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Stroke diagnosis Caroline Lawson Consultant Nurse - stroke.

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1 Stroke diagnosis Caroline Lawson Consultant Nurse - stroke

2 Aims & objectives Overview of stroke & TIA Key risk factors Initial treatment plan Case studies

3 The impact on the future Due to the demographic composition of the population, although mortality is reducing, the overall incidence of stroke is likely to rise over the next 20 years It is estimated that between 1983 and 2023, there will be a 30% increase in first ever strokes This is going to have a major impact on service provision and should be influencing service development now

4 What is a Stroke? A disruption to the blood supply in the brain resulting in the brain not working normally

5 Types of Stroke IschaemicHaemorrhagic

6 TIA A syndrome of –sudden onset –focal neurological deficit Loss or decrease power Loss or altered sensation Speech difficulty Loss of vision Loss of balance or dizziness –lasting less than 24 hours –Vascular origin

7 Amaurosis Fugax Painless visual loss in one eye that is secondary to retinal ischaemia

8 What happens post stroke Infarct or Haemorrhage Core Ischemic Zone Ischaemic Penumbra ↓ ↓ Blood flow severely depleted Blood flow moderately depleted ↓ ↓ Oxygen & glucose depleted Collateral circulation supplies ↓ ↓ Necrosis of neurons & if no reperfusion = necrosis glial cells




12 Diffusion-weighted imaging Major stoke Minor stroke TIA

13 Risk factor modification Factor Hypertension (raised blood pressure) Smoking Diabetes Blocked carotid artery Raised cholesterol Atrial fibrillation ( irregular heart beat) Risk reduction with treatment 38% 50% within one year; baseline after 5 years 44% reduction with tight blood pressure control in patients with diabetes and hypertension 50% 20-30% with statins in patients with known CHD 68% when treated with warfarin Non-modifiable: Age, gender, race/ethnicity, heredity

14 Risk of Recurrent Stroke People who have already suffered an ischemic stroke or TIA are at highest risk of a second stroke or death Approximately 17% of strokes are second strokes Second stroke risk is highest in the 7 days following the event American Heart Association. Heart Disease and Stroke Statistics 2003 update. Sacco RL et al. Stroke. 1998; 29(10): 2118-24. German Stroke Databank.

15 Cumulative risk of stroke after TIA 0 2 4 6 8 10 12 14 07 2128 Days Risk of stroke (%) 2002-2004 1981-1984 Lancet 2005; 366: 29-36

16 HRT Women have a lower risk of CVE than men but the risk rises post menopause HRT increases risk by 30% CVE – 20% increased risk Venous thrombotic event – 50% Dual HRT – doubles risk of VTE

17 Primary stroke prevention through risk factor modification 50,000 100,000 47,000 23,500 61,500 246,500 Estimated potential number of strokes prevented out of a total of 500,000 strokes annually in the USA Key A = Hypertension B = Cigarette smoking C = Atrial fibrillation D = Heavy alcohol use E = Hypercholesterolaemia 0100,000150,000200,000 A B C D E

18 0 10 20 30 < 3535 - 4445 - 5455 - 6465 - 7475 - 84≥ 85 Age (years) Rates per 1000 population per year Non-fatal stroke Non-fatal myocardial infarction Non-fatal acute peripheral vascular events Age-specific rates of non-fatal stroke vs myocardial infarction vs acute PVD events in OXVASC Lancet 2005; 366: 1773-83

19 Stroke in young adults Cardiac problems – hole in heart Clotting problems / sickle cell Illicit drugs

20 Heroin – Slows respiratory rate, Slows heart rate Lowers blood pressure Infective endocarditis Cocaine – Narrows blood vessels – rise in BP 23 fold increase in risk of heart attack in hour post use Long term BP alteration causes atheroma build up – resulting in coronary artery disease US – 1 in 4 of all MI in age group of 18-45 linked to cocaine use Quereshi et al 1999 Circulation 99:2731-41

21 Amphetamine Adrenaline-type effect on body – Increases heart rate Increases BP – risk of Stroke Alters electrical activity of heart – arrthymia Ecstasy Related to amphetamine Sudden arrthymia Risk of Stroke

22 Glue / Solvents Heart rhythm disturbances – causing sudden death Cardiomyopathy Cannabis low dose - Fast heart rate large dose - Slow heart rate, lower blood pressure Risk of sudden death (no associated other cause) Heart attack - 4 fold higher within the hour following cannabis use Mittleman et al 2001 Circulation 103: 2805-9

23 Secondary prevention General population: Smoke 27% Obese 25% Alcohol 28% Exercise 70% QOF in N Ireland: Anticoag of AF : 90% patients BP < 150/90 : 70% Chol < 5 : 60% Antiplat for TIA/ Stroke: 90%

24 Link between ED & atherosclerosis 39% - 59% of men with heart disease experience ED Atherosclerosis affects main vessels and peripheral arteries Penile arteries 1- 2mm in diameter. Carotid arteries 5 -7 mm Plaque build up can show as chronic problem ED 3 times more likely to have a stroke than those without ED

25 ED & atherosclerosis Montorsi et al 2006: 93% of pts with ED and CAD - ED came before the CAD symptoms an average 2 years earlier 2003: N = 300 Prevalence of ED 49% Of these 67% developed ED 3 years prior to A C S Moderate to severe ED (not mild) 10yr relative risk of CAD increased by 65% Stroke 43%

26 Drugs with S.E. of impotence Spironolactone Doxazosin Indapamide Bendroflumethiazide Felodipine Amlodipine Nifedipine Enalapril Darifenacin Nebivolol Lansoprazole Atrovastatin Ramipril Lisinopril Gabapentin Amioderone Omeprazole Ranitidine / Cimetidine Carbamazipine Haloperidole

27 Stroke diagnosis

28 Typical stroke mimics Seizures24% Syncope23% Sepsis10% Somatisation7% Migraine6% Labyrinthitis4% Tumour3% Low BM3%


30 BP:___/____BM:____ If BM <3.5 mmol/L treat & reassess when normal Has there been loss of consciousness or syncope? Has there been seizure activity? Is there NEW ACUTE onset – or on waking from sleep?: 1. Asymmetric facial weakness 2. Asymmetric hand weakness 3. Asymmetric arm weakness 4. Asymmetric leg weakness 5. Speech disturbance 6. Visual field defect Y (-1) Y (+ 1) N (0) N (0) If score totals > 0 assume diagnosis of Stroke If score 0, -1 or -2 stroke diagnosis is unlikely but not excluded. Patient should be discussed with Stroke Physician or Stroke Nurse Consultant if stroke diagnosis still thought to be likely GCS: ____



33 Agitation and distress…

34 Headache…

35 Nausea and vomiting…

36 Acute hypertension…

37 Cerebral bleed…

38 Confusion…

39 Visual disturbances…

40 –Loss or decrease power –Loss or altered sensation –Speech difficulty –Loss of vision –Loss of balance or dizziness

41 Following confirmation of clinical diagnosis

42 CT Normal Brain imaging

43 Lacunar Strokes Likely to present in TIA clinic Account for 25% of all strokes <1.5-2cm diameter 20% due to embolic pathology Different epidemiology than most strokes therefore low risk of early reoccurrence, mortality > likely to have intrinsic SVD ? Vasospasm, microatheroma leading to occlusion, endothelical dysfunction or leak leading to oedema

44 Secondary prevention Antiplatelet Relative risk reduction of 18% Adding MR dipyridamole RRR ↑ 37% Clopidogrel

45 Anticoagulation (Warfarin) Should be started in every patient in AF unless contraindicated RRR in secondary prevention of 66% v placebo Should not be started until haemorrhage excluded, and 14 days have passed since onset of symptoms Should also be considered if the IS stroke is associated with mitral valve disease or prosthetic heart valves


47 Cholesterol Reduction Evidence suggests the lower the cholesterol the better All patients should be advised to reduce saturated fat in their diet RCP recommend treatment with a statin for patients with total cholesterol >3.5mmol/L Different patients require different therapies

48 Carotid endarterectomy Carotid ultrasound should be performed on any patient considered for carotid endarterectomy Surgery would be considered where carotid stenosis is greater than 70% Smoking cessation Reduction in alcohol intake Healthy diet & weight reduction

49 Carotid Artery Stenosis Common Carotid External Carotid Stenosis at bifurcation of Internal Carotid



52 Benefit from carotid surgery number of strokes prevented by 100 operations Severity of narrowing Delay to surgerySevereModerate Less than 2 weeks:3215 2 – 4 weeks:163 4 – 12 weeks:100 More than 12 weeks:8-3 Lancet 2004; 363: 915-24

53 Rapid treatment of symptomatic patients time from last event to randomisation No. of Strokes prevented per 1000 CEAs at 3 years adapted from Rothwell 2004

54 TIA clinic Treat seriously – regardless of duration of symptoms Investigate & treat – quickly Driving -same laws as with a stroke - For multiple TIAs 3 months cessation rather than 1 month

55 Cumulative risk of stroke after TIA 0 2 4 6 8 10 12 14 07 2128 Days Risk of stroke (%) 2002-2004 1981-1984 Lancet 2005; 366: 29-36

56 ABCD 2 Score Risk factorCategoryScore A AgeAge≥60 Age<60 1010 B Blood pressure at assessment SBP>140 or DBP≥90 Other 1010 C Clinical FeaturesUnilateral weakness Speech disturbance Other 210210 DDDD Duration Diabetic ≥60 minutes 10-59 minutes <10 minutes 21012101 TOTAL7

57 Patient admitted with a diagnosis of TIA Symptoms TOTALLY resolved ABCD Score < 4 ABCD Score 4 or more Discharge home: Take bloods / Investigations Stat Aspirin 300mg Continue Aspirin 75mg until clinic Patient info leaflet Advice not to drive for one month Refer to TIA clinic. (fax form) Patient to expect wait of 1-2 weeks Refer to KAR or on call medical registrar: Consider in-patient CT scan If seen & for discharge: Take bloods / investigations Stat Aspirin 300mg Continue Aspirin 75mg until clinic Patient info leaflet Advice not to drive 1/12 Refer to TIA clinic. (fax form) Patient will be seen within 7days Refer to medical team Take blood ECG CXR Admit for CT In hours: Refer to CL – Consultant Stroke Nurse (bleep 2826) Refer to DG - research Nurse (bleep 2556) If scanned and assessed safe for discharge (social and medical): CT normal or infarct Give Aspirin 300mg stat Daily Aspirin 75mg & Dipyridamole 200mg MR BD Simvastatin 20mg if Cholesterol > 5 Patient info leaflet Advice not to drive one month Refer to TIA clinic. (fax form) Patient will be seen within one 7 days Symptoms lasting >6 hours or residual symptoms

58 Case studies & example CT scans

59 Age 46 Onset : Sudden Outcome : organ transplant


61 75 year old. 2 hours post symptoms of left sided weakness NIHSS – 13 Sensation Partial facial weakness Left sided weakness Partial hemianopia GP wife Haematologist son

62 24hrs later NIHSS = 1 Mild facial weakness Discharged home Day 5 Entered into CLOTs Risk factors not identified

63 75 year old. 2 hour history. NIHSS 24

64 Deterioration: Mild GI Bleed Dropped GCS Rescan 11.00 Care of Dying pathway. Died that evening Family request donation to ITU

65 Reperfusion: the Holy Grail of Acute Ischaemic Stroke Occluded proximal MCA

66 History: 77 y old found collapsed at his nursing home 2 hours earlier. F. Farrall, Kane, Wardlaw RL

67 Further History: 24 hrs later, GCS fell: partial seizure activity R arm and R face; eyes deviated R. BASP CT Training BASP CT Training Farrall, Kane, Wardlaw RL

68 89 man - severe headache, worsening vision & decline in mobility

69 BASP CT Training BASP CT Training Farrall, Kane, Wardlaw RL 89 man - severe headache, worsening vision & decline in mobility

70 44 year old Fit & healthy Marathon runner Multiple TIAs


72 17 year old left sided weakness Sudden onset



75 60 year old female Smoker



78 47 year old male Smoker Low social situation Aphasia & dyspraxia



81 54 year old TIA previous week Carotid duplex NAD Out of area Progressive RHS weakness Echo NAD




85 The documents of power

86 MONEY £105 million over 3 years £32m NHS £45m local authority £12m public awareness £16m training & education


88 Public awareness 60% general public unable to recognise 3 symptoms of stroke 30% would call 999 50% GPs would refer to A&E immediately Stroke Association Re TIA: 33% seen within 1 week. If increase to review in 24 hours then reduce risk of CVE by 18% £12 million / 3 years for increased national awareness

89 Summary Stroke is becoming a greater problem – increased costs with relatively poor outcomes Early diagnosis & treatment is essential CT scans can give false normal results Identification of underlying cause is not always possible Not just what happens to the elderly Now is the “time” for stroke – there is £££


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