tia
TRANSCRIPT
Tia slidesTia slidesTia slidesTia slides
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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
Physicians and require medical Physicians and require medical interpretation. They are not to be used for interpretation. They are not to be used for personal diagnosis, treatment or treatment personal diagnosis, treatment or treatment recommendations. Consult your doctor for recommendations. Consult your doctor for
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
Risk of strokeRisk of stroke
AetiologyAetiology
DiagnosisDiagnosis
Assessment and investigationsAssessment and investigations
Risk factors Risk factors
TreatmentTreatmentTIAsTIAs
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
Risk of strokeRisk of stroke
AetiologyAetiology
DiagnosisDiagnosis
Assessment and investigationsAssessment and investigations
Risk factors Risk factors
TreatmentTreatmentTIAsTIAs
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
Risk of strokeRisk of stroke
AetiologyAetiology
DiagnosisDiagnosis
Assessment and investigationsAssessment and investigations
Risk factors Risk factors
TreatmentTreatmentTIAsTIAs
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
Carotid bruitCarotid bruitCarotid bruitCarotid bruit
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
Carotid bruitCarotid bruitCarotid bruitCarotid bruit
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
Risk of strokeRisk of stroke
AetiologyAetiology
DiagnosisDiagnosis
Assessment and investigationsAssessment and investigations
Risk factorsRisk factors
TreatmentTreatmentTIAsTIAs
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
Risk of strokeRisk of stroke
AetiologyAetiology
DiagnosisDiagnosis
Assessment and investigationsAssessment and investigations
Risk factors Risk factors
TreatmentTreatmentTIAsTIAs
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.
12.6%12.6%had had TIA TIA 2 yr.2 yr.
10.5%10.5%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
dy/dx TIAdy/dx TIAdy/dx TIAdy/dx TIA
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
dy/dx TIAdy/dx TIAdy/dx TIAdy/dx TIA
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
dy/dx TIAdy/dx TIAdy/dx TIAdy/dx TIA
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
dy/dx TIAdy/dx TIAdy/dx TIAdy/dx TIA
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