1. GP Lecture Programme 3 February 2010
Dr Stephen Louw
Stroke Physician
RVI Newcastle upon Tyne

2. Population Relative Risk for Stroke
High ABCD2 score: 8% chance in next 2 days
AF 5 – 17x (if >2 risk factors, 18% stroke p.y.)
Hypertension 3-4
Alcohol 4
Migraine: 2.16
IHD 2-4
CCF 2-4
Diabetes 2-4
Smoking
Hyperlipidaemia – uncertain as a sole risk
PFO 26% of general population have a PFO.

3. Commonest TIAs Middle Cerebral Artery Territory
Total or partial anterior Circulation TIA
Hemiplegia/hemianaeasthesia
Homonymous hemi-anopia
Cortical problem: dysphasia/visual or sensory neglect
Lacunar-type: pure motor or sensory or mixed
Amaurosis fugax
Post circulation (difficult to diagnose)

4. ABCD2 Score 2-day risk 7-day risk 90-day risk 5 4.1% 5.9 9.8 7 8.1%
Middle Cerebral Artery Territory The focus of ABCD2 scale Validation and refinement of scores to predict very early stroke risk after TIA: Johnston SC, Rothwell PM et al. Lancet Jan. 27:369:
ABCD2
Score
2-day risk
7-day risk
90-day risk 5
4.1%
5.9
9.8 7
8.1%
11.7
17.8

5. Middle Cerebral Artery Territory The focus of ABCD2 scale
The focus of investigations in hospital:
Identify patients with critical internal carotid artery stenosis
Rapid referral for carotid endarterectomy
CEA
Benefits: reduces stroke risk by 50%
Risks: immediate death or stroke: 2 – 3%

6. Carotid Endarterectomy European Carotid Surgery Trialists’ Collaboration Group (ECTST) The Lancet 1998;351: CLASSIC PAPER
Patients with recent TIA or stroke and 70 – 99% carotid stenosis clearly benefit in terms of stroke prevention. Confirmed NASCET (1991)
Pts with <70% stenosis were harmed by CEA.
NNT (surgery) 14 pts to prevent a major ipsilateral carotid territory stroke over the next 5 years.

7. Limb shaking TIA 1-2 min duration Usually severe carotid stenosis
Often good surgical candidates
Differential diagnosis
Partial seizure
Tremor

8. Capsular warning TIA Geoffrey Donnan (Australia) Neurology 1993;43:957
4.5% of TIAs
Ischemia due to haemodynamic phenomena in a diseased, single, small penetrating vessel
Leads to lacunar infarct and involved a single penetrating vessel

9. Posterior Circulation TIA
POCS TIA is more likely if:
·         true diplopia
·         DDK
·         past pointing
·         Dysarthria

10. Posterior Circulation TIA
Low predictive rate for POCS TIA if:
Isolated features of
‘Dizziness’,
unsteadiness,
vertigo or
‘ataxia’.
                                 

11. Transient Global Amnesia
Sudden onset of disorientation
amnesia for immediate events
Speech intact
No other focal neurology
Resolves within minutes

12. Unusual types of Migraine
Ocular migraine
Transient loss of vision
Usually with headache
Basilar type migraine
Affects both sides
Rarely motor signs
Aura may include:
Blindness
Vertigo
Diplopia
Dysarthria
Ataxia

13. Stroke

14. Rapid recognition of symptoms and diagnosis
Use the FAST tool to screen for stroke or TIA outside hospital
NOTES FOR PRESENTERS:
Key points to raise:
There is evidence that rapid treatment improves outcome after stroke or TIA.
Additional information:
Hypoglycaemia should be excluded as the cause of sudden-onset neurological symptoms.
The diagnosis in people who are admitted to accident and emergency (A&E) with a suspected stroke or TIA should be rapidly established using a validated tool such as ROSIER (Recognition of Stroke in the Emergency Room).
Recommendation in full:
In people with sudden onset of neurological symptoms a validated tool, such as FAST (Face Arm Speech Test), should be used outside hospital to screen for a diagnosis of stroke or TIA.
Reproduced with permission from The Stroke Association

15. How accurate is FAST? Diagnostic Accuracy of Stroke Referrals…J Harbison, O Hossain, D Jenkinson, J Davis, SJ Louw, GA Ford.Stroke 2003;34:71-76
487 patients; 356 stroke/TIA
FAST used by ambulance paramedics
23% = non-stroke
46% admitted within 3 hours
Primary Care Doctors
29% = non-stroke
14% admitted within 3 hours ER

16. Limitations of FAST Does not take pre-existing disability into account
Low sensitivity for posterior circulation strokes:
occipital lobes (vision)
cerebellum (often no weakness)
brain stem (sensory deficit, cranial nerve lesions)

17. TIME IS BRAIN Time window: stroke to needle 4.5 hrs
Suspected
stroke?
Within
3.5
hours?
Call 999: blue light patient into stroke unit

18. Time-windows for thrombolysis
A limit (not a ‘target’)
Anterior circulation strokes
4.5 hours

19. Reason for time-limit
For every 3 patients we thrombolyse, one will have a significantly less marked level of impairment.
but…..
One in 30 patients we thrombolyse, will be harmed (including death) due to symptomatic bleeding (including intracranial).

20. r-TPA in Newcastle upon Tyne
In total 4 major bleeds – 2 deaths
PH 2

21. Time-windows for thrombolysis
A limit (not a ‘target’)
Anterior circulation strokes
4.5 hours
Anterior circulation strokes in very young people
6 hours (intra-arterial thrombolysis)

22. Time-windows for thrombolysis
A limit (not a ‘target’)
Anterior circulation strokes
4.5 hours
Anterior circulation strokes in very young people
6 hours (intra-arterial thrombolysis)
Posterior circulation strokes
12 hours (intra-arterial thrombolysis)

23. Fast track system: Newcastle
All cases blue lighted by ambulance to Acute Medical Unit (AMU)
Ambulance paramedics notify before setting off from patient’s home
AMU SpR/Senior Nurse phones Stroke Consultant and Notifies CT scan personnel

24. Cases NOT for 999 referral Low likelihood of benefit from rTPA
poor pre-stroke functional level
dementia, Nursing Home
uncertain onset time (e.g. “woke up with stroke”)
seizure
High risk of bleeding complix from rTPA
surgery/major trauma within the last 2 weeks
on warfarin, bleeding tendency

25. Common Stroke Mimics Seizure – Todd’s paralysis
Cardiovascular collapse
Migraine
Labyrinthine disorders
Infection- related delirium (“?dysphasia with no other focal neurological deficit”)

26. Improving stroke services in the North East
Primary prevention
FATS 5 guidelines
Anticoagulation for AF
Hypertension
Secondary prevention: Spotting TIAs
Rapid referral of acute stroke
Enhanced rehabilitation services