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All About Strokes Allan L Bernstein MD Neurology.

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Presentation on theme: "All About Strokes Allan L Bernstein MD Neurology."— Presentation transcript:

1 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

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 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 CVD = cardiovascular disease; MRI = magnetic resonance imaging

8 Estimates of the Cost of Stroke $65.5 billion* in 2008 Average cost of ischemic stroke within 30 days $13,019 (mild) $20,346 (severe) Mean lifetime cost of ischemic stroke $140,048 *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 HTN Heart disease (CHD, HF, AF) DM and hyperglycemia Prior stroke or TIA Sacco RL et al. Neurology. 1999;53(7 suppl 4):S15 AF = atrial fibrillation; CHD = coronary heart disease; DM = diabetes mellitus; HF = heart failure; HTN = hypertension

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

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: ABCD 2 Score for 2- or 7-Day Risk of Stroke Johnston SC et al. Lancet. 2007;369(9558):283 Rothwell PM et al. Lancet. 2005;366(9479):29 AAge≥60 years1 point BBlood pressure SBP >140 mm Hg or DBP ≥90 mm Hg 1 point CClinical features Unilateral weakness2 points Speech disturbance without weakness 1 point D Duration of symptoms ≥60 minutes2 points 10 – 59 minutes 1 point DDiabetes 1 point Maximum score 7 points DBP = diastolic blood pressure; SBP = systolic blood pressure

28 National Stroke Association (NSA) Guidelines for the Management of TIAs FactorComment HospitalizationConsider 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 Johnston SC et al. Ann Neurol. 2006;60(3):301 CT/CTA = computed tomography/computed tomographic angiography CUS = carotid ultrasound

29 NSA Guidelines for the Management of TIAs: Evaluation FactorComment General EKG, CBC, serum electrolytes, creatinine, fasting blood glucose, lipids Brain imagingCT/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 Johnston SC et al. Ann Neurol. 2006;60(3):312 CBC = complete blood count CEA = carotid endarterectomy TCD = transcranial Doppler TEE = transesophageal echocardiogram TTE = transthoracic echocardiogram


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