2021 Update on Stroke Diagnosis and Management (Josephson, 1/27/2021)

If you have never heard Dr. Andy Josephson (neuro-hospitalist extraordinaire from UCSF) give a lecture, you are missing out. I was blessed to have Dr. Josephson as a teacher during medical school, and he gives lectures at the UCSF Hospital Medicine Conference every year. Always high high yield. Silver linings of pandemic life-- Grand Rounds speakers can speak from anywhere in the world. 

Here is a link to a recording of his presentation: https://youtu.be/QWkQLJfRNBo. For those of you who prefer the written word, here are the highlights:

• 15% strokes are hemorrhagic, 85% strokes ischemic 
• the ONLY way to tell them apart is a non-contrast head CT
• Time of onset=last time seen normal 
• DON'T ask When did your stroke start? 
• Rather ask When was the last time you were completely well?

UCSF "Stroke Protocol" for evaluation of acute stroke symptoms

• Non-contrast CT of the head (to r/o hemorrhage stroke)
• CT Angiogram (from aortic arch to the top of the head)
• CT perfusion study (CTP), in image above areas red are infarcted/dead, green areas are at risk but could be salvaged
• Post contrast CT of the head

Speed matters: time is brain; for every 15 minutes earlier administration of tPA,

• significantly lower in house mortality
• significantly lower rates of intracranial hemorrhage (ICH)
• significantly more independent ambulation at discharge
• significantly higher rate of discharge to home

2021 Acute Stroke Timeline

• 0-4.5 hours since last seen normal--> IV tPA 
• 0-6 hours--> mechanical embolectomy for all with large vessel occlusion (LVO), done in interventional suite, requires transfer from SSRRH
• 6-24 hours-->  mechanical embolectomy for SOME (based on CT perfusion)--> this is relatively NEW

Mechanical Embolectomy

• In 2015, there were 5 major trials in NEJM that show embolectomy helped if done within 6 hours of symptom onset
• CT Angiogram is used to determine if there is a LVO (many have in small blood vessel that will respond to tPA but cannot be removed)
• 2018 DAWN and DEFUSE3 studies showed benefit in certain population up to 24 hours out using CTP (a lot of green but very little red, then the clot should be removed)
• now CTP helps us decide who can benefit from clot extraction

Everyone within 4.5 hours should get tPA

If you are within 6 hours, you should get embolectomy

If you are within 6-24 hours, CTP should drive the decision of who should be transferred for embolectomy

Standard work up for Large Vessel Stroke

• Cardioembolic: atrial fibrillation, clot in heart, paradoxical embolus (telemetry, TEE with bubble)
• Aortic arch (TEE with bubble)
• Carotids (CTA, ultrasound, MRA, angiogram)
• Intracranial vessels (CTA, MRA, angiography)

TEE is superior to TEE for: LA appendage, R to L shunt, examination of the aortic arch. TEE finds additional findings in 52% and changes management in 10%. However, most hospitals still do TTE first and then only TEE in limited cases.

Atrial Fibrillation can be missed if you don't monitor long enough

• Standard care is EKG, 48 hours of telemetry
• Everyone with stroke with unclear etiology should get long term cardiac event monitoring (21-30 days): 15-20% of patients with cryptogenic stroke otherwise unexplained had afib detected, clearly changes managemetn, probably cost effective

Should we anticoagulate in stroke? Nope, unless a fib, rare hypercoagulable states (e.g. APLS)

What about PFO? 1/4-1/5 the population has a PFO (true in stroke patients too)

Really only a VERY large PFO make people at risk for stroke. 3 large trials <2017 showed that closing PFOs didn't give any benefit. In 2017, 3 trials found that a SUBGROUP of patients with stroke and PFO would benefit from closure. Don't close all of them!

Consider PFO closure if patient

1.  <60 years AND 
2. You can be sure that PFO is most likely etiology after a thorough work up AND the qualifying event is a stroke (not a TIA) that appears embolic (not lacunar). Probably only large PFOs or those with an ASD
3. Moderate or Large PFO only

What about heparin? Nope. No indication for heparin in stroke.

Anti-platelets are the mainstay of stroke management

• ASA 50mg-1.5gm equal long term efficacy, so go with 81mg (always fine)
• Aggrenox (effective but rarely used due to $$, headache, BID)
• Clopidogrel is effective
• Of note, there is NO long term benefit in dual anti-platelet therapy (DAPT)-- that is, combination with ASA (should stop long term DAPT)
• BUT DAPT may have benefit for short term post minor stroke x 21 days
• Ticragelor can also be used in combination with ASA for short-term, but study shows more bleeding

Permissive Hypertension: 220/120 unless IV tPA then max is 185 systolic x 24 hours

when to stop is controversial, start htn meds before discharge (~72 hours) and aim for normo-tension over a matter of weeks. Choose thiazides and ACE-I first (best secondary prevention)

TIA vs. Stroke (up to 30% of TIA have infarct on MRI)

• Conceptually same disorder, same workup same treatment
• TIA should be aggressively worked up  because of risk of stroke is highest during the 7-14 days after a TIA
• Aggressive TIA treatment with ASA/statin/evaluation: you can reduce risk of stroke in short-term by 80%