Presentation on theme: "AN OVERVIEW OF STROKE Recent perspectives"— Presentation transcript:
1 AN OVERVIEW OF STROKE Recent perspectives DR. A.V. SRINIVASAN“Knowledge can be communicated but not Wisdom”- Hermann Hesse
2 IntroductionImproved 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.
3 “The True Art of Memory is The Art of Attention” - S.Johnson Injured Brainyrs - Stroke occurs2. Guidelines for 24hrs: MandatoryLevel of EvidenceLevel A: Based on RCT or Meta analy. of RCTLevel B: Based on Robust Experiment or Observation StudiesLevel C: Based on Expert opinion.25% men20% women
4 According to WHODoctor assessment of Handicap may not coincide with Patients Assessment. Neurologist depends on physiotherapy, occupation therapy and speech therapy in rehabilitating the stroke patients.
5 NEUROLOGIC PREDICTORS. Flaccid Paralysis for more than 96 hrsWhen tendon reflexes recover without return of voluntary movement – prognosis poorRecovery of sensory less in usual to a degree. Postion sense recovers but not pain and temperatureRecovery from Dysphasia is never completeDysarthria usual improves and Dysphagia never improvesDiplopia due to brain stem is usually permanentConjugate gaze – recoversVertigo improves but hearing loss is permanentPseudobulbar palsy permanent
6 REHABILITATION OF STROKE Assessment of functionMotor, postural, perceptual, cognitive, communication and autonomicIndependence and self-careWalking dressing washing, toileting and feedingAvailable servicesNursingPhysiotherapyOccupational therapyClinical psychologyMedical social worker plus self-help groups (‘Stroke Club’)
7 EARLY MANAGEMENT AND REHABILITATION Consist ofSkin careIV therapy in disabled patientsCaution due to confusionAuditory and visual deficitSplint and bracesComplications include the following
8 Complications include the following: A. Contractures
9 Complications include the following: b. Treatment of SpasticityTREATMENT MODALITIES FOR SPASTICITYSurgeryNerve BlocksMotor Point BlocksDrugs: Dantrolene, Baclofen, DiazepamMuscle Stretching ProgramPrevention of Nociception
10 Complications include the following: c. Reflex sympathetic Dystrophyd. Physiological Deconditioning.PHYSIOLOGICAL DECONDITIONINGLoss of Normal Postural ReflexesIncreased Resting Pulse RateCatabolic Nutritional State-Psychological DepressionLower Vital CapacitySlowing of GI TractVenous StasisUrinary Stasis
11 Complications include the following: e. Swallowing disordersf. CVD and Heterotrophic ossification7. Psychological factors
12 FACTORS GOVERNING THE OUTCOME OF STROKE REHAB. Good outcome –Mild to moderate neurologic damage with mild moderate paresis not associated with sensory or visual problemsPatients not demented or depressed
13 FACTORS GOVERNING THE OUTCOME OF STROKE REHAB. Walking 150 feet without assistances (Goal )Motor alone – 0.9Motor Sensory Visual – 0.5Barthal index score – 95 normalMotor alone - 0.6
14 FACTORS GOVERNING THE OUTCOME OF STROKE REHAB. Motor deficits alone reach their goals within 12 weeksFraminham study – recovery from stroke 3 monthsAdams – recovery from stroke 2 years
15 FUTURE TRENDS IN REHABILITATION (Sensory Modulation) Anatomical PrinciplesSomatosensory SystemLimbic SystemVisual SystemPhantom ExperiencesThe man who missed his foot for penisGaze TinnitusEar Lobe stimulation produces as an eroatic sensation in nipplePhantom Pain
16 FUTURE TRENDS IN REHABILITATION (Sensory Modulation) Role of Parietal LobeClinical ImplicationsSynesthesia - Virtual reality boxAllesthesia - Extinction of referred sensationCaloric test - Disappearance of Anosognosia
17 SUMMARYThe 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.
18 “ We Sometimes think we have forgotten something when 1. History And Examinationa. Stroke clerking Performa (1994) R.C.P.1. Improved patient Assessment2. Improved Management - not clear3. Improved outcome - not clearb. Examination1. Secure Diag of Stroke2. Specify Impairment3. Identify sub type of Ischemic stroke“ We Sometimes think we have forgotten something whenin fact we never really learned it in the first place” Imp.Your Memory Skills
19 Guide: 4(B) Investigations:(Sagar 1995)- 435 PTS) Through Action You Create your Own Education D.B. ELLISGuide: 3 (B) - CPRImpaired Consciousness - From Stroke Resuscitation is rarely successful Schneider 1993Guide: 4(B) Investigations:(Sagar 1995)- 435 PTS)Chest x-ray 16% ABNOnly 4% change clinical managementOrder x-ray chest if WT Loss or chest symptoms present
20 Guide 5: (B) ECG: Guide 6: (C) CT: Cardiac cause of Death (30 days) Ebrahim 1990.All conscious patients to have ECGGuide 6: (C) CT:Routine CT Head is a Intell lazy approachKing’s fund forum(1988) gives useful frameworkWeir 1994 Clinical scoring cannot distinguishDo CT if a) Uncertainty of Strokeb) If Anticoagulation or Anti Platelet treatment contemplated
21 Whatever the Mind can conceive and Believe, Guide 7:(B) M.R.I.Moha 1995, - Unclear for Implications for clinical practiceNo Routine MRI indication in Acute StrokeWhatever the Mind can conceive and Believe,the mind can Achieve Napoleon Hill
22 Imagination is more Important than Knowledge Guide 8: (B) ECHO no RoutineEcho in Acute StrokeTOE Vs. TTEAmer Heart Asson (1997) - same conclusionYield is very low. (Leung 1993; Chambors 1997)Only when ABN ECGS - change clinical management
23 Guide 9: (A) - Dopp scan for selected PTS: 80% > more benefits from EndarterectomyMinor stroke -No disabilitySubst Storke -Good recovery do dopplerMedically fit
24 Guide 10: (B) Management: Fever (Worst Prog.) Reith 1996Hypoxia ( Moroney 1996) - Exac. by seizures Pneumonia and Arrythmias - Worst outcomeHyperbaric O2 ineffective (Nighoghossaln 1995)Haemodilut. Plasm Expanders; venesectionNo evidence for efficacy (As plund )Check ABG only if Hypoxia suspected.
25 You are what you think and not what you think you are Annoymous Guide 11: (A) Steroids and Hyperosmolar agents Unproven treatment - should not be usedTumor oedma responds but not cytotoxic stroke oedma qialbash No effect on survival or improv. In funct. OutcomeManntol - (Boysen 1997) - short term effective statistically in conclusiveYou are what you think and not what you think you are Annoymous
26 Guide 12: (B) - Blood Pressure We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts R.B. SchmeckGuide 12: (B) - Blood PressureDefer - acute reduction of BP - 10 days unless HT Encephalopathy or adrtic dissection presentMoris Increase BP - falls in 10 daysUK - 5mm in D.B.P. 1/3 storke - Low BP prompt correct of hypovoll. and withdrawal of hypotonic drugsCollins HT - Prim. stroke preventNeal 1996 (Current RCT) - HTs in stroke survivors -study needed
27 EAFT 1995 Less than 2 PT - No effect SPAF 1996 > 5 - Bleeding Guide 13: (A/B) - AFAF / ISCH Stroke/ Mild disability - warfarin after 48 Hrs (Longer for larger)Aspirin for othersEAFT 1995 Less than 2 PT - No effectSPAF 1996 > 5 - Bleeding
28 Guide 14:(B/C) - Blood sugar Weir (1997) > 8 mm d/Lit - Poor outcomeAcute MI + 11 mm d/Lit - Intensive Insulin - improved (Malmberg 1997)A great many people think they are thinking when they are merely re arranging their prejudices W. James
29 Guide 15: (A) Cholesterol Many Ideas grow better when transplanted into another mind than in the one where they sprang UP O.W. HolmosGuide 15: (A) CholesterolProsp. Study collob.: Epidem study do not supportBlaun 1997: Metranauetic - Chollest & statin 30% decrease - stroke in CAHD patients.Sacks Tot chol: decrease to 4.8 mmol/Lit benefits
30 Guide 16: (A/C) Deep vein thrombosis Kalra days - stroke Pts - 50%Sandercock Pul embol 6-16% onlyIst IV or twice daily - Hemorrage greaterGradual 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.
31 Guide 17: (A/B) Pressure sure Event health care (1995) specialised low pressure mattress systems to be used than stand Hospital - mattressEvery discovery contains an irrational element or 4 creative intuition Khrl Popper
32 Manag of infarction Guide 18: (A) I have never let my Medical schooling interfere with my education Mark TwainManag of infarctionGuide 18: (A)Aspirin /Day3 yrs 40% reduces of vascular events in 1000 pts (APTC )Stroke sub type value ? (TACI, PACI, LACI, POCI)Dienners , synergy possibel with clopidogrel ticlopidine etc.
33 Anti Coagulation Warfarin - AF In sinus rhythm - uncertain Spirit 1997 low dose ABP + Warfarin in TIA & Minorstorke - Stopped of HEHeparin (IST 1997) - Signif. reduction in early death (12 fewor in 1000) not better than aspirinSo avoid Heparin (A)
34 When they tell you to grow up, they mean stop growing P. Diccaso Thrombolysis (A)Warlow Uncertain clinical benefit at the expense of greater hazard avoid - thrombolysisWhen they tell you to grow up, they mean stop growing P. Diccaso
35 A (Neurologist’s) life is like a piece of paper on which everyone who passes by leaves an impression Chines proverbGuide 20: (I) HemorrhageHankey and hon 1997: Supra tentorial evacuation for ICH is controversial - AvoidInfra tentorial - YesMain Indication - Deteriorating or depressed consciousness
36 Guide 21 : Ventilation-Decreased level of consciousness - increased mortality and poor final outcome- Absent pupillary light responses - poor prognosisA medical school should not be a preparation for life. A school should be life
37 “By the deficits we may know the talents By 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
38 STROKE-TO-DEMENTIA (Dr. A.V. Srinivasan, Dr. S. Balasubramanian, Dr. R. Sowntharya, Dr. S. Rajesh)Dr. A. V. SrinivasanAddl. Prof. Of NeurologyInstitute of Neurology,Chennai.
39 Pathogenesis of dementia due to SIVD Lacunar hypothesisBinswanger’s subtype of SIVDVaD with coexisting Alzheimer’s diseaseExpert is one who think to hischosen mode of ignorance
40 Two diverging/converging pathways associated with SIVD Risk factor CVD Ischemic Brain injury MRI lesion Clinical syndromeHTNArteriosclerosis 1. occlusion complete infarct lacune lacunnar stateArteriosclerosis 2. Hypoperfusion incomplete infarct WHSM Bingswanger syndromeExperience can be defined asyesterday’s answer to today’s problems
41 Clinical syndromes Lacunar state --- 85% Strategic infarct dementia(e.g. thalamic dementia) --- unknown %Binswanger’s syndrome ---10 – 15%Take time to think; it is the source of powerTake time to read; it is the foundation of wisdomTake time to work; it the price of success
42 Features suggestive of vascular dementia From the historyOnset associated with a strokeImprovement following acute eventAbrupt onsetFrom the examFindings typical of stroke e.g., hemiparesis, hemianopiaFrom imagingInfarct(s) above the tentoriumEvery thing should be made as simple as possible; but not simpler
43 Categories of vascular Dementia CategoryClinical presentationLacunar infarctionsProgressive dementia, focal deficits, or apathetic, frontal-lobe-like syndrome, may have no stroke historySingle strategic infarctionsSudden onset aphasia, agnosia, anterograde amnesia, frontal lobe syndromeMultiple infarctionsStep-wise appearance of cognitive & motor deficitsMixed AD – VaDProgressive dementia with remote or concurrent history of strokeWhite matter infarctions (Binswanger’s disease)Dementia, apathy, agitation, bilateral cortico-spinal/bulbar signs
44 NINDS-AIREN criteria for VaD Probable 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 PATIENCEare the 3 great physicians
45 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 judgementDefinite 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
46 Diagnostic criteria Hachinski’s ischemic score DSM IV criteria ADDTC criteriaNINDS – AIREN criteriaBinswanger’s criteriaOpinion is ultimately determined by the feelingsand not by the intellect
47 “Healthy Mind and Healthy expression of Emotion go hand in Hand” Short comingsNot interchangeable hence four fold rise in frequencyDSM IV R most liberalNINDS- AIREN criteria conservativeGold standard for VaD (pathological definition difficult)Most of the criteria failed to distinguish between small and large vessel subtypes“Healthy Mind and Healthy expression of Emotion go hand in Hand”
49 Diagnosis and prognosis contd…. Vascular phenotype : “CVD”ArteriosclerosisAmyloid angiopathyOther small vessel disease“You have got to be before you can doand do before you can have”
50 Diagnosis and prognosis contd…. Vascular distributionMechanism of Brain injuryPathological phenotype “Infarct”Single arterySmall arterioleAcute ischemiaMultiple lacunar infarctsSingle strategically placed lacunar infarctBorder zoneChronichypo perfusionWhite matter demyelination and axonal loss
51 Diagnosis and prognosis contd…. Neuro imaging phenotypeCT 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
53 “Fools Admire but of men of sense approve” - A. Pope PrognosisRisk factorsAdvanced ageEducationLacunar subtypeLt. Hemisphere CVANon whiteDevelops dementia following ischemic stroke“Fools Admire but of men of sense approve” A. Pope
54 Prognosis contd…. 2. In Lacunar stroke - Leukoariosis is a poor prognosis3. Recurrence of strokeHenceAtrophycognitive impairmentWMSH are inter related in SIVD“Social Isolation is in itself a pathogenic Factor for disease production”
55 Prevention & Treatment Primary preventionControl of risk factors in mid lifeFramingham Heart StudyHASSARICSystolic hypertension in Europe double blind trialAt twenty the will rulesAt thirty the intellectAt forty Judgment
56 Prevention & Treatment contd… Secondary preventionBelow 135 mm of Hg cognitive impairmentPresence of lacunes and white matter changes may be used as a marker for high risk groupLittle is known – for effectiveness in other risk factorsA woman’s desire for revenge outlasts all her other emotions
57 Prevention & Treatment contd… Anti dementia drug trials (not based on subtype of VaD)Alkaloid derivatives(hydergine or nicergoline)PentoxyfyllinePiracetamMemantineDonepezilGingko bilobaModest benefitThought is the labour of the intellectReverie is its pleasure
58 Role of RIVASTIGMINE in SIVD No.of patients : 10Age group : 50 – 80 yearsFemale : 4Male : 6Most of them had diabetes and hypertensionNot based on subtype of VaD30% showed remarkable cognitive, curative and affective deficitFuture study needed“ He who cannot forgive others destroys the bridge over which he himself must pass” - Annoy
59 Strategies to prevent – STROKE-TO-DEMENTIA Treat hypertension optimallyTreat diabetesControl hyperlipidaemiaPersuade patients to cease smoking and decrease alcohol intakePrescribe anticoagulants for atrial fibrillationProvide antiplatelet therapy for high risk patientsA open foe may prove a curse ; buta pretended friend is worse
60 Strategies to prevent – STROKE-TO-DEMENTIA contd… Perform carotid endarterectomy for severe (>70%) carotid stenosisUse dietary control for diabetes, obesity and hyperlipidaemiaRecommend 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
61 READ not to contradict or confute Nor to Believe and Take for Granted but TO WEIGH AND CONSIDER THANK YOU
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