http://indigo.ie/~arhc

Age-Related Health CareAdelaide and Meath Hospital Dublin

incorporating the National Children’s Hospital

Dept of Medical GerontologyTrinity College Dublin

http://indigo.ie/~arhc

Stroke in Ireland

•Kills more people than breast cancer, lung cancer and bowel cancer combined

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Stroke is…...

• a focal or global neurological deficit• of presumed vascular origin• lasting more than 24 hours• or causing death within 24 hours

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A TIA is…...

• a focal or global neurological deficit• of presumed vascular origin• lasting less than 24 hours

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Stroke burden

• 9,250 acute strokes/year• 25% die in first year• 30,000 with residual disability

– 48% hemiparesis– 22% cannot walk– 24-53% need help in ADLs– 12-18% aphasic

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Impact

• Personal: – “..more impact than my wedding, or the

birth of my first child”

• 2nd most expensive illness• Most common cause of acquired

physical disability• Most expensive single DRG medically

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Biggest advance in Stroke Care

Not, not, not

Thrombolysis

Stroke Units

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Stroke Units• Reduce death, disability,

institutionalization• Reduce death and disability by 25%• NNT

– 33 to save a death– 20 to regain independence– 20 to prevent institutionalize

• Save 2-11 days hospital• If this were a tablet………..

Cochrane 2005

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Stroke Units• Direct care of a specialist in stroke care

and interdisciplinary team• Clearly defined continuum of care• Geographical unit preferable• CT/MRI on site• Main base general hospital• Take all patients referred

http://indigo.ie/~arhc

Vascular surgeon

Radiologist

Public Health

Geriatrician

RehabilitationistNeurologist

GP

PHN

Person with stroke

Carer

Hospital nurses

Physiotherapy

Occupational therapySpeech therapySocial workPsychology

Clinical nutrition

http://indigo.ie/~arhc

3 tasks•Was it a stroke?•What did the stroke cause?

–Cognitive impairment–Dysphagia–Gait disorder–Sensory–Inattention

•What caused the stroke?

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http://indigo.ie/~arhc

Vulnerable Tissue:

Work Fast!

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Brain attack• ABC• Diagnosis• Stabilize

• BP, O2, Temp, glucose

• Swallow• Positioning• Stroke Service

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History

• Patient• Collateral/witness

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Cincinnati Prehospital Stroke Scale

• Facial droop• Arm drift• Speech

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4 level neuro Ax• End of the bed• Alertness (GCS), language, cognition• Classical neuro examination

– Cranial nn– PTCS– Reflexes

• ‘Parietal’ signs– Inattention/neglect– Agnosia– Apraxia

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Differential

• Tumour• Meningitis/encephalitis• Seizure• Epilepsy• Migraine• Metabolic causes• MS

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TIA’s• 38% 'true' TIA• 10% had migraine• 9% had faints• 9% had possible TIAs, 9% had 'funny turns’• 6% had epilepsy• 6% had vertigo• 0.8% had hypoglycaemia• 0.4% had brain tumours

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ABCD of TIA treatment• 10% stroke risk within one week: 30% if high

score• ABCD Score

– Age - >60 = 1– Blood Pressure - Syst > 140 or Diast > 90 = 1– Clinical

• Motor = 2• Speech = 1

– Duration• > 1 hour = 2• 10-59 min = 1

Rothwell, Lancet 2005

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Urgent investigations

• Glucose• FBC• U + E• ECG

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Urgent CT

• Head injury• Suspicion sub-arachnoid

– Headache– Meningism

• Neurological deterioration• Possibility of thrombolysis

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BP

• Ischaemic stroke - dangerous to treat if not > 220/140

• Sub-arachnoid - neurology advice - nimodipine and normal blood pressure

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Stabilize

• Keep euglycaemic• Antipyretics for pyrexia

• O2: avoid hypoxia

• NPO until swallow assessed• Early advice on positioning

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First 12 hours

• Stroke Service• Book CTB (within 48 hours)• Book other tests as appropriate:

– Carotid dopplers– Holter monitor– ECHO– ……..

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Pharmacological

• Anti-platelets– NSA, Asantin R, clopidrogel

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Strategies: who can benefit?

• 150-250 strokes yearly in a Dublin hospital– Stroke Unit 100%– Aspirin 80%– Neuroprotective strategies 90%– Thrombolysis 5%

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iv Thrombolysis

• 3 Streptokinase: terminated• European r-TPA: no overall change• NINDS r-TPA: modest improvement

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NINDS rt-PA regime

• Within 3 hours (mean 90 mins)• 0.9 mg/kg (max 90mg)• 10% bolus• 90% over one hour• Systolic <185, Diastolic <110• BP managed by algorithm

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Contra-indications

• PUD• Recent surgery• Recent arterial puncture• Abnormal coagulation• BP not manageable to 185/110• No sign of established stroke on CT - NB

difficult

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Cochrane review

• Excess of deaths – 23% thrombolysis– 18% controls

• Reduction death and disability– 45% thrombolysis– 51% controls

• Treat 16 patients to avoid one death/disability

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The real world....Chiu, Stroke 1998

• 6% receive rt-PA• Those who don't:

– Time 37%– ICH 22%– Minor/rapidly resolving symptoms 19%– Nonstroke Dx 12%

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Acute treatment

• Aspirin• LMW Heparin• Thrombolysis

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Neuroprotective

• Nimodipine• Glutamate antagonists• Na channel antagonists/glycine

antagonists• Opioid antagonists• Antoxidants/Free radical scavengers

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Management issues

• Reducing delay• Stroke unit approach• CT access and expertise (?

telemedicine)• Neuro-ICU

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http://indigo.ie/~arhc

Unmet needs post-stroke

• 38% no personal contact GP• 46% attended DH• 79% had health concerns• 64% required Rx advice• 18% had resumed smoking

Martin Scot Med 2002

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6 Months after discharge

• 58% in the community• 87% had seen GP• 48% reviewed in OPD

Crowe IMJ 2002

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Remediable risk factors

• Smoking• Alcohol• Exercise• Obesity, DM• Psychosocial

• BP• Lipids• Homocysteine• Infections• Inflammation,

thrombosis

Sem Vasc Med 2002, 2, 229-445

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Fibrinogen

•Adds to likelihood of event•Reduce inflammation?

– Flu vaccine– Reduces stroke hospitalization by 16%

Nichol NEJM 3 April 2003

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Healthy lifestyle is anticoagulant and anti-

inflammatory

• Weight loss, exercise• Reduce vascular inflammation and

insulin resistance

• So, stop smoking, keep walking!

Esposito, JAMA, April 9, 2003

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• Antithrombotics

• BP reduction

• Cholesterol

• Diet and DM

• Exercise/rehabilitation

• Forget smoking/Flu jabs

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Antiplatelets

• 25% reduction in all events• CHD• Stroke• VTE• Revascularization

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BP reduction

• Diuretics and ACE-Inhibitor• Primary prevention trials suggest drug

equivalence• Cave postural symptoms!

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Statins

• All patients with stroke• Fire and forget• Highest effective dose• Simvastatin 40• Pravastatin 40• Atorvostatin 10

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http://indigo.ie/~arhc

Carotid endarterectomy

• Carotid territory stroke TIA in last 6 months

• >70% stenosis (about 5% of our patients)

• NNT 15 to prevent death or disability over 2-6 years

• Surgically fit patients• Surgeons with <6% complication rates

http://indigo.ie/~arhc

• Antithrombotics

• BP reduction

• Cholesterol

• Diet and DM

• Exercise/rehabilitation

• Forget smoking/Flu jabs