5/26/16 Neurology Headlines from 2015 Disclosures & 2016 Vanja Douglas, MD None Sara & Evan Williams Foundation Endowed Neurohospitalist Chair Associate Professor of Clinical Neurology UCSF Department of Neurology Neurohospitalist Program Objectives Case • Describe the treatments available for acute • 73 y/o man with sudden onset right sided ischemic stroke weakness and aphasia • Compare and contrast carotid endarterectomy and stenting • Eating breakfast with wife at 9:00 AM • Explain why TIA should be treated urgently • Arrived in ED at 9:55 AM • Discuss evidence-based treatments for back pain • List treatment options for agitation in dementia • Identify emerging treatments for migraine • Effectively examine patients with possible concussion 1
5/26/16 Which of the following is NOT an Acute Stroke Management evidence-based treatment option for this patient? • IV tPA: 0 to 3 hours • Intravenous tissue plasminogen activator (IV • IV tPA: 3 to 4.5 hours* tPA) • Embolectomy: 0 to 6 hours • Intra-arterial tPA • Mechanical embolectomy • Clock starts: • Combination of IV tPA and mechanical – Last seen normal embolectomy • Clopidogrel *Not FDA approved; approved in Europe Image By Sun Ladder - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=10959166 Acute Stroke Management Acute Stroke Management • IV tPA: 0 to 3 hours • Embolectomy: 0 to 6 hours – 39% no disability vs. 26% no disability – Large vessel occlusions only (20% of all ischemic stroke patients) – Number needed to treat: 7 – 19-40% independent vs. 33-71% independent • IV tPA: 4 to 4.5 hours – NNT 3 to 7.5 – 52% no disability vs. 45% no disability • Up to 12 hours for basilar occlusions – NNT : 14 Jauchet al, Stroke 2013 Public Domain, https://commons.wikimedia.org/w/index.php?curid=244840 9 Powers et al, Stroke 2015 2
5/26/16 Non-contrast CT head 10:03 AM CT Angiogram Groin puncture 11:40 AM 3
5/26/16 4 days post-thrombectomy: Mild right hemiparesis TICI 3 recanalization: 12:13 PM In which patient is carotid stenting Case NOT an evidence-based alternative to endarterectomy? • During the angiogram, 80% narrowing of the left internal carotid artery is confirmed. • 64 year-old woman with 80% stenosis • The 73 y/o patient asks what he can do to • 64 year-old man with 80% stenosis prevent a future stroke. • 76 year-old man with 80% stenosis • 71 year-old man with 80% stenosis and prior neck radiation and NYHA Class III heart failure 4
5/26/16 Symptomatic Carotid Stenosis Carotid Endarterectomy Roffiet al., Eur Heart J 2009 Rothwell et al., Lancet 2003 Endarterectomy vs. Stenting: 10 year Endarterectomy vs. Stenting follow-up • Increased odds of stroke or death within 30 • Stroke or B Stroke or Death 100 20 periprocedural death days of treatment with stenting 15 80 Stenting – Stenting: 98 (11.0%) Patients (%) – OR 1.72 (1.29-2.31) 10 60 – CEA: 71 (7.9%) 5 Endarterectomy 40 • Equivalent risk of stroke during follow up 0 – Hazard ratio 1.37 20 0 1 2 3 4 5 6 7 8 9 10 – OR 0.93 (0.60-1.45) (1.01 – 1.86) 0 0 1 2 3 4 5 6 7 8 9 10 Follow-up (yr) • All risk difference • Risk difference only seen in patients >70 years No. at Risk Endarterectomy 1240 1127 1056 967 848 744 703 624 442 245 67 seen in patients 70 Stenting 1262 1111 1049 979 889 777 741 679 479 265 68 – <70: OR for stenting 1.16 (0.80-1.67) and older – ≥70: OR for stenting 2.20 (1.47-3.29) Bonatiet al., Cochrane Database Syst Rev 2012 Brott et al., NEJM 2016; Howard et al., Lancet 2016 5
5/26/16 Case TIA: Unstable Angina of the Brain • You are called to admit a patient who • 10% will have a stroke in 90 days experienced 2 hours of right arm weakness • Half of these will occur in the first 2 days and trouble speaking earlier in the day. He was normal by the time he got to the ED. He • Is there a way to identify who is at highest is a 63 year-old man with hypertension and risk? diabetes, taking aspirin, lisinopril, and • Is there anything you can do to prevent stroke metformin. after TIA? • Blood pressure at triage was 150/85. High Risk TIA: The ABCD 2 Score ABCD 2 Score Clinical Features Points Age ≥ 60 1 point Blood pressure ≥ 140/90 1 point Clinical Symptoms Speech impairment without weakness 1 point Unilateral weakness 2 points Diabetes 1 point Duration 10 to 59 minutes 1 point ≥ 60 minutes 2 points Johnston et al, Lancet 2007 Johnston et al, Lancet 2007 6
5/26/16 Cumulative Incidence of the Composite Outcome in the Modifying Recurrence Risk Overall Population. Rothwell et al, Lancet 2007 Ama re nco P e t a l. N E ngl J Me d 2 0 1 6 ;3 7 4 :1 5 3 3 -1 5 4 2 . A Role for Dual Antiplatelet Therapy? TIA: Unstable Angina of the Brain • CHANCE: • Work up and treat emergently; admit if necessary to expedite workup – 5,170 patients within 24 hours of TIA or minor stroke • Treatment – Aspirin for 90 days vs. clopidogrel (300 mg loading – Antiplatelets, anticoagulation or endarterectomy dose followed by 75 mg daily) for 90 days Risk factor modification combined with aspirin 75 mg for 21 days • Consider dual antiplatelet therapy for 21 days – 8.2% vs. 11.7% with stroke at 90 days – Favored combination therapy; HR 0.68 (p<0.001) • POINT Trial ongoing Wang et al, NEJM 2013 7
5/26/16 Which of the following is an evidence- Case based therapy for acute low back pain? • A 47 year-old man presents to your office with several days of severe low back pain. • Physical therapy • He has a history of chronic low back pain for • Naproxen the past 5 years. • Oxycodone • His neurological examination is normal. • Naproxen + cyclobenzaprine Low Back Pain in the ED Physical therapy? Wait a month. Education & No PT x4 weeks PT x4 weeks Improvement on (n=108) (n=112) 323 patients randomized RMDQ at 1 week Naproxen 9.8 (7.9-11.7) 3 months: 3 months: ODI 41.3 -> ODI 40.9 -> 6.6 9.8 Naproxen + cyclobenzaprine 10.1 (7.9-12.3) Naproxen + 1 year: 1 year: 11.1 (9.0-13.2) oxycodone/acetaminophen ODI 7.0 ODI 9.0 Friedman et al., JAMA 2015 Fritz et al., JAMA 2015 8
5/26/16 Do you prescribe steroids for acute Steroids for Sciatica? radicular pain due to lumbar disk herniation (sciatica)? Steroids (n=181; Placebo (n=88); baseline ODI baseline ODI 51.2) 51.1) • Yes 3-week 3-week • No ODI 37.5 ODI 32.2 1 year ODI 1 year ODI 13.4 20.7 No significant change in pain No difference in surgery rates Goldberg et al., JAMA 2015; image from Wikimedia Commons For Low Back Pain, Treat the Brain • 342 patients randomized to – Mindfulness based stress reduction – Cognitive behavioral therapy – Usual care Cherkinet al., JAMA 2016 Richmond et al., PLOS One 2015 9
5/26/16 Which of the following is associated Case with excess mortality when used in patients with dementia? • One of your 84 year-old patients with Alzheimer Dementia is brought in by his wife • Donepezil for an urgent appointment. • Citalopram • In the past several months he has become • Valproate paranoid, aggressive and occasionally • Dextromethorphan-Quinidine agitated. • Quetiapine Case • A 56 y/o woman comes to your office complaining of headaches. She has 4 severe headaches per month and usually misses 2 days of work per month as a result. • Sumatriptan works well for the headaches but • 220 patients randomized • Uncertain clinical benefit but… sometimes she runs out before she is eligible • Improvement on multiple outcome for refills. measures • Serious adverse events: • 7.9% with dextromethorphan • 4.7% with placebo Cummings et al., JAMA 2015 10
5/26/16 Which of the following are NOT Change in Headache Days: Episodic evidence based prophylactic therapies Migraine for migraine headaches? • Valproate • T opiramate • Propranolol • Verapamil • Metoprolol • Petasites (butterbur) • Amitriptyline • Riboflavin • Venlafaxine • Gabapentin Bigalet al., Lancet Neurol 2015 Change in Headache Days: Chronic Bonus Case Migraine • A 19 year-old college student comes into your office the day after hitting his head against the goalpost during soccer practice. There was no loss of consciousness. • He is complaining of a headache and is worried he had a concussion that may affect his performance on his upcoming final exams. • He has a history of migraines. Bigalet al., Lancet Neurol 2015 11
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