stroke and Carotis stenosis

Question 1

According to BMF 2022 SAPT and DAPT should be used for different patient groups. What is SAPT and DAPT?

Answer 1

SAPT= single antiplatelet therapy. -aspirin, aspirin/extended-release dipyramidole or Clopidogrel.

DAPT= Aspirin and Clopidogrel or Tiagrelor (usually used for 21-30 days and then SAPT.)

Question 2

When is SAPT used? Why?

Answer 2

• To reduce risk of recurrent ischaemic stroke in patients with NON-cardioembolic ischaemic stroke or transient iscaemic attack.

Question 3

When is DAPT used? Why?

Answer 3

It can be used for 21-30 days after minor acute non-cardioembolic ischaemic stroke or high-risk TIA. It is shown to be more efficient than SAPT, but prolonged use is associated with higher haemorrhagic risk without reduction in stroke recurrence compared to SAPT.

Question 4

How good is aspirin compared to placebo in reducing the relative risk of recurrent stroke?

Answer 4

22%

Question 5

When could Ticagrelor be an option to Clopidogrel/ASA?

Answer 5

In pt with intracranial stenosis.

Question 6

There are differences between different guidelines (NASCET and ECST) how to measure the % of stenosis. This gain different info on when to do CEA. But what is the general rule?

Answer 6

CEA is reasonable in asymptomatic pt with more than 70% ICA stenosis if risk of perioperative stroke, MI and death is low. In Sweden -under age 75 yo.

Question 7

What is CAS?

Answer 7

Carotid artery stenting

Question 8

What has been proven for symtomatic stenosis (stroke/TIA) of more than 50% extracranial carotis stenosis?

Answer 8

CEA is better than only medical treatment.

Question 9

What is golden standard for decision on grade of stenosis?

Answer 9

Carotid ultrasound.

Question 10

What cranial nerves are at risk in CEA

Answer 10

• glossopharyngeus
• hypoglossus
• vagus-recurrens.

Question 11

4 important clinical rekomendations for patients with carotis stenosis

Answer 11

• Clopidogrel or ASA (if symtoms give DAPT)
• Statin
• blood pressure control
• Smoking sessation

Question 12

What is the postinterventional rec. for pt that has recieved a stent?

Answer 12

DAPT for 6 months.

Question 13

When -in correlation to symtoms- has a CEA to be done?

Answer 13

Within 48h. The risk of new stroke from a plack is at greatest risk within this time. Then the plack is stabilized again. After 3 months the use of surgery is doubtful.

Question 14

WHen is DAPT to be started in relation to CEA surgery?

Answer 14

This can be debated (UME) but to start it already while waiting for quick investigation and surgery seems to minimize risk for complications from the plack without raising risk of bleeding correlated to surgery.

Question 15

What are the maimal allowed complication risks for mortality or stroke correlated to CEA for symtomatic and asymtomatic stenosis?

Answer 15

5% symtomatic
3% asymtomatic

Question 16

What are requirements for CEA surgery in the post TIA/stroke setting?

Answer 16

• The patient him/herself! wants surgery and UNDERSTAND.
• Other diseases are not a hinder for surgery
• Carotisstenosis correlated symtoms not older than 7 days (preferably 48h)

Question 17

What is screening teqnique and what is evaluation teqnique for carotis stenosis?

Answer 17

Screening after TIA/stroke= CT angiography
Evaluation is found = doppler.

Question 18

WHen should a echocardiogram be done (preferably tranesophagal)?

Answer 18

• ECG that is not normal
• Auskultation or anamnesia correlating with heart disease
• high suspicion of cardiell embolisation stroke (several vascular terretories affected)

Question 19

WHen is correction of PFO indicated?

Answer 19

• younger than 60yo
• kryptogen stroke
  -should be done within 6mo

Question 21

Why should ranitidin or pantoprazol be used together with Clopidogrel and not omeprazol?

Answer 21

intraction risk.

Question 22

What is the Swedish medical treatment route after stroke/TIA (without bleeding)?

Answer 22

• LOAD. within 48h give 500mg ASA. (300 CLopidogrel if ASA cannot be given)
• Thereafter 75mg Clopidogrelx1 from day2.

** IF minor stroke, NIHSS less than 3 or ABCD2 score more than 4 - give DAPT. = ASA 75mgx1 + during the first 10-21 days also Clopidogrel 75mgx1

*** BUT if atrialfibrillation is found Apixaban is given instead of ASA/Clopidogrel

Question 23

What is the POINT/CHANCE study?

Answer 23

CHANCE was a chinese RCT
POINT was an american RCT
Both trials tested Clopidogrel vs placebo for 90 days after minor stroke and TIA. CHANCE= 300mg loading dose
POINT=600mg loading dose.

CHANCE: The risk of recurrent stroke in the first 90 days was 32% lower with absolute reduction ~ 3.5%. The rate of hemorrhagic
stroke was the same (0.3%). The risk of any bleeding was 2.3% in the dual antiplatelet group v. 1.6% with aspirin
alone and the risk of severe bleeding was about 0.2% in both groups.

Question 24

What is Apixaban?

Answer 24

Its a antikoagulation drug used in case of Atrial fibrillation instead of antiplatelet therapy after TIA/stroke. INdependently of wether the AF was the cause of stroke.

Question 25

What is ABCD2 score?

Answer 25

Age:
1p if 60 or more
BP:
1p if 140/90 or more
Clinic:
1p if dysphasia w/o weakness.
2p hemiparesis w or w/o other symtoms.
Duration of sympthoms:
0p less than 10min
1p 10-59min
2p more than 60min.
Diabetes:
1p -independently if just found or known.

Question 26

Postopertively after CEA - what is the systolicBP BP ordination?

Answer 26

Between 120-160 systolic BP.

Question 27

What is the medical treatment after stroke/TIA?

Answer 27

Life long Clopidogrel and atorvastatin treatment.

Question 28

What does cryptogenic mean?

Answer 28

obscure or unknown.

Question 29

What is ABCD score for DAPT?

Answer 29

Several clinical trials have demonstrated that dual antiplatelet therapy (DAPT) benefited patients with transient ischaemic attack (TIA) with an ABCD2 score ≥4.