imaging in acute stroke – the clinical case for change · what is the best imaging strategy for...
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Imaging in Acute Stroke – the clinical case for change
Dr Jim McilmoyleConsultant in Stroke MedicineBlackpool Victoria Hospital
2 June 2009
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Time is brain
Neurons lost Accelerated aging
Per Minute 1.9 million 3.1 weeks
Per Stroke 1200 million 36 years
J. Saver; Stroke 2006;37;263-266
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How effective is thrombolysis
NNT to improve the mRS by 1 point = 3NNT to prevent 1 patient being dependent or
dead = 10
NNH with symptomatic deterioration = 16NNH with worse outcome at 3 months = 30
For every 100 patients treated 32 have a better final outcome and 3 a worse outcome.
Arch Neurol. 2004;61:1066-1070
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Converting a stroke into a TIA.
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Baseline Day 1
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National Sentinel Audit of Stroke 2008
59% of stroke patients have brain scanning within 24 hours of stroke98% of patients had a brain scan
21% of patients had scan within 3 hoursApproximately 15% of patients are eligible for thrombolysis – only 1% receive it.
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What is the best imaging strategy for acute stroke?
Average cost of a NHS CT in Scotland :-£30 - £90 in normal working hours£55 - £173 out of hours
“Scan all immediately” cost least and achieved most QALYs
Cost of providing CT is less than inpatient care
Wardlaw JM et al, Health Technol Assess 2004;8(1)
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Stroke Mimics
SeizuresSepsisSyncopeSomatisation
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Rapid Access TIA clinics
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Why TIA’s are important
Warning that blood clots are affecting the brain.
40% of strokes are preceded by a TIA
20% risk of stroke within 4 weeks
Half of this risk is within the first 48 hours.
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ABCD2 stroke predictor post TIAThe Lancet 2007;369:283-92
Age 60 yrs or older 1
Blood pressure >140/90 mmHg 1
Clinical features Unilateral weaknessSpeech disturbance (no weakness)Other
21
0
Duration 60 min or longer10 – 59 minutes< 10 minutes
210
Diabetes 1
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Rapid Access TIA clinics
DiagnosisOne stop shop – carotid doppler +/- MRI DWI scan1 performed at one visitOptimisation of secondary preventionEarly referral for carotid endarterectomy if indicatedAdvice on healthy lifestyle, driving & stroke
1. NICE Guidelines Stroke 2008
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TIA mimics
Glioblastomas and other intracranial tumorsHemiplegic migraineFocal seizures caused by AVM, cavernous angioma, tumors and old strokesDemyelinating lesionsTemporal arteritis
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NICE Guidelines Stroke 2008
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Potentiality
550 deaths avoided annually
1700 more people with full recovery annually
£20 million saved
NAO: Reducing Brain Damage: Faster access to better stroke care - Nov 2005
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Clinical trials of iv tPA in stroke
ECASS I – Oct 1995
NINDS – Dec 1995
ECASS II – Oct 1998
SITS-MOST – Jan 2007