Stroke - the size of the problem

1. Stroke - the size of the problem

2. What is a stroke? • What is a transient ischaemic attack? • What is the size of the problem?

3. What is a stroke? • What is a transient ischaemic attack? • What is the size of the problem?

4. Stroke = “brain attack” = Rapid onset of focal (or at times global) cerebral deficit, lasting at least 24 hours (or leading to earlier death), and for which there is no cause other than a vascular one

5. 3 main pathological types • ~ 80% ischaemic • ~ 15% primary intracerebral haemorrhage • ~ 5% subarachnoid haemorrhage

6. What is a stroke? • What is a transient ischaemic attack? • What is the size of the problem?

7. TIA (transient ischaemic attack) = “brain attack” = • “Mini stroke” • Definition as for stroke except lasts < 24 hours (and not fatal) • Vast majority are ischaemic

8. What is a stroke? • What is a transient ischaemic attack? • What is the size of the problem?

9. Measuring the burden of stroke mortality incidence prevalence outcome cost

10. Causes of death worldwide in 1990: WHO / World BankGlobal Burden of Disease Study

11. Causes of death worldwide in 1990: WHO / World BankGlobal Burden of Disease Study Millions All causes 50.5 Coronary heart disease 6.3 (12% of total) Cancer (all types) 6.1 (12% of total) Cerebrovascular disease 4.4 (9% of total)

12. Global burden of stroke - mortality • 4.4 million deaths worldwide in 1990 • 2/3 of these deaths in developing countries • Stroke deaths likely to double by 2020 • 3rd commonest cause of death after coronary heart disease and cancer • Mortality data do not tell the whole story, since most strokes are not fatal • Major burden of stroke is chronic disability

13. Incidence of first-ever-in-a-lifetime stroke in the Oxfordshire Community Stroke Project (Bamford et al 1990)

14. Cumulative percentage of first-ever-in-a-lifetime strokes by age in the Oxfordshire Community Stroke Project, 1981-1984 Three quarters of the strokes occur in > 65 year olds Half the strokes occur in > 75 year olds years

15. Age and sex standardised annual incidence of stroke, age 45 to 84 years, in 10 ‘ideal’ community- based studies in the 1980s and 1990s (Sudlow and Warlow 1997)

16. Stroke in the UKpopulation ~ 60 million • 125,000 strokes each year • GP (list = 2000) would see ~ 4 per year • 250,000 disabled stroke survivors • GP would have ~ 7 such patients on list

17. Outcome after a stroke Describing the effects on an patient: • (Death) • WHO classification: Impairment Disability Handicap

18. Outcome after a stroke • About 20% will die within one month • By one year over half will be either dead (30%) or dependent (25%) • After a 1st stroke, 10% will have another stroke in the first year, and 5% per year thereafter • Also at risk of serious vascular disease elsewhere. About half eventually die of coronary heart disease

19. % of patients with different outcomes one year after first-ever stroke(Oxfordshire Community Stroke Project, n = 675) 100 80 Independent 60 Dependent % Dead 40 20 0 All types PICH SAH Ischaemic stroke

20. Cost of stroke Accounts for about 6% of NHS and Social Services expenditure = £2.3 billion per year

21. Percentage of hospital costs spent on different aspects of stroke care(Western General Hospital, Edinburgh) Doctoring 19% Therapy 31% Drugs 10% Investigations 40% Other 5% Overheads 14% Nursing 81%