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Stroke Mark Sudlow Consultant and Senior Lecturer Stroke Northumbria/NHCT/University of Newcastle.

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Presentation on theme: "Stroke Mark Sudlow Consultant and Senior Lecturer Stroke Northumbria/NHCT/University of Newcastle."— Presentation transcript:

1 Stroke Mark Sudlow Consultant and Senior Lecturer Stroke Northumbria/NHCT/University of Newcastle

2 Money talks NAO estimates of cost of stroke £7 billion annually NAO estimates of cost of stroke £7 billion annually –Of which £2.2 billion are direct costs to NHS –Cf £1.9 billion for coronary heart disease Incidence the same as coronary heart disease – but greater associated disability Incidence the same as coronary heart disease – but greater associated disability Recommend ways to save money Recommend ways to save money DOH obliged to make formal response via Public Accounts Committee DOH obliged to make formal response via Public Accounts Committee NAO to review progress NAO to review progress

3 NAO Recommend Faster access to specialist care for patients with TIA Faster access to specialist care for patients with TIA –High risk on same day –Lower risk within a week maximum Faster access to specialist stroke care Faster access to specialist stroke care –Acute stroke units –Early scanning – 24 hours maximum –Thrombolysis - ?10% target and timed benchmarks for onset to needle Better long term care provision Better long term care provision

4 Response from DOH Stroke is no longer under Elderly or Long Term Conditions but under Vascular Disease Stroke is no longer under Elderly or Long Term Conditions but under Vascular Disease Working parties set up to look at recommendations on changing provision of care Working parties set up to look at recommendations on changing provision of care NICE asked to fast track guidelines NICE asked to fast track guidelines Intercollegiate Acute Stroke and TIA Guidelines Intercollegiate Acute Stroke and TIA Guidelines

5 Transient Ischaemic Attack High early risk and effective early treatment

6 Risk in Transient Ischaemic Attack Risk of completed stroke within a week = 10% Risk of completed stroke within a week = 10% Risk > 20% if Risk > 20% if –More than one TIA in 7 days –3 or more of  BP > 140/90  Unilateral weakness of speech disturbance  Duration > 60 mins  Diabetes The unstable angina of the brain The unstable angina of the brain

7 Effective treatment Aspirin 75 mg od – reduces risk by 25% Aspirin 75 mg od – reduces risk by 25% Dipyridamole MR 200mg bd – reduces risk by further 20% when added to aspirin Dipyridamole MR 200mg bd – reduces risk by further 20% when added to aspirin Cholesterol reduction Cholesterol reduction Blood pressure reduction Blood pressure reduction Smoking Smoking Exercise Exercise Alcohol Alcohol

8 No surgery Surgery < 2 weeks 31.5%6.9% 2-4 weeks 21.7%8.4% 4-12 weeks 17.6%7.1% >12 weeks 15.6%7.7%

9 What to do.. Identify high risk patients and refer for urgent admission Identify high risk patients and refer for urgent admission –More than one TIA in 7 days –3 or more of  BP > 140/90  Unilateral weakness of speech disturbance  Duration > 60 mins  Diabetes Refer lower risk patient urgently to TIA clinic Refer lower risk patient urgently to TIA clinic Start aspirin and consider dipyridamole Start aspirin and consider dipyridamole

10 What we will do.. Admit high risk patients Admit high risk patients –Start treatment –Arrange urgent imaging –Refer to vascular surgery – where they will be seen within a couple of days See lower risk patients within a week of referral See lower risk patients within a week of referral –Start treatment –Information –Lifestyle advice –Arrange imaging –Refer to vascular surgery – where they will be seen within two weeks

11 Acute Stroke FAST response allows life saving treatment

12 Evidence for specialist care Clear evidence that hospitalisation and treatment by a coordinated specialist team improves mortality and outcome Clear evidence that hospitalisation and treatment by a coordinated specialist team improves mortality and outcome –Absolute improvement of 10% Increasing evidence that early specialist care is the key Increasing evidence that early specialist care is the key

13 Evidence for early aspirin 1% absolute reduction in recurrence and mortality if given within 24 hours 1% absolute reduction in recurrence and mortality if given within 24 hours Requires CT scan to exclude haemorrhage Requires CT scan to exclude haemorrhage

14 Evidence for thrombolysis Within 3 hours of onset of symptoms Within 3 hours of onset of symptoms With CT scan showing no haemorrhage With CT scan showing no haemorrhage 10% absolute improvement in number of patients with minimal disability 10% absolute improvement in number of patients with minimal disability

15 What to do.. If a patient presents or calls with symptoms suggesting acute stroke If a patient presents or calls with symptoms suggesting acute stroke Call an ambulance Call an ambulance

16 What we will do.. If a patient presents with stroke within thrombolysis window If a patient presents with stroke within thrombolysis window –Immediate referral to stroke specialist –Immediate scanning –Thrombolysis If a patient present outside that window If a patient present outside that window –Admit to specialist stroke ward –CT scan within 24 hours –Preventative treatment started early –Coordinated specialist assessment and rehabilitation –Information –Lifestyle advice

17 Secondary Prevention Need for risk reduction as for any high risk vascular disease With a few minor additions

18 Risk of MI, cardiac death and further stroke is similar to after MI Risk of MI, cardiac death and further stroke is similar to after MI Strategies are broadly similar Strategies are broadly similar

19 Aspirin Aspirin Statin Statin Blood pressure – best evidence is for ACE and thiazide Blood pressure – best evidence is for ACE and thiazide

20 Stroke specific Dipyridamole MR 200 mg bd for at least 2 years Dipyridamole MR 200 mg bd for at least 2 years Risk of further stroke is particularly high with atrial fibrillation Risk of further stroke is particularly high with atrial fibrillation –15% absolute per annum –Benefits of warfarin highest in this group Risk of further stroke is particularly high with carotid stenosis Risk of further stroke is particularly high with carotid stenosis –Carotid ultrasound and intervention if good recovery –Particularly important in partial anterior circulation strokes

21 What to do.. Annual check Annual check –Antiplatelets –Blood pressure –Cholesterol –Lifestyle

22 What we will do.. Arrange ongoing rehabilitation Arrange ongoing rehabilitation Outpatient check at 6 weeks (as an inpatients if not discharged) Outpatient check at 6 weeks (as an inpatients if not discharged) Outpatient check at six months Outpatient check at six months

23 Life After Stroke Isolation and Dependency

24 Information Information Inclusion of function and mood in annual screening Inclusion of function and mood in annual screening Access to social services and rehabilitation review Access to social services and rehabilitation review

25

26 How it should be

27 Presentation 64 year old man 64 year old man Sudden onset at 11 am of Sudden onset at 11 am of –Complete loss of speech –Total paralysis of right arm and leg Called GP surgery Called GP surgery –Advised to call 999 ambulance Arrives hospital Arrives hospital –No speech –Right hemianopia –Right face, arm and leg paralysis

28 Expected outcome DeadDependentIndependentRecurrence TACI60%35%5%6% PACI15%20%65%17% POCI20%20%60%20%

29 CT scan CT scan Thrombolysis Thrombolysis Statin that night Statin that night Aspirin and dipyridamole start the next day Aspirin and dipyridamole start the next day

30 Arrival 2 hours 7 days VisionHemianopiaQuadrantanopiaNormal SpeechAphasia Mild aphasia NeglectTotalMildNone Face Total paralysis Mild weakness Arm Total paralysis Mild weakness Normal Leg Total paralysis Mild weakness Normal

31 Carotid doppler on day 7 Carotid doppler on day 7 95% stenosis of left carotid artery 95% stenosis of left carotid artery Urgent referral to vascular surgery Urgent referral to vascular surgery Seen in vascular outpatients 2 days later and arranged for urgent admission Seen in vascular outpatients 2 days later and arranged for urgent admission Carotid stenting 2 weeks after stroke Carotid stenting 2 weeks after stroke

32 Out of stroke unit by 10 days Out of stroke unit by 10 days Out after carotid intervention by 2 weeks after stroke Out after carotid intervention by 2 weeks after stroke On treatment with On treatment with –Aspirin –Dipyridamole –Simvastatin –Perindopril –Bendroflumethiazide

33 Cholesterol 3.2 Cholesterol 3.2 Blood pressure 128/76 Blood pressure 128/76 Stopped smoking Stopped smoking Complete recovery Complete recovery Minimal ongoing risk Minimal ongoing risk

34 With a coordinated approach from With a coordinated approach from –Ambulance service –Primary care –Emergency care –Stroke service –Vascular surgeons We can do this We can do this

35 And save money And save money


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