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What neurologist may add to the care and cure of of stroke patients, or… Peter Sandercock Perugia December 2007 What is the place of the neurologist in.

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Presentation on theme: "What neurologist may add to the care and cure of of stroke patients, or… Peter Sandercock Perugia December 2007 What is the place of the neurologist in."— Presentation transcript:

1 What neurologist may add to the care and cure of of stroke patients, or… Peter Sandercock Perugia December 2007 What is the place of the neurologist in stroke medicine?

2 In America…to perform many expensive investigations?

3 In the UK…to diagnose a rare cause of stroke by clinical examination?

4 Role of neurologist in acute phase of stroke

5 Acute care: the neurologist will often be involved at all points in the ‘path of acute care’

6 Acute brain attack If neurologist finds NO clinical evidence of ‘stroke mimic’, e.g.: epileptic seizure, migraine, Hypo- orhyper-glycaemia, or other obvious non-stroke diagnosis -> do CT CT/MR Scan Non-stroke pathology Subdural, tumour Scan: Normal, Infarct, intracerebral bleed, SAH

7 NIHSS helps distinguish ‘stroke’ from ‘non- stroke mimic’

8 NIHSS and ‘stroke’ vs ‘not stroke’ About one third of patients with NIHSS 1-4 do not have an acute stroke NIHSS > 4 is a useful indicator that the deficit is due to a stroke

9 If CT or MR excludes blood and ‘stroke mimic’ neurologist decides Probably ELIGIBLE for thrombolysis’ Known time of onset Unilateral neurological signs Increasing NIH score (>4) Abnormal vascular signs (AF, PVD) Probably NOT ELIGIBLE Deficit first noted on waking from sleep Prior cognitive impairment Loss of consciousness at/soon after onset Seizure Can walk now ( too mild)

10 Some clinical problems, where neurologist very helpful

11 ? POCI Man 75 years, arrives at ER 3.5 hrs after, sudden onset ‘dizziness’ and unsteadiness Exam: Unsteady when standing No limb ataxia NIHSS = 2 ? POCI ?Hyper-attenuating basilar artery?

12 What to do? MR and angiography not available ‘Outside 3 hour window’: iv thrombolysis not approved If this is a basilar thrombosis, could he deteriorate rapidly if not treated? Randomised in IST-3

13 Migraine or ischaemic stroke? This 53-year-old female patient with acute headache and right-sided hemianopia. Not treated with thrombolysis, because significance of abnormality not appreciated Krings et al, Stroke. 2006;37:399-403.)

14 Initial CT (A to C) show a hyperattenuating posterior cerebral artery (arrow in B). On follow- up (D to F), a large PCA infarction is now visible.

15 Blood on CT can be a)missed if not looked for carefully b)Have disappeared if the patient presents a day or more after the haemorrhage Subarachnoid haemorrhage with focal deficit (eg hemiparesis) due to delayed cerebral ischaemia

16 Patient has clinical diagnosis of ‘acute stroke’ but CT is normal.

17 The time of onset of stroke symptoms is known precisely You have an experienced stroke physician/stroke neurologist able to see the patient urgently in A&E or at CT scan room Urgent non-contrast CT scan is interpreted by someone with expertise in acute stroke CT -> MRI not essential; its place in routine acute stroke care yet to be determined Can you diagnose ‘acute ischaemic stroke suitable for thrombolysis’ without DWI MR? Yes, if:

18 ‘Telephone neurology’ in acute stroke to patient / family: confirm diagnosis, seek consent. Neurologist to general physician: advice, IST-3 helpline

19 Role in prevention

20 Neurologists and ‘dizzy turns’ a 50 year old woman (depressed, just started on anti-depressant) has an episode where speech is ‘dizzy and confused’. At emergency department: BP 180/90. Normal examination. diagnosis ‘?reaction to anti-depressant;’ Management ‘stop drug and go home’, but does refer neurologist

21 Neurologist asks about other symptoms: the day before she describes a brief episode of loss of vision in the left eye (amaurosis fugax).

22 The correct diagnosis An ocular and a cerebral TIA in the distribution of the left internal carotid artery High early risk of stroke Immediate action required

23 High early risk of stroke after TIA 0 2 4 6 8 10 12 14 07 2128 Days Risk of stroke (%) OXVASC OCSP Lancet 2005; 366: 29-36 10% risk of stroke by 7 days

24 Management Start dual antiplatelet therapy, statin and anti-hypertensive immediately Immediate carotid ultrasound study - often performed by neurologist

25 Overall, 62% of patients referred with ‘TIA’ were found to have other diagnoses migraine syncope/pre-syncope ‘funny turn’(= event it is not possible to categorise) vertigo or dizziness only epilepsy transient global amnesia cerebral tumour Oxfordshire Community Stroke Project: of 542 patients referred with possible TIAs, in 317 (62%) the diagnosis was not a TIA

26 Neurologist organises management of TIA and minor stroke Urgent brain imaging if symptoms persist > 1-2 hours high ABCD 2 score, ?admit to hospital for treatment & investigation Aspirin Add dipyridamole in high-risk cases Statin to lower cholesterol Blood pressure lowering: diuretic and angiotensin converting enzyme (ACE) inhibitor Urgent non-invasive carotid imaging -> endarterectomy < 2 weeks if severe stenosis

27 Role of neurologist in care of stroke patients?

28 The neurologist is often the leader of the multi-disciplinary team on the stroke unit

29 Research led by neurologists identified effective stroke treatments Treatment acute ischaemic stroke –Aspirin, –Thrombolysis Prevention –Anticoagulants in AF –Antiplatelet for secondary prevention after TIA/stroke –Carotid surgery for symptomatic stenosis

30 Diagnosis of in acute phase Management in the acute phase Lead multidisciplinary team on stroke unit Co-ordinate stroke services, including secondary prevention Lead research The neurologist has many roles in cure and care of stroke


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