TIA s differential diagnosis and treatment L J Kappelle

TIA’s differential diagnosis and treatment L. J. Kappelle, University Medical Centre Utrecht, The Netherlands

Transient Ischaemic Attack (TIA) clinical diagnosis

Transient Ischaemic Attack (TIA) clinical diagnosis l focal neurological deficit l sudden onset l brain or retina l no unconsciousness, no amnesia l functional outcome is more important than duration of the neurological deficit !

TIA should be considered a serious warning TIA’s 2 1 3 ischaemic stroke

TIA – a difficult diagnosis l 29% referred by general practitioner did not have a TIA Harbison, Stroke 2003; 34: 71 -6. l 60% of patients, diagnosed at the emergency Prabhakaran, room, did not have a TIA Cerebrovas Dis 2008; 26: 630 -5. l in 11% of patients two neurologists disagreed Koudstaal, Stroke 1986; 17: 723 -8.

Transient Ischaemic Attack (TIA) neurological deficit time

migraine aura or equivalent neurological deficit time

epileptic seizure neurological deficit time

transient neurological deficits l TIA l migraine l epileptic seizure l anxiety, overbreathing l myasthenia gravis l transient global amnesia l. . .

man, 72 years; sudden onset of numbness in left arm and leg that disappeared after 30 minutes. Neurological exam: normal

take home message 1 l the diagnosis of TIA may be difficult; take your time for the history l after the diagnosis of a TIA: make a CT-scan or MRI -scan

TIA or minor ischaemic stroke: natural history 40 20

early risk of stroke after TIA population base studies with face to face follow up study n/N % (95% CI) 2 days risk 7 days risk Giles, Lancet Neurol 2007; 6: 1063 -72.

early risk of stroke after TIA population base studies with face to face follow up study n/N % (95% CI) 2 days risk 7 days risk Giles. Lancet Neurol 2007; 6: 1063 -72.

early risk of stroke after TIA study n/N % (95% CI) 2 days risk 7 days risk Giles. Lancet Neurol 2007; 6: 1063 -72.

early risk of stroke after TIA study n/N % (95% CI) 2 days risk 7 days risk Giles, Lancet Neurol 2007; 6: 1063 -72.

prognosis after TIA: ABCD 2 score Johnston, Lancet 2007; 369: 283 -92.

prognosis after TIA: ABCD 2 score l age ≥ 60 years 1 l blood pressure ≥ 140/90 mm Hg 1 l clinical features: weakness 2 speech l duration : ≥ 60 min 10 – 59 min l diabetes mellitus 1 2 1 1

prognosis after TIA: ABCD 2 score Johnston, Lancet 2007; 369: 283 -92.

take home message 2 l the risk of recurrent stroke after TIA or minor ischaemic stroke is highest during the first week

secondary prevention after TIA or non-disabling ischaemic stroke

secondary prevention after TIA or non-disabling ischaemic stroke l antiplatelet therapy l antihypertensive drugs l statin l diet l exercise

secondary prevention after TIA or non-disabling ischaemic stroke l antiplatelet therapy Ø reduce the long-term l antihypertensive drugs risk of future stroke l statin with 80% l diet l exercise Hackam, Stroke 2007; 38: 1881 -5.

antiplatelet regimens that have been tested in patients with TIA and sinus rhythm Hankey, Lancet Neurol 2010; 9: 273 -84.

antiplatelet regimen after TIA

risk of early recurrent stroke after TIA or minor stroke according to treatment

risk of early recurrent stroke after TIA or minor stroke according to treatment Oxvasc : median delay of treatment: 20 days 2004 -2007 : median delay of treatment: 1 day 2002 -2004 Rothwell. Lancet 2007; 370: 1432 -42.

early treatment after TIA or minor stroke : median delay of treatment: 20 days 2004 -2007 : median delay of treatment: 8% absolute risk reduction: 1 day 2002 -2004 20 days 1 day Rothwell. Lancet 2007; 370: 1432 -42.

take home message 3 l antiplatelet therapy should be started as soon as possible after the diagnosis of TIA

modifiable risk factors and relative risk of stroke

modifiable risk factors and relative risk of stroke Hypertension Cardiac disease* Diabetes mellitus Smoking Elevated cholesterol 0 1 2 3 4 5 6 7 8 9 10 Relative Risk Sacco Stroke 1997; 28: 1507 -17.

hypertension and risk of stroke

take home message 4 l management of vascular riskfactors is the most important aspect of secondary prevention after TIA or minor ischaemic stroke

15% of ischaemic stroke occurs in patients with atrial fibrillation

statine statine

Heart Protection Study simvastatine vs. placebo in high-risk individuals Lancet 2002; 360: 7 -22.

take home message 5 l patients who suffered from a TIA and have atrial fibrillation should be treated with warfarin l patients who suffered from a TIA should be treated with statines, unless cholesterol is < 3. 5 mmol/l

duplex MR- angiography CT- angiography

risk reduction of ipsilateral stroke and peri-operative death as a result of carotid surgery, according to the degree of stenosis % % Rothwell Lancet 2003; 361: 107 -16.

risk reduction of carotid surgery versus medical treatment in symptomatic patients with 70 - 99% ICA stenosis 70 -99% stenosis 40 50 -69% stenosis 30 ARR % 20 10 0 - 10 0 -2 2 -4 4 -12 > 12 time from event to randomisation (weeks)

risk reduction of carotid surgery versus medical treatment in symptomatic patients with 70 - 99% ICA stenosis 70 -99% stenosis 40 50 -69% stenosis 30 ARR % 20 10 0 - 10 0 -2 2 -4 4 -12 > 12 time from event to randomisation (weeks) Rothwell. Lancet 2004; 363: 915 -24.

take home message 6 l carotid endarterectomy should be performed in patients with high grade stenosis and should be performed as soon as possible after a TIA or minor ischaemic stroke

management of TIA - conclusions

management of TIA - conclusions l take your time for the history l TIA is an emergency; secondary prevention should start as soon as possible! l management of vascular riskfactors is the most important aspect of secondary prevention l every patient with a TIA in the carotid territory needs to undergo duplex ultrasound examination

short-term outcome after stenting versus carotid endarterectomy according to age CEA worse CAS worse Carotid Stenting Trialists’ Collaborators

Lancet 2002; 360: 7 -22.

MRI FLAIR MRI diffusie 0831432

6 -1 x 100% = 83% 6 6 mm. 1 mm.