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

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 1.5-2.9 Hyperlipidaemia – uncertain as a sole risk PFO 26% of general population have a PFO.

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)

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 2007. Jan. 27:369:283-92. 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

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%

Carotid Endarterectomy European Carotid Surgery Trialists’ Collaboration Group (ECTST) The Lancet 1998;351:1379-87 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.

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

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

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

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

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

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

Stroke

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

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

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)

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

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

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).

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

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)

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)

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

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

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

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