Work-up for stroke/tia : what is the minimal workup needed?

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Jocelin Wells
7 years ago
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1 Work-up for stroke/tia : what is the minimal workup needed? F E R A S J E R A D E H - B O U R S O U L I A N, M D N E U R O H O S P I T A L I S T N O R T H M I S S I S S I P P I M E D I C A L C E N T E R

2 TIA vs Stroke Transient ischemic attack : Brief episode of neurologic dysfunction that typically lasts less than an hour; results from focal cerebral, spinal cord, or retinal ischemia Not associated with acute tissue infarction N Engl J Med. Nov AHA/ASA in 2009

3 In people who have a TIA, the incidence of subsequent stroke is as high as 11% over the next 7 days and 24-29% over the following 5 years. Giles MF et al Lancet Neurol. Dec 2007 Should we do the TIA workup in the inpatient or outpatient settings??

4 Johnston et al, Lancet 2007

5 Johnston et al, Lancet 2007

6 Stroke and TIA work up In the ED : Is this an acute stroke? Triaged with the same priority as MI or severe trauma.

7 Airway, breathing and circulation ( ABC ) History and physical examination Stroke mimics : seizures, hypoglycemia, complicated migraine, conversion disorder, hypertensive encephalopathy, drug toxicity, etc. National institutes of health stroke scale ( NIHSS ) Blood work CBC, Basic metabolic panel, Glucose level, drug screen, PT/INR/PTT. EKG CT Brain without contrast or MRI.

8 Eligibility for IV tpa Age > 18 years Clinical diagnosis of ischemic stroke causing a measurable neurological deficit Time of onset of symptoms or time last known well < 4.5 hours 0-3 hours ( FDA approved ) hours ( recommended by AHA/ASA ) ECASS 3 trial, N Engl J Med. 2008

9 Contraindications for IV tpa CT findings suggesting ICH, SAH, or established major acute stroke Suspicion of SAH (even if head CT is negative for hemorrhage) Seizure at onset Major surgery within 14 days History of intracranial hemorrhage, brain aneurysm, vascular malformation or brain tumor Recent active internal bleeding Platelets < 100,000; heparin use within 48 hours with PTT > 40 ; INR > 1.7 or Current use of direct thrombin inhibitors or direct factor Xa inhibitors. Known bleeding diathesis or other major disorder associated with increased bleeding risk SBP > 185 or DBP > 110 mm Hg, or aggressive treatment (IV medication) necessary to achieve these limits Symptoms minor and rapidly improving

10 Dose : 0.9 mg/kg to a maximum of 90 mg First 10% of calculated dose as intravenous bolus dose Remaining 90% of calculated dose given in infusion over 1 hour

11 ICU monitoring for 24 hours No antiplatelet drugs, heparin or Lovenox for 24 hours SBP < 180 DBP < 105 CT Brain in 24 hours Risk of bleeding is 6 %

12 Brain imaging CT of Brain without contrast : Main purpose in acute settings is to exclude a brain bleed. Hypodensity in a specific vascular territory Negative in the first few hours Sensitivity increases after 24 hours The presence of early CT signs of infarction implies a worse prognosis Wardlaw JM et al, Radiology. 2005

13 Stroke imaging, Medscape

14 Hyperdense MCA sign : Indicates the presence of thrombus inside the artery lumen (bright artery sign) Can be visualized on noncontrast CT in 30 to 40 percent of patients with an MCA distribution stroke Evaluation of early computed tomographic findings in acute ischemic stroke., Marks MP et al, Stroke This finding is highly specific for MCA occlusion, although it may be less useful for predicting outcome.

16 MRI DWI : Detect a signal related to the movement of water molecules between two closely spaced radiofrequency pulses. This technique can detect abnormalities due to ischemia within 3 to 30 minutes of onset Sorensen AG et al Radiology DWI apparent diffusion coefficent Map (ADC) Magnetic resonance imaging in acute stroke, Medscape

17 Vascular imaging Carotid Ultrasound Safe and inexpensive Screens the extracranial carotids only MR angiography Without contrast ( time - of -flight ) or with contrast Screens intracranial and extracranial arteries CT angiography Better sensitivity and specificity than MRA Conventional cerebral Angiography Gold standard Invasive Permanent neurological deficit or death in up to 0.2 %

18 Symptomatic patients : Recently symptomatic with % stenosis --- > CEA is recommended if life expectancy is at lease 5 years ( Grade 1A) Recently symptomatic men with % stenosis -- > CEA is suggested rather than medical management if life expectancy is at least five years ( Grade 2A) Recently symptomatic woman with % --- > medical management rather than CEA is suggested ( Grade 2B ). Recently symptomatic with < 50 % stenosis ---> medical management is recommended ( Grade 1A ) AAN guidelines

19 Asymptomatic patients : CEA rather than medical treatment is suggested for medically stable men with asymptomatic carotid stenosis of 60 to 99 % who have a life expectancy of at least five years ( Grade 2B ) Medical management rather than CEA is suggested women ( Grade 2B ) AAN guidelines

20 Echocardiography TTE vs TEE TTE is widely available, noninvasive, cheaper, and easier to perform TEE is more invasive, more expensive and not always available. TTE and TEE sensitivity for LV thrombi is similar LA thrombi are detected on TTE in only 39% to 73% of patients, versus 93% to 100% on TEE Patent foramen ovale (PFO) is detected as low as 50% of the time on TTE and 89% to 100% on TEE and only 58% to 62% of vegetations are seen with TTE compared to 82% to 100% with TEE Egeblad H et al Scand Cardiovasc J Peterson GE et al, Circulation. 2003

21 Screening test Lipid panel Hgba1c Dysphagia screening

22 Thanks,

Level III Stroke Center Data Collection Requirements

Who? Level III Stroke Center Data Collection Requirements All LERN Level III Stroke Centers. LERN Level I and II Stroke Centers have reporting requirements to The Joint Commission or other Board approved