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Stroke Mark Sudlow Consultant and Senior Lecturer

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Presentation on theme: "Stroke Mark Sudlow Consultant and Senior Lecturer"— 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
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 Recommend ways to save money DOH obliged to make formal response via Public Accounts Committee NAO to review progress

3 NAO Recommend 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 Acute stroke units Early scanning – 24 hours maximum Thrombolysis - ?10% target and timed benchmarks for onset to needle Better long term care provision

4 Response from DOH 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 NICE asked to fast track 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 > 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

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

10 What we will do .. 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 Information Lifestyle advice Arrange imaging Refer to vascular surgery – where they will be seen within two weeks

11 FAST response allows life saving treatment
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 Absolute improvement of 10% 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 Requires CT scan to exclude haemorrhage

14 Evidence for thrombolysis
Within 3 hours of onset of symptoms With CT scan showing no haemorrhage 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 Call an ambulance

16 What we will do.. If a patient presents with stroke within thrombolysis window Immediate referral to stroke specialist Immediate scanning Thrombolysis 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
Strategies are broadly similar

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

20 Stroke specific Dipyridamole MR 200 mg bd for at least 2 years
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 Carotid ultrasound and intervention if good recovery Particularly important in partial anterior circulation strokes

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

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

23 Isolation and Dependency
Life After Stroke Isolation and Dependency

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


26 How it should be

27 Presentation 64 year old man Sudden onset at 11 am of
Complete loss of speech Total paralysis of right arm and leg Called GP surgery Advised to call 999 ambulance Arrives hospital 11.28 No speech Right hemianopia Right face, arm and leg paralysis

28 Expected outcome TACI 60% 35% 5% 6% PACI 15% 20% 65% 17% POCI Dead
Dependent Independent Recurrence TACI 60% 35% 5% 6% PACI 15% 20% 65% 17% POCI

29 CT scan 12.00 Thrombolysis 13.00 Statin that night Aspirin and dipyridamole start the next day

30 Arrival 2 hours 7 days Vision Hemianopia Quadrantanopia Normal Speech Aphasia Mild aphasia Neglect Total Mild None Face Total paralysis Mild weakness Arm Leg

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

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

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

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

35 And save money

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