Prognos 90 dagar efter TIA (N=1707) Interventioner vid TIA, Afx, strake 10,5% stroke Hälften dessa under första 2 dagarna 2009-04-01 Arne Lindgren Neurologiska Kliniken Universitetssjukhuset i Lund 2,6% avlidna 12,7% ny TIA Sammanlagt 25,1% ny händelse IJohnstonse et al JAMA2000;284:2901-2906I Prognostiska faktorer Diffusions-MR och TIA Skador syns i 48 % - 67% av fallen1,2 Table3 independentrisk Facto" for Table 4 90-Day 5troke Risk by Number Stroke Within 90 Da)" (N = 1707)" of Risk Factors" Odds Ratio (95%CI) PValue No (0/0) N;Je>60 Y 18(11-27) 01 I I Dlabetes-melituS 20!14-29) <001 Risk Stroke Within DUrationof spisade 23 13-421 005 Factors No Patients 90 Days >10 min O 22(1) 0(0) Weakness witt1 19(14-26) <001 episode 1 179 {10} 5 (3) Speech impairment 15(11-21) 01 2 509 {30} 35 (7) withepisode 3 584 (34) 63 (11) *6asedQf\logi$tici:'Icfvdogall3$$OOated3Ii- 4 337 (20) 51 (15) 8bSesi1univariateanatysistp<2O}withstepwiaee1mi 5 76(4) 26(34) natfonot variab!eano! contjibuting(p>10} CI indl cat;m confidercetntervar, -Risk factors ara is1ed intabie 3 DW-MR i genomsnitt 17 tim efter insjuknandet1 1 Kidwell CS et al Streke 1999;30:1174-1180 2 Rovira A et al AJNR 2002;23:77-83 IJohnston se et al JAMA2000;284:2901-2906I Utredning Om klassisk TIA sista 1-2 (-4) veckorna: Akut bedömning på sjukhus DT inom ett dygn, senast inom en vecka Ultraljud av a carotis så snart att carotiskirurgi kan utföras inom 2 veckor (gärna tidigare) TIA för mer än 2-4 veckor sedan: Poliklinisk utredning utan onödigt dröjsmål Recidiv av TIA Differentialdiagnostik Ev ytterligare utredningsbehov? 1
Sammanfattning TIA allvar1igare prognos (10-20% stroke-risk på 3 månader) än tidigare uppfattat Ca hälften av nya stroke inom ca 2 dagar Allvar1igareprognos Längre TIA-duration - StorkärIssjukdom Hypertoni Mindre allvar1igprognos - Amaurosis fugax Nya data: Bakgrund Rotihwell PM, Johnston SC Transienl isci1emic attacks: Stratifylng risk Stroke 2006;37:320-322 Johnslon SC, Rothwell PM, Nguyen-Huynh MN, Giles MF, Elklns JS, Bernstein AL, Sidney S Validalion and refinement of scores lo pnedict very early strake risk aller transient ischaemic attack Lancet 2007;369:283-292 Barnett KM, Johnston KC New!ransienl ischemic attack guidelines: A slep forward butjoumey just begun Ann Neuro/ 2006;60:273-274 Hankey GJ When the patient fails to respond lo treairnent: TIAs that go on, and on Pract Neuro/ 2008;8:103-111 Lindgren A, Norrving B, Thömqvist M Ökad risk för strake efter TIA Nya data stödjer snabb handläggning Läkartidningen 2004;101 :1102-6 ABCD2 score Age 0:60 years [1 point] Blood pressure 0:140190 mm Hg [1 point] Cllnical features: - unilateral weakness [2 points] - speech impalrment without weakness [1 point] Duration - 0:60 min [2 points] - 10-59 min [1 point] Diabetes [1 point] 'I i i 2S 20 15 ID "lo, -,, -"'" Imgodays Maximum 7 polnts 6-7 points: high risk (81% 2-day risk) (21%) 4-5 points: moderate risk (41% 2-day risk) (45%) 0-3 points: low risk (10% 2-day risk) (34%) Johnslon SC el al Validation and refinemenl of scores lo predict very ear1yslrake risk aller!ransienl ischaemic attack Lancet 2007;369:283-292 ABQ»SCOlEc short-term mkof stebyabq»l(ore insixgroupscantined (n-t799) As""' Johnslon se el al Validation and refinemenl of scores lo predict very ear1y strake risk aller!ransient ischaemic attack Lancet 2007;369:283-292 Tre nya artiklar Rothwell PM et al Effect of urgent tfeatment of transient ischaemic attack and minor stroke on ear1y recurrent stroke (express study): A prospective population-based sequential comparison Lancet 2007;370:1432-1442 Kennedy J et al Fast assessment of stroke and tfansient ischaemic attack to prevent ear1y recurrence (faster): A randomised controlled pilot trial Lancet Neuro/ 2007;6:961-969 Lavallee PC et al A transient ischaemic attack clinie with round-the-clock access (sos-tia): Feasibility and effects Lancet Neuro/ 2007;6:953-960 3 år 24 h access N=1085 SOS-TIA 701 confirmed TIA or minor strake Lavallee PC el al A!ransienl ischaemic attack clinic with round-ihe-dock access (soslia): 2
SOS-TIA 5% AC treatment for AF 74% seen same day 5% urgent caratid revascularization 90 day strake rate 124% vs expected 596% mpnn 643(5911t)Iie:IiI1iGeTIo'IS 1144(13)pwilbk:1 Sa(5JmlfIDflr1io::$trol:es 240=:=r1s -- 7O{2')!I}1pdIs$ 21(9"4Jepl1eptk: 1O(4'!i)1nXIeq0l'1md: 8)bentJn FiptAf 2:I"atIMtpumbers mrtj\rt"dosi5byv-w"neurok>gists er Kao(o-3) Of OOthi!I) 'Asdiig"odbyMRI{""tOS) tper(errtao}es(#tl>e:;wj piiltmtwff,)l\jdo1ltoo-isd!,mic: Oi"!l,,Is-m'-'rr-foaIOtnotdevlyfo:i rftowl'oiogi eventsrowhidilm fi1ood;:af<met KldCOUlse'Jf ml'lorm <id notml\ltm criteriafadetinitqrpw;lbltlaofovlother t"f'09f ddlnitcfkpoyibioyffkir-:"llk'\eqepiorrnig<1l\ illtp1tnevroloo;rtth"noocgm Vol 6 N<M!m2007 Lavallee PC et al A transient ischaemic attack clinic with round-the-clock access (sostia): Lavallee PC et al A transient ischaemic attack clinic with round-the-clock access (sostia): EXPRESS Phase 1 TIA and minor strake clinie Appointment based Treatment recommendations Phase 2 TIA and minor strake clinie No appointment necessary Direct treatment B 14 12 [ 10 15 p=00015 10 20 30 40 50 60 70 80 90 Time (day» Figure 1: Risk of recurrent strake after first seeking medical attention in all patients with TIA or streke in the who!e study population (A) and in all patients with TIA (B) Rothwell PM et al Lancet 2007370:1432-1442 Rothwell PM et al Lancet 2007370:1432-1442 12 10 - Phase1 - Phase2 t: 8 "ö 4 p'ooool o 10 20 30 40 50 60 70 80 90 Tim (day» Flgure 2: Risk of recurrent strake after first seeking medical attention in all patients with TIA or stroke who we re referred to the study clinlc Rothwell PM et al Lancet 2007370: 1432-1442 ==='-' '';: i:rc ' ie : figurr3:(umulative proportions of patients prescrlbm new medication since firstseeking m«ikal attention l: J (A)Äny rtatfn drog (inpatints not alreadyon a statin); (B)dopidogfel (usu11y t: _ in additionto aspirin); (C) initjationof a first bloodpressure-icpj/ermgdrug(in q patients not afread)' on SlKhmt'dkation); (O) ( initiation oftwo biocid- pr(!5sure-towering dfv95(in patients previously on noneor (01)1 one drug) i (Iopidogrel W<kSgiven for 4 weeks orly i : '';:1 11 t"'! -----' ""--Of-t- Rothwell PM al I 2007370:143O_1AAO 3
The 90-day risk of recurrent strake in the patients referred to the study clinie was: 103% (32/310 patients) in phase 1 2-1% (6/281 patients) in phase 2 (adjusted hazard ratio 0-20, 95% CI 008-0-49; p=0-0001); Rothwell PM et al Lancet 2007'370:1432-1442 Rothwell PM et al Lancet 2007'370:1432-1442 Förkortad väntetid Carotis- TEA 3-4 stroke förhindrade i EXPRESS Ro 70 60 'i! so 140 "ö! 30 aria Minorstroke 20 10 Mo, T 'Ned Thu Fri Sat Day(lfwcck s'" Figun4: Day of presentation f(lf an patic!nt$ with TIA or minor stf'oice in th study popvlationwho first $ought mediul auentiqn via thcirptimary<are physkiao Rothwell PM et al Lancet 2007'370:1432-1442 "we decided not to run the study clinie at weekends in phase 2" Rothwell PM et al Lancet 2007'370:1432-1442 Slutsatser TIA = Akut instabilt cerebrovaskulärt syndrom Surgery at centre with low complication rate: Akut utredning och behandling inneliggande - Om TIA senaste 3-4 veckorna - Symptomatic: less than 6% perioperative morbidity and mortality Sacco et al 2006 - Asymptomatic: less than 3% perioperative morbidity and mortality ACAS study Jama 1995;273:1421-8 4
Benefits greater if: - more severe stenosis - 75 years or more - recent stroke (rather than TIA) - hemispheric symptoms rather than transient monocular blindness Sacco et al Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: Stroke 2006;37:577-617 Trombocythämmare - ASA eller ASA + DP Statiner - Simvastatin 20-40 mg - Kolesterol 5 mmol/l, LDL 3 mmol/l Blodtrycksmediciner OBS skillnad vs stroke! - Tiazid - ACE-hämmare Diabetes Rökning, livsstil Carotiskirurgi högst 2 veckor Behandling 5