09/10/2018 1 Challenges in classifying ischemic stroke DNS efterårsmøde 5. oktober 2018 Sofie Amalie Simonsen Enhed for klinisk apopleksiforskning Rigshospitalet, Glostrup Patogenese for iskæmisk apopleksi • Småkars sygdom • Arteriosklerose i de store kar • Emboli • Sjældne årsager • Kryptogen Warlow et al. Stroke: A practical guide to management 1998 Hvorfor skal vi klassificere apopleksi? • Korrekt behandling • Prognose • Risikofaktorer • Forskning • Forståelse for mekanismer indenfor apopleksi • Personlig medicin • Biomarkører • Genetik Baggrund Klassifikation af iskæmisk apopleksi Baggrund Kim et al. 2014 1 Adams et al. 1993 2 Ay et al. 2005 TOAST 1 SSS-TOAST 2 CCS 3 ASCOD 4 Subtypes LAA CE SVO OD UD LAA CE SVO OD UD Supra-aortic LAA CE SVO OD UD Atherosclerosis CE Small-vessel disease Dissection Other Significant stenosis degree for diagnosing LAA >50% >50% >50% Stenosis with plaque ulceration or thrombus <50% at the side of the penetrating artery >50% <50% with endoluminal thrombus Mobile thrombus at aortic arch Diameter limitation for SVO 15 mm 20 mm 20 mm 15 mm Other advantages Simple Convenient Accurately predicts prognosis Logicals Reduced prevalence of strokes of undetermined etiology Web-based Evidence-based Convenient if equipment available Integration of non-causative factors Other disadvantages High prevalence of strokes of undetermined etiology Low validity and reliability in specific subtypes Complex algorithm Depends on modern diagnostic tools Needs equipment to connect to web side Difficulty in interpretation Too many subtypes 3 Ay et al. 2007 4 Amarenco et al. 2009 and 2013 Cerebral små-kars sygdom Baggrund 1 Wardlaw et al. 2013 2 Staals et al. 2015 * Inkluderet i small vessel disease (SVD) score2 * * * * Standards for reporting vascular changes on neuroimaging (STRIVE) 1 Formål At undersøge objektive mål for små- og stor-kars sygdom hos apopleksipatienter og associationen til TOAST klassifikationen
3
Embed
Challenges in classifying ischemic stroke - neuro.dk · 09/10/2018 3 Cerebral småkars sygdom og TOAST Resultater A B C D SVD score 4 3 2 1 0 Stor-kars sygdom Kardioemboli Små-kars
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
09/10/2018
1
Challenges in classifying ischemic stroke
DNS efterårsmøde 5. oktober 2018
Sofie Amalie SimonsenEnhed for klinisk apopleksiforskning
Rigshospitalet, Glostrup
Patogenese for iskæmisk apopleksi
• Småkars sygdom
• Arteriosklerose i de store kar
• Emboli
• Sjældne årsager
• Kryptogen
Warlow et al. Stroke: A practical guide to management 1998
Hvorfor skal vi klassificere apopleksi?
• Korrekt behandling• Prognose• Risikofaktorer• Forskning• Forståelse for mekanismer indenfor apopleksi• Personlig medicin• Biomarkører• Genetik
Baggrund
Klassifikation af iskæmisk apopleksi
Baggrund
Kim et al. 20141 Adams et al. 19932 Ay et al. 2005
>50% >50% >50% Stenosis with plaque ulceration or thrombus<50% at the side of the penetrating artery
>50%<50% with endoluminal thrombusMobile thrombus at aortic arch
Diameter limitation for SVO 15 mm 20 mm 20 mm 15 mm
Other advantages SimpleConvenientAccurately predicts prognosis
LogicalsReduced prevalence of strokes of undetermined etiology
Web-basedEvidence-basedConvenient if equipment available
Integration of non-causative factors
Other disadvantages High prevalence of strokes of undetermined etiologyLow validity and reliability in specific subtypes
Complex algorithm Depends on modern diagnostic toolsNeeds equipment to connect to web side
Difficulty in interpretationToo many subtypes
3 Ay et al. 20074 Amarenco et al. 2009
and 2013
Cerebral små-kars sygdom
Baggrund 1 Wardlaw et al. 20132 Staals et al. 2015
* Inkluderet i small vessel disease (SVD) score2
* * * *
Standards for reporting vascular changes on neuroimaging (STRIVE)1
Formål
At undersøge objektive mål for små- og stor-kars sygdom hos apopleksipatienter og associationen til TOAST klassifikationen
09/10/2018
2
Metode
• Observationelt prospektivt studie• Klinisk verificeret apopleksi, ikke TCI• Inklusion ≤ 7 dage (akut)• Genundersøgelse ≈ 6 måneder efter apopleksien (follow-up)
Metode
Undersøgelsesprogram
• Standard udredningsprogram• CT scanning• Tidligere sygdomme• Medicin• Telemetri og EKG• Ultralyd af karotiderne• Blodprøver• (Ekkokardiografi)• (Cerebral angiografi)
• TOAST• MR scanning
• STRIVE• SVD score
Metode
Yderligere test for perifer vaskulær funktionEndotel dysfunktionReaktive hyperæmi index (RHI)
Perifer storkars sygdomAnkel brachial index (ABI)
Metode
Resultater
• 110 patienter• Inklusion median 2 dage (0-7)• Median alder: 68 år (range 36–88)• Kvinder: 48 (43%) • Iskæmisk apopleksi: 99 (90%) • Median NIHSS: 2 (range 1–16)• 73 in-hospital follow-up, median 191 days (157-242)
• AFLI and carotis stenose ≥ 50% var associeret til TOAST (kardioemboli og stor-kars sygdom)• SVD scoren var ikke associeret til TOAST (små-kars sygdom)• Ingen af de ekstra vaskulære parametre var associeret til TOAST
Konklusion
Perspektiver
Der er behov for en ny operationel klassifikation af iskæmisk apopleksi når vi skal • Forstå mekanismer bag apopleksi• Udvikle personlig medicin herunder biomarkører og genetik
Perspektiver
Tak for opmærksomheden
Patienter og pårørendeHelle Klingenberg Iversen, MD, DMSc, Enhed for klinisk apopleksiforskning,