ANTALYA OCTOBER 2011

University of PoitiersMedical School

URGENT MANAGEMENT OF TIA

AND TIA CRESCENDO

TIA’YI takiben erken cerrahi strategy

Uygulanmalidir - neden

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

Presented at the Annual meeting of the SVS, Washington, 2000

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OXVASC 2002-2004

OCSP 1981-1986

Lancet 2005; 366: 29-36

CUMULATIVE RISK OF STROKE AFTER TIA

OXVASC & OCSP

Naylor AR, Time is brain, The Surgeon 2007

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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%

HIGH RISK TIA: CLINICAL PREDICTORS

Johnston & Rothwell et al. Lancet 2007; 369:283-92

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.

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

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)

TIME PATIENTS %

n=118

Less than 48 hours 9 7.6

3 – 7 Days 89 75.4

8 – 14 Days 20 17.0

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

Carotid Doppler Ultrasound

CT scan

MRI

HIGH RISK TIA

NEUROVASCULAR IMAGING

BRAIN IMAGING

Imaging N =118

CT scan only 32

MRI only 23

CT-scan & MRI 63

Results N=118

Acute Infarction 69

Bleeding 7

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

DAY 1 DAY 8 DAY 15

IMAGING N

Carotid Doppler Ultrasound 118

CT-scan 63

MRI 55

Angiography 29

Mean degree of carotid artery stenosis = 79 ± 8 %

CAROTID IMAGING

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

INTRA PLAQUE HEMORRHAGE

CAROTID IMAGING - MRI

CAROTID IMAGING - CTA

Always: Aspirin, statin, drugs lowering arterial

pressure

General anaesthesia

Heparin before clamping (5000 UI)

Systematic shunting

CEA + patch or eversion

Completion angiography

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

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• 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 ?