STROKE DISEASE In a nutshell

The Prevention and Management of Stroke by Dr Irfan Shakir

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

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

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

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

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)

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

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

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

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

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

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

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

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

Treatment(TIA) Antiplatelets Aspirin Clopidogrel Add ons Dipyridamole

Treatment(TIA)

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 0.9-4.9%) Number Needed to Treat (NNT) 34

Anticoagulation in (AF)

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

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

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

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

Fast Test for Stroke

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.

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

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

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

Stroke Units(evidence) Stroke Care Stroke Units(evidence)

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

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

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

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

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

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

Stroke Classification POCS Vertigo Diplopia Ataxia Isolated hemianopia

Stroke Classification

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

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

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

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

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.

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

Multidisciplinary Assessment Stroke Care Multidisciplinary Assessment Within 24- 48 hours of admission using protocols to have documented assessment of: Consciousness level Swallowing Pressure sores risk

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

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

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

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

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

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)