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