1. STROKE DISEASE
In a nutshell

2. The Prevention and Management of Strokeby
Dr Irfan Shakir

3. Size of the Problem 110,000 new strokes every year
10,000 under 55 years of which 1,000 under 30 years
In addition 30,000 repeat strokes
Incident higher in Africans and South Asians
Third most common cause of death, 30% mortality at one month most die within first 10 days

4. Size of the Problem
85% of the strokes infarcts
15% haemorrhagic

5. Size of the Problem Biggest cause of long term disability
Though 65% of survivors can live independently
35% are significantly disabled of these 5% need residential care

6. Risk Factors Lifestyle
Poor diet(Salt and fat intake too high, not enough fruit and vegetables)
Low level of physical activity
Alcohol misuse
Smoking

7. Individual Risk Factors
Previous stroke or TIA
Hypertension
Atrial fibrillation(AF)
Coronary heart disease(CHD)
Peripheral vascular disease(PVD)
Carotid stenosis
Metabolic diseases(diabetes, hyperlipidaemia, obesity)

8. Transient Ischaemic Attack(TIA)
Management
Transient Ischaemic Attack(TIA)
Definition:Focal neurological symptoms and signs of sudden onset of presumed vascular origin which completely resolve within 24 hours(i.e. hemiparesis, hemipraesthesia, dysphasia, amaurosis fugax), consider other diagnosis if loss of consciousness, dizziness, funny turn, or unexplained collapse

9. Management(TIA) Refer for specialist assessment
Use ABCD2 Score to stratify

10. ABCD2 Score for Transient Ischaemic Attack
A (Age); 1 point for age >60 years,
B (Blood pressure > 140/90 mmHg); 1 point for hypertension at the acute evaluation.
C (Clinical features); 2 points for unilateral weakness, or 1 for speech disturbance alone
D (symptom Duration); 1 point for 10–59 minutes,or 2 points for >60 minutes.
D (Diabetes); 1 point

11. ABCD2 Score for Transient Ischaemic Attack
Score 1-3: Low risk
Score 4-5: Medium risk
Score >5 :High risk

12. ABCD2 Score for Transient Ischaemic Attack
Department of Health
Score 1-3 see and investigate within one week
Score 4 or above see and investigate within 24 hours

13. Management(TIA)Risk Factors
Alcohol
Atrial Fibrillation
Family history
Migraine
Hypertension
Coronary Heart Disease
Diabetes
Hyperlipidaemia
Current smoker

14. Management(TIA) Investigations 1
All Patients(if possible before attendance at the clinic)
Full Blood Count(FBC)
Urea and Electrolytes(U&E’s)
ESR
Fasting Sugar
Fasting Lipids

15. Management(TIA) Investigations 2
As appropriate
ECG
Echocardiograph
Carotid Doppler
CT head
MR head and angiogram
Auto-antibody screen
Thrombophilia screen

16. Treatment(TIA) Antiplatelets Aspirin Clopidogrel Add ons Dipyridamole

17. Treatment(TIA)

18. Treatment(TIA) Anticoagulation
No benefit unless source of embolism present
Consider in all patients in AF as increased risk 3-7 fold but advantage over Aspirin not that large Absolute Risk Reduction(ARR) 2.9% (95% CI %) Number Needed to Treat (NNT) 34

19. Anticoagulation in (AF)

20. Treatment(TIA) Carotid Stenosis
Symptomatic 70-99% stenosis benefits from carotid endarterectomy ARR 6.7% NNT 15 over 3 years

21. Treatment(TIA) Hypertension
Compared with CHD evidence not as strong but 37% risk reduction has been reported if BP lowered to 140/85.
About 50% of deaths in stroke survivors due to cardiac events

22. Treatment(TIA) Cholesterol
Evidence is not as strong as in CHD. Reduction has to be larger than CHD. As majority have CHD and PVD treatment is important. Lower it if cholesterol > 3.5
? Upper age limit because of side-effects

23. Stroke
Diagnosis
Focal neurological symptoms and signs of sudden onset which persists for more than 24 hours.
Diagnosis is primarily clinical

24. Fast Test for Stroke

25. ROSIER Scale for Stroke
Has there been loss of consciousness or syncope? Yes (-1) No (0)
Has there been seizure? Yes (-1) No(0)
Is there a NEW ACUTE onset (or on awakening from sleep)
Asymetrical facial weakness Yes (+1) No (0)
Asymetrical arm weakness Yes (+1) No (0)
Asymetrical leg Weakness Yes (+1) No (0)
Speech disturbance Yes (+1) No (0)
Visual field defect Yes (+1) No (0)
Total Score ____ (-2 to +5)
Stroke is likely if total scores are > 0. Scores of </=0 have a low possibility of stroke but not completely excluded.

26. Who to Admit to Hospital
Stroke Care
Who to Admit to Hospital
All with disabling stroke
Minor disability stroke patients can be looked after at home if investigations and full multidisciplinary assessment can be done rapidly followed by specialised rehabilitation

27. Stroke Care HOW IN HOSPITAL
All patients should be admitted to a dedicated acute stroke care area as soon as diagnosis has been made.
Acute Stroke Unit care is better for outcome.
NNT = 20

28. Stroke Care
How in hospital: Rehab Stroke Units
NNT 9-16

29. Stroke Units(evidence)
Stroke Care
Stroke Units(evidence)

30. Stroke Care Stroke Assessment Good history and clinical examination
Investigations to confirm diagnosis
Risk factors
Multidisciplinary assessment

31. Neurological Examination
Stroke Care
Neurological Examination
Power
Sensation
Visual fields
Visuo-spatial disturbance
Speech
Swallowing

32. Clinical Classification
Stroke Care
Clinical Classification
TACS=Total Anterior Circulation Stroke
PACS=Partial Anterior Circulation Stroke
LACS=Lacunar Stroke
POCS=Posterior Circulation Stroke

33. Stroke Classification
TACS
Hemi-motor and sensory deficit
Hemianopia
Cortical Dysfunction
a) Dysphasia or
b) Visuo-spatial disturbance

34. Stroke Classification
PACS
Any two of the following
Hemi-motor and sensory deficit
Hemianopia
Cortical Dysfunction
a) Dysphasia or
b) Visuo-spatial disturbance

35. Stroke Classification
LACS
Pure motor hemiplegia
Pure sensory loss
Motor and sensory loss

36. Stroke Classification
POCS
Vertigo
Diplopia
Ataxia
Isolated hemianopia

37. Stroke Classification

38. Stroke Investigations
Full Blood Count(FBC)
Urea and Electrolytes(U&E’s)
ESR or Plasma viscosity
Fasting Sugar
Fasting Lipids
ECG
INR if on anticoagulation or clotting abnormality suspected

39. Stroke Investigations
Imaging
CT head immediately to deliver thrombolysis or as soon as possible with view to start antiplatelet treatment but no later than 24 hours
On anticoagulant immediately if haemorrhage seen give treatment to reverse
Chest X-ray if cardiac or chest disease present or suspected

40. Stroke Investigations
Consider
Carotid Doppler
Auto-antibody Screen
Thrombophylia Screen
Echocardiograph
Coagulation Screen

41. Stroke Care Acute Stroke Unit
Give 300mg Aspirin as soon as haemorrhage excluded unless suitable for thrombolysis
Dysphagia screen
Manage hydration
Control blood sugar
Manage pyrexia
Manage hypoxia

42. Stroke Care Acute Stroke Unit
Hypertension: Observe for 2-3 days unless diastolic persistently above 115 or evidence of accelerated hypertension. Lower BP using drugs which do not cause sudden drop.

43. Multidisciplinary Team
Stroke Care
Multidisciplinary Team
THERAPISTS
OCCUPATIONAL THERAPIST
PHYSIOTHERAPIST
SPEECHTHERAPIST
DIETICIAN
PSYCHOLOGIST
SOCIAL WORKER
PHARMACIST
NURSE
DOCTOR

44. Multidisciplinary Assessment
Stroke Care
Multidisciplinary Assessment
Within hours of admission using protocols to have documented assessment of:
Consciousness level
Swallowing
Pressure sores risk

45. Multidisciplinary Assessment
Stroke Care
Multidisciplinary Assessment
Nutritional status
Cognitive impairment
Communication
Moving and handling

46. Stroke Care(Rehabilitation)
Manage
Using protocols
Continence
Nutrition
Shoulder pain
Discharge planning

47. Stroke Care(Rehabilitation)
Goal Setting
Must involve patient
Family if appropriate

48. Stroke Care(Rehabilitation)
Carers and Families
Give information on nature of stroke and treatment available
Assess and reduce stress
Give individual psychological support

49. Stroke Care(Rehabilitation)
Ongoing Care
Once patient can transfer from bed to chair specialist stroke teams are effective in any of the following settings
Home
Day hospital
Nursing Home
Residential Home

50. Stroke Care Secondary Prevention
As for Transient Ischaemic Attack (TIA)
Lifestyle (diet,exercise, smoking, alcohol)
Antiplatelets
Anticoagulation in AF
Carotid Stenosis
Hypertension
Metabolic Diseases(diabetes, cholesterol, obesity)