduction strokes/yr - reduce incidence of CVA from 7% to 5% in patients with TIA (25%).incidence of CVA from 7% to 5% in patients with TIA (25%).

TIAsTIAs

Annual risk CVA, MI, vascular death Annual risk CVA, MI, vascular death following TIA minor CVAfollowing TIA minor CVA

Annual risk CVA, MI, vascular death Annual risk CVA, MI, vascular death following TIA minor CVAfollowing TIA minor CVA

CVACVA 6.7 %6.7 %

MIMI 2.52.5

DeathDeath 7.27.2

CVA, MI, Vascular deathCVA, MI, Vascular death 8.68.6

CVA, MI, DeathCVA, MI, Death 10.3 10.3

TIAsTIAs

TIAsTIAsTIAsTIAs


AetiologyAetiology

DiagnosisDiagnosis




TIAs - TIAs - sitesiteTIAs - TIAs - sitesite

10% vertebrobasilar 10% vertebrobasilar

80% carotid 80% carotid

10% uncertain10% uncertain

17% are purely retinal 17% are purely retinal (amaurosis fugax) better prognosis(amaurosis fugax) better prognosis

TIAsTIAs

TIAsTIAsTIAsTIAs

Approximate frequencies of main causes of Approximate frequencies of main causes of ischaemic stroke & presumably TIAsischaemic stroke & presumably TIAs

RaritiesRarities 5%5%AtherothromboembolismAtherothromboembolism 50%50%Embolism - heartEmbolism - heart 20%20%Intracranial small vessel diseaseIntracranial small vessel disease 25%25%

TIAsTIAs

TIAs - TIAs - territoryterritoryTIAs - TIAs - territoryterritory

Carotid Either VertebrobasilarCarotid Either VertebrobasilarDysphasiaDysphasia +++ +++Monocular visual loss (am fugax) +++Monocular visual loss (am fugax) +++Dyspraxia, visuospatial problems +++Dyspraxia, visuospatial problems +++Unilateral weaknessUnilateral weakness ++++ - - + +Unilateral sensoryUnilateral sensory ++++ - - + +Dysarthria*Dysarthria* + -+ - +++ +++Dysphagia*Dysphagia* + -+ - +++ +++Ataxia*Ataxia* +++ +++Diplopia*Diplopia* +++ +++Vertigo*Vertigo* + +Bilateral visual lossBilateral visual loss +++ +++Bilateral sensoryBilateral sensory +++ +++Crossed sensory/motorCrossed sensory/motor +++ +++

* = in isolation, not TIA* = in isolation, not TIA + may occur - +++ v common+ may occur - +++ v commonTIAsTIAs

Transient ischaemic attacksTransient ischaemic attacksTransient ischaemic attacksTransient ischaemic attacks

TIAsTIAs

Carotid TIAsCarotid TIAsCarotid TIAsCarotid TIAs

Hemiparesis / hemisensory lossHemiparesis / hemisensory loss

DysphasiaDysphasia

ApraxiaApraxia

Visuospatial problemsVisuospatial problems

Homonymous hemianopiaHomonymous hemianopia

Amaurosis fugaxAmaurosis fugaxTIAsTIAs

Amaurosis fugaxAmaurosis fugaxAmaurosis fugaxAmaurosis fugax

Risk of CVA Risk of CVA

half that of a TIA half that of a TIA with a cerebral event with a cerebral event

TIAsTIAs

Transient Transient ischaemic ischaemic

attacksattacks

Transient Transient ischaemic ischaemic

attacksattacks

TIAsTIAs

Vertebrobasilar TIAsVertebrobasilar TIAsVertebrobasilar TIAsVertebrobasilar TIAs Vertigo, Vomiting, AtaxiaVertigo, Vomiting, Ataxia

Diplopia - disorder of conjugate eye movementDiplopia - disorder of conjugate eye movement - vertical or horizontal - vertical or horizontal

Cortical blindness or isolated hemianopiaCortical blindness or isolated hemianopia

Bilateral motor or sensory defectBilateral motor or sensory defect

Ipsilateral cranial nerve deficit and Ipsilateral cranial nerve deficit and contralateral motor or sensory defect contralateral motor or sensory defect

TIAsTIAs

TIAsTIAsTIAsTIAs


AetiologyAetiology

DiagnosisDiagnosis




TIA - TIA - diagnosisdiagnosisTIA - TIA - diagnosisdiagnosis

The main 'diagnostic' tool for TIA is a careful The main 'diagnostic' tool for TIA is a careful clinical historyclinical history

Of referrals from GPs 38% in one study Of referrals from GPs 38% in one study had a 'true' TIA,had a 'true' TIA,

10% migraine, 9% faints, 9% 'funny turns'10% migraine, 9% faints, 9% 'funny turns'

9% possible TIAs, 6% epilepsy, 6% vertigo9% possible TIAs, 6% epilepsy, 6% vertigo

0.8% hypoglycaemia, 0.4% brain tumours0.8% hypoglycaemia, 0.4% brain tumours TIAsTIAs

TIA - TIA - diagnostic criteria (i)diagnostic criteria (i)TIA - TIA - diagnostic criteria (i)diagnostic criteria (i)

Focal neurological or monocular symptomsFocal neurological or monocular symptoms

-ve symptom (weak-numb-dysphasia-visual loss)-ve symptom (weak-numb-dysphasia-visual loss)

rare +ve (paraesthesia, limb shaking, flashes light)rare +ve (paraesthesia, limb shaking, flashes light)

abrupt onset secs, no march or intensificationabrupt onset secs, no march or intensification

resolve gradually but completely, 1 hr, lasting for seconds resolve gradually but completely, 1 hr, lasting for seconds rare - ? Afibrare - ? Afib

TIATIA

TIA - TIA - diagnostic criteria (ii)diagnostic criteria (ii)TIA - TIA - diagnostic criteria (ii)diagnostic criteria (ii)

usually no warning - ?Ep, migraine or provocationusually no warning - ?Ep, migraine or provocation

headache may occur during or afterheadache may occur during or after

loss consciousness rare - ?Ep, syncopeloss consciousness rare - ?Ep, syncope

frequent stereotyped attacks suggest partial Epfrequent stereotyped attacks suggest partial Ep

TIATIA

TIA - TIA - symptoms (i)symptoms (i)TIA - TIA - symptoms (i)symptoms (i)

Unilateral weakness/heaviness/clumsiness Unilateral weakness/heaviness/clumsiness 50%50%

Unilateral sensory symptomsUnilateral sensory symptoms 3535

Slurred speechSlurred speech 2323

Transient monocular blindnessTransient monocular blindness 1818

Difficulty speaking (dysphasia)Difficulty speaking (dysphasia) 1818

Unsteadiness (ataxia)Unsteadiness (ataxia) 1212

TIATIA

TIA - TIA - symptoms (ii)symptoms (ii)TIA - TIA - symptoms (ii)symptoms (ii)

Dizziness (vertigo)Dizziness (vertigo) 5%5%

Homonymous hemianopiaHomonymous hemianopia 55

Double visionDouble vision 55

Bilateral limb weaknessBilateral limb weakness 44

DysphagiaDysphagia 11

Crossed motor and sensory lossCrossed motor and sensory loss 11

TIATIA

TIAsTIAsTIAsTIAs


AetiologyAetiology

DiagnosisDiagnosis




Carotid bruitCarotid bruitCarotid bruitCarotid bruit

Can’t be used to determine if Can’t be used to determine if

symptomatic patients have ICA symptomatic patients have ICA

stenosis amenable to surgery.stenosis amenable to surgery.

TIAsTIAs


4% all > 45 years4% all > 45 years

26 - 53% symptomatic pts26 - 53% symptomatic pts

10% bruit, no stenosis10% bruit, no stenosis

71% severe stenosis, no bruit 71% severe stenosis, no bruit

30% ICA occlusion - bruit - ? ECA30% ICA occlusion - bruit - ? ECA

TIAsTIAs

Carotid bruit + TIACarotid bruit + TIACarotid bruit + TIACarotid bruit + TIA

40% carotid TIA localised stenosis40% carotid TIA localised stenosis

Increases if Increases if TIA’s briefTIA’s brief bruitbruit

amaurosis fugax tooamaurosis fugax too

10% may have complete occlusion10% may have complete occlusion

Risk CVA up to 10 % yr 1, death IHD 10%/yrRisk CVA up to 10 % yr 1, death IHD 10%/yr

TIAsTIAs


Stroke rate, Stroke rate, asymptomatic asymptomatic - 0.6% /yr- 0.6% /yrasymptomatic, bruit asymptomatic, bruit - 2.7% /yr- 2.7% /yr

symptomatic ICA symptomatic ICA - 10 % /yr- 10 % /yr

Bruit : 0.6 - 2.4% develop TIABruit : 0.6 - 2.4% develop TIA

Stroke side Stroke side does not always equate with bruit sidedoes not always equate with bruit side

TIAsTIAs

Carotid bruitCarotid bruitCarotid bruitCarotid bruit Increased risk of stroke, myocardial infarction and death. Increased risk of stroke, myocardial infarction and death.

Bruits are absent in > 1/3 patients with high grade stenosis. Bruits are absent in > 1/3 patients with high grade stenosis.

10% of patients with less than 50% stenosis will have a bruit. 10% of patients with less than 50% stenosis will have a bruit.

Bruit does not select out those who need endarterectomy.Bruit does not select out those who need endarterectomy.

TIAsTIAs

TIAs - TIAs - routineroutine investigationsinvestigationsTIAs - TIAs - routineroutine investigationsinvestigations

FBPFBP

ESR/CRP, +/- plasma viscosityESR/CRP, +/- plasma viscosity

U&E, blood sugarU&E, blood sugar

Serum cholesterol - TFTsSerum cholesterol - TFTs

ECGECG

TIAsTIAs

TIA - TIA - who to duplex scan (i) ?who to duplex scan (i) ?TIA - TIA - who to duplex scan (i) ?who to duplex scan (i) ?

Symptomatic in carotid territory Symptomatic in carotid territory (TIA or non-disabling CVA) (TIA or non-disabling CVA)

Willing to take the immediate risk of Willing to take the immediate risk of operation/arteriography operation/arteriography

(perioperative stroke or death in up to 10%) (perioperative stroke or death in up to 10%) for the long-term gain (unoperated risk of stroke by 2 for the long-term gain (unoperated risk of stroke by 2 years of up to 20%, overall gain of 10%)years of up to 20%, overall gain of 10%)

TIAsTIAs

TIA - TIA - who to duplex scan (ii) ?who to duplex scan (ii) ?TIA - TIA - who to duplex scan (ii) ?who to duplex scan (ii) ?

Recent symptoms (past 6 months)Recent symptoms (past 6 months)

No other life threatening diseaseNo other life threatening disease

No marked pulmonary/airways diseaseNo marked pulmonary/airways disease

No uncontrolled hypertension, cardiac failure or No uncontrolled hypertension, cardiac failure or ischaemic heart diseaseischaemic heart disease

No clinically significant dementiaNo clinically significant dementia

TIAsTIAs

TIA - TIA - who to duplex scan (iii) ?who to duplex scan (iii) ?TIA - TIA - who to duplex scan (iii) ?who to duplex scan (iii) ?

No marked frailtyNo marked frailty

No marked generalised arteriopathyNo marked generalised arteriopathy

No significant chronic liver or renal diseaseNo significant chronic liver or renal disease

TIAsTIAs

EEG, CT and MRI in TIAEEG, CT and MRI in TIAEEG, CT and MRI in TIAEEG, CT and MRI in TIA

Not indicated monocularNot indicated monocular

CT if > 1 TIA esp. carotid, arterectomyCT if > 1 TIA esp. carotid, arterectomy

Consider MRI if vertebrobasilar continuing & CT no Consider MRI if vertebrobasilar continuing & CT no helphelp

EEG if in doubt - EEG if in doubt - 35% c Ep always abnormal35% c Ep always abnormal50% occasionally50% occasionally15% never15% never

TIAsTIAs

TIAsTIAsTIAsTIAs


AetiologyAetiology

DiagnosisDiagnosis


Risk factorsRisk factors


Stroke - Stroke - risk factorsrisk factorsStroke - Stroke - risk factorsrisk factors

Age *Age *

MaleMale

BP* - causalBP* - causal

Smoking x 1.5 esp SAHSmoking x 1.5 esp SAH

FibrinogenFibrinogen

Diabetes x 2 *Diabetes x 2 *

Black / SE AsianBlack / SE Asian

Social deprivationSocial deprivation

MI / angina +MI / angina +

Cardiac failure +Cardiac failure +

LVHLVH

A Fib - x 6, x 18 M StenA Fib - x 6, x 18 M Sten

Claudication +Claudication +

Carotid bruitCarotid bruit

TIA x 5 - x 10TIA x 5 - x 10

TIAsTIAs

Stroke - prevalence of vascular risk factors - Stroke - prevalence of vascular risk factors - first time ever cerebral infarctfirst time ever cerebral infarct

Stroke - prevalence of vascular risk factors - Stroke - prevalence of vascular risk factors - first time ever cerebral infarctfirst time ever cerebral infarct

BP > 160/90BP > 160/90 52 %52 %

Angina or MIAngina or MI 3838

Current smokerCurrent smoker 2727

Claudication/ no foot pulsesClaudication/ no foot pulses 2525

Major cardiac embolic sourceMajor cardiac embolic source 2020

TIATIA 1414

Cx arterial bruitCx arterial bruit 1414

Diabetes mellitusDiabetes mellitus 1010

Any of = Any of = 80%80%

TIAsTIAs

Risk CVA, MI, vascular death Risk CVA, MI, vascular death following TIA minor CVAfollowing TIA minor CVA

Risk CVA, MI, vascular death Risk CVA, MI, vascular death following TIA minor CVAfollowing TIA minor CVA

PVDPVD 2.312.31

Carotid & vertebral TIAsCarotid & vertebral TIAs 2.032.03

MaleMale 1.981.98

Residual neurological signsResidual neurological signs 1.931.93

AgeAge 1.821.82

TIA brain vs eyeTIA brain vs eye 1.751.75

LVHLVH 1.721.72

Number of TIAs past yearNumber of TIAs past year 1.161.16

TIAsTIAs

TIA - TIA - risk of further CVArisk of further CVATIA - TIA - risk of further CVArisk of further CVA

A CVA rather than a TIAA CVA rather than a TIA

Frequent TIAsFrequent TIAs

Ulcerated plaque - soft plaqueUlcerated plaque - soft plaque

Stenosis above 80% Stenosis above 80%

are all associated with a greater stroke riskare all associated with a greater stroke riskTIAsTIAs

TIAsTIAsTIAsTIAs


AetiologyAetiology

DiagnosisDiagnosis




TIA - TIA - hospital admissionhospital admissionTIA - TIA - hospital admissionhospital admission

Symptoms suggestive CVA > 1hr.Symptoms suggestive CVA > 1hr.

> 2 TIAs in 1 week> 2 TIAs in 1 week

Pyrexia + TIAPyrexia + TIA

Severe hypertension + TIASevere hypertension + TIA

Atrial fibrillation, recent MI + TIAAtrial fibrillation, recent MI + TIA

TIAsTIAs

TIAsTIAsTIAsTIAs

Treating 1,000 patients with a history of Treating 1,000 patients with a history of cerebrovascular disease (mild stroke/TIA) will cerebrovascular disease (mild stroke/TIA) will prevent 37 cardiovascular events at 3 years prevent 37 cardiovascular events at 3 years (death, non-fatal stroke or myocardial (death, non-fatal stroke or myocardial infarction).infarction).

TIAsTIAs

Risk reduction, non-fatal CVA/MI, Risk reduction, non-fatal CVA/MI, vascular & non-vascular deaths, vascular & non-vascular deaths,

for antiplatelet Rx in TIA mild CVAfor antiplatelet Rx in TIA mild CVA

Risk reduction, non-fatal CVA/MI, Risk reduction, non-fatal CVA/MI, vascular & non-vascular deaths, vascular & non-vascular deaths,

for antiplatelet Rx in TIA mild CVAfor antiplatelet Rx in TIA mild CVA

7.5%

0%

30% 16/1215/1000

30%15/1214/1000

18%15/1213/1000

7%7% % reduction% reduction15/1215/12 months Rxmonths Rx1/10001/1000 events preventedevents prevented

% p

atie

nts

affe

cted

% p

atie

nts

affe

cted

TIAsTIAs

Aspirin - Aspirin - TIA & StrokeTIA & StrokeAspirin - Aspirin - TIA & StrokeTIA & Stroke

For 3 years 25% decrease risk ofFor 3 years 25% decrease risk of

Non fatal strokeNon fatal strokeNon fatal M InfarctNon fatal M InfarctDeath from cardiovascular causeDeath from cardiovascular cause

(1,000 prevents 37 cardiovascular events in 3 years) (1,000 prevents 37 cardiovascular events in 3 years)

TIAsTIAs

Drugs & ischaemic strokeDrugs & ischaemic strokeDrugs & ischaemic strokeDrugs & ischaemic stroke

Aspirin in healthy middle ageAspirin in healthy middle ageUSAUSA First MI relative risk down 44%First MI relative risk down 44%GB no decrease in MI,vascular deathGB no decrease in MI,vascular deathNEJM 1997, if CRP raised does decrease MI/CVANEJM 1997, if CRP raised does decrease MI/CVA

ClopidrogelClopidrogel - - Caprie study, edge over aspirin (0.05% difference, 1:200)Caprie study, edge over aspirin (0.05% difference, 1:200)

AspirinAspirin++persantinpersantin - - ESPS2 study combination x2 effect of single.ESPS2 study combination x2 effect of single.

TIAsTIAs

AspirinAspirinAspirinAspirin

Apparently healthy menApparently healthy men

C-reactive protein > 2.1 mg/l :-C-reactive protein > 2.1 mg/l :-

risk stroke doublerisk stroke double

risk MI tripledrisk MI tripled

aspirin decreased this xs risk by 53%aspirin decreased this xs risk by 53%

NEJM 1997; 336: 973-9.NEJM 1997; 336: 973-9.

Dipyridamole retard Dipyridamole retard Risk reduction forRisk reduction for TIATIA

Dipyridamole retard Dipyridamole retard Risk reduction forRisk reduction for TIATIA

18

22

36

0

5

10

15

20

25

30

35

40

Persantin retard Aspirin Combination

Persantin retard

Aspirin

Combination

In TIA/mild stroke - aspirin 50 mg, dipyridamol retard 200 mg bd, n = 6602In TIA/mild stroke - aspirin 50 mg, dipyridamol retard 200 mg bd, n = 6602

13.2%13.2%had had TIA TIA 2 yr.2 yr.



16.4%16.4%placeboplacebohad TIA had TIA 2 yr.2 yr.

European stroke prevention study. J Neur Sci 1996; 143: 1-13.European stroke prevention study. J Neur Sci 1996; 143: 1-13.

CAPRIE - ClopidrogelCAPRIE - ClopidrogelCAPRIE - ClopidrogelCAPRIE - Clopidrogel

Inhibits ADP-platelet aggregrationInhibits ADP-platelet aggregration

Recent Recent strokestroke, M Infarct, PVD , M Infarct, PVD n = 19,185: 1-3 yr, x = 1.91 yr.n = 19,185: 1-3 yr, x = 1.91 yr.

Clopidrogel 75mg vs aspirin 325 mgClopidrogel 75mg vs aspirin 325 mg

MI, Ischaemic stroke, vascular deathMI, Ischaemic stroke, vascular death

Clopidrogel 5.32% vs. Aspirin 5.83% annuallyClopidrogel 5.32% vs. Aspirin 5.83% annually

p= 0.043, relative risk reduction of 8.7% intention to treat (9.4% on treatment)p= 0.043, relative risk reduction of 8.7% intention to treat (9.4% on treatment)

Lancet 1997; 348: 1329-39Lancet 1997; 348: 1329-39

Aspirin secondary preventionAspirin secondary preventionAspirin secondary preventionAspirin secondary prevention

In patients with a history of In patients with a history of unstable angina, unstable angina,

myocardial infarction, myocardial infarction, TIA or TIA or

stroke stroke aspirin reduces the deaths from aspirin reduces the deaths from

cardiovascular causes by one sixth, cardiovascular causes by one sixth, non-fatal MI or stroke by 1/3 non-fatal MI or stroke by 1/3

(in patients who had an annual risk of 8-11% /yr). (in patients who had an annual risk of 8-11% /yr).

Aspirin reduces recurrent stroke by around 25%.Aspirin reduces recurrent stroke by around 25%.TIAsTIAs

European stroke prevention study 2European stroke prevention study 2European stroke prevention study 2European stroke prevention study 2

Mild stroke or TIA, 2 yr follow upMild stroke or TIA, 2 yr follow up

Stroke risk (or death) 18% (13%) c aspirinStroke risk (or death) 18% (13%) c aspirin

16% (15%) c persantin 16% (15%) c persantin retardretard

37% (24%) with both37% (24%) with both

TIAsTIAs

CAPRIE studyCAPRIE studyCAPRIE studyCAPRIE study

Recent ischaemic stroke, MI or symptomatic Recent ischaemic stroke, MI or symptomatic peripheral arterial diseaseperipheral arterial disease

Follow-up 1-3 yearsFollow-up 1-3 years

Risk ischaemic CVA, MI, vascular deathRisk ischaemic CVA, MI, vascular deathClopidrogel 5.3% per yr. Aspirin 5.8% per yr.Clopidrogel 5.3% per yr. Aspirin 5.8% per yr.

Drop out 21%, age 62.5 yrDrop out 21%, age 62.5 yr

(Antiplatelets Trialist’s Collab. Asp decr 25%)(Antiplatelets Trialist’s Collab. Asp decr 25%)

TIAsTIAs

Drugs & ischaemic stroke/TIA - arterialDrugs & ischaemic stroke/TIA - arterialDrugs & ischaemic stroke/TIA - arterialDrugs & ischaemic stroke/TIA - arterial

RecommendationsRecommendations

TIA/CVA non cardioembolic - aspirin is the standardTIA/CVA non cardioembolic - aspirin is the standard

Consider aspirin + Persantin retardConsider aspirin + Persantin retard

Conside Clopidrogel if reactions to above drugsConside Clopidrogel if reactions to above drugs

? Clopidrogel niche in peripheral vascular disease? Clopidrogel niche in peripheral vascular disease

Significant carotid stenosis - arterectomy if suitableSignificant carotid stenosis - arterectomy if suitable

Embolic stroke/TIA - consider warfarinEmbolic stroke/TIA - consider warfarinTIAsTIAs

Carotid stenosisCarotid stenosisCarotid stenosisCarotid stenosis

70 - 99% 10%/yr - CVA70 - 99% 10%/yr - CVA

Willing for surgeryWilling for surgery

Carotid TIA last few weeks/monthCarotid TIA last few weeks/month

No significant intracranial arterial diseaseNo significant intracranial arterial disease

Fit for surgery - BP, MI, IHD, LVF/CHFFit for surgery - BP, MI, IHD, LVF/CHF

TIAsTIAs

Carotid endarterectomyCarotid endarterectomyCarotid endarterectomyCarotid endarterectomy

Symptomatic carotid artery diseaseSymptomatic carotid artery disease TIA - retinal or cerebralTIA - retinal or cerebral

70 - 99 % stenosis, surgery better 70 - 99 % stenosis, surgery better 9% c.f. 26% risk stroke in 2 years9% c.f. 26% risk stroke in 2 years

- stenosis measured angiographically- stenosis measured angiographically- colour coded doppler & B mode ultrasonography - still - colour coded doppler & B mode ultrasonography - still imprecise correlationimprecise correlation

TIAsTIAs

Endarterectomy - TIAsEndarterectomy - TIAsEndarterectomy - TIAsEndarterectomy - TIAs

Aspirin decrease incidence CVA 25% 7 to 5%Aspirin decrease incidence CVA 25% 7 to 5%

Endarterectomy abolishes ipsilateral strokeEndarterectomy abolishes ipsilateral stroke

11-12% TIA’s consideration for arterectomy11-12% TIA’s consideration for arterectomy

Arterectomy decrease incidence stroke by 1%Arterectomy decrease incidence stroke by 1%

Indicated symptomatic stenosis 70-99%Indicated symptomatic stenosis 70-99%

Mortality arterectomy < 3%Mortality arterectomy < 3%

TIAsTIAs

Endarterectomy - Endarterectomy - guidelinesguidelinesEndarterectomy - Endarterectomy - guidelinesguidelines

Asymptomatic bruit & > 60% stenosis in men, Asymptomatic bruit & > 60% stenosis in men, or in men & women if severe contralateral stenosis. or in men & women if severe contralateral stenosis.

Endarterectomy halves the risk of stroke in those with Endarterectomy halves the risk of stroke in those with severe asymptomatic stenosis, absolute risk of stroke low severe asymptomatic stenosis, absolute risk of stroke low & surgery is usually not indicated.& surgery is usually not indicated.

Severe symptomatic stenosis (greater than 70%) in men Severe symptomatic stenosis (greater than 70%) in men and women. Risk of stroke is highest within weeks or and women. Risk of stroke is highest within weeks or months of the ischaemic event.months of the ischaemic event.

TIAsTIAs

Symptomatic Symptomatic carotid stenosiscarotid stenosisSymptomatic Symptomatic carotid stenosiscarotid stenosis

NASCET trial risk ipsilateral CVA at 2 years :-NASCET trial risk ipsilateral CVA at 2 years :- 26% for medical Rx 26% for medical Rx 9% for surgical Rx 9% for surgical Rx

At 5 years At 5 years risk of ipsilateral CVA risk of ipsilateral CVA 10%10% risk of any stroke risk of any stroke 18%18% risk of deathrisk of death 27%27%In those Rx surgically. In those Rx surgically.

Endarterectomy decreases risk CVA by x6 - x10Endarterectomy decreases risk CVA by x6 - x10

TIAsTIAs

Symptomatic Symptomatic carotid stenosiscarotid stenosisSymptomatic Symptomatic carotid stenosiscarotid stenosis

10 arterectomies will save 1 stroke10 arterectomies will save 1 stroke

Incidence of stroke reduction < 1%Incidence of stroke reduction < 1%

Still cost efficientStill cost efficient

TIAsTIAs

Asymptomatic carotid stenosis (ACS)Asymptomatic carotid stenosis (ACS)Asymptomatic carotid stenosis (ACS)Asymptomatic carotid stenosis (ACS)

Of 50% present in 25% hypertensivesOf 50% present in 25% hypertensives

Of 50% present in 12% p. vasc diseaseOf 50% present in 12% p. vasc disease

Smoker c Smoker c lipids, IHD, AAA, ACS likelylipids, IHD, AAA, ACS likely

TIA, CVA more likely c soft plaqueTIA, CVA more likely c soft plaque

>50% stenosis 7% risk CVA 2 years>50% stenosis 7% risk CVA 2 years

>50% stenosis & BP 1/3 CVA 5 years>50% stenosis & BP 1/3 CVA 5 years

Soft plaque < 75%, 20% CVA TIA 3 yearsSoft plaque < 75%, 20% CVA TIA 3 yearsTIAsTIAs

Asymptomatic Asymptomatic carotid stenosiscarotid stenosisAsymptomatic Asymptomatic carotid stenosiscarotid stenosis

30% > 50 yr have some carotid artery disease30% > 50 yr have some carotid artery disease

Stenosis > 50% in 4% middle aged & elderlyStenosis > 50% in 4% middle aged & elderly

< 1% middle aged & elderly stenosis > 80%< 1% middle aged & elderly stenosis > 80%

Asymptomatic stenosis > 75% Asymptomatic stenosis > 75% Risk ipsilateral CVA 2.5% per year (1% < 75%) Risk ipsilateral CVA 2.5% per year (1% < 75%) Risk fatal coronary heart disease 6.5% per year Risk fatal coronary heart disease 6.5% per year

5 yr medical Rx risk CVA 10.6%5 yr medical Rx risk CVA 10.6%

5 year surgical risk CVA 5.8%5 year surgical risk CVA 5.8%TIAsTIAs

TIAs - TIAs - practical points (1)practical points (1)TIAs - TIAs - practical points (1)practical points (1)

Acute focal neurological defectAcute focal neurological defectmonocular, clears 24 hr, usually half hr.monocular, clears 24 hr, usually half hr.

30% c TIA get CVA by 5 years30% c TIA get CVA by 5 years

Global symptoms in isolation rarely due to TIAGlobal symptoms in isolation rarely due to TIAloss consciousness, presyncope, dizziness, loss consciousness, presyncope, dizziness,

confusion, incontinenceconfusion, incontinence

Presence/absence carotid bruit ‘unhelpful’Presence/absence carotid bruit ‘unhelpful’for diagnosing significant carotid diseasefor diagnosing significant carotid disease

TIAsTIAs

TIAs - TIAs - practical points (2)practical points (2)TIAs - TIAs - practical points (2)practical points (2)

Investigation include FBP, ESR, BS, lipids, ECG Investigation include FBP, ESR, BS, lipids, ECG

Admit crescendo TIAs - occurring daily or >Admit crescendo TIAs - occurring daily or >

Treat risk factors - AF, BP, smoking, C2H5, lipidsTreat risk factors - AF, BP, smoking, C2H5, lipids

Antiplatelet therapy - 25% Antiplatelet therapy - 25% CVA / MI/ vasc CVA / MI/ vasc Warfarin for AFWarfarin for AF

Endarterectomy for selected pts. Endarterectomy for selected pts.

TIAsTIAs

TIAs - TIAs - dy/dx - transient deficitdy/dx - transient deficitTIAs - TIAs - dy/dx - transient deficitdy/dx - transient deficit

MigraineMigraine

EpilepsyEpilepsy

Intracranial tumour (up to 1 ‘TIAs’)Intracranial tumour (up to 1 ‘TIAs’)

SyncopeSyncope

SubduralSubdural

HypoglycaemiaHypoglycaemia

DemyelinationDemyelination

IC bleed - but usually lasts daysIC bleed - but usually lasts daysTIAsTIAs

dy/dx TIAdy/dx TIAdy/dx TIAdy/dx TIA

Was the event vascular - very likely ifWas the event vascular - very likely if

Signs SABESigns SABE

Carotid territory + focal loud long ipsilateral bruitCarotid territory + focal loud long ipsilateral bruit

M Infarct last 3-4 weeksM Infarct last 3-4 weeks

Rheumatic atrial fibrillationRheumatic atrial fibrillation

TIATIA


Was the event vascular - likely ifWas the event vascular - likely if

A fib & NR valvular heart diseaseA fib & NR valvular heart disease

Arterial bruit anywhereArterial bruit anywhere

Prosthetic heart valve & on warfarinProsthetic heart valve & on warfarin

TIATIA


Was the event vascular - unlikelyWas the event vascular - unlikely

< 40, years< 40, years

no vascular risk factorsno vascular risk factors

no symptomatic vascular diseaseno symptomatic vascular disease

TIATIA

dy/dx TIAsdy/dx TIAsdy/dx TIAsdy/dx TIAs

attack usually lasts < 60 min, thereforeattack usually lasts < 60 min, therefore

diagnosis relies on clinical historydiagnosis relies on clinical history

BUT history/memory of event may be poorBUT history/memory of event may be poor

diagnosis open to inter/intra-observer variationdiagnosis open to inter/intra-observer variation

so let’s concentrate on serious but remediable so let’s concentrate on serious but remediable differential diagnosesdifferential diagnoses

TIATIA

Breakdown of transient neurological Breakdown of transient neurological symptoms Oxford Community Stroke Projectsymptoms Oxford Community Stroke Project

39% TIAs39% TIAs

10.4% migraine10.4% migraine

9.6% syncope9.6% syncope

9.0% funny turn9.0% funny turn

6.6% isolated vertigo6.6% isolated vertigo


5.8% epilepsy5.8% epilepsy

3.4% TG amnesia3.4% TG amnesia

< 1% isolated diplopia< 1% isolated diplopia

< 1% drop attack< 1% drop attack

12% possible TIA12% possible TIATIATIA


Possible causes transient neurological symptomsPossible causes transient neurological symptoms

Focal ischaemia* Focal ischaemia* + SA+ SA Labyrinthine disease*Labyrinthine disease*

Migraine aura*Migraine aura* Metabolic, Gluc Metabolic, Gluc ++, Ca, Na, Ca, Na

Partial (focal) epilepsy*Partial (focal) epilepsy* Peripheral nervePeripheral nerve

TGA*TGA*+ -+ - MyastheniaMyasthenia

Intracranial lesionIntracranial lesion PsychologicalPsychological

MSMS Key : *commonest Key : *commonest ++most imptmost imptTIATIA

Migraine Migraine vs TIA (i)vs TIA (i)Migraine Migraine vs TIA (i)vs TIA (i)

Younger pt +/- family historyYounger pt +/- family history

Positive focal cerebral/visual aura Positive focal cerebral/visual aura

Aura develops over 5-20 min, lasts < 60 minAura develops over 5-20 min, lasts < 60 min

Homonymous, unilateral or central visual c/oHomonymous, unilateral or central visual c/oZig zag, Fortification spectra, ScintillationsZig zag, Fortification spectra, Scintillations

TIATIA

Migraine Migraine vs TIA (ii)vs TIA (ii)Migraine Migraine vs TIA (ii)vs TIA (ii)

Somatosensory or motor paraesthesia/heavinessSomatosensory or motor paraesthesia/heaviness

Evolve and spread over a period of minutes e.g.. arm., Evolve and spread over a period of minutes e.g.. arm., face, tongueface, tongue

Headache, nausea, photo, phonophobia cin 1 hrHeadache, nausea, photo, phonophobia cin 1 hr

Headache usually lasts 4 - 72 hrHeadache usually lasts 4 - 72 hr

TIATIA

Migraine Migraine with aurawith auraMigraine Migraine with aurawith aura

2 attacks fulfilling B & C2 attacks fulfilling B & C

B) At least 3 of :-B) At least 3 of :-i) One or more focal cerebral cortical/brainstem aura, i) One or more focal cerebral cortical/brainstem aura, completely reversiblecompletely reversibleii) At least 1 aura symptom develops gradually over > 4 ii) At least 1 aura symptom develops gradually over > 4 min, or 2 or more in successionmin, or 2 or more in successioniii) No aura symptom > 1 hriii) No aura symptom > 1 hriv) Headache follows aura within 1 hriv) Headache follows aura within 1 hr

C) No evidence of related organic diseaseC) No evidence of related organic disease

TIAsTIAs

Danger signs Danger signs for ‘migraine’for ‘migraine’Danger signs Danger signs for ‘migraine’for ‘migraine’

sudden onset of ‘worst ever headache’sudden onset of ‘worst ever headache’

progressive courseprogressive course

onset with exertiononset with exertion

onset of headache during or after middle ageonset of headache during or after middle age

headache & decreased level of consciousnessheadache & decreased level of consciousness

headache and meningismheadache and meningism

headache & abnormal physical signs e.g. feverheadache & abnormal physical signs e.g. fever

TIAsTIAs

Migraine Migraine without aurawithout auraMigraine Migraine without aurawithout aura

5 attacks fulfilling BCDE5 attacks fulfilling BCDE

B) headache 4 to 72 hrB) headache 4 to 72 hr

C) 2 of :- unilateral, pulsating, at least mod C) 2 of :- unilateral, pulsating, at least mod severe, worse on exercise severe, worse on exercise

D) During headache at least 1 of :D) During headache at least 1 of :i) nausea &/or vomitingi) nausea &/or vomitingii)photophobia & phonophobiaii)photophobia & phonophobia

E) No evidence of related organic diseaseE) No evidence of related organic diseaseTIAsTIAs

Case history Case history TIA vs migraineTIA vs migraineCase history Case history TIA vs migraineTIA vs migraine

55 yr. old male55 yr. old male

Driving home heaviness, pins & needles R armDriving home heaviness, pins & needles R armCleared in 1/2 hrCleared in 1/2 hrThen couldn’t read newspaper, garbled speechThen couldn’t read newspaper, garbled speechJazzy effect R visual field next 2 hoursJazzy effect R visual field next 2 hoursFamily h/o migraineFamily h/o migraine

TIATIA

TIA TIA vs epilepsyvs epilepsyTIA TIA vs epilepsyvs epilepsy

Ep positive motor/sensory phenomenaEp positive motor/sensory phenomena

Spreads quickly over next minuteSpreads quickly over next minute

TIA +ve phenomena affect body parts simultaneouslyTIA +ve phenomena affect body parts simultaneously

Todds paralysis can follow partial or grand malTodds paralysis can follow partial or grand mal

Transient speech arrest - aimless staring, amnesia Transient speech arrest - aimless staring, amnesia

dy/dx TIA & partial seizure can be difficultdy/dx TIA & partial seizure can be difficult

TIATIA

Case history Case history TIA vs EpilepsyTIA vs EpilepsyCase history Case history TIA vs EpilepsyTIA vs Epilepsy

64 year old woman64 year old woman

6 week h/o 20 attacks pins & needles R arm+leg6 week h/o 20 attacks pins & needles R arm+leg

Lasted 5 minsLasted 5 mins

Start foot, spread affecting leg+arm over 1 minStart foot, spread affecting leg+arm over 1 min

Like water ‘running up my leg’Like water ‘running up my leg’

Each attack identicalEach attack identical

CT Glioma left parietal lobeCT Glioma left parietal lobeTIATIA

Transient global amnesiaTransient global amnesiaTransient global amnesiaTransient global amnesia

Middle aged and elderlyMiddle aged and elderly

Sudden disorder memory - appears ‘confused’Sudden disorder memory - appears ‘confused’

Anterograde & often retrograde amnesia few hr.Anterograde & often retrograde amnesia few hr.

No other problems, patient can even driveNo other problems, patient can even drive

CVA amnestic syndrome if affects ant. thalamusCVA amnestic syndrome if affects ant. thalamus

Look for vert gaze palsy, c’spinal, spinothal, tractLook for vert gaze palsy, c’spinal, spinothal, tract

TIATIA

Intracranial structural lesionsIntracranial structural lesionsIntracranial structural lesionsIntracranial structural lesions

Sometimes causes intermittent neurological symptoms Sometimes causes intermittent neurological symptoms (tumour, AVM, aneurysm)(tumour, AVM, aneurysm)

0.4% UK TIA/aspirin trial - intracranial tumour0.4% UK TIA/aspirin trial - intracranial tumour

Focal jerk/shake, sensory phenomena, loss Focal jerk/shake, sensory phenomena, loss consciousness, speech arrest.consciousness, speech arrest.

Partial ep., vascular steal, ICP change, bleedPartial ep., vascular steal, ICP change, bleed

TIATIA

TIAs - TIAs - dangerdanger TIAs - TIAs - dangerdanger

Suspect brain tumour if :-Suspect brain tumour if :-

Pure sensory, esp c march of symptomsPure sensory, esp c march of symptoms

Jerking of a limb during an attackJerking of a limb during an attack

Loss of consciousnessLoss of consciousness

Speech arrestSpeech arrest

TIAsTIAs

TIA TIA vs structural lesion - case historyvs structural lesion - case historyTIA TIA vs structural lesion - case historyvs structural lesion - case history

78 year old woman78 year old woman

Multiple attacks weakness/clumsiness 4mths.Multiple attacks weakness/clumsiness 4mths.

Lasted 10-45 minsLasted 10-45 mins

Aspirin, attacks continuedAspirin, attacks continued

R frontal meningiomaR frontal meningioma

TIATIA

IC haemorrhage IC haemorrhage & others (i)& others (i)IC haemorrhage IC haemorrhage & others (i)& others (i)

Small bleed may mimic TIASmall bleed may mimic TIA

Chronic subdural can Chronic subdural can Aphasia, speech arrest. Aphasia, speech arrest. Headache 80% Headache 80%

MS - usually 3rd - 4th decadeMS - usually 3rd - 4th decade can present suddenly can present suddenly optic neuritis, unilateral myelitis, dystonic limb optic neuritis, unilateral myelitis, dystonic limb

TIATIA

IC haemorrhage IC haemorrhage & others (ii)& others (ii)IC haemorrhage IC haemorrhage & others (ii)& others (ii)

Labyrinthine disorder - vertical nystagmus b’stemLabyrinthine disorder - vertical nystagmus b’stem

Menieres, BPV, B recurrent vertigo, viral labyrinth Menieres, BPV, B recurrent vertigo, viral labyrinth

Hypoglycaemia - can - transient hemiparesisHypoglycaemia - can - transient hemiparesis

P Nerve lesion, myashtenia - brainstem TIA, P Nerve lesion, myashtenia - brainstem TIA, psychologicalpsychological

TIATIA

Syncope : loss consciousness /postural tone 2Syncope : loss consciousness /postural tone 200 ischaemia ischaemia

Key to diagnosis sound clinical history & examinationKey to diagnosis sound clinical history & examination

Consciousness dependsConsciousness depends on ascending reticular on ascending reticular activating system activating system activating the two activating the two cerebral hemispheres cerebral hemispheres

TIATIA

Non-focal sudden neurological deficits (i)Non-focal sudden neurological deficits (i)Non-focal sudden neurological deficits (i)Non-focal sudden neurological deficits (i)

If a patient presents with syncope :If a patient presents with syncope :

Exclude heart diseaseExclude heart disease

Valvular eg. A StenosisValvular eg. A Stenosis

HOCMHOCM

Conducting systemConducting system

Exclude carotid sinus syndromeExclude carotid sinus syndrome

Exclude epilepsyExclude epilepsyTIATIA

Non-focal sudden neurological deficits (ii)Non-focal sudden neurological deficits (ii)Non-focal sudden neurological deficits (ii)Non-focal sudden neurological deficits (ii)

Transient unresponsiveness in the elderlyTransient unresponsiveness in the elderly

Drop attack - falling without warningDrop attack - falling without warning

majority were cryptogenic, female x age 44 yr.majority were cryptogenic, female x age 44 yr.

no loss of consciousnessno loss of consciousness

no warning signs or symptomsno warning signs or symptoms

dy/dx vertebrobasilar insuff - diplopia, vertigody/dx vertebrobasilar insuff - diplopia, vertigo

Narcolepsy -cataplexy : sleepiness, loss of toneNarcolepsy -cataplexy : sleepiness, loss of tone

Giddiness / dizzinessGiddiness / dizzinessTIATIA

Non-focal sudden neurological deficits (iii)Non-focal sudden neurological deficits (iii)Non-focal sudden neurological deficits (iii)Non-focal sudden neurological deficits (iii)

TIA/mild CVA - TIA/mild CVA - strategy (istrategy (i))TIA/mild CVA - TIA/mild CVA - strategy (istrategy (i))

Early specialist referralEarly specialist referral

Identify and treat any specific disease Identify and treat any specific disease (rare - e.g., an arteritis, SABE). (rare - e.g., an arteritis, SABE).

Anticoagulants in those with AFib Anticoagulants in those with AFib (CAT scan) (CAT scan)

TIAsTIAs

TIA/mild CVA - TIA/mild CVA - strategy (ii)strategy (ii)TIA/mild CVA - TIA/mild CVA - strategy (ii)strategy (ii)

Antiplatelet drugsAntiplatelet drugs

Modify vascular risk factors - Modify vascular risk factors - BP, smoking, hyperlipidaemia BP, smoking, hyperlipidaemia

Select for duplex carotid scansSelect for duplex carotid scans the fewer still for arteriography the fewer still for arteriography the fewer still for endarterectomy the fewer still for endarterectomy.

TIAsTIAs

Tia

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