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Stroke diagnosis. Caroline Lawson Consultant Nurse - stroke. Aims & objectives. Overview of stroke & TIA Key risk factors Initial treatment plan Case studies. The impact on the future.
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Stroke diagnosis Caroline Lawson Consultant Nurse - stroke
Aims & objectives • Overview of stroke & TIA • Key risk factors • Initial treatment plan • Case studies
The impact on the future • Due to the demographic composition of the population, although mortality is reducing, the overall incidence of stroke is likely to rise over the next 20 years • It is estimated that between 1983 and 2023, there will be a 30% increase in first ever strokes • This is going to have a major impact on service provision and should be influencing service development now
A disruption to the blood supply in the brain resulting in the brain not working normally What is a Stroke?
Types of Stroke Ischaemic Haemorrhagic
TIA • A syndrome of • sudden onset • focal neurological deficit • Loss or decrease power • Loss or altered sensation • Speech difficulty • Loss of vision • Loss of balance or dizziness • lasting less than 24 hours • Vascular origin
Amaurosis Fugax • Painless visual loss in one eye that is secondary to retinal ischaemia
What happens post stroke Infarct or Haemorrhage Core Ischemic Zone Ischaemic Penumbra ↓ ↓ Blood flow severely depleted Blood flow moderately depleted ↓ ↓ Oxygen & glucose depleted Collateral circulation supplies ↓ ↓ Necrosis of neurons & if no reperfusion = necrosis glial cells
Diffusion-weighted imaging TIA Major stoke Minor stroke
Factor Hypertension (raised blood pressure) Smoking Diabetes Blocked carotid artery Raised cholesterol Atrial fibrillation ( irregular heart beat) Risk reduction with treatment 38% 50% within one year; baseline after 5 years 44% reduction with tight blood pressure control in patients with diabetes and hypertension 50% 20-30% with statins in patients with known CHD 68% when treated with warfarin Non-modifiable:Age, gender, race/ethnicity, heredity Risk factor modification
Risk of Recurrent Stroke • People who have already suffered an ischemic stroke or TIA are at highest risk of a second stroke or death • Approximately 17% of strokes are second strokes • Second stroke risk is highest in the 7 daysfollowing the event American Heart Association. Heart Disease and Stroke Statistics 2003 update. Sacco RL et al. Stroke. 1998; 29(10): 2118-24. German Stroke Databank.
Cumulative risk of stroke after TIA 14 2002-2004 1981-1984 12 10 8 Risk of stroke (%) 6 4 2 0 0 7 14 21 28 Days Lancet 2005; 366: 29-36
HRT Women have a lower risk of CVE than men but the risk rises post menopause HRT increases risk by 30% CVE – 20% increased risk Venous thrombotic event – 50% Dual HRT – doubles risk of VTE
Primary stroke prevention throughrisk factor modification A 246,500 B 61,500 Key A = Hypertension B = Cigarette smoking C = Atrial fibrillation D = Heavy alcohol use E = Hypercholesterolaemia C 47,000 D 23,500 E 100,000 0 100,000 150,000 200,000 50,000 Estimated potential number of strokes prevented out of a total of 500,000 strokes annually in the USA
30 Non-fatal stroke Non-fatal myocardial infarction Non-fatal acute peripheral vascular events 20 Rates per 1000 population per year 10 0 < 35 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 ≥ 85 Age (years) Age-specific rates of non-fatal stroke vs myocardial infarction vs acute PVD events in OXVASC Lancet 2005; 366: 1773-83
Stroke in young adults • Cardiac problems – hole in heart • Clotting problems / sickle cell • Illicit drugs
Heroin – • Slows respiratory rate, Slows heart rate • Lowers blood pressure • Infective endocarditis • Cocaine – • Narrows blood vessels – rise in BP • 23 fold increase in risk of heart attack in hour post use • Long term BP alteration causes atheroma build up – resulting in coronary artery disease • US – 1 in 4 of all MI in age group of 18-45 linked to cocaine use Quereshi et al 1999 Circulation 99:2731-41
Amphetamine • Adrenaline-type effect on body – • Increases heart rate • Increases BP – risk of Stroke • Alters electrical activity of heart – arrthymia • Ecstasy • Related to amphetamine • Sudden arrthymia • Risk of Stroke
Glue / Solvents • Heart rhythm disturbances – causing sudden death • Cardiomyopathy • Cannabis • low dose - Fast heart rate • large dose - Slow heart rate , lower blood pressure • Risk of sudden death (no associated other cause) • Heart attack - 4 fold higher within the hour following cannabis use Mittleman et al 2001 Circulation 103: 2805-9
Secondary prevention General population: Smoke 27% Obese 25% Alcohol 28% Exercise 70% QOF in N Ireland: Anticoag of AF : 90% patients BP < 150/90 : 70% Chol < 5 : 60% Antiplat for TIA/ Stroke: 90%
Link between ED & atherosclerosis • 39% - 59% of men with heart disease experience ED • Atherosclerosis affects main vessels and peripheral arteries • Penile arteries 1- 2mm in diameter. • Carotid arteries 5 -7 mm • Plaque build up can show as chronic problem • ED 3 times more likely to have a stroke than those without ED
ED & atherosclerosis • Montorsi et al 2006: 93% of pts with ED and CAD - ED came before the CAD symptoms an average 2 years earlier • 2003: N = 300 Prevalence of ED 49% • Of these 67% developed ED 3 years prior to A C S • Moderate to severe ED (not mild) • 10yr relative risk of CAD increased by 65% • Stroke 43%
Spironolactone Doxazosin Indapamide Bendroflumethiazide Felodipine Amlodipine Nifedipine Enalapril Darifenacin Nebivolol Lansoprazole Atrovastatin Ramipril Lisinopril Gabapentin Amioderone Omeprazole Ranitidine / Cimetidine Carbamazipine Haloperidole Drugs with S.E. of impotence
Typical stroke mimics • Seizures 24% • Syncope 23% • Sepsis 10% • Somatisation 7% • Migraine 6% • Labyrinthitis 4% • Tumour 3% • Low BM 3%
BP:___/____ GCS: ____ BM:____ If BM <3.5 mmol/L treat & reassess when normal Has there been loss of consciousness or syncope? Has there been seizure activity? Is there NEW ACUTE onset – or on waking from sleep?: 1. Asymmetric facial weakness 2. Asymmetric hand weakness 3. Asymmetric arm weakness 4. Asymmetric leg weakness 5. Speech disturbance 6. Visual field defect Y (-1) Y (-1) Y (+ 1) Y (+ 1) Y (+ 1) Y (+ 1) Y (+ 1) Y (+ 1) N (0) N (0) N (0) N (0) N (0) N (0) N (0) N (0) If score totals > 0 assume diagnosis of Stroke If score 0, -1 or -2 stroke diagnosis is unlikely but not excluded. Patient should be discussed with Stroke Physician or Stroke Nurse Consultant if stroke diagnosis still thought to be likely
Loss or decrease power • Loss or altered sensation • Speech difficulty • Loss of vision • Loss of balance or dizziness
Brain imaging CT Normal
Lacunar Strokes • Likely to present in TIA clinic • Account for 25% of all strokes • <1.5-2cm diameter • 20% due to embolic pathology • Different epidemiology than most strokes therefore low risk of early reoccurrence, mortality • > likely to have intrinsic SVD ? Vasospasm, microatheroma leading to occlusion, endothelical dysfunction or leak leading to oedema
Secondary prevention Antiplatelet • Relative risk reduction of 18% • Adding MR dipyridamole RRR ↑ 37% • Clopidogrel
Anticoagulation (Warfarin) • Should be started in every patient in AF unless contraindicated • RRR in secondary prevention of 66% v placebo • Should not be started until haemorrhage excluded, and 14 days have passed since onset of symptoms • Should also be considered if the IS stroke is associated with mitral valve disease or prosthetic heart valves
Cholesterol Reduction • Evidence suggests the lower the cholesterol the better • All patients should be advised to reduce saturated fat in their diet • RCP recommend treatment with a statin for patients with total cholesterol >3.5mmol/L • Different patients require different therapies
Carotid endarterectomy • Carotid ultrasound should be performed on any patient considered for carotid endarterectomy • Surgery would be considered where carotid stenosis is greater than 70% • Smoking cessation • Reduction in alcohol intake • Healthy diet & weight reduction
Carotid Artery Stenosis External Carotid Stenosis at bifurcation of Internal Carotid Common Carotid