Investigations for Stroke and TIA What, When and Where (…and Who and Why)

1. Investigations for Stroke and TIA What, When and Where (…and Who and Why) K. Butcher, MD, PhD, FRCP(C) University of Alberta WMC Health Sciences Centre

2. Disclosures Speaker’s Honoraria Novo Nordisk Boeringher Ingelheim Sanofi-Aventis Servier Roche Grant-in-Aid Salary Award Grant-in-Aid Salary Award Grant-in-Aid Salary Award Grant-in-Aid Consultant Novo Nordisk

3. Learning Objectives • The requirement for urgent brain imaging in patients with new onset focal neurological deficits. • The tempo of brain imaging required in patients with suspected TIA versus stroke, and the relationship to treatment decisions. • The available options for brain as well as intracranial and extracranial vascular imaging. Participants will also appreciate the advantages and disadvantages of each imaging modality. • Appropriateness and timing of various cardiac investigations, including ECG, Holter monitoring and echocardiography. • Appropriate blood work to be performed in stroke and TIA patients.

4. Outline • Acute investigations • Imaging • Laboratory/other • Secondary prevention investigations Tempo of investigations in Stroke and TIA

5. Case • 58 year old male with a history of hypertension and smoking complains of headache to his office co-workers. One minute later, he develops left sided facial droop and falls to his left. • EMS is called and he is brought to your ED. BP is 190/100, HR is 90 BPM and he is in NSR. • Investigation of choice?

6. Acute CT Scan

7. Acute Stroke Treatment: The Need for Speed Pre-tPA Post-tPA

8. Time is Brain N = 2799 Adjusted odds ratio of stroke recovery 4.5 hours NNT=14 Stroke onset to treatment time [min] The ATLANTIS, ECASS, AND NINDS rt-PA Study group, 2002

9. ECASS III Results

10. Who Needs Imaging? Patients with Focal CNS Symptoms and Signs

11. Acute Stroke HistoryPrimary goal: Stroke or not stroke? Focal neurological deficits Weakness Speech problems Visual symptoms Headache Vertigo/Dizziness– never stroke in isolation Sensory changes

12. Imaging Triage: Physical Exam The NIH Stroke Scale: RAPID and directed examination

13. Planning the Tempo of Investigations • Establish true time of onset • Cardiovascular risk factors: • Previous stroke, ischemic heart disease • Hypertension • Atrial fibrillation • Diabetes • Smoker • CV medications • Younger patients: • Mimics: Migraine, epilepsy • Specific mechanism (esp. younger patients): dissection

14. Putting Symptoms into Context • Left sided numbness for 1 hour • 23 year old female with history of migraine • 52 year old male with history of STEMI 6 weeks ago

15. FIXED/PERSISTENT CNS DEFICITS IMAGE IMMEDIATELY TRANSIENT CNS DEFICITS IMAGE WITHIN 24 H IMAGING TEMPO: SUMMARY

16. Investigation and Treatment Strategies

17. Alberta Provincial Stroke Strategy: Telstroke Alberta Wetaskiwin

18. Expediting Diagnosis: Tele-Radiology

19. Future Directions: Portable CT

20. CT: Early Infarct Sign 42 year old F, 2.5 hours of non-fluent dysphasia and Right U/E weakness

21. 24 hour Follow-up Scan (post r-tPA)

22. Alberta Stroke Program Early CT Score (ASPECTS)

23. CT: Early Infarct Sign

24. Hypo-attenuation: Acute Infarction

25. Extensive Hypo-attenuation and Sulcal Effacement

26. 24 hour Follow-up Scan (post r-tPA)

27. Isolated Sulcal Effacement/Swelling

28. 24 hour Follow-up Scan (post r-tPA)

29. Initial Investiagions: ABC’s Airway and Breathing: Oxygen Saturation Keep Sp02 >92%

30. Initial Investigations: ABC’s Circulation:12 lead ECG, cardiac and NIBP monitor if available

31. Frequency of Hypertension in Acute Stroke Hypertensive Adapted fromLeonardi-Bee et al, Stroke: 33, 1315, 2002

32. Laboratory Investigations Glucose (critical…why?) CBC (Platelets >100 for tPA) INR, PTT (INR < 1.7 for tPA) Lytes, Cr, BUN In thrombolysis, the utility of waiting for these labs must be weighed against the time is brain concept

33. Imaging Blood Vessels

34. Hyperdense MCA Sign

35. Hyperdense Dot Sign

36. ADVANCED IMAGING

37. CT Angiography

38. Diffusion-Weighted Imaging: DWI CT T2 DWI

39. DWI Evolution: Natural History 4 hours 24 hours

40. Time course of DWI Evolution -11 min +11 min 3 hours 24 hours Hjort et al, Ann. Neurol, 2005

41. Value of DWI in Ischemic Stroke

42. What is the Ischemic Penumbra?

43. Penumbral Imaging: MRI No Reperfusion Reperfusion

44. Imaging the Penumbra: CT Perfusion Non-contrast CT CT Angiogram Blood Flow

45. Investigations for Secondary Prevention

46. TIA Investigation: Is there a rush? Gladstone D et al. CMAJ. 2004 Mar 30;170(7):1099-104.

47. TIA Risk Stratification:ABCD2 Score A: age > 60 years – 1 point B: BP (systolic>140mmHg, diastolic>90 mmHg). Either 1 point. (max 1 point) C:clinical – unilateral weakness =2, speech only = 1 D: Duration, >60 minutes =2, 10-59 =1, <10 =0 D2: Diabetes=1 Rothwell PM, Lancet 2005; 366:29-36, Johnston, SC, Lancet 2007;369:283-292.

48. ABCD 2 score: Front-loaded Risks Score 2-day risk 7day risk90 day risk • High risk 6-7 8.1% 11.7% 17.8% • Moderate risk 4-5 4.1% 5.9% 9.8% • Low risk 0-3 1.0% 1.2% 3.1%

49. What do they Need?

50. 1. Brain Imaging: CT or MRI Even brief symptoms cause areas of permanent injury ~50% of all TIA’s are associated with permanent damage, particularly if symptoms last > 1 hour Kidwell C et al. Stroke 1999; 6:1174-1180.