1. Get Brain Smart!

2. Neurology Neurology Migraine ALS Parkinson’s Headache Seizures Neuropathy Cardiology Cardiology Stroke Heart attack Arrhythmias Heart failure Valvular disease

3. Everything you ever wanted to know about stroke (but were afraid to ask) Timothy Lukovits, M.D.

4. stroke

5. Objectives Highlight some important differences and similarities between heart attack and stroke Highlight some important differences and similarities between heart attack and stroke Motivate you to prevent a stroke Motivate you to prevent a stroke

6. How is a stroke different from a heart attack? A stroke is a sudden neurological deficit caused by a blood vessel problem A stroke is a sudden neurological deficit caused by a blood vessel problem 2 types 2 types Ischemic strokes Ischemic strokes Hemorrhagic strokes Hemorrhagic strokes The effects of a stroke are extremely varied The effects of a stroke are extremely varied

8. Why is heart attack easier to recognize than stroke ? Painful Painful Public and health care providers commonly recognize symptoms and need for action Public and health care providers commonly recognize symptoms and need for action Often painless Often painless the stroke itself often affects awareness of symptoms the stroke itself often affects awareness of symptoms Poor recognition of symptoms and need for action Poor recognition of symptoms and need for action

9. Copyright restrictions may apply. Pancioli, A. M. et al. JAMA 1998;279:1288-1292. Respondents unable to name 1 warning sign or risk factor for stroke

10. Which of the following are warning signs of stroke? A. Sudden weakness or numbness of the face, arm or leg, especially on one side of the body B. Sudden confusion, trouble speaking or understanding C. Sudden chest pain D. Sudden trouble seeing in one or both eyes E. Sudden trouble walking, dizziness, loss of balance or coordination F. Sudden, severe headache with no known cause A. Sudden weakness or numbness of the face, arm or leg, especially on one side of the body B. Sudden confusion, trouble speaking or understanding C. Sudden chest pain D. Sudden trouble seeing in one or both eyes E. Sudden trouble walking, dizziness, loss of balance or coordination F. Sudden, severe headache with no known cause

11. A. Sudden weakness or numbness of the face, arm or leg, especially on one side of the body B. Sudden confusion, trouble speaking or understanding C. Sudden chest pain D. Sudden trouble seeing in one or both eyes E. Sudden trouble walking, dizziness, loss of balance or coordination F. Sudden, severe headache with no known cause A. Sudden weakness or numbness of the face, arm or leg, especially on one side of the body B. Sudden confusion, trouble speaking or understanding C. Sudden chest pain D. Sudden trouble seeing in one or both eyes E. Sudden trouble walking, dizziness, loss of balance or coordination F. Sudden, severe headache with no known cause

12. Diagnosis is relatively easy. EKG and cardiac enzymes readily available. Diagnosis is relatively easy. EKG and cardiac enzymes readily available. Diagnosis is difficult. Many things can mimic stroke. There is no blood test for stroke. MRI not readily available. Diagnosis is difficult. Many things can mimic stroke. There is no blood test for stroke. MRI not readily available. Is heart attack easier to diagnose than stroke?

14. Isolated weakness right index finger JS Kim, Neurology, 2002 MRI with diffusion weighted imaging

15. Where is the stroke?

17. CT scan of arteries of neck and head

18. Cause is usually rupture of a plaque within a coronary artery Cause is usually rupture of a plaque within a coronary artery So the diagnostic and treatment strategy is fairly straightforward (find the blockage and open it up!) So the diagnostic and treatment strategy is fairly straightforward (find the blockage and open it up!) Atherosclerosis is important, but there are many other causes Atherosclerosis is important, but there are many other causes Determining the cause in an individual is often a deductive process Determining the cause in an individual is often a deductive process Are the causes of heart attack and stroke different?

19. There are many potential causes of stroke

20. Stroke is not just a brain disease and often the brain is just an innocent bystander Usually caused by diseases that are affect the entire vascular system (atherosclerosis) Usually caused by diseases that are affect the entire vascular system (atherosclerosis) Material blocking brain arteries usually comes from outside the brain (atrial fibrillation, carotid artery disease) Material blocking brain arteries usually comes from outside the brain (atrial fibrillation, carotid artery disease)

21. How is a Cardiologist different than a Neurologist Basically a plumber or electrician Basically a plumber or electrician Diagnostician Diagnostician Detective Detective Daredevil Daredevil

22. Case Healthy 61 year-old man developed confused speech 1 day after falling out of a tree. Healthy 61 year-old man developed confused speech 1 day after falling out of a tree. August 11 th, topping a tree, fell and sustained a left collar bone fracture and small puncture of the lung. August 11 th, topping a tree, fell and sustained a left collar bone fracture and small puncture of the lung. Next night suddenly developed confused speech. Next night suddenly developed confused speech.

27. Trauma (fall out of a tree) Trauma (fall out of a tree) Vascular problem (leg vein injury) Vascular problem (leg vein injury) Blood disorder (hypercoagulability) Blood disorder (hypercoagulability) Congenital heart anomaly (patent foramen ovale) Congenital heart anomaly (patent foramen ovale)

28. How are heart attack and stroke SIMILAR? Time is critical Time is critical The first priority is to save tissue at risk The first priority is to save tissue at risk

29. Kidwell 2004

30. You need to call 911 ASAP for both heart attack and stroke! There is a 3 hour time limit for the medication t-PA, and the sooner it’s given the better! There is a 3 hour time limit for the medication t-PA, and the sooner it’s given the better! Future strokes may be prevented if we identify the cause of stroke ASAP Future strokes may be prevented if we identify the cause of stroke ASAP People brought by ambulance are treated faster People brought by ambulance are treated faster Neurological deterioration and other complications may be prevented if a patient is hospitalized earlier Neurological deterioration and other complications may be prevented if a patient is hospitalized earlier

32. June 2006 7AM: A 75 year-old woman collapsed at home, brought to her local emergency room. She cannot move her right side or speak. The doctors there are not comfortable using t-PA so transfer to DHMC is requested. June 2006 7AM: A 75 year-old woman collapsed at home, brought to her local emergency room. She cannot move her right side or speak. The doctors there are not comfortable using t-PA so transfer to DHMC is requested. 1:02 PM: Arrival DHMC ED. 1:02 PM: Arrival DHMC ED.

35. 4:49 PM artery is opened

38. The system needs to be very coordinated The system needs to be very coordinated

40. Improving Stroke Care at DHMC PREPARED INDIVIDUALIZED CARE PROTOCOLS TO DECREASE ERRORS A TEAM APPROACH RAPID EVALUATION

41. Ways everyone here can prevent a stroke Identify and control risk factors Identify and control risk factors If a warning sign of stroke occurs, get attention If a warning sign of stroke occurs, get attention

44. 10y risk 88% !

45. 10y risk 13% !

46. Preventing a heart attack or stroke is MUCH more effective (and safer) than a procedure! Preventing a heart attack or stroke is MUCH more effective (and safer) than a procedure!

50. HJM Barnett 1999

51. Copyright restrictions may apply. Barnett, H. J. M. et al. Arch Neurol 2000;57:40-45. The medical and surgical 5-year Kaplan-Meier curves of freedom from ipsilateral stroke and perioperative stroke and death indicate a 5.9% difference favoring endarterectomy at 5 years in the Asymptomatic Carotid Atherosclerosis Study (ACAS)

52. Copyright ©2005 American Heart Association Alamowitch, S. et al. Stroke 2005;36:27-31 Kaplan-Meier 5-year risks of ipsilateral ischemic stroke for NASCET patients according to gender and degree of internal carotid artery stenosis in the medical and surgical groups

55. 18/111 (16%) received t-PA Average cost for transportation $4,623

56. 2004: 144 pts Rx t-PA 50% had t-PA started at 1 of 47 referring hospitals >50% of these have <60 beds

58. Meyer 2005

59. MGH TeleStroke MGH TeleStroke

60. Effectiveness of Stroke Prevention Absolute risk reduction in a year: Strategy ARR (%) Warfarin for atrial fibrillation8 Warfarin for atrial fibrillation8 Carotid endarterctomy for symptomatic dz4 Carotid endarterctomy for symptomatic dz4 Smoking cessation2 Smoking cessation2 Antihypertensive therapy if BP elevated2 Antihypertensive therapy if BP elevated2 Cholesterol lowering medications2 Cholesterol lowering medications2 Aspirin1-2 Aspirin1-2

61. Schaebitz W-R, 2000

63. anticoag RG Hart 2003

64. Stroke Diagnosis 40 years ago

65. Stroke Warning Signs Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause Sudden, severe headache with no known cause Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause Sudden, severe headache with no known cause

66. What is a TIA ? Transient Ischemic Attack=Stroke symptoms that resolve with a short time. Transient Ischemic Attack=Stroke symptoms that resolve with a short time. Can be a warning sign of impending stroke. Can be a warning sign of impending stroke. The highest risk period of stroke following a TIA is the first 2 weeks. The highest risk period of stroke following a TIA is the first 2 weeks. The risk of stroke soon after a TIA can now be estimated. The risk of stroke soon after a TIA can now be estimated.

67. ABCD 2 Tool risk of stroke following TIA AAge> or = 601 BBlood pressure >140/901 CClinical features unilateral weakness2 speech impairment 1 D 2 Duration > 60 min2 10-59 min1 Diabetes1

70. ABCDEF Systolic BP*95-105130-148130-148130-148130-148130-148 DiabetesNoNoYesYesYesYes CigarettesNoNoNoYesYesYes Prior Atrial Fib.NoNoNoNoYes Yes Prior CVDNoNoNoNoNoYes Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318. *BP in millimeters of mercury (mmHg)

71. Which action would you take if you thought someone was having a heart or stroke? A. take the person a hospital B. advise the person to call a doctor C. call 911 D. call a spouse or family member E. do something else

72. Which action would you take if you thought someone was having a heart or stroke? A. take the person a hospital B. advise the person to call a doctor C. call 911 D. call a spouse or family member E. do something else

73. Bleeding into the heart doesn’t occur Bleeding into the heart doesn’t occur Brain hemorrhage is common Brain hemorrhage is common

74. CT scan: ischemic stroke

75. Intracerebral hemorrhage at 1 hour and 6 hours

76. Intra-arterial thrombolysis Time window=6 hours

77. High resolution MRI to identify the unstable plaque Chu B, Circulation 2005

78. You need to open the artery You need to open the artery

80. Like with heart disease, the treatment and prevention of stroke needs to be individualized! A 65 yo man attends a vascular disease prevention fair and an ultrasound shows a blockage of his left carotid artery. He is told to speak to his doctor ASAP and he becomes worried that there is a “time bomb” ticking in his neck. A 65 yo man attends a vascular disease prevention fair and an ultrasound shows a blockage of his left carotid artery. He is told to speak to his doctor ASAP and he becomes worried that there is a “time bomb” ticking in his neck.

82. 11/30/06