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Transcript

 

Lee Tetreault:

Hello and welcome to frequently asked questions from the session Update in the Diagnosis and Management of Stroke and TIA. We are joined today by Dr. Yolanda Reyes-Iglesias, MD. She is the Stroke Director for the Miami VA Hospital and Associate Vice Chair for Undergraduate Medical Education, Neurology Clerkship Director, University of Miami, Miller School of Medicine. Doctor, before we get started today, can we go over some of the key pointers from today's session? 

Yolanda Reyes-Iglesias: 

Sure. One of the key pointers from today's session is that eligible acute ischemic stroke patients can undergo mechanical thrombectomy now up to 24 hours from the last time seen well. In addition, it has been demonstrated that in patients with a minor stroke or transient ischemic attack, the use of short-term dual anti-platelet therapy is beneficial if it's started within the first 24 hours of patient symptoms. In addition, the approval of direct oral anti-coagulants and their respective reversal agents has definitely increased and used during the last years.

Lee Tetreault:

Thank you, Doctor. Let's get into some of these frequently asked questions. First, what is the risk of a recurrent stroke? 

Yolanda Reyes-Iglesias: 

Well, the risk is highly dependent upon the cause of the stroke. We know that recurring stroke is usually higher for patients that have a prior history of strokes or transient ischemic attack, specially in the first 48 hours after the symptoms.

Lee Tetreault:

What is new in the treatment of transient ischemic attacks? 

Yolanda Reyes-Iglesias: 

We have now two clinical trials, the CHANCE and the POINT trial. Both of them had shown the benefit of short-term dual anti-platelet therapy for patients that have a non-cardioembolic, non-disabling stroke or transient ischemic attacks in preventing further stroke recurrence, further cardiac death or myocardial infarction.

Lee Tetreault:

What is the time window for mechanical thrombectomy? 

Yolanda Reyes-Iglesias: 

Recent studies now have shown that mechanical thrombectomy can be beneficial up to 24 hours after ischemic stroke onset in eligible patients.

Lee Tetreault:

What are the new trends in stroke prevention? 

Yolanda Reyes-Iglesias: 

We know that if patient have a cryptogenic stroke or an embolic stroke of a known etiology, screening for obstructive sleep apnea in these patients and long-term cardiac monitoring should be considered. 

Lee Tetreault:

What are the current recommendations for patients who have a stroke and a patent foramen ovale? 

Yolanda Reyes-Iglesias: 

Consideration for patent foramen ovale closure in combination with anti-platelet therapy should be considered in young patients usually less than age 50 that have large right-to-left cardiac shunts, embolic-appearing strokes, and when no other etiology for the stroke is found.

Lee Tetreault:

And finally, doctor, now that we have new, direct oral anticoagulants available, what is the role of Warfarin in patients with atrial fibrillation and stroke? 

Yolanda Reyes-Iglesias:

We know that Warfarin is still the preferred oral agent. If patients have atrial fibrillation and stroke in addition having a mechanical heart valve or moderate to severe mitral stenosis. Warfarin is also still the preferred oral agent in patients that have an intracardiac thrombi and a stroke. The preferred oral agent for patients with severe renal impairment or endstage renal disease on hemodialysis must be decided on an individual basis, but in these cases Warfarin tends to be the preferred agent as well.

Lee Tetreault:

This is great information, Doctor. Thank you so much for your time today.