32 Representation of Penumbra in Acute Stroke. Thomas, S. H. et al. N Engl J Med 2006;354:
33 ACUTE CARETime 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
34 Next Steps If no bleed, start aspirin. If on aspirin, stop Hypoxic patients (saturation <95%) should have OxygenStart I.V. saline as necessary. Avoid dextrose on day 1.Swallow assessment ASAP. NBM till then.If no bleed, start aspirin. If on aspirin, stopon admission, and resume if no bleed.Rectal aspirin if unable to swallow.Blood Pressure should not be lowered unlessencephalopathy or aortic dissection or BP VERY high
35 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.
36 Continuing Management Refer to Stroke Team within 24 hours of admissionTransfer to Stroke Unit / Stroke \Team Care same day if possibleWhy?
37 Continuing Management – Stroke Unit Meta-analysis by the Stroke Unit Trialist's collaboration18% + reduction in death or dependencedeath 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
38 Acute Treatment Easy – early aspirin for almost all. 10 in 1000 extra will walk outHarder – thrombolysis for a few.1 in 10 extra will walk out
39 Will it work? Per 1000 treated Intracranial bleed NNH 22 Death NNT 236 Death / Dependent NNT 101 or more point >mRS NNT 3THE EARLIER THE BETTER
40 Bleeds Reverse coagulopathy Refer neurosurgery for cerebellar bleeds Less evidence for other sites? > 30ml near the surface.
41 TRANSIENT MONOCULAR BLINDNESS Is it a TIA?Suddenonset of focal or globallossof cerebral functionORTRANSIENTMONOCULARBLINDNESS
42 Is it a stroke /TIA? POSITIVE FEATURES - TIA LESS LIKELY TINGLING rather than numbnessFlashing lights rather than loss of visionJerking rather than paralysisDepends on a good history / witness statement
43 Is it a stroke / TIA? 23% of strokes preceded by TIA stroke risk after TIA: 2 days %7 days %90 days %
44 ABCD2 Score A) Age 60 or older = 1 B) Raised BP – systolic > 140 / diastolic > 90 = 1C) Unilateral weakness = Speech disturbance without weakness = other = 0D) Duration > 60 min = min = < 10 min = 0D) Diabetes = 13 or over is significant6/7 may need admitted.
46 Is the ABCD Score Useful…… TRIAGE of TIA with MRI MRI DWI +ve scans thought to be extra useful
47 STROKE RATE after TIA EXPRESS study BeforeAfterRisk of recurrent stroke after first seeking medical attention in patients with TIAROTHWELL, The Lancet 2007;370:
48 INITIAL MANAGEMENT OF TIA Establish diagnosis / Check risk factors:Aspirin Cholesterol Blood Pressure AFDiabetes Ischaemic Heart Disease PVDCarotid disease Cardioembolic sourceIf “classic” TIA < 20 min, may give aspirin till seen at OPC.
49 Risk factor reduction Blood pressure to target ~ 130 / 80 Cholesterol to target ~ <4.0 mmol/lAntiplatelet drugs:Anticoagulation for AFLifestyle advice
50 Drug treatment Blood pressure: diuretic / ACE combination Cholesterol - simvaststatin / atorvastatinAntiplatelet: aspirin 300 mg for 2 weeks, then 75mg; clopidogrel 75 mg or aspirin + dipyridamole retardAnticoagulation for AF - INR 2 - 3
51 BLEEDS: 20 - 42 % DEATH RATE AT 1 MONTH RecurrenceVASCULAR DEATH %1 month 1yr 2 yrs 3yrREINFARCTS: 12 % FIRST YR 4-5% / YR AFTERBLEEDS: % DEATH RATE AT 1 MONTH(worst in men >75)
52 Road to Recovery -Sitting balance first, standing unsupported, walking, then independence
53 Why did it get worse? Stroke in progression Vessel re-embolises / dissectsBleed into infarcted areaSeizureHypoxiaUnderperfusion
54 If only I had / hadn’t……… Usually not true - inevitable.The usual ONLYwarning is a TIA.Long term primary prevention best….even thenCould prevent only half of all stroke.