Case-Based Stroke Education Series January 26, 2017 Moderator: Dr. - PowerPoint PPT Presentation

South West Stroke Project Case-Based Stroke Education Series January 26, 2017 Moderator: Dr. Shanil Narayan Consultant: Dr. G. Bryan Young

Faculty/Presenter Disclosure Faculty: Dr. Bryan Young, Dr. Shanil Narayan, Dr. Ali Kara, Dr. Tom Haffner Relationships with commercial interests: No actual or potential conflicts of interest in relation to this educational program

Disclosure of Commercial Support This program has received financial support from: South West Local Health Integration Network – Ontario Ministry of Health and Long-Term Care Potential for conflict(s) of interest:  Planning committee member, Dr. Gord Schacter • Member of Lundbeck Advisory Board • Participated in the following clinical trials in the past two years: Novartis, Sanofl Aventis, Bristol Myers Squib  Planning committee member, Dr. Paul Gill • Participated in the following clinical trial in the past two years: DETECT study

Mitigating Potential Bias  The Planning Committee mitigated bias by ensuring there was no industry involvement in the planning or the education content.  To comply with accreditation requirements of the College of Family Physicians of Canada and The Royal College of Physicians and Surgeons of Canada, speakers were provided with Declaration of Conflict of Interest forms, which were reviewed by the Regional Stroke Education Coordinator on behalf of the Planning Committee and submitted to the Western University’s CPD Office.  The Planning Committee reviewed the initial presentation supplied by the speaker to ensure no evidence of bias.

South West Stroke Project Stroke Rounds Case 1 Dr Shanil Narayan

Patient A  84 M seen in ER for suspected R MCA infarct  PMH  Hyperchol, Afib. Prev CVA (2014)  L weakness previously “almost completely recovered”  MEDS  Coumadin  Ramipril, Lipitor  Non smoker

Patient A  Initially described by paramedics as L sided.  Described by ER MD as minimally responsive and unclear if focal weakness 0530  Awoke around 0300 “unwell” but nothing focal described – Back to bed 0330  Wife checked on him at 0500 and unable to speak and not moving L side. 911 activated

Patient A  In ER Severe Expressive Aphasia + NIH 26  CT head  previous R MCA stroke with Encephalomalacia.  Old lacunar infact l. Lentiform nucleus.  No retrievable clot.  CBC N. INR 1.5. Glucose 8.7

Patient A  What are our thoughts and concerns?

Patient A  Differential Diagnosis; Stoke (ischemic or hemorrhagic) vs. Seizure  What is time of Stroke onset?  What are high risk features?

Risks of Thrombolysis  Complications related to intravenous r-tPA (average)  symptomatic intracranial hemorrhage 6%  major systemic hemorrhage 2%  angioedema 5%  3 - 4.5 hour window “relative? contraindications”  Patient is < 80 years of age  Patient does not have a history of both diabetes AND stroke  Patient is not taking Warfarin (Coumadin) or any other anticoagulant regardless of INR/coagulation results  NIHSS is < 25  Written informed consent obtained from patient and/or family – required when IV tPA given within the 3-4.5 hour window.  Scoring systems?  HAT (Hemorrhage after Thrombolysis)  iScore

Patient A  tPA 0630 (3 hours after last seen normal)  Rapid improvement  Day 1 family and patient thought “back to normal”  Singular concern was some impulsivity  Strong family supports  Discharged home on Day 3 with community stroke team.

BY’s Comments  Whew! Controversial case. Dodged a bullet?  Of ischemic stroke patients about 20% waken with the stroke.  Clinically we go with “last time seen well” or “without any new deficits” for timing stroke onset.  However, this probably excludes many wake- up stroke (WAS) patients from recanalization therapy.

Assessing Suitable WAS Patients if time of onset not clear  Requires neuro-imaging:  MR: - perfusion-diffusion mismatch - DWI/ADC vs. FLAIR  CT angiography: CT vs CBF/CT perfusion vs CBV.  Requires protocols and full cooperation of radiology/neuroradiology and intervention (if EVT attempted)  Trials still ongoing – stay tuned.

MR angio with Gadolium Deriving Flow Measure Drop in signal intensity

MRA in Left Hemisphere Ischemic Stroke

CTA in Left Hemisphere Stroke

DW ADC FLAIR and CT perfusion in WUS

In Patient A’s Case  Was he really in usual health at 0300h?  Neurological exam: expressive aphasia or muteness (right hemisphere stroke)?  No absolute contraindication to tPA but very close to the 3-4.5 hour window, for which he would be excluded: age, on anticoagulant (even with subtherapeutic INR).

THROMBOLYSIS NIHSS Treatment expanded to 4.5h (NINDS rtPA Stroke Study/ECASSIII) For >3hrs thrombolysis is considered except for : age >80yr, NIHSS >25, any anticoagulation use; hx of previous stroke + diabetes m. Expansion of window provides modest yet clinically worthwhile improvements rtPA (alteplase) 0.9 mg/kg with 10% given in 1 minute and the remainder over 1 hour EARLIER TREATMENT = BETTER OUTCOME Grand Rounds

Hemorrhage after Thrombolysis (HAT score)

South West Stroke Project Stroke Rounds Case 2 Dr Tom Haffner

Patient B  68 Caucasian M seen in ER for suspected L MCA infarct (outside of window)  Expressive aphasia, sudden onset 2 days ago  PMH  Afib, prev ablation (2014)  “complex migraine” presenting with aphasia 2014  MEDS  ASA  Propranolol (for “migraines”)  Non smoker

Patient B  Expressive aphasia on exam  Neurological exam otherwise normal  Afib on the monitor and EKG  CT head (non-contrast):  No acute infarct  No old infarct  Small vessel ischemic changes  Carotid ultrasound  Stable mild plaque bilaterally

Patient B  LDL 3.11 TC: 4.62 HDL 0.87  Echo:  Dilated LA  No thrombus  EF normal CHADS = 3 (presumed TIA/small stroke not seen on CT) Plan?

Patient B  Apixiban 5mg BID started  Rosuvastatin 40mg started  Aphasia improves but doesn’t completely resolve Further tests?  MRI  CT angio

Comes back …  2 weeks later. Ongoing spells of sudden worsening of expressive aphasia which resolve after 30min.  flashing lights preceding the events?  Pt convinced “complex migraine” but doesn ’ t get better with propranolol + candesartan  Also, felt to have some right sided neglect by OT  Compliant with meds  CT head repeated  No acute infarct  Now what?

 Ophthamology removes foreign body in eye  MRI head  Acute infarction in territory of left MCA consistent with embolic source  No other areas of infarction  Change mgmt?  Failure of apixiban?  Add ASA?  Alternative diagnosis?

 CT angiogram  Severe stenosis in M1 of left MCA (8mm x 4mm)  Discussion points: 1. Should I have ordered CT angio up front? • Carotids only mild dx. • Probable cause of stroke (afib) • Expensive to do CT angio for every stroke pt 2. When should you think about intracranial stenosis? 3. How do you manage intracranial stenosis + Afib and recent stroke • ASA + plavix? • Abixiban + ASA? • Stent?

Risk factors for intracranial stenosis  Black, Hispanic, Asian  Age  Hypertension  Hyperlipidemia/dyslipidemia  Smoking  Diabetes

Mgmt of intracranial stenosis  ASA + plavix x 90 days  Statin  Lower BP  No role for stenting (SAMMPRIS trial)

 Case discussed with neuro  ASA + Plavix x 2 months then, • Risk stroke from stenosis > risk from afib?  ASA + apixiban for how long?

Patient B: BY Comments  Migraine is always a diagnosis of exclusion with a stroke syndrome.  DDx between cardioembolic vs artery origin. Was the MCA stenosed or did it contain a non- occluding embolus (partly recanalized?)  Fairly low CHADS2 score: risk of stroke probably about 1.9%/year if stroke not cardioembolic and >8%/year if its was.  Risk of stroke from intracranial MCA stenosis: 4- 9% at 3 months, 8-12% at 1 year with medical management (SAMMPRIS study)

Symptomatic Intracranial Arterial Stenosis • SAMMPRIS study (NEJM 2011) showed worse outcome for stented patients cf medically managed group. • Endarterectomy not feasible. • EC-IC bypass was shown to be futile (NEJM, 1985). • Therefore no procedural intervention is of value. • Antiplatelets and control of risk factors are indicated.

Patient B: BY comments  Intracranial arterial stenosis carries a high risk for ischemic stroke. Therefore, CTA (arch to vertex)or MRA is recommended for all ischemic strokes and TIAs.  Antiplatelets are indicated along with control of risk factors (no stenting or EC-IC bypass!).  A fib is worrisome, especially since we cannot be certain of source of stroke. Might anticoagulate as well.

South West Stroke Project Stroke Rounds Case 3 Dr. Ali Alnoor Kara

Patient C  71F from home with husband  RFR: Witnessed R sided facial droop and expressive aphasia at 1530h by husband  PMHx:  T2DM  Dyslipidema  Previous Stroke in 2012 - no residual deficits

 Medications:  Atorvastatin 40mg PO Daily  Gliclazide MR 60mg PO Daily  Allergies: NKDA