TIA Separating the benign from the malignant imaging and treatment

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TIA Separating the benign from the malignant
imaging and treatment

• Andrew M. Demchuk, MD FRCPC
• Director, Calgary Stroke Program
• Chair, Pillar 2 Acute Stroke and Emergency
  Services, APSS
• Associate Professor
• Department of Clinical Neurosciences
• University of Calgary

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Disclosure Slide

• In the last 2 years
• My research has been funded by CIHR, HSF
  Alberta/NWT/Nunavut, CSN, AHFMR, NovoNordisk
  Canada
• I have received speaker fees/honouraria from
  Sanofi Aventis, Boehringer-Ingelheim,
  Astra-Zeneca
• I hold no stock or direct investment in any
  pharmaceutical or device company related to
  cerebrovascular disease

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Explosion of technologic advances in imaging
1970 1980 1990 1995 1996 1998 2000 2001 2002
2003 2004 2005 2006 2007 2008
tPA
CT scan
ASA
Stroke unit
Single channel TCD
DWI- MRI PWI-MRI
4th gen CT
Power Mmode TCD
4 - slice CTA CTP 64
slice-CTA
Toshiba Aquilion 320
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Who is vulnerable?
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Which Tests Should We Perform
Gladstone D et al. CMAJ. 2004 Mar
30170(7)1099-104.
Speech, motor, gt10 min, age gt60, diabetes
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Carotid Doppler Imaging
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Eliasziw M et al. CMAJ 2004 Mar 30170(7)1105-9.
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TIA and CT

• Stroke. 2003 Dec34(12)2894-8.
• TIA population 67 CT performed
• 4 13/322 had evidence of infarct on CT
• CT does identify the mass lesions causing spells
  SDH, tumour etc

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Diffusion Weighted Imaging - mMRI
Kidwell C et al. Stroke 1999 61174-1180.
Couttts SB et al. Annals of Neurology
200557848-854 Krol A et al. Stroke 2005

• 50 of all TIAs associated with permanent
  damage. Especially if it lasts gt 1 hour.

Strokes positive troponin
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Presence of ischemia portends higher risk
Coutts SB et al.Stroke 2008392461-2466.
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SOS-TIA Study TIAs with and without infarcts
Lancet Neurology 20076953-960
4.76 90d stroke rate 1.34 90d stroke
rate
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ABCD2MRI Coutts SB et al. Int J Stroke 2008
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Transcranial DopplerEmboli Detection

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ICA Stenosis and MES and Risk
Valton L et al. Stroke1998292125-2128.
Mulloy J et al. Stroke 1999301440-1443.
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What is the most practical test for TIA in the ED?
Carotid doppler ?
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CT angiography ideal for ED

• Patient already in ED
• Test immediately follows NCCT
• Quick
• comprehensive evaluation of pipes

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Arch-Vertex CTA Improves Symptom Relevant Vasc
Abn Detection
504 acute CTAs performed for TIA/minor stroke
patients. Steffenhagen N et al. ESC 2008
(poster) Symptom relevant cervical
abnormalities Symptomatic ICA gt50
stenosis/occlusion 9.6 ICA ulcerated
plaque/ILT/dissection 3.6 Symptomatic VA
stenosis/occl/diss 2.8 Symptom relevant
intracranial abnormalities MCA
occlusion 4.4 MCA stenosis/non-occlusive
thrombus 4.8 ACA/PCA stenosis/occl/diss 2.0
distal ICA stenosis/occl/diss 2.8 VA/basila
r stenosis/occl/diss 3.6 vasculitis/AVM 0
.8 Symptom relevant Great vessel
abnormalities Aortic arch thrombus/severe
atheroma 1.2 Total Symptom Relevant major
vascular abn 31.2
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Intracranial occlusion high risk
Coutts SB et al.Stroke 2008392461-2466.
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Large Artery Atherosclerosis at Highest Risk
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Large Artery Atherosclerosis at Highest Risk
Lovett, J. K. et al. Neurology 200462569-573
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Barcelona TIA prognosis study
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VB Stenosis at High Risk
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CTA findings weve described

• Donut sign 3.1 incidence
• resolves with antithrombotic tx
• iNOT 2.7 incidence
• resolves in half

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CT

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CAS/DP

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Conclusions
Benign Malignant

• Symptoms dizziness/vertigo numbness
  altitudinal blindness speech weakness
• Timing weeks ago days ago hours ago
• Duration sec few minutes gt10
  minutes
• Risk factors no Htn, DM
• Frequency multiple one to few
• Imaging stroke damage/occlusion
  emboli
• abnormalities in the pipes
  
• No rush to see/ discharge to clinic See
  urgently/admit

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Treatment options
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EXPRESS
Lancet 20073701432-1442.
2002-2004 NHS clinic care
Urgent evaluation 2005-2007 ASAclopidogrel X
30d, BP lowering, statin, carotid surgery
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FASTER Study Design 90 day treatment and
primary outcome
All patients within 24 hours of qualifying event
NIHSS lt3 or speech/motor symptoms gt 5 minutes
duration All receive ASA
Randomized
Placebo
Clopidogrel 300 mg load then 75 mg daily
Further stratification of randomisation for all
patients
Simvastatin 40 mg daily
Placebo
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FASTER
FASTER stroke event rate
Lancet Neurology 2007
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CARESS
Circulation 20051112233-2240.

ITT analysis Clopidogrel
ASA ASA p-value n 51
56 MES baseline 9.5 13.5 11.6
17.8 MES day 2 3.3 6.4 9.5
14.6 lt0.001 MES day7 1.8 3.9 5.9
9.3 0.001 Stroke rate 0 7.1
NS
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FASTER
Lancet Neurology 2007
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FASTER 2 Phase 3 efficacy randomized trial
Within 24 hours of qualifying event NIHSS lt3,
speech/motor TIAlt24h all receive ASA
Randomized
Clopidogrel 300 mg load then 75 mg daily X 21days
Placebo
ASA alone for remainder of first 3 months
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Early Carotid Surgery Much Better gt70 w/o
near-occlusion
Rothwell PM et al. Stroke 2004352855-2861.
NNT 3
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Early Carotid Surgery Better in 50-69 stenosis
NNT 7
Rothwell PM et al. Stroke 2004352855-2861.
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TIA approach

• Urgent referral to Stroke Prevention Clinic
• expedited work-up
• Calgary
• Page stroke team if
• speech or motor TIA or minor stroke lt48h from
  onset.
• CTA arch/vertex usually and triage admission
  accordingly
• Treatment focused on antithrombotic therapy,
  early carotid revascularization
• Low risk TIA or other spells - Routine referral
  to SPC

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Emboli Detection and Risk of Stroke
JNNP 200272338-342.
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FASTER 2 CTA substudy Does dual
antiplatelet therapy work best in setting of
major symptom relevant vascular abnormality?
Within 24 hours of qualifying event NIHSS lt3, all
receive ASA
Baseline CTA
Randomized
Placebo
Clopidogrel 300 mg load then 75 mg daily X 21days
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