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

2. 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.

3. “The True Art of Memory is The Art of Attention” - S.Johnson
Injured Brain
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

4. 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.

5. 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

6. 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’)

7. 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

8. Complications include the following:
A. Contractures

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. “ 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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 )
Check ABG only if Hypoxia suspected.

25. 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 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

26. 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 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 HT - Prim. stroke prevent
Neal 1996 (Current RCT) - HTs in stroke survivors -study needed

27. 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

28. 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

29. 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.: Epidem study do not support
Blaun 1997: Metranauetic - Chollest & statin 30% decrease - stroke in CAHD patients.
Sacks Tot chol: decrease to 4.8 mmol/Lit benefits

30. Guide 16: (A/C) Deep vein thrombosis
Kalra days - stroke Pts - 50%
Sandercock Pul embol 6-16% only
Ist IV or 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.

31. 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

32. 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 /Day
3 yrs 40% reduces of vascular events in 1000 pts (APTC )
Stroke sub type value ? (TACI, PACI, LACI, POCI)
Dienners , synergy possibel with clopidogrel ticlopidine etc.

33. 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)

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

35. 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

36. 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

37. “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

38. 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.

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. “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”

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

49. 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”

50. 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

51. 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

52. 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

53. “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

54. 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”

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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

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