CVA and Transient ischemic attack (TIA)

 

TIA

sudden onset of a focal and transient (< 24 hours) neurological deficit due to brain ischemia

Male > Female (3:1)

 

SIGNS AND SYMPTOMS

Carotid circulation (hemispheric) - monocular visual loss, hemiplegia, hemianesthesia, neglect, aphasia, visual field defects; less often headaches, seizures, amnesia, confusion

Vertebrobasilar (brainstem or cerebellar) - bilateral visual obscuration, diplopia, vertigo, ataxia, facial paresis, Horner's syndrome, dysphagia, dysarthria

Cerebellar or brainstem lesion in patients with headache, nausea, vomiting and ataxia

 

Lacunar stroke vs embolic stroke

lacunar : motor, sensory

            not cognitive

            small lesions <5mm

            poorly controlled HTN, DM

embolic : all

 

SPECIAL TESTS

Duplex carotid ultrasonography

Cerebral angiography

 

W/U

echo

carotid US, carotid angio

MRI/MRA

repeat CT

 

ECG

Transthoracic echocardiogram (TTE); if normal and a cardiac source is suspected, follow with transesophageal echocardiogram

Holter monitoring

EEG for suspected seizure

INR and partial thromboplastin time (PTT) (Coumadin prolongs INR)

Antiphospholipid antibodies

 

IMAGING

Acute phase - CT of head to rule out hemorrhage

Angiography - carotid arterial stenosis

Digital substraction - stenosis

 

TREATMENT

APPROPIATE HEALTH CARE Acute phase: Outpatient for investigations; inpatient for surgery

GENERAL MEASURES

 Strict control of medical risk factors, e.g., diabetes, hypertension, hyperlipidemia, cardiac disease

 Counseling towards cessation of smoking

SURGICAL MEASURES

In medically fit patients with non-disabling stroke, carotid endarterectomy (CEA) is indicated for stenosis of 70-99% on side ipsilateral to stroke; CEA is of modest benefit for carotid stenosis 0f 50-69% and depends on risk factors.

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) showed no benefit of CEA above medical therapy alone in stenosis of <50%. .

ACTIVITY No restrictions

DIET As appropriate to underlying medical problems (diabetic diet, low fat diet, low salt diet etc.)

 

Management of TIA

O2

IV access

CT head

transfer to ICU

NPO

urine catheter

urine Cx

VDRL, cardiolipin, prot C, S

EKG Holter monitor

MEDS

ASA, plavix

IV heparin

PO coumadin 2d prior to d/c

ranitidine

IV fluid

Milk of magnesia : prevent constipa

shift position q2hrs

Pneumatic stockings

Digoxin if arrhythmia

ACUTE NON-HGE CVA IN 3HRS

tPA

 

MEDICATIONS

DRUG(S) OF CHOICE

Enteric coated aspirin (EC ASA) 50-325 mg/day,or

Clopidogrel (Plavix) 75 mg daily; ticlopidine's descendent has fewer side effects, and shows a slight advantage over ASA

Dipyridamole-aspirin (Aggrenox) - extended release, 200 mg/25 mg capsule po bid; more efficacious than aspirin alone, but more costly

Contraindications:

EC ASA - active peptic ulcer disease, hypersensitivity to aspirin, patients who had bronchospastic reaction to ASA or other nonsteroidal anti-inflammatory drugs

Ticlopidine - known hypersensitivity to the drug, presence of hematopoietic disorders, presence of a hemostatic disorder, conditions associated with active bleeding, severe liver dysfunction

Precautions:

EC ASA - may aggravate pre-existing peptic ulcer disease , may worsen symptoms in some patients with asthma

Ticlopidine - 2.4% of patients develop neutropenia (0.8% severe neutropenia) which is reversible with cessation of drug. Monitor blood counts every 2 weeks for the first 3 months.

Clopidogrel and ticlopidine - TTP can occur

Significant possible interactions:

EC ASA - may potentiate effects of anticoagulants and sulfonylurea, hypoglycemic agents

Ticlopidine - digoxin plasma levels decreased 15%, theophylline half-life increased from 8.6 to 12.2 hours

 

PATIENT MONITORING

Followup every 3 months for first year then yearly

PREVENTION/AVOIDANCE

 Stop smoking

 Control blood pressure, diabetes, hyperlipidemia

 Antiplatelet therapy

 Angiotensin converting enzyme (ACE) inhibitors

 Statins

POSSIBLE COMPLICATIONS

Stroke

Seizure

Trauma if patient experiences sudden fall due to weakness

EXPECTED COURSE/PROGNOSIS

5-20% risk of stroke on ipsilateral side within one year and cumulative thereafter. Frequency increases with addition of multiple risk factors and severity of carotid stenosis.

 

ASSOCIATED CONDITIONS

Atrial fibrillation

Major cause of death in first five years after a TIA is cardiac disease

 

AGE-RELATED FACTORS

Pediatric:

Cardiac (especially developmental abnormalities)

Metabolic - homocystinuria, Fabry's disease

Geriatric: Atrial fibrillation is a frequent cause of TIA among the elderly

Others: Adults < 45 years old most likely to have a cardiac source of embolism

PREGNANCY A hypercoagulable state is associated with pregnancy and parturition

 

 

 

STROKE

The sudden onset of a focal neurological deficit resulting from either infarction or hemorrhage within the brain

 

Lacunar stroke vs embolic stroke

lacunar : motor, sensory

            not cognitive

            small lesions <5mm

            poorly controlled HTN, DM

embolic : all

 

 

Incidence/Prevalence in USA: Overall incidence 160/100,000 (age 50/–65, 1000/100,000; > 80, 3000/100,000). Prevalence 135/100,000.

 

Male > Female (3:1), but equalizes after menopause

 

SIGNS AND SYMPTOMS

• Carotid circulation (hemispheric): Hemiplegia, hemianesthesia, neglect, aphasia, visual field defects; less often headaches, seizures, amnesia, confusion

• Vertebrobasilar (brainstem or cerebellar): Diplopia, vertigo, ataxia, facial paresis, Horner’s syndrome, dysphagia, dysarthria

• Impaired level of consciousness

• Cerebellar lesion in patients with headache, nausea, vomiting and ataxia

 

 

RISK FACTORS

• Age

• Hypertension

• Cardiac disease

• Smoking

• Diabetes

• Antiphospholipid antibodies

• Family history

• Atrial fibrillation

• Hyperlipidemia

 

 

DIAGNOSIS

• Duplex carotid ultrasonography

• Cerebral angiography

• ECG

• Transthoracic echocardiogram (TTE); if normal and a cardiac source is suspected, followup with transesophageal echocardiogram

• Holter monitoring

• EEG for suspected seizure

• International normalized ratio (INR) and partial thromboplastin time (PTT). Coumadin prolongs PT.

• Antiphospholipid antibodies

 

IMAGING Acute phase: CT of head to rule out hemorrhage

CT without contrast

            bleeding seen better

            no LP prior to CT

            immediate changes=large stroke

            if +ve    hgic or large isch cva

            if -ve     smaller isch cva:  CT evolves over 3-5days - repeat

 

TREATMENT

APPROPRIATE HEALTH CARE

• Acute phase: Inpatient care, preferably in a stroke unit

• Surgical therapy: In medically fit patients with non-disabling stroke, carotid endarterectomy is indicated for stenosis of > 70% on side ipsilateral to stroke; medical therapy for < 50% stenosis, 50–69% depends on risk factors

 

GENERAL MEASURES

• Maintain oxygenation

• Monitor cardiac rhythm for 48 hours

• Control hyperglycemia (keep glucose < 220 mg/dL [12.1 mmol/L])

• Control of hypertension pressure if > 200/100 mm Hg (26.6/13.3 kPa)

• Prevent hyperthermia

• Early introduction of physiotherapy and ambulation

• Subcutaneous heparin 5,000 units subcutaneously every 12 hours

 

Search for source of embolus

1. Echocardiography

            TTE or TEE for thrombus

2. Carotid doppler US

assymptomatic -

            >80% end arterectomy

            <80% ASA

symptomatic -

            >50% end arterectomy

            <50% ASA

if amoris fugus "curtain across eyes" or ulcerative carotid stenosis then

            must do endarterectomy

internal carotid artery more likely to be involved

Prior to end arterectomy

            angio to confirm then stent

Workup

 

ACTIVITY Ambulate as soon as possible

 

DIET

• Alert with no dysphagia: Diet as tolerated (no added salt if hypertensive)

• Alert with dysphagia: Pureed dysphagia diet or nasogastric feeding tube if indicated

 

MEDICATIONS

• IV tissue plasminogen activator (tPA) 0.9 mg/kg in highly selected cases within 3 hours of ischemic stroke

• Enteric coated aspirin (EC ASA) 50–325 mg/day

or

• Dipyridamole-aspirin (Aggrenox) - extended release, 200 mg/25 mg capsule po bid; more efficacious than aspirin alone

• Clopidogrel (Plavix)75 mg/day is ticlopidine’s descendent, has fewer side effects, but shows an only slight advantage over ASA

 

AT D/C

d/c heparin & ranitidine

continue coumadin

            monitor, INR 1.0-2.0

if stenosis > 50% consult neuroSx

 

Rx Lacunar

            antiplatelets

                        plavix, ticlopidine, ASA

 

Rx Embolic

            anticoagulants

 

 

Contraindications:

• EC ASA - active peptic ulcer disease, hypersensitivity to aspirin, patients who had bronchospastic reaction to ASA or other non-steroidal anti-inflammatory drugs

• Ticlopidine - known hypersensitivity to the drug, presence of hematopoietic disorders, presence of a hemostatic disorder, conditions associated with active bleeding, severe liver dysfunction

 

Precautions:

• EC ASA - may aggravate pre-existing peptic ulcer disease, may worsen symptoms in some patients with asthma

• Ticlopidine - 2.4% of patients develop neutropenia (0.8% severe neutropenia) which is reversible with cessation of drug; monitor blood counts every 2 weeks for the first 3 months

• Clopidogrel and ticlopidine - TTP can occur

 

Significant possible interactions:

• EC ASA - may potentiate effects of anticoagulants and sulfonylurea, hypoglycemic agents

• Ticlopidine - digoxin plasma levels decreased 15%, theophylline half-life increased from 8.6 to 12.2 hours

 

ALTERNATIVE DRUGS

• Ticlopidine (Ticlid) 250 mg po bid - has fallen out of favor due to unfavorable side effect profile, risk of neutropenia and need for CBC monitoring

 

FOLLOWUP

PATIENT MONITORING

Follow every 3 months for first year then yearly

 

PREVENTION/AVOIDANCE

• Stop smoking

• Control blood pressure, diabetes, hyperlipidemia

• Use alcohol in moderation, if at all

• Regular exercise

• Maintain positive psychological outlook

• Maintain weight control

• Antiplatelet drugs

• Angiotensin converting enzyme (ACE) inhibitors

• Statins

 

EXPECTED COURSE/PROGNOSIS

• Variable depending on severity of stroke

• Posterior circulation strokes have a higher acute mortality rate but generally make a better functional recovery than hemispheric strokes

 

ASSOCIATED CONDITIONS

Major cause of death in first five years after a stroke is cardiac disease

 

AGE-RELATED FACTORS

Pediatric:

• Cardiac (especially developmental abnormalities)

• Metabolic: Homocystinuria, Fabry’s disease

Geriatric: Amyloid (congophilic) angiopathy is most prevalent in elderly, especially if patient also has dementia

Others: Adults < 45 years old most likely to have a cardiac source of embolism

PREGNANCY

• Parturition may increase risk of rupture for aneurysm; amniotic fluid embolism may cause stroke at time of delivery

• Postpartum period associated with increased risk for cerebral venous thrombosis