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STROKE DISEASE
In a nutshell
The Prevention and Management of Stroke
by
Dr Irfan Shakir
110,000 new strokes every year 10,000 under 55 years of which 1,000
under 30 years In addition 30,000 repeat strokes Incident higher in Africans and South
Asians Third most common cause of death, 30%
mortality at one month most die within first 10 days
Size of the Problem
85% of the strokes infarcts
15% haemorrhagic
Size of the Problem
Biggest cause of long term disability
Though 65% of survivors can live independently
35% are significantly disabled of these 5% need residential care
Size of the Problem
Risk Factors
Lifestyle
Poor diet(Salt and fat intake too high, not enough fruit and vegetables)
Low level of physical activity Alcohol misuse Smoking
Individual Risk Factors Previous stroke or TIA Hypertension Atrial fibrillation(AF) Coronary heart disease(CHD) Peripheral vascular disease(PVD) Carotid stenosis Metabolic diseases(diabetes,
hyperlipidaemia, obesity)
Transient Ischaemic Attack(TIA)
Definition:Focal neurological symptoms and signs of sudden onset of presumed vascular origin which completely resolve within 24 hours(i.e. hemiparesis, hemipraesthesia, dysphasia, amaurosis fugax), consider other diagnosis if loss of consciousness, dizziness, funny turn, or unexplained collapse
Management
Refer for specialist assessment Use ABCD2 Score to stratify
Management(TIA)
ABCD2 Score for Transient Ischaemic Attack
A (Age); 1 point for age >60 years, B (Blood pressure > 140/90 mmHg); 1 point for
hypertension at the acute evaluation.
C (Clinical features); 2 points for unilateral weakness, or 1 for speech disturbance alone
D (symptom Duration); 1 point for 10–59 minutes,or 2 points for >60 minutes.
D (Diabetes); 1 point
ABCD2 Score for Transient Ischaemic Attack
Score 1-3: Low risk Score 4-5: Medium risk Score >5 :High risk
ABCD2 Score for Transient Ischaemic Attack
Department of Health
Score 1-3 see and investigate within one week
Score 4 or above see and investigate within 24 hours
Hypertension Coronary Heart
Disease Diabetes Hyperlipidaemia Current smoker
Alcohol Atrial
Fibrillation Family history Migraine
Management(TIA)Risk Factors
All Patients(if possible before attendance at the clinic)
Full Blood Count(FBC) Urea and Electrolytes(U&E’s) ESR Fasting Sugar Fasting Lipids
Management(TIA)Investigations 1
Management(TIA)Investigations 2
As appropriate
ECG Echocardiograph Carotid Doppler CT head MR head and angiogram Auto-antibody screen Thrombophilia screen
Antiplatelets Aspirin Clopidogrel
Add ons Dipyridamole ? Clopidogrel
Treatment(TIA)
Treatment(TIA)
Anticoagulation No benefit unless source of embolism
present Consider in all patients in AF as increased
risk 3-7 fold but advantage over Aspirin not that large Absolute Risk Reduction(ARR) 2.9% (95% CI 0.9-4.9%) Number Needed to Treat (NNT) 34
Treatment(TIA)
Anticoagulation in (AF)
Carotid Stenosis
Symptomatic 70-99% stenosis benefits from carotid endarterectomy ARR 6.7% NNT 15 over 3 years
Treatment(TIA)
Hypertension Compared with CHD evidence not as
strong but 37% risk reduction has been reported if BP lowered to 140/85.
About 50% of deaths in stroke survivors due to cardiac events
Treatment(TIA)
Cholesterol Evidence is not as strong as in CHD.
Reduction has to be larger than CHD. As majority have CHD and PVD treatment is important. Lower it if cholesterol > 3.5
? Upper age limit because of side-effects
Treatment(TIA)
Diagnosis Focal neurological symptoms and
signs of sudden onset which persists for more than 24 hours.
Diagnosis is primarily clinical
Stroke
Fast Test for Stroke
ROSIER Scale for Stroke Has there been loss of consciousness or syncope? Yes
(-1) No (0) Has there been seizure? Yes (-1) No(0)Is there a NEW ACUTE onset (or on awakening from sleep)1. Asymetrical facial weakness Yes (+1) No (0)2. Asymetrical arm weakness Yes (+1) No (0)3. Asymetrical leg Weakness Yes (+1) No (0)4. Speech disturbance Yes (+1) No (0)5. Visual field defect Yes (+1) No (0) Total Score ____ (-2 to +5)Stroke is likely if total scores are > 0. Scores of </=0 have
a low possibility of stroke but not completely excluded.
Who to Admit to Hospital All with disabling stroke Minor disability stroke patients can be
looked after at home if investigations and full multidisciplinary assessment can be done rapidly followed by specialised rehabilitation
Stroke Care
HOW IN HOSPITAL All patients should be admitted to a
dedicated acute stroke care area as soon as diagnosis has been made.
Acute Stroke Unit care is better for outcome.
NNT = 20
Stroke Care
How in hospital: Rehab Stroke Units
Stroke Care
NNT 9-16
Stroke Units(evidence)
Stroke Care
Stroke Assessment Good history and clinical examination Investigations to confirm diagnosis Risk factors Multidisciplinary assessment
Stroke Care
Neurological Examination Power Sensation Visual fields Visuo-spatial disturbance Speech Swallowing
Stroke Care
Clinical Classification TACS=Total Anterior Circulation
Stroke PACS=Partial Anterior Circulation
Stroke LACS=Lacunar Stroke POCS=Posterior Circulation Stroke
Stroke Care
TACS Hemi-motor and sensory deficit Hemianopia Cortical Dysfunction
a) Dysphasia or b) Visuo-spatial disturbance
Stroke Classification
PACSAny two of the following Hemi-motor and sensory deficit Hemianopia Cortical Dysfunction
a) Dysphasia or b) Visuo-spatial disturbance
Stroke Classification
LACS Pure motor hemiplegia Pure sensory loss Motor and sensory loss
Stroke Classification
POCS Vertigo Diplopia Ataxia Isolated hemianopia
Stroke Classification
6month mortality
3 month recurrence
TACS 50% LOW
PACS 10% HIGH
LACS 7% LOW
POCS 14% HIGH
Stroke Classification
Full Blood Count(FBC) Urea and Electrolytes(U&E’s) ESR or Plasma viscosity Fasting Sugar Fasting Lipids ECG INR if on anticoagulation or clotting
abnormality suspected
Stroke Investigations
Imaging CT head immediately to deliver
thrombolysis or as soon as possible with view to start antiplatelet treatment but no later than 24 hours
On anticoagulant immediately if haemorrhage seen give treatment to reverse
Chest X-ray if cardiac or chest disease present or suspected
Stroke Investigations
Consider
Carotid Doppler Auto-antibody Screen Thrombophylia Screen Echocardiograph Coagulation Screen
Stroke Investigations
Acute Stroke Unit Give 300mg Aspirin as soon as
haemorrhage excluded unless suitable for thrombolysis
Dysphagia screen Manage hydration Control blood sugar Manage pyrexia Manage hypoxia
Stroke Care
Acute Stroke Unit Hypertension: Observe for 2-3 days
unless diastolic persistently above 115 or evidence of accelerated hypertension. Lower BP using drugs which do not cause sudden drop.
Stroke Care
Multidisciplinary Team THERAPISTS
OCCUPATIONAL THERAPIST PHYSIOTHERAPIST SPEECHTHERAPIST
DIETICIAN PSYCHOLOGIST SOCIAL WORKER PHARMACIST NURSE DOCTOR
Stroke Care
Multidisciplinary Assessment Within 24- 48 hours of admission
using protocols to have documented assessment of:
Consciousness level Swallowing Pressure sores risk
Stroke Care
Multidisciplinary Assessment
Nutritional status Cognitive impairment Communication Moving and handling
Stroke Care
ManageUsing protocols Continence Nutrition Shoulder pain Discharge planning
Stroke Care(Rehabilitation)
Goal Setting
Must involve patient Family if appropriate
Stroke Care(Rehabilitation)
Carers and Families
Give information on nature of stroke and treatment available
Assess and reduce stress Give individual psychological
support
Stroke Care(Rehabilitation)
Ongoing Care Once patient can transfer from bed to
chair specialist stroke teams are effective in any of the following settings
Home Day hospital Nursing Home Residential Home
Stroke Care(Rehabilitation)
As for Transient Ischaemic Attack (TIA) Lifestyle (diet,exercise, smoking, alcohol) Antiplatelets Anticoagulation in AF Carotid Stenosis Hypertension Metabolic Diseases(diabetes, cholesterol,
obesity)
Stroke CareSecondary Prevention