urgent management of tia
TRANSCRIPT
![Page 1: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/1.jpg)
ANTALYA OCTOBER 2011
University of PoitiersMedical School
URGENT MANAGEMENT OF TIA
AND TIA CRESCENDO
TIA’YI takiben erken cerrahi strategy
Uygulanmalidir - neden
![Page 2: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/2.jpg)
Identify predictors of stroke following a TIA
Describe how neurovascular imaging may
identify those patients.
Describe the appropriate management of a
high risk TIA patient
![Page 3: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/3.jpg)
Presented at the Annual meeting of the SVS, Washington, 2000
![Page 4: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/4.jpg)
0
2
4
6
8
10
12
14
0 7 14 21 28
Days
Ris
k o
f str
oke (
%)
OXVASC 2002-2004
OCSP 1981-1986
Lancet 2005; 366: 29-36
CUMULATIVE RISK OF STROKE AFTER TIA
OXVASC & OCSP
![Page 5: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/5.jpg)
Naylor AR, Time is brain, The Surgeon 2007
Nu
mb
er
of str
oke
sp
reve
nte
d
on
10
00
pa
tie
nts
with
TIA
![Page 6: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/6.jpg)
Nu
mb
er
of str
oke
sp
reve
nte
d
on
10
00
pa
tie
nts
with
TIA
![Page 7: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/7.jpg)
POINTS
Age ≥ 60 1
Blood pressure ≥ 140/90 1
Clinical features
Unilateral weakness 2
Speech disturbance w/o weakness 1
Duration of symptoms
> 10 min < 59 min 1
≥ 60 min 2
Diabetes 1
Johnston & Rothwell et al. Lancet 2007
Risk: Score < 5 = 4%; Score of 5 = 16%; Score ≥ 6 = 35%
![Page 8: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/8.jpg)
HIGH RISK TIA: CLINICAL PREDICTORS
Johnston & Rothwell et al. Lancet 2007; 369:283-92
![Page 9: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/9.jpg)
WHO IS AT RISK?
Case report
• 70 year old right-handed male with a history of
diabetes is seen after an episode three hours
previously of TIA with right hemiparesis lasting 65
minutes.
• This is his second episode in a week.
• Blood pressure of 160/80.
![Page 10: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/10.jpg)
WHO IS AT RISK?
Age 70 1
BP 160/80 1
Weakness 2
65 minutes 1
Diabetes 1
ABCD2 score = 6
RISK OF STROKE
Risk Days
11% 7
17% 30
22% 90
![Page 11: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/11.jpg)
118 consecutive patients with TIA and
severe carotid stenosis operated within 2
weeks (2000-2009)
• TIA n= 118
• Including 47 TIA crescendo (> 2 AIT/24h)
During the same time period of time 1823 CEA were done for Stroke (n=911) and for asymptomatic patients with severe carotid stenosis (n=794)
![Page 12: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/12.jpg)
TIME PATIENTS %
n=118
Less than 48 hours 9 7.6
3 – 7 Days 89 75.4
8 – 14 Days 20 17.0
![Page 13: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/13.jpg)
Score ABCD2 Stroke risk at3-month (%)
Patients(n=118)
I 3 0
II 3 0
III 3 9
IV 9 25
V 12 45
VI 17 34
VII 25 5
MEAN STROKE RISK OF OUR PATIENTS = 14.4 ± 3.8% at 90 days
![Page 14: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/14.jpg)
Carotid Doppler Ultrasound
CT scan
MRI
HIGH RISK TIA
NEUROVASCULAR IMAGING
![Page 15: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/15.jpg)
BRAIN IMAGING
Imaging N =118
CT scan only 32
MRI only 23
CT-scan & MRI 63
Results N=118
Acute Infarction 69
Bleeding 7
![Page 16: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/16.jpg)
Factors predicting positive DWI*
• Symptoms lasting > 1 hour
• Motor deficits
• Aphasia
40-60% of TIA pts have evidence of
ischemic injury on DWI with a higher risk of
subsequent stroke
Even brief
symptoms
cause areas
of
permanent
injury
* DWI: Diffusion weighted imaging on MRICEA Day 9
![Page 17: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/17.jpg)
DAY 1 DAY 8 DAY 15
![Page 18: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/18.jpg)
IMAGING N
Carotid Doppler Ultrasound 118
CT-scan 63
MRI 55
Angiography 29
Mean degree of carotid artery stenosis = 79 ± 8 %
CAROTID IMAGING
![Page 19: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/19.jpg)
LESIONS n (%)
Intra plaque hemorrhage 28 (24)
Plaque rupture 25 (21)
Near occlusion with fresh thrombus 9 (8)
Carotid stenosis > 3.5 cm in length 32 (27)
CAROTID LESION
![Page 20: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/20.jpg)
INTRA PLAQUE HEMORRHAGE
CAROTID IMAGING - MRI
![Page 21: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/21.jpg)
CAROTID IMAGING - CTA
![Page 22: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/22.jpg)
Always: Aspirin, statin, drugs lowering arterial
pressure
General anaesthesia
Heparin before clamping (5000 UI)
Systematic shunting
CEA + patch or eversion
Completion angiography
![Page 23: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/23.jpg)
![Page 24: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/24.jpg)
![Page 25: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/25.jpg)
![Page 26: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/26.jpg)
![Page 27: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/27.jpg)
![Page 28: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/28.jpg)
![Page 29: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/29.jpg)
![Page 30: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/30.jpg)
![Page 31: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/31.jpg)
SYMPTOMS DEATH STROKE DEATHSTROKE †
TIA (n=71) 1 1 2 (2.8%)TIA Crescendo (n=47) 0 2 2 (4.2%)TIA All patients (n=118) 1 3 4 (3.4%)
STROKE (n=911) 7 23 41 (4.5%)Asympt.(n=794) 0 4 4 (0.5%)
† All patients being evaluated by neurologists
![Page 32: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/32.jpg)
Nu
mb
ero
f st
rok
esp
reven
ted
on
10
00
pa
tien
ts w
ith
TIA
![Page 33: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/33.jpg)
• CEA is recommended within two weeks in
patients with TIA
• CEA can be performed with a low combined
stroke and death rate
• Optimal perioperative medical management
and standardized operative techniques are
essential
• Is this deliverable to your hospital ?
![Page 34: Urgent management of tia](https://reader030.vdocument.in/reader030/viewer/2022032421/55a745df1a28ab3f518b468a/html5/thumbnails/34.jpg)