Post on 19-Jan-2016
description
Early recognition and treatment of Transient Ischaemic Attack (TIA)
Prof. Pierre Amarenco, Paris, France
What is a TIA….
• “Brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one-hour
• and without evidence of acute infarction”.
Albers GW, Caplan LR, Easton JD et al. N Engl J Med 2002;347:1713-16
TIA : Symptom of stroke or ministroke ?
Four Different Perspectives to define « TIAs »
• In the community: Recognition of transient symptoms to detect patients at risk for imminent
stroke:
– Transient Neurologic Symptoms or
– Acute CerebroVascular Syndrome
• Epidemiology study: differentiiation between transient and permanent symptoms without
necessary brain imaging available (duration might be useful)
• Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion
(qualifying for brain infarction)
• In the setting of a stroke unit: differentiation between transient symptoms from persisting
symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion)
and those without (e.g, different prognosis, risk stratification perspective)
Four Different Perspectives to define « TIAs »
• In the community: Recognition of transient symptoms to detect patients at risk for imminent
stroke:
– Transient Neurologic Symptoms or
– Acute CerebroVascular Syndrome
• Epidemiologic study: differentiiation between transient and permanent symptoms without
necessary brain imaging available (duration might be useful)
• Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion
(qualifying for brain infarction)
• In the setting of a stroke unit: differentiation between transient symptoms from persisting
symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion)
and those without (e.g, different prognosis, risk stratification perspective)
Four Different Perspectives to define « TIAs »
• In the community: Recognition of transient symptoms to detect patients at risk for imminent
stroke:
– Transient Neurologic Symptoms or
– Acute CerebroVascular Syndrome
• Epidemiology study: differentiiation between transient and permanent symptoms without
necessary brain imaging available (duration might be useful)
• Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion
(qualifying the neurologic event as a brain infarction)
• In the setting of a stroke unit: differentiation between transient symptoms from persisting
symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion)
and those without (e.g, different prognosis, risk stratification perspective)
Four Different Perspectives to define « TIAs »
• In the community: Recognition of transient symptoms to detect patients at risk for imminent
stroke:
– Transient Neurologic Symptoms or
– Acute CerebroVascular Syndrome
• Epidemiology study: differentiiation between transient and permanent symptoms without
necessary brain imaging available (duration might be useful)
• Therapeutic trials: differentiation between TIA without brain lesion from those with brain lesion
(qualifying for brain infarction)
• In the setting of a stroke unit: differentiation between transient symptoms from persisting
symptoms eligible for tPA, and later between transient symptoms with brain lesion (infartion)
and those without (e.g, different prognosis, risk stratification perspective)
Current view
• Use the term– “Cerebrovascular syndrome” to qualify any
suspiscion of ischemic stroke (whether transient or permanent, ischemic or hemorrhagic)
• Keep the term– “TIA” for symptoms without brain lesion on
neuro-imaging
Cumulative risk of stroke after TIA
0
5
10
15
20
25
0 30 60 90Days
TIA
Minor stroke
BMJ 2004; 328: 326-8
Cumulative risk of stroke TIA vs minor stroke
Lancet 2005; 366: 29-36
OXVASC
0
2
4
6
8
10
12
14
0 7 14 21 28
Days
Ris
k o
f st
roke
(%
)
OCSP
TIA: diagnosis needed
• 2,416 pts [OXVASC, OCSP, ECST, UK-TIA]• 23% of strokes preceded by a TIA
– 17% same day– 9% day before
– 43% within 7 days before index stroke
Rothwell P et al. Neurology 2005;64:817-820
Very Early Management in a TIA Clinic :
80% stroke risk reduction at 3 months
Rothwell et al. Lancet. 2007
EXPRESSNext day visit
SOS-TIASame day visit (24/24hr)
Lavallée et al. Lancet Neurol. 2007
SOS-TIA
• TIA clinic, 24/24 h, 7/7 d
• Objectives :
To make an urgent diagnosis of TIA
To find out the cause
in less than 4 hours
To prevent a stroke within the next hours/days/weeks
Educational leaflet on TIA
Mailed to:
15 000 PCP, cardiologists, ophthalmologists, emergency physicians, neurologists in Ile-de-France (administrative region of Paris)
Give 300 mg of ASA
Pre-hospital
Yesterday, I was watching TV, and suddendly theRemote control fell down from my right hand. I couldnot move my fingers during 3 minutes. And then, suddendlyI have totally recovered. Is it some fatigue, Doctor?
Do you know?This is a TIAThis patient is at risk for a massive stroke within thenext hours?What to do?Don’t down grade the symptomsTell the patient he is at risk for imminent stroke butthat we can avoid itTell him we have to do immediate diagnostic testingand treatment
TIA symptoms:
Carotid (anterior circulation)• transient monocular blindness• hemiplegie• hemi sensory loss• speech difficulties (aphasia)
Vertebrobasilar (posterior circulation):• hemiplegie (may involved both sides, not at the same moment)• unilateral paresthesia (same)• total or partial visual field defect (one or both sides)• ataxia with gait unstability
SUSPICION of TIA
0 800 888 248N°Vert
24/24 - 7/7Nurse practitioner : Monday - Friday 9h to 17 h
Senior Vascular Neurologist on duty 17h to 9h and w.e.
SOS TIA
TIA POSSIBLE
ADMISSION at the Day Clinic
SOS-TIALavallée et al. Lancet Neurol. 2007
2003-2005
100% of patients had their work-up done in < 4 hrs75% of patients were discharged home 3 or 4 hrs after admission to the SOS-TIA clinic
SOS-TIA Model vs.
Recognition of TIAs - PCPsGPs - Cardiologists - Ophthalmologists
1st Step
Vs.Admission
to TIA Clinic
100%
3rd Step
Discharge
100%75% Admissionto Stroke Unit
25%
LOS
6.5 days
TRIAGEStratifying the risk
According to a quick work-upAnd underlying cause
< 1 dayvs.
2nd StepAdmission
To Stroke Unit
100% ABCD2 score
Usual Care
European Stroke Organisation
2008 Recommendations
Cerebrovasc Dis. 2008;25(5):457-507. Epub 2008 May 6
NICE recommendations
July 2008
ABCD2 Score
Johnston C, Rothwell PM etal. Lancet 2006
Short-Term Risk of Stroke by ABCD2 Score
Johnston C, Rothwell PM etal. Lancet 2006
1622 -> 1176 Definite or possible TIAs
Does ABCD2 score less than 4 allow more time to evaluate patients with TIA ?
Amarenco P, Labreuche J, Lavallée PC, et al. Stroke. 2009
1622 -> 1176 Definite or possible TIAs
SOS-TIA update 2003-2009
HTN/Diabetes/Cholesterol/Smoking…
Genes / Age / Gender / Hs-CRP / ACE / TM …
Predicting Short/Long-Term High-Risk of Stroke/MI
TIA
Stroke/MI
CLINICAL EVENTS
MARKERS OF RISK
MODIFIABLE RISK FACTORS
Stenosis
Plaque
Intima-Media Thickness
DWI/MRI
A-FibOther CSE
Triaging TIAs: MRI
Calvet D et al. Stroke. 2009;40:187-192
ABDC2 + I
0
1
2
3
4
5
6
7
8
9
10
≤1 2 3 4 5 6 7ABCD2 score
OR
fo
r in
farc
tio
n o
n b
rain
im
agin
g
DWI- imaged cohorts
CT- imaged cohorts
Giles M, Rothwell PM, Amarenco P, et al. Stroke 2010
ABDC2 + I
Giles M, Rothwell PM, Amarenco P, et al. Stroke 2010
Causes of Brain InfarctionsCauses of Brain Infarctions
IntracranialIntracranialAtherosclerosisAtherosclerosis
CarotidCarotidPlaque withPlaque with
ArteriogenicArteriogenicEmboliEmboli
Aortic ArchAortic ArchPlaquePlaque
CardiogenicCardiogenicEmboliEmboli
PenetratingPenetratingArteryArteryDiseaseDisease
Flow Flow Reducing Reducing Carotid Carotid StenosisStenosis
Atrial FibrillationAtrial Fibrillation
Valve DiseaseValve Disease
Left Ventricle ThrombiLeft Ventricle Thrombi
SOS-TIAUltra-early Neurosonographic evaluation
in definite TIA13% ECG abnormalities (10% AF)
Carotid US97.3% of 1881pts
Carotid athero
Carotid stenosis ≥70%
DTC97.3% of 1881 pts
Intracranial stenosisOr occlusion
TTE/TEE96%/77% of pts
Aortic arch pl≥4 mmMajor CSEPFO/ASA
65%
8.6%
13.9%
14%2%19%
Lavallée PC, Labreuche J, Meseguer E et al. & Meseguer E, Lavallée PC, Mazighi M, et al. & Slaoui T, Lavallée PC, Labreuche J et al.
SOS-TIA: stratifying the risk with TCD
Meseguer E, Lavallée PC, Mazighi M, et al. Ann Neurol. 2010
SOS-TIAStratifying the risk on the presence of carotid plaque on carotid ultrasound
examination
Risk of combined stroke, myocardial infarction and vascular death from time of presenting withsuspected TIA according to presence or absence of ICA atherosclerosis
Carotid plaque
No carotid plaque
Age and sex adjustedRR=1.83 (95%CI, 0.84-4.01) log-rank, p=0.001
1-yr rate of Stroke, MI, Vasc Death 3.7% vs. 1.3%
N=1756
SOS-TIA: Immediate Preventive Strategy for Mr B.
• Antiplatelet agent, pre-hospital• Blood pressure lowering• Statin therapy (after lipid profile determination in
fasting condition)• Smoking cessation• Anti diabetic treatment• Oral anticoagulant (e.g., Atrial fibrillation)• Carotid endarterectomy (stenosis ≥70%)
CONCLUSIONS• TIA is an emergency: work-up has to be done < 24 hours, in a dedicated organized structure (TIA clinic)
• With fast evaluation = same day discharged for up to 75% of pts (Pt satisfaction/Cost-effectiveness)
• Risk becomes extremely low compared to that expected with a RRR= 80% at 3 months
• TIA clinic should be developed in all comprehensive stroke centres for same day evaluation
• It is no longer possible to wait more than 12 hours to do the evaluation of a TIA
What should be the early management of TIA patients
• Admission to a dedicated structure (no matter the setting)
• Immediate evaluation and treatment• A priori defined immediate process of care
– Brain imaging– Arterial and cardiac evaluation– Blood testing– Full clinical evaluation
• Decision on orientation by a senior stroke specialist: discharged home or admission to SU