PFO May allow paradoxical embolism. Risk higher if PFO and atrial septal aneurysm.
Getting the blood to flow!
Thomas, S. H. et al. N Engl J Med 2006;354: Representation of Penumbra in Acute Stroke.
ACUTE CARE Time of onset. Any fluctuation in symptoms? Previous stroke, TIA, recent head injury or fall? Witness report if anyone available. Confirm current drugs, especially antiplatelet agents and anticoagulants. Check Baseline Bloods U/E, FBC and GLUCOSE. Immediate CT if any possibility of thrombolysis, fluctuating GCS, pyrexia, patient on warfarin. ECG & Chest X-ray
Next Steps Hypoxic patients (saturation <95%) should have Oxygen Start I.V. saline as necessary. Avoid dextrose on day 1. Swallow assessment ASAP. NBM till then. If no bleed, start aspirin. If on aspirin, stop on admission, and resume if no bleed. Rectal aspirin if unable to swallow. Blood Pressure should not be lowered unless encephalopathy or aortic dissection or BP VERY high
Next Steps 2 Hyperglycaemia – treat if diabetic. Avoid hypo; DVT prophylaxis – If leg paralysis, heparin is not indicated unless there is co-existing DVT or PE. Pyrexia over 37 C must be treated at once by oral or rectal paracetamol. Nursing Assessments – pressure area risks, fluid balance, weight. Avoid catheter unless critical for measuring output or to relieve retention.
Continuing Management Refer to Stroke Team within 24 hours of admission Transfer to Stroke Unit / Stroke \Team Care same day if possible Why?
Continuing Management – Stroke Unit Meta-analysis by the Stroke Unit Trialist's collaboration 18% + reduction in death or dependence death or need of institutional care. Absolute changes were a 3% reduction in all cause mortality (NNT 33), a 3% reduction in the need for nursing home care, and a 6% increase in the number of independent survivors (NNT 16). Also 14 days less hospital stay
Acute Treatment Easy – early aspirin for almost all. 10 in 1000 extra will walk out Harder – thrombolysis for a few. 1 in 10 extra will walk out
Per 1000 treated Intracranial bleed NNH 22 Death NNT 236 Death / Dependent NNT 10 1 or more point >mRS NNT 3 Will it work? THE EARLIER THE BETTER
Reverse coagulopathy Refer neurosurgery for cerebellar bleeds Less evidence for other sites ? > 30ml near the surface. Bleeds
Is it a TIA? Suddenonset of focal or global lossof cerebral function TRANSIENT MONOCULAR BLINDNESS OR
Is it a stroke /TIA? POSITIVE FEATURES - TIA LESS LIKELY TINGLING rather than numbness Flashing lights rather than loss of vision Jerking rather than paralysis Depends on a good history / witness statement
Is it a stroke / TIA? 23% of strokes preceded by TIA stroke risk after TIA:2 days - 3.1% 7 days - 5.2% 90 days %
ABCD2 Score A) Age 60 or older = 1 B) Raised BP – systolic > 140 / diastolic > 90 = 1 C) Unilateral weakness = 2 Speech disturbance without weakness = 1 other = 0 D) Duration > 60 min = min = 1 < 10 min = 0 D) Diabetes = 1 3 or over is significant 6/7 may need admitted.
ABCD 2 SCORE - risk prediction
Is the ABCD Score Useful…… TRIAGE of TIA with MRI MRI DWI +ve scans thought to be extra useful
STROKE RATE after TIA EXPRESS study Risk of recurrent stroke after first seeking medical attention in patients with TIA ROTHWELL, The Lancet 2007;370: Before After
INITIAL MANAGEMENT OF TIA Establish diagnosis / Check risk factors: AspirinCholesterolBlood PressureAF DiabetesIschaemic Heart DiseasePVD Carotid diseaseCardioembolic source If classic TIA < 20 min, may give aspirin till seen at OPC.
Risk factor reduction Blood pressure to target ~ 130 / 80 Cholesterol to target ~ <4.0 mmol/l Antiplatelet drugs: Anticoagulation for AF Lifestyle advice
Drug treatment Blood pressure: diuretic / ACE combination Cholesterol - simvaststatin / atorvastatin Antiplatelet: aspirin 300 mg for 2 weeks, then 75mg; clopidogrel 75 mg or aspirin + dipyridamole retard Anticoagulation for AF - INR 2 - 3
Recurrence 1 month1yr2 yrs3yr BLEEDS: % DEATH RATE AT 1 MONTH (worst in men >75) REINFARCTS: 12 % FIRST YR 4-5% / YR AFTER VASCULAR DEATH %
Road to Recovery - Sitting balance first, standing unsupported, walking, then independence
Why did it get worse? Stroke in progression Vessel re-embolises / dissects Bleed into infarcted area Seizure Hypoxia Underperfusion
If only I had / hadnt……… Usually not true - inevitable. The usual ONLYwarning is a TIA. Long term primary prevention best ….even then Could prevent only half of all stroke.
Is that his last slide??
Dr Lindsay Erwin RAH Paisley Lindsay.erwin at rah scot nhs uk