AN OVERVIEW OF STROKE Recent perspectives DR. A.V. SRINIVASAN “Knowledge can be communicated but not Wisdom” - Hermann Hesse

Introduction Improved technology and treatment for stroke has decreased mortality and prolonged survival but disability from stroke remain Major health care concern. Although Rehabilitation is one of the oldest forms of treatment, it is least understood. Some physicians uneasiness with rehabilitation has its origin in Medical Training. Traditional Medical training emphasis on diagnosis and curative treatment. When cure is not possible patient needs Rehabilitation Therapy, Counseling and Support in the face of physical disability, feeling of failure and futility.

“The True Art of Memory is The Art of Attention” - S.Johnson Injured Brain 1. 45 85 yrs - Stroke occurs 2. Guidelines for 24hrs: Mandatory Level of Evidence Level A: Based on RCT or Meta analy. of RCT Level B: Based on Robust Experiment or Observation Studies Level C: Based on Expert opinion. 25% men 20% women

According to WHO Doctor assessment of Handicap may not coincide with Patients Assessment. Neurologist depends on physiotherapy, occupation therapy and speech therapy in rehabilitating the stroke patients.

NEUROLOGIC PREDICTORS. Flaccid Paralysis for more than 96 hrs When tendon reflexes recover without return of voluntary movement – prognosis poor Recovery of sensory less in usual to a degree. Postion sense recovers but not pain and temperature Recovery from Dysphasia is never complete Dysarthria usual improves and Dysphagia never improves Diplopia due to brain stem is usually permanent Conjugate gaze – recovers Vertigo improves but hearing loss is permanent Pseudobulbar palsy permanent

REHABILITATION OF STROKE Assessment of function Motor, postural, perceptual, cognitive, communication and autonomic Independence and self-care Walking dressing washing, toileting and feeding Available services Nursing Physiotherapy Occupational therapy Clinical psychology Medical social worker plus self-help groups (‘Stroke Club’)

EARLY MANAGEMENT AND REHABILITATION Consist of Skin care IV therapy in disabled patients Caution due to confusion Auditory and visual deficit Splint and braces Complications include the following

Complications include the following: A. Contractures

Complications include the following: b. Treatment of Spasticity TREATMENT MODALITIES FOR SPASTICITY Surgery Nerve Blocks Motor Point Blocks Drugs: Dantrolene, Baclofen, Diazepam Muscle Stretching Program Prevention of Nociception

Complications include the following: c.  Reflex sympathetic Dystrophy d. Physiological Deconditioning. PHYSIOLOGICAL DECONDITIONING Loss of Normal Postural Reflexes Increased Resting Pulse Rate Catabolic Nutritional State- Psychological Depression Lower Vital Capacity Slowing of GI Tract Venous Stasis Urinary Stasis

Complications include the following: e. Swallowing disorders f. CVD and Heterotrophic ossification 7. Psychological factors

FACTORS GOVERNING THE OUTCOME OF STROKE REHAB. Good outcome – Mild to moderate neurologic damage with mild moderate paresis not associated with sensory or visual problems Patients not demented or depressed

FACTORS GOVERNING THE OUTCOME OF STROKE REHAB. Walking 150 feet without assistances (Goal ) Motor alone – 0.9 Motor Sensory Visual – 0.5 Barthal index score – 95 normal Motor alone - 0.6

FACTORS GOVERNING THE OUTCOME OF STROKE REHAB. Motor deficits alone reach their goals within 12 weeks Framinham study – recovery from stroke 3 months Adams – recovery from stroke 2 years

FUTURE TRENDS IN REHABILITATION (Sensory Modulation) Anatomical Principles Somatosensory System Limbic System Visual System Phantom Experiences The man who missed his foot for penis Gaze Tinnitus Ear Lobe stimulation produces as an eroatic sensation in nipple Phantom Pain

FUTURE TRENDS IN REHABILITATION (Sensory Modulation) Role of Parietal Lobe Clinical Implications Synesthesia - Virtual reality box Allesthesia - Extinction of referred sensation Caloric test - Disappearance of Anosognosia

SUMMARY The goal of rehabilitation is to permit a return to function. In pursuit of this goal, proper management of secondary disabilities is essential. Clinical objectives include: prevention of contractures, retardation of deconditioning, maximization of nutritional status, optimal treatment of associated medical problems, and providing appropriate psychological support to family and patients.

“ We Sometimes think we have forgotten something when 1. History And Examination a. Stroke clerking Performa (1994) R.C.P. 1. Improved patient Assessment 2. Improved Management - not clear 3. Improved outcome - not clear b. Examination 1. Secure Diag of Stroke 2. Specify Impairment 3. Identify sub type of Ischemic stroke “ We Sometimes think we have forgotten something when in fact we never really learned it in the first place” Imp.Your Memory Skills

Guide: 4(B) Investigations:(Sagar 1995)- 435 PTS) Through Action You Create your Own Education - D.B. ELLIS Guide: 3 (B) - CPR Impaired Consciousness - From Stroke Resuscitation is rarely successful Schneider 1993 Guide: 4(B) Investigations:(Sagar 1995)- 435 PTS) Chest x-ray 16% ABN Only 4% change clinical management Order x-ray chest if WT Loss or chest symptoms present

Guide 5: (B) ECG: Guide 6: (C) CT: Cardiac cause of Death (30 days) Ebrahim 1990. All conscious patients to have ECG Guide 6: (C) CT: Routine CT Head is a Intell lazy approach King’s fund forum(1988) gives useful framework Weir 1994 Clinical scoring cannot distinguish Do CT if a) Uncertainty of Stroke b) If Anticoagulation or Anti Platelet treatment contemplated

Whatever the Mind can conceive and Believe, Guide 7:(B) M.R.I. Moha 1995, - Unclear for Implications for clinical practice No Routine MRI indication in Acute Stroke Whatever the Mind can conceive and Believe, the mind can Achieve Napoleon Hill

Imagination is more Important than Knowledge Guide 8: (B) ECHO no Routine Echo in Acute Stroke TOE Vs. TTE Amer Heart Asson (1997) - same conclusion Yield is very low. (Leung 1993; Chambors 1997) Only when ABN ECGS - change clinical management

Guide 9: (A) - Dopp scan for selected PTS: 80% > more benefits from Endarterectomy Minor stroke -No disability Subst Storke -Good recovery do doppler Medically fit

Guide 10: (B) Management: Fever (Worst Prog.) Reith 1996 Hypoxia ( Moroney 1996) - Exac. by seizures Pneumonia and Arrythmias - Worst outcome Hyperbaric O2 ineffective (Nighoghossaln 1995) Haemodilut. Plasm Expanders; venesection No evidence for efficacy (As plund - 1997) Check ABG only if Hypoxia suspected.

You are what you think and not what you think you are Annoymous Guide 11: (A) Steroids and Hyperosmolar agents Unproven treatment - should not be used Tumor oedma responds but not cytotoxic stroke oedma qialbash 1997 - No effect on survival or improv. In funct. Outcome Manntol - (Boysen 1997) - short term effective statistically in conclusive You are what you think and not what you think you are Annoymous

Guide 12: (B) - Blood Pressure We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts R.B. Schmeck Guide 12: (B) - Blood Pressure Defer - acute reduction of BP - 10 days unless HT Encephalopathy or adrtic dissection present Moris 1997 - Increase BP - falls in 10 days UK - 5mm in D.B.P. 1/3 storke - Low BP prompt correct of hypovoll. and withdrawal of hypotonic drugs Collins 1994 - HT - Prim. stroke prevent Neal 1996 (Current RCT) - HTs in stroke survivors -study needed

EAFT 1995 Less than 2 PT - No effect SPAF 1996 > 5 - Bleeding Guide 13: (A/B) - AF AF / ISCH Stroke/ Mild disability - warfarin after 48 Hrs (Longer for larger) Aspirin for others EAFT 1995 Less than 2 PT - No effect SPAF 1996 > 5 - Bleeding

Guide 14:(B/C) - Blood sugar Weir (1997) > 8 mm d/Lit - Poor outcome Acute MI + 11 mm d/Lit - Intensive Insulin - improved (Malmberg 1997) A great many people think they are thinking when they are merely re arranging their prejudices W. James

Guide 15: (A) Cholesterol Many Ideas grow better when transplanted into another mind than in the one where they sprang UP O.W. Holmos Guide 15: (A) Cholesterol Prosp. Study collob.: 1993 - Epidem study do not support Blaun 1997: Metranauetic - Chollest & statin 30% decrease - stroke in CAHD patients. Sacks 1996 - Tot chol: decrease to 4.8 mmol/Lit benefits

Guide 16: (A/C) Deep vein thrombosis Kalra 1995 - 10 days - stroke Pts - 50% Sandercock 1993 - Pul embol 6-16% only Ist 1997 - 5000 IV or 12500 twice daily - Hemorrage greater Gradual stocking value - useful in Surg - pts but its value not evaluated - (Wells 1994) Use with caution - if periph artery insuf. is present hence do not use heparin on stockings.

Guide 17: (A/B) Pressure sure Event health care (1995) specialised low pressure mattress systems to be used than stand Hospital - mattress Every discovery contains an irrational element or 4 creative intuition Khrl Popper

Manag of infarction Guide 18: (A) I have never let my Medical schooling interfere with my education Mark Twain Manag of infarction Guide 18: (A) Aspirin 75 - 150 /Day 3 yrs 40% reduces of vascular events in 1000 pts (APTC - 1994) Stroke sub type value ? (TACI, PACI, LACI, POCI) Dienners - 1996, synergy possibel with clopidogrel ticlopidine etc.

Anti Coagulation Warfarin - AF In sinus rhythm - uncertain Spirit 1997 low dose ABP + Warfarin in TIA & Minorstorke - Stopped of HE Heparin (IST 1997) - Signif. reduction in early death (12 fewor in 1000) not better than aspirin So avoid Heparin (A)

When they tell you to grow up, they mean stop growing P. Diccaso Thrombolysis (A) Warlow 1997 - Uncertain clinical benefit at the expense of greater hazard avoid - thrombolysis When they tell you to grow up, they mean stop growing P. Diccaso

A (Neurologist’s) life is like a piece of paper on which everyone who passes by leaves an impression - Chines proverb Guide 20: (I) Hemorrhage Hankey and hon 1997: Supra tentorial evacuation for ICH is controversial - Avoid Infra tentorial - Yes Main Indication - Deteriorating or depressed consciousness

Guide 21 : Ventilation -Decreased level of consciousness - increased mortality and poor final outcome - Absent pupillary light responses - poor prognosis A medical school should not be a preparation for life. A school should be life

“By the deficits we may know the talents By the exception we may discern rules By studying the pathology, We construct the model of health And tools we need to affect our own life mould our destiny, Change ourselves and our society In ways that as yet we can only imagine” - Lawrence Miller

STROKE-TO-DEMENTIA (Dr. A.V. Srinivasan, Dr. S. Balasubramanian, Dr. R. Sowntharya, Dr. S. Rajesh) Dr. A. V. Srinivasan Addl. Prof. Of Neurology Institute of Neurology, Chennai.

Pathogenesis of dementia due to SIVD Lacunar hypothesis Binswanger’s subtype of SIVD VaD with coexisting Alzheimer’s disease Expert is one who think to his chosen mode of ignorance

Two diverging/converging pathways associated with SIVD Risk factor CVD Ischemic Brain injury MRI lesion Clinical syndrome HTN Arteriosclerosis 1. occlusion complete infarct lacune  lacunnar state Arteriosclerosis 2. Hypoperfusion incomplete infarct WHSM  Bingswanger syndrome Experience can be defined as yesterday’s answer to today’s problems

Clinical syndromes Lacunar state --- 85% Strategic infarct dementia(e.g. thalamic dementia) --- unknown % Binswanger’s syndrome --- 10 – 15% Take time to think; it is the source of power Take time to read; it is the foundation of wisdom Take time to work; it the price of success

Features suggestive of vascular dementia From the history Onset associated with a stroke Improvement following acute event Abrupt onset From the exam Findings typical of stroke e.g., hemiparesis, hemianopia From imaging Infarct(s) above the tentorium Every thing should be made as simple as possible; but not simpler

Categories of vascular Dementia Category Clinical presentation Lacunar infarctions Progressive dementia, focal deficits, or apathetic, frontal-lobe-like syndrome, may have no stroke history Single strategic infarctions Sudden onset aphasia, agnosia, anterograde amnesia, frontal lobe syndrome Multiple infarctions Step-wise appearance of cognitive & motor deficits Mixed AD – VaD Progressive dementia with remote or concurrent history of stroke White matter infarctions (Binswanger’s disease) Dementia, apathy, agitation, bilateral cortico-spinal/bulbar signs

NINDS-AIREN criteria for VaD Probable vascular dementia : cognitive decline from a previously higher level in three areas of function including memory; evidence of cerebrovascular disease by neurologic exam and neuroimaging; onset of dementia either abruptly or within 3 months of a recognized stroke. Possible vascular dementia : Dementia in the absence of either neuroimaging evidence of infarction or in the absence of a clear temporal relationships between dementia and stroke. NATURE, TIME AND PATIENCE are the 3 great physicians

NINDS-AIREN criteria for VaD contd… AD with cerebrovascular disease : Patients with possible AD who have imaging evidence for infarction, or clinical history of stroke, both of which appear incidental by clinical judgement Definite vascular dementia : Probable vascular dementia plus histopathological evidence of infarction in the absence of other histological markers of dementia (e.g., plaques, tangles, pick bodies, etc.,) Truth comes out of error sooner than that of confusion

Diagnostic criteria Hachinski’s ischemic score DSM IV criteria ADDTC criteria NINDS – AIREN criteria Binswanger’s criteria Opinion is ultimately determined by the feelings and not by the intellect

“Healthy Mind and Healthy expression of Emotion go hand in Hand” Short comings Not interchangeable hence four fold rise in frequency DSM IV R most liberal NINDS- AIREN criteria conservative Gold standard for VaD (pathological definition difficult) Most of the criteria failed to distinguish between small and large vessel subtypes “Healthy Mind and Healthy expression of Emotion go hand in Hand”

Diagnosis and prognosis Risk factors Modifiable Non-modifiable Hypertension Age Hyperglycemia Gender Race Heredity Discipline Weighs ounces Regret weighs Tons

Diagnosis and prognosis contd…. Vascular phenotype : “CVD” Arteriosclerosis Amyloid angiopathy Other small vessel disease “You have got to be before you can do and do before you can have”

Diagnosis and prognosis contd…. Vascular distribution Mechanism of Brain injury Pathological phenotype “Infarct” Single artery Small arteriole Acute ischemia Multiple lacunar infarcts Single strategically placed lacunar infarct Border zone Chronic hypo perfusion White matter demyelination and axonal loss

Diagnosis and prognosis contd…. Neuro imaging phenotype CT lucency (lacunes and leukoariosis) MRI hyper intensity (lacunes and WMSH) A true commitment is a heart felt promise to yourself from which you will not back down - D. Mcnally

Diagnosis and prognosis contd…. Localisation / neural network Clinical phenotype or syndrome Cortico-basal ganglia – thalamocortical loops Lacunar state Apathy, depression, abulia Dysexecutive syndrome Normal visual fields parkinsonism Cortico-basal ganglia thalamocortical loops Strategic infarct dementia Frontal lobe syndrome Deep white matter connections Binswanger’s syndrome Slowly progressive depression, bradykinesia, dysexecutive syndrome, gait apraxia, urinary incontinence

“Fools Admire but of men of sense approve” - A. Pope Prognosis Risk factors Advanced age Education Lacunar subtype Lt. Hemisphere CVA Non white Develops dementia following ischemic stroke “Fools Admire but of men of sense approve” - A. Pope

Prognosis contd…. 2. In Lacunar stroke - Leukoariosis is a poor prognosis 3. Recurrence of stroke Hence Atrophy cognitive impairment WMSH are inter related in SIVD “Social Isolation is in itself a pathogenic Factor for disease production”

Prevention & Treatment Primary prevention Control of risk factors in mid life Framingham Heart Study HASS ARIC Systolic hypertension in Europe double blind trial At twenty the will rules At thirty the intellect At forty Judgment

Prevention & Treatment contd… Secondary prevention Below 135 mm of Hg cognitive impairment Presence of lacunes and white matter changes may be used as a marker for high risk group Little is known – for effectiveness in other risk factors A woman’s desire for revenge outlasts all her other emotions

Prevention & Treatment contd… Anti dementia drug trials (not based on subtype of VaD) Alkaloid derivatives (hydergine or nicergoline) Pentoxyfylline Piracetam Memantine Donepezil Gingko biloba Modest benefit Thought is the labour of the intellect Reverie is its pleasure

Role of RIVASTIGMINE in SIVD No.of patients : 10 Age group : 50 – 80 years Female : 4 Male : 6 Most of them had diabetes and hypertension Not based on subtype of VaD 30% showed remarkable cognitive, curative and affective deficit Future study needed “ He who cannot forgive others destroys the bridge over which he himself must pass” - Annoy

Strategies to prevent – STROKE-TO-DEMENTIA Treat hypertension optimally Treat diabetes Control hyperlipidaemia Persuade patients to cease smoking and decrease alcohol intake Prescribe anticoagulants for atrial fibrillation Provide antiplatelet therapy for high risk patients A open foe may prove a curse ; but a pretended friend is worse

Strategies to prevent – STROKE-TO-DEMENTIA contd… Perform carotid endarterectomy for severe (>70%) carotid stenosis Use dietary control for diabetes, obesity and hyperlipidaemia Recommend lifestyle changes (e.g., weight loss, exercise, reduce stress, decrease salt intake) Intervene early for stroke and transient ischemic attacks with neuroprotective agents (e.g., propentofylline, calcium channel antagosists, N-methyl-D-aspartate receptor antagonists, antioxidants) Provide intensive rehabilitation after stroke

READ not to contradict or confute Nor to Believe and Take for Granted but TO WEIGH AND CONSIDER THANK YOU