Stroke: Transient Ischemic Attack (TIA)
Guest: Dr. Aquilla “Quill” Turk – Radiology/Neuro Interventional
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Quill Turk who is Assistant Professor of Radiology and an intervention neuro, or brain, radiologist here at the Medical University of South Carolina. Dr. Turk, let’s talk about something that, I guess, most people refer to as spells or, maybe, TIAs, and I understand, now, some folks are calling it chronic stroke. Just what are these spells, or TIAs, consisting of?
Dr. Quill Turk: Oftentimes, people have these TIAs, or transient ischemic attacks, which are symptoms where somebody may have a point where they have garbled speech or they lose the ability to have their arm work correctly for them, or their leg work correctly for them and it’ll often last for minutes at a time and then go away. To some degree, with those patients, it can actually be related to a narrowing of a blood vessel inside the brain. That’s a newer area evolving in our field which we have a lot of interest in because it’s now something that we do have a treatment for.
Dr. Linda Austin: What is actually happening when a vessel is narrowing and then, I guess, expanding back to normal again?
Dr. Quill Turk: The majority of the time that patients have TIAs, it can be related to hardening of the arteries in their neck and their brain, and elsewhere. It’s oftentimes related to atherosclerosis, or a buildup of plaque in these blood vessels, which is why there’s a big push now for optimizing patients with statin drugs, to control their cholesterol and lipids, and everything else, as well as watching blood pressure. And the reason is, as these plaques build up, there are two things that could happen. One is, we disturb blood flow. As blood flow gets disturbed, it can activate platelets, and that can form little clots, and that can go downstream and cause some of these events, which is also the reason why aspirin is such a positive drug for this. And there’s a new drug, plavix, that many people are also utilizing for these areas.
In addition to disturbing blood flow and forming these little platelet aggregates, the plaque itself can rupture and material, cholesterol, from the plaque, can also become loose and go downstream and plug up blood vessels and cause people to have symptoms as well.
Dr. Linda Austin: I would imagine that some people tend to be kind of stoic about these episodes and ignore them. But it sounds like they could, potentially, be the warning sign of something serious to come.
Dr. Quill Turk: Absolutely. Oftentimes, it’s kind of the shot over the bow, so to speak, giving people the warning that there is a larger stroke coming down the road. And we do have some studies that have been done in the past. There’s a study, called the Wasset Study, which compared coumadin, which is a very potent blood thinner, against aspirin, looking at patients with intercranial atherosclerosis. What it showed us is that patients that have significant intercranial atherosclerosis, if they have symptoms related to this and they’re on these medicines, which, in the past, were the only potential treatments that we had, are still at significant risk of having stroke, up to, and depending on the degree of stenosis, or narrowing, of the blood vessel, a 20-35 percent risk of stroke in the next year.
Dr. Linda Austin: Wow, that’s pretty high. And that’s just in one year?
Dr. Quill Turk: That’s just in one year. And that’s with the best treatment that we have, using these medicines.
Dr. Linda Austin: So, how do you, then, as an interventional neuroradiologist, go about treating these folks?
Dr. Quill Turk: Well, in the past, we’ve taken devices that the cardiologists have used to treat narrowings in the blood vessels in the heart and we’ve applied them in the brain. However, we’ve always been very limited because these devices were made to get to the heart blood vessels, which are relatively straightforward, whereas the blood vessels in the brain are very curvy and often very far out. So, we’ve not been able to reach many of those narrowings with these stents to open up the blood vessels. However, in the last couple years, newer stents have come out that are specifically designed to treat these narrowings in the blood vessels in the brain and we’ve applied those to quite a few patients and have had very good success rates, so far.
Over the course of the next year, there’s a new trial that’ll be coming out, called the Sampras Trial, no relation to Pete Sampras, where we’ll be randomizing patients into the best medical therapy versus getting this new stent for treatment of these atherosclerotic lesions in the brain.
Dr. Linda Austin: Do you know, roughly, when that trial will start?
Dr. Quill Turk: It’s projected to start in the first quarter of 2008.
Dr. Linda Austin: Oh, in just a few months then?
Dr. Quill Turk: Yes.
Dr. Linda Austin: Wow, very exciting. Who is a good candidate, and who is not a good candidate, for this kind of therapy?
Dr. Quill Turk: In my opinion, a person who is a good candidate is somebody who is already taking medicine, aspirin, plavix, coumadin, some type of blood thinner or anti-platelet medicine and, despite being on that, are continuing to have symptoms and those symptoms are in the part of the brain that is supplied by a blood vessel that has a narrowing of significance.
Dr. Linda Austin: Now, I noticed you didn’t say anything about the age of that ideal candidate or the medical status. Are there those considerations also?
Dr. Quill Turk: In my opinion, no. I’ve treated people over 90 years old with this and, you know, they’ve been able to have very good function and return back to their normal lifestyle. So, fortunately, in our field, the surgeries are not very invasive; it’s a minimally invasive surgery. Probably the hardest thing for patients to get over is, really, the anesthesia, you know, because they undergo a general anesthetic and that’s not always the easiest to come back around from. So, I find that age is really not an issue. It really comes down to, more, that the symptoms match the areas of their narrowing.
Dr. Linda Austin: It must be very rewarding for you to know that you are preventing some very serious problems in these patients.
Dr. Quill Turk: That’s the real key, to prevent stroke. But, at the same time, there’s also, oftentimes, a lot of symptoms that these patients harbor that are unmasked after we treat them. We frequently get comments from families about how their father’s woken up, or their grandfather is now back to his old self. We’re doing research into this as well, looking at cognitive and how well they perform at daily tasks and how well they think and can balance their checkbook, and do all the things that we take for granted. You know, as we get older, we just think that, oh, those things naturally decline.
It is curious that, maybe, some of this is related to the brain not getting enough blood. It’s not something we know, but it’s something that we hope can, maybe, help determine in the future.
Dr. Linda Austin: How widely available is this procedure?
Dr. Quill Turk: Stenting of the blood vessels in the brain is something that we’ve been doing for many years, but, again, it’s been utilizing devices for the heart in the brain. Therefore, it wasn’t done very frequently at all. Only in the last two years has it been done more regularly, as we’ve had devices that are indicated for use in the brain’s blood vessels.
However, with that said, there are still, probably, only 10 or 15 centers in the country that have had significant use. And when I say significant use, I mean, we’re talking, they’ve put in more than 40 or 50 of these stents. Fortunately, I’m in that group of high users, so we’ve got quite a lot of experience that we’re able to offer people presenting to us here at MUSC.
Dr. Linda Austin: Dr. Turk, thank you so much for talking with us today.
Dr. Quill Turk: Thank you.
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