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Acute Stroke

Acute Stroke . A Neurological Emergency. Acute Stroke. Show stroke is an emergency Discuss stroke subtypes Appropriate investigations. Acute stroke. Benefits of treatment Acute therapy inpatient and outpatient Prevention primary and secondary. Acute Stroke. Common Serious

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Acute Stroke

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  1. Acute Stroke • A Neurological Emergency

  2. Acute Stroke • Show stroke is an emergency • Discuss stroke subtypes • Appropriate investigations

  3. Acute stroke • Benefits of treatment • Acute therapy • inpatient and outpatient • Prevention • primary and secondary

  4. Acute Stroke • Common • Serious • Preventable • Treatable

  5. Acute Stroke • Medical Emergencies • Rapid onset • Poor prognosis • Need for prompt treatment

  6. Acute StrokeA Medical Emergency • Comes on quickly • Poor prognosis • 12% mortality at 7 days • 19% at 30 days • 31% at one year • Needs urgent treatment • TIME = BRAIN

  7. Is it a Stroke? • Focal Signs • Negative symptoms • Sudden onset • Appropriate context • Older age group • Vascular risk factors

  8. What kind of stroke? • TACI • PACI • LACI • POCI

  9. OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION SYSTEM • TACI • Large cortical stroke • MCA +/- ACA territories • Higher cerebral dysfunction • Dysphasia • Acalculia • Neglect • AND • Hemianopia • And • 2/3 of face/arm/leg

  10. OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION SYSTEM • PACI • 2 out of 3 of TACI • OR • motor/sensory deficit more restricted than LACI • OR • Higher centre dysfunction alone

  11. OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION SYSTEM • LACI • Pure motor stroke • Pure sensory stroke • Sensorimotor stroke • Ataxic hemiparesis • Dysarthria-clumsy hand syndrome

  12. OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION SYSTEM • POCI • Ipsilateral cranial nerve lesion with contralateral motor/sensory deficit • Bilateral motor/sensory deficits • Conjugate gaze palsy • Pure cerebellar deficit • Isolated homonymous visual field defect

  13. Investigations • Is it a stroke? • Difficult in 1st 6 hours • Type of stroke dictates investigations and their urgency

  14. Investigations • CT • Fast • Reliable • Available • Differentiates between ICH and ischaemic stroke • May show alternate diagnosis

  15. Investigations • CT • When? • As soon as practicable for most patients • Haemorrhagic transformation and primary ICH can be difficult to differentiate

  16. Investigations • ECG • FBC • Renal function • BGL • ESR or CRP • Cholesterol

  17. Investigations • TACI • Few needed • LACI • As above • POCI • As above • PACI • Carotid duplex • Possibly TOE

  18. Emergency Management • Dr Christopher Trethewy • Trelawney – the unofficial Cornish anthem

  19. Acute stroke treatment

  20. Acute Stroke Treatment • Does the patient qualify for thrombolytic therapy? • Clearly defined time of onset • Less than 3 hours • No contraindications to thrombolysis • Stroke not too mild nor too severe • DIRECTLY TO ED, DO NOT PASS GO

  21. Acute Stroke Treatment • Recombinant tissue plasminogen activator • Given within 3 hours • To patients with appropriate stroke and CT • REDUCES DEATH and DISABILITY at 3/12 • NNT 18 • NNH 34

  22. Acute Stroke Treatment • rTPA • Expensive • 5% of strokes • High risk of harm if not ideal subjects

  23. Acute Stroke Treatment • Stroke Units • Coordinated, goal directed rehabilitation • Oxygenation • Fever management • Early mobilization • BGL management • PATHWAYS DON'T HELP

  24. Acute Stroke Treatment • Aspirin • Started within 48 hours • Reduces death, disability, recurrent stroke • Improves recovery • NNT 111 • NNH • 2 ICH per 1 000 • 4 bleeds per 1 000

  25. Acute Stroke Treatment • BP reduction • Possibly harmful early • Neuroprotection • No proven benefit to date

  26. Prevention • BP lowering • Possibly ACE-I esp in diabetes • Smoking cessation • Lipid lowering (maybe) • Anticoagulation for Afib if other risk factors • Aspirin if other vascular disease

  27. Secondary prevention • Aspirin (and modified release dipyridamole) • Anticoagulation if Afib • CEA if symptomatic stenosis >70% • BP lowering • Smoking cessation • Lipid lowering

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