an overview of stroke recent perspectives dr. a.v. srinivasan knowledge can be communicated but not...
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AN OVERVIEW OF STROKERecent perspectives
DR. A.V. SRINIVASAN
“Knowledge can be communicated but not Wisdom”- Hermann Hesse
Introduction
Improved technology and treatment for stroke has decreased mortality and prolonged survival but disability from stroke remain Major health care concern.
Although Rehabilitation is one of the oldest forms of treatment, it is least understood. Some physicians uneasiness with rehabilitation has its origin in Medical Training. Traditional Medical training emphasis on diagnosis and curative treatment. When cure is not possible patient needs Rehabilitation Therapy, Counseling and Support in the face of physical disability, feeling of failure and futility.
1. 45 85 yrs - Stroke occurs
2. Guidelines for 24hrs: MandatoryLevel of Evidence
Level A: Based on RCT or Meta analy. of RCT
Level B: Based on Robust Experiment or Observation Studies
Level C: Based on Expert opinion.
25% men
20% women
“The True Art of Memory is The Art of Attention” - S.Johnson
Injured Brain
According to WHO
Doctor assessment of Handicap may not coincide with Patients Assessment. Neurologist depends on physiotherapy, occupation therapy and speech therapy in rehabilitating the stroke patients.
NEUROLOGIC PREDICTORS.
Flaccid Paralysis for more than 96 hrs When tendon reflexes recover without return of voluntary
movement – prognosis poor Recovery of sensory less in usual to a degree. Postion
sense recovers but not pain and temperature Recovery from Dysphasia is never complete Dysarthria usual improves and Dysphagia never improves Diplopia due to brain stem is usually permanent Conjugate gaze – recovers Vertigo improves but hearing loss is permanent Pseudobulbar palsy permanent
REHABILITATION OF STROKE Assessment of function
Motor, postural, perceptual, cognitive, communication and autonomic
Independence and self-care Walking dressing washing, toileting and feeding
Available services Nursing Physiotherapy Occupational therapy Clinical psychology Medical social worker plus self-help groups (‘Stroke
Club’)
EARLY MANAGEMENT AND REHABILITATION
Consist of1. Skin care 2. IV therapy in disabled patients 3. Caution due to confusion 4. Auditory and visual deficit 5. Splint and braces 6. Complications include the following
Complications include the following:
A. Contractures
b. Treatment of Spasticity
TREATMENT MODALITIES FOR SPASTICITY Surgery
Nerve Blocks
Motor Point Blocks
Drugs: Dantrolene, Baclofen, Diazepam
Muscle Stretching Program
Prevention of Nociception
Complications include the following:
c. Reflex sympathetic Dystrophy d. Physiological Deconditioning.
PHYSIOLOGICAL DECONDITIONING
Loss of Normal Postural Reflexes
Increased Resting Pulse RateCatabolic Nutritional State-Psychological Depression
Lower Vital CapacitySlowing of GI Tract
Venous StasisUrinary Stasis
Complications include the following:
e. Swallowing disordersf. CVD and Heterotrophic ossification
Complications include the following:
7. Psychological factors
FACTORS GOVERNING THE OUTCOME OF STROKE REHAB.
Good outcome – Mild to moderate neurologic damage
with mild moderate paresis not associated with sensory or visual problems
Patients not demented or depressed
Walking 150 feet without assistances (Goal ) Motor alone – 0.9 Motor Sensory Visual – 0.5 Barthal index score – 95 normal
• Motor alone- 0.6• Motor Sensory Visual – 0.5
FACTORS GOVERNING THE OUTCOME OF STROKE REHAB.
Motor deficits alone reach their goals within 12 weeks
Framinham study – recovery from stroke 3 months
Adams – recovery from stroke 2 years
FACTORS GOVERNING THE OUTCOME OF STROKE REHAB.
FUTURE TRENDS IN REHABILITATION (Sensory Modulation)
Anatomical Principles Somatosensory System Limbic System Visual System
Phantom Experiences The man who missed his foot for penis Gaze Tinnitus Ear Lobe stimulation produces as an eroatic
sensation in nipple Phantom Pain
Role of Parietal Lobe Clinical Implications
Synesthesia - Virtual reality box Allesthesia - Extinction of
referred sensation Caloric test - Disappearance of
Anosognosia
FUTURE TRENDS IN REHABILITATION (Sensory Modulation)
SUMMARY
The goal of rehabilitation is to permit a return to function. In pursuit of this goal, proper management of secondary disabilities is essential. Clinical objectives include: prevention of contractures, retardation of deconditioning, maximization of nutritional status, optimal treatment of associated medical problems, and providing appropriate psychological support to family and patients.
1.History And Examination
a.Stroke clerking Performa (1994) R.C.P.1. Improved patient Assessment2. Improved Management - not clear3. Improved outcome - not clear
b. Examination1. Secure Diag of Stroke2. Specify Impairment3. Identify sub type of Ischemic stroke
“ We Sometimes think we have forgotten something when in fact we never really learned it in the first place”
Imp.Your Memory Skills
Guide: 3 (B) - CPR Impaired Consciousness - From Stroke
Resuscitation is rarely successful Schneider 1993
Guide: 4(B) Investigations:(Sagar 1995)-435 PTS)
Chest x-ray 16% ABN Only 4% change clinical management Order x-ray chest if WT Loss or chest
symptoms present
Through Action You Create your Own Education- D.B. ELLIS
Guide 5: (B) ECG: Cardiac cause of Death (30 days) Ebrahim 1990. All conscious patients to have ECG
Guide 6: (C) CT: Routine CT Head is a Intell lazy approach King’s fund forum(1988) gives useful framework Weir 1994 Clinical scoring cannot distinguish Do CT if a) Uncertainty of Stroke
b) If Anticoagulation or Anti Platelet treatment contemplated
Guide 7:(B) M.R.I.
Moha 1995, - Unclear for Implications for clinical practice
No Routine MRI indication in Acute Stroke
Whatever the Mind can conceive and Believe, the mind can Achieve
Napoleon Hill
Imagination is more Important than Knowledge Guide 8: (B) ECHO no Routine
Echo in Acute Stroke TOE Vs. TTE Amer Heart Asson (1997) - same
conclusion Yield is very low. (Leung 1993;
Chambors 1997) Only when ABN ECGS - change clinical
management
Guide 9: (A) - Dopp scan for selected PTS: 80% > more benefits from
Endarterectomy Minor stroke -No disability Subst Storke -Good recovery do
doppler Medically fit
Guide 10: (B) Management: Fever (Worst Prog.) Reith 1996 Hypoxia ( Moroney 1996) - Exac. by seizures
Pneumonia and Arrythmias - Worst outcome Hyperbaric O2 ineffective (Nighoghossaln
1995) Haemodilut. Plasm Expanders; venesection No evidence for efficacy (As plund - 1997)Check ABG only if Hypoxia suspected.
Guide 11: (A) Steroids and Hyperosmolar agents Unproven treatment - should not be used Tumor oedma responds but not
cytotoxic stroke oedma qialbash 1997 - No effect on survival or improv. In funct. Outcome
Manntol - (Boysen 1997) - short term effective statistically in conclusive
You are what you think and not what you think you are
Annoymous
We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts
R.B. Schmeck
Guide 12: (B) - Blood Pressure Defer - acute reduction of BP - 10 days unless
HT Encephalopathy or adrtic dissection present
Moris 1997 - Increase BP - falls in 10 days UK - 5mm in D.B.P. 1/3 storke - Low BP prompt
correct of hypovoll. and withdrawal of hypotonic drugs
Collins 1994 - HT - Prim. stroke prevent Neal 1996 (Current RCT) - HTs in stroke
survivors -study needed
Guide 13: (A/B) - AF AF / ISCH Stroke/ Mild disability -
warfarin after 48 Hrs (Longer for larger) Aspirin for others
EAFT 1995 Less than 2 PT - No effect SPAF 1996 > 5 - Bleeding
A great many people think they are thinking when they are merely re arranging their prejudices
W. James
Guide 14:(B/C) - Blood sugar Weir (1997) > 8 mm d/Lit - Poor
outcome Acute MI + 11 mm d/Lit - Intensive
Insulin - improved (Malmberg 1997)
Many Ideas grow better when transplanted into another mind than in the one where they sprang UP
O.W. Holmos
Guide 15: (A) Cholesterol Prosp. Study collob.: 1993 - Epidem
study do not support Blaun 1997: Metranauetic - Chollest &
statin 30% decrease - stroke in CAHD patients.
Sacks 1996 - Tot chol: decrease to 4.8 mmol/Lit benefits
Guide 16: (A/C) Deep vein thrombosis Kalra 1995 - 10 days - stroke Pts - 50% Sandercock 1993 - Pul embol 6-16% only Ist 1997 - 5000 IV or 12500 twice daily -
Hemorrage greater Gradual stocking value - useful in Surg - pts
but its value not evaluated - (Wells 1994) Use with caution - if periph artery insuf. is
present hence do not use heparin on stockings.
Every discovery contains an irrational element or 4 creative intuition
Khrl Popper
Guide 17: (A/B) Pressure sure Event health care (1995) specialised
low pressure mattress systems to be used than stand Hospital - mattress
I have never let my Medical schooling interfere with my education
Mark Twain
Manag of infarction Guide 18: (A)
• Aspirin 75 - 150 /Day• 3 yrs 40% reduces of vascular events in
1000 pts (APTC - 1994)• Stroke sub type value ? (TACI, PACI, LACI,
POCI)• Dienners - 1996, synergy possibel with
clopidogrel ticlopidine etc.
Anti Coagulation Warfarin - AF
In sinus rhythm - uncertain Spirit 1997 low dose ABP + Warfarin in
TIA & Minorstorke - Stopped of HE Heparin (IST 1997) - Signif. reduction in
early death (12 fewor in 1000) not better than aspirin
So avoid Heparin (A)
When they tell you to grow up, they mean stop growing
P. Diccaso
Thrombolysis (A)
Warlow 1997 - Uncertain clinical benefit at the expense of greater hazard avoid - thrombolysis
A (Neurologist’s) life is like a piece of paper on which everyone who passes by leaves an impression
- Chines proverb
Guide 20: (I) Hemorrhage
Hankey and hon 1997: Supra tentorial evacuation for ICH is controversial - Avoid
Infra tentorial - Yes Main Indication - Deteriorating or
depressed consciousness
A medical school should not be a preparation for life. A school should be life
3 D ied
3 4 R ed tag
7 D ied
2 1 d isch ton ver h om e
3 D ied
8 D isc fo rp a llim a
1 D iscH om e
6 4 D isch ar 6 7 D ied
1 3 1In tu b a tion
9 3N ot In tu b
2 2 4 P ts Guide 21 : Ventilation -Decreased level of consciousness - increased mortality and poor final outcome - Absent pupillary light responses - poor prognosis
“By the deficits we may know the talentsBy the exception we may discern rulesBy studying the pathology,We construct the model of healthAnd tools we need to affect our own life mould our
destiny,Change ourselves and our societyIn ways that as yet we can only imagine”
- Lawrence Miller
STROKE-TO-DEMENTIA(Dr. A.V. Srinivasan, Dr. S. Balasubramanian,
Dr. R. Sowntharya, Dr. S. Rajesh)
Dr. A. V. Srinivasan
Addl. Prof. Of Neurology
Institute of Neurology,
Chennai.
Pathogenesis of dementia due to SIVD
1. Lacunar hypothesis2. Binswanger’s subtype of SIVD3. VaD with coexisting Alzheimer’s
disease
Expert is one who think to his chosen mode of ignorance
Two diverging/converging pathways associated with SIVD
Risk factor CVD Ischemic Brain injury MRI lesion Clinical syndrome
HTN
Arteriosclerosis 1. occlusion complete infarct lacune lacunnar state
Arteriosclerosis 2. Hypoperfusion incomplete infarct WHSM Bingswanger syndrome
Experience can be defined as
yesterday’s answer to today’s problems
Clinical syndromes
1. Lacunar state --- 85%2. Strategic infarct dementia(e.g.
thalamic dementia) --- unknown %3. Binswanger’s syndrome --- 10 – 15%
Take time to think; it is the source of power
Take time to read; it is the foundation of wisdomTake time to work; it the price of success
Features suggestive of vascular dementia
From the historyOnset associated with a strokeImprovement following acute eventAbrupt onset
From the examFindings typical of stroke e.g., hemiparesis, hemianopia
From imagingInfarct(s) above the tentorium
Every thing should be made as simple as possible; but not simpler
Categories of vascular DementiaCategory Clinical presentation
Lacunar infarctions Progressive dementia, focal deficits, or apathetic, frontal-lobe-like syndrome, may have no stroke history
Single strategic infarctions
Sudden onset aphasia, agnosia, anterograde amnesia, frontal lobe syndrome
Multiple infarctions Step-wise appearance of cognitive & motor deficits
Mixed AD – VaD Progressive dementia with remote or concurrent history of stroke
White matter infarctions (Binswanger’s disease)
Dementia, apathy, agitation, bilateral cortico-spinal/bulbar signs
NINDS-AIREN criteria for VaDProbable vascular dementia : cognitive
decline from a previously higher level in three areas of function including memory; evidence of cerebrovascular disease by neurologic exam and neuroimaging; onset of dementia either abruptly or within 3 months of a recognized stroke.
Possible vascular dementia : Dementia in the absence of either neuroimaging evidence of infarction or in the absence of a clear temporal relationships between dementia and stroke.
NATURE, TIME AND PATIENCE are the 3 great physicians
NINDS-AIREN criteria for VaD contd…
AD with cerebrovascular disease : Patients with possible AD who have imaging evidence for infarction, or clinical history of stroke, both of which appear incidental by clinical judgement
Definite vascular dementia : Probable vascular dementia plus histopathological evidence of infarction in the absence of other histological markers of dementia (e.g., plaques, tangles, pick bodies, etc.,)
Truth comes out of error sooner than that of confusion
Diagnostic criteria
1. Hachinski’s ischemic score2. DSM IV criteria3. ADDTC criteria4. NINDS – AIREN criteria5. Binswanger’s criteria
Opinion is ultimately determined by the feelings
and not by the intellect
Short comings1. Not interchangeable hence four fold rise in
frequency2. DSM IV R most liberal3. NINDS- AIREN criteria conservative4. Gold standard for VaD (pathological definition
difficult)5. Most of the criteria failed to distinguish
between small and large vessel subtypes
“Healthy Mind and Healthy expression of Emotion go hand in
Hand”
Diagnosis and prognosis
Risk factorsModifiable Non-modifiableHypertension AgeHyperglycemia Gender
Race Heredity
Discipline Weighs ounces Regret weighs Tons
Diagnosis and prognosis contd….
Vascular phenotype : “CVD” Arteriosclerosis Amyloid angiopathy Other small vessel disease
“You have got to be before you can do
and do before you can have”
Diagnosis and prognosis contd….Vascular
distributionMechanism of Brain injury
Pathological phenotype “Infarct”
Single arterySmall arteriole
Acute ischemia Multiple lacunar infarcts
Single artery Acute ischemia Single strategically placed lacunar infarct
Border zoneSmall arteriole
Chronic hypo perfusion
White matter demyelination and axonal loss
Diagnosis and prognosis contd….
Neuro imaging phenotype
CT lucency (lacunes and leukoariosis)
MRI hyper intensity (lacunes and WMSH)
A true commitment is a heart felt promise to yourself from which you will not back down -
D. Mcnally
Diagnosis and prognosis contd….
Localisation / neural network
Clinical phenotype or syndrome
Cortico-basal ganglia – thalamocortical loops
Lacunar stateApathy, depression, abulia Dysexecutive syndromeNormal visual fieldsparkinsonism
Cortico-basal ganglia thalamocortical loops
Strategic infarct dementiaDysexecutive syndromeFrontal lobe syndrome
Deep white matter connections
Binswanger’s syndromeSlowly progressive depression, bradykinesia, dysexecutive syndrome, gait apraxia, urinary incontinence
Prognosis
1. Risk factors Advanced age Education Lacunar subtype Lt. Hemisphere CVA Non white
Develops dementia following ischemic stroke
“Fools Admire but of men of sense approve”
- A. Pope
Prognosis contd….
2. In Lacunar stroke - Leukoariosis is a poor prognosis3. Recurrence of strokeHence Atrophy cognitive impairment WMSH are inter related in SIVD
“Social Isolation is in itself a pathogenic
Factor for disease production”
Prevention & Treatment
Primary preventionControl of risk factors in mid lifea. Framingham Heart Studyb. HASSc. ARIC d. Systolic hypertension in Europe double
blind trialAt twenty the will rules
At thirty the intellect
At forty Judgment
Prevention & Treatment contd…
Secondary prevention Below 135 mm of Hg cognitive impairment Presence of lacunes and white matter
changes may be used as a marker for high risk group
Little is known – for effectiveness in other risk factors
A woman’s desire for revenge outlasts all her other emotions
Prevention & Treatment contd…
Anti dementia drug trials (not based on subtype of VaD)
Alkaloid derivatives(hydergine or nicergoline)PentoxyfyllinePiracetamMemantineDonepezilGingko biloba
Modest benefit
Thought is the labour of the intellect
Reverie is its pleasure
Role of RIVASTIGMINE in SIVD
No.of patients : 10Age group : 50 – 80 yearsFemale : 4Male : 6Most of them had diabetes and hypertension Not based on subtype of VaD 30% showed remarkable cognitive, curative and
affective deficitFuture study needed
“ He who cannot forgive others destroys the bridge over which he
himself must pass” - Annoy
Strategies to prevent – STROKE-TO-DEMENTIA
Treat hypertension optimally Treat diabetes Control hyperlipidaemia Persuade patients to cease smoking and
decrease alcohol intake Prescribe anticoagulants for atrial fibrillation Provide antiplatelet therapy for high risk
patients
A open foe may prove a curse ; but
a pretended friend is worse
Strategies to prevent – STROKE-TO-DEMENTIA contd…
Perform carotid endarterectomy for severe (>70%) carotid stenosis
Use dietary control for diabetes, obesity and hyperlipidaemia
Recommend lifestyle changes (e.g., weight loss, exercise, reduce stress, decrease salt intake)
Intervene early for stroke and transient ischemic attacks with neuroprotective agents (e.g., propentofylline, calcium channel antagosists,
N-methyl-D-aspartate receptor antagonists, antioxidants)
Provide intensive rehabilitation after stroke
READ not to contradict or confuteNor to Believe and Take for Granted but TO WEIGH AND CONSIDER
THANK YOU