Presentation is loading. Please wait.

Presentation is loading. Please wait.

Allan L Bernstein MD Neurology

Similar presentations


Presentation on theme: "Allan L Bernstein MD Neurology"— Presentation transcript:

1 Allan L Bernstein MD Neurology
All About Strokes Allan L Bernstein MD Neurology

2 Definition of Stroke Ischemic stroke: Clot blocks blood flow
through one of the arteries feeding the brain

3 Definition of Stroke Hemorrhagic stroke:
Weakened blood vessel ruptures allowing bleeding into brain

4 Definition of Stroke Deprived of oxygen, nerve cells in affected
area begin to die. Body function lost in part of body controlled by ischemic blood cells.

5 Residual Effects of Stroke
Survivors can be left with paralysis, inability to speak, visual field deficits, emotional problems, etc.

6 Stroke Facts Approx 50% of stroke deaths occur before the
patient reaches the hospital This statistic outlines the need for more community education.

7 Impact of Stroke in the United States
Of all CVDs, stroke is the third leading cause of death Annual incidence 780,000 strokes 600,000 first attacks 180,000 recurrent attacks 15% of strokes are heralded by TIA 90-day risk of stroke after TIA: 3%–17% Highest risk within the first 30 days CVD = cardiovascular disease; MRI = magnetic resonance imaging American Heart Association. Heart Disease and Stroke Statistics–2008 Update. Dallas, Texas: American Heart Association; 2008 Rosamond W et al. Circulation. 2008;117(4);e25

8 Estimates of the Cost of Stroke
Average cost of ischemic stroke within 30 days $13,019 (mild) $20,346 (severe) Mean lifetime cost of ischemic stroke $140,048 $65.5 billion* in 2008 *Estimated direct and indirect costs American Heart Association. Heart Disease and Stroke Statistics–2008 Update. Dallas, Texas: American Heart Association; 2008; Rosamond W et al. Circulation. 2008;117(4);e25

9 Signs and Symptoms of a Stroke
Sudden numbness or weakness in face, arm, or leg (especially one side of body)

10 Signs and Symptoms of a Stroke
Sudden confusion, trouble speaking or understanding

11 Signs and Symptoms of a Stroke
Sudden trouble seeing in one or both eyes

12 Signs and Symptoms of a Stroke
Sudden trouble walking, dizziness, loss of balance or coordination

13 Signs and Symptoms of a Stroke
Facial droop Arm drift

14 Risk Factors Hypertension Hyperlipidemia Diabetes Obesity Smoking Age
Family History Atrial Fibrillation Hx of TIAs Decreased physical activity

15 Acute stroke care VERY LIMITED TIME TO ACT
Four and a half hours from onset of symptoms to active treatment Must be an observed onset Must be seen at a facility where acute stroke care is available Sonoma County is excellent for TPA but has NO COMPREHENSIVE CENTER

16 “Clot Busting” rTPA (tissue plasminogen activator
Dissolves clots and keeps new ones from forming for up to 12 hours Good but dangerous. Brain tissue gets soft Other areas may also bleed

17 Role of a Stroke Center Acute care with appropriate access to specialists Ongoing education of the entire stroke team Rapid evaluation by imaging and lab Clear guidelines for prevention of complications

18 Role of a Stroke Center Team approach to ensure safety while in the hospital Prevent blood clots in the legs Prevent falls Prevent choking or aspiration Ensure appropriate control of diabetes and blood pressure Prevent secondary infections

19 Role of a Stroke Center Rehabilitation
Motor: physical therapy Speech: speech and swallowing therapy Occupational therapy Depression-identify and plan treatment Family involvement in all aspects of care Prevention of next event

20 Role of a Stroke Center Preventing the next event
Discharge planning Antiplatelet medication Anti cholesterol/lipid medication Blood pressure control Education re: life style modifications

21 Risk Factors Hypertension Hyperlipidemia Diabetes Obesity Smoking Age
Family History Atrial Fibrillation Hx of TIAs Decreased physical activity

22 Risk Factors for Stroke Recurrence
Early stroke recurrence Stroke subtype High for large artery, extra- and intracranial occlusive disease Elevated blood glucose HTN Late stroke recurrence Age Heart disease (CHD, HF, AF) DM and hyperglycemia Prior stroke or TIA AF = atrial fibrillation; CHD = coronary heart disease; DM = diabetes mellitus; HF = heart failure; HTN = hypertension Sacco RL et al. Neurology. 1999;53(7 suppl 4):S15

23 Defining Stroke Subtype Is an Important Consideration in Recurrent Stroke Prevention
Hemorrhagic stroke 12% Other 5% Cryptogenic 30% Atherosclerotic cerebrovascular disease 20% Small vessel disease “lacunae” 25% Cardiogenic embolism 20% Ischemic stroke 88% Albers GW et al. Chest. 2004;126(3 suppl):438S Thom T et al. Circulation. 2006;113(6):e85 23 23

24 Recent TIA: A Neurologic Emergency
Risk of stroke after TIA 10.5% occurred within 90 days and half occurred within 2 days (Kaiser-Permanente HMO study) Risks may have been previously underestimated 1%─2% at 7 days and 2%─4% at 30 days True risk Up to 10% at 7 days and as high as 15% at 30 days Time window for prevention is brief 17% of TIAs occur on the day of stroke 43% during the 7 days prior to stroke Rothwell PM. Nat Clin Pract Neurol. 2006;2(4):174

25 Prevention of Recurrent Stroke
Evaluation for risk factors HTN, DM, hyperlipidemia Evaluation for cause Arterial diseases, heart diseases Coagulopathies Management of risk factors Lifestyle and medications Antithrombotic therapy Surgical or endovascular interventions Sacco RL et al. Stroke. 2006;37(2):577

26 Johnston SC et al. Ann Neurol. 2006;60(3):301

27 Predicting Risk of Stroke After TIA: ABCD2 Score for 2- or 7-Day Risk of Stroke
Age ≥60 years 1 point B Blood pressure SBP >140 mm Hg or DBP ≥90 mm Hg C Clinical features Unilateral weakness 2 points Speech disturbance without weakness D Duration of symptoms ≥60 minutes 10–59 minutes Diabetes Maximum score 7 points Johnston SC et al. Lancet. 2007;369(9558):283 Rothwell PM et al. Lancet. 2005;366(9479):29 DBP = diastolic blood pressure; SBP = systolic blood pressure

28 National Stroke Association (NSA) Guidelines for the Management of TIAs
Factor Comment Hospitalization Consider within 24–48 hours of first TIA Timely hospital referral of recent (within 1 week) TIA and hospital admission is generally recommended in the case of crescendo TIAs, symptoms longer than 1 hour, symptomatic carotid stenosis >50%, known cardiac-source embolism, hypercoagulable state, or appropriate California or ABCD score Hospitals/practitioners should have local admission policy and referral policy for specialists’ assessments Local written protocols for diagnostic testing Clinical evaluation Specialized clinic for rapid assessment and evaluation within 24–48 hours Timing of initial assessment For recent TIA, need same-day access to imaging such as CT/CTA, MRI/A, and/or CUS If not admitted to hospital, rapid (within 12 hours) access to urgent assessment and investigation If TIA occurred in past 2 weeks and the patient was not hospitalized, prompt (24–48 hour) investigations (CUS, blood work, EKG, echocardiogram) needed CT/CTA = computed tomography/computed tomographic angiography CUS = carotid ultrasound Johnston SC et al. Ann Neurol. 2006;60(3):301

29 NSA Guidelines for the Management of TIAs: Evaluation
Factor Comment General EKG, CBC, serum electrolytes, creatinine, fasting blood glucose, lipids Brain imaging CT/CTA or MRI/A; TCD is complementary Carotid imaging Doppler ultrasound; CTA and/or MRA for supra-aortic vessels if Doppler not reliable or CEA considered; conventional angiogram if Doppler and MRA/CTA discordant or not feasible Cardiac evaluation TTE or TEE in patients younger than 45 years when neck, brain, and hematology studies negative for cause CBC = complete blood count CEA = carotid endarterectomy TCD = transcranial Doppler TEE = transesophageal echocardiogram TTE = transthoracic echocardiogram Johnston SC et al. Ann Neurol. 2006;60(3):312


Download ppt "Allan L Bernstein MD Neurology"

Similar presentations


Ads by Google