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Neurogenic Pain and Depression

Neurogenic Pain and Depression. Prof. A.V. SRINIVASAN , MD, DM, Ph.D , F.A.A.N, F.I.A.N.D.Sc Emeritus Professor The Tamilnadu Dr. M.G.R. Medical University Former Head Institute of Neurology, Madras Medical College. 20-1-11. Is survival a mere stroke of Luck?.

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Neurogenic Pain and Depression

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  1. Neurogenic Pain and Depression Prof. A.V. SRINIVASAN, MD, DM, Ph.D, F.A.A.N, F.I.A.N.D.Sc Emeritus Professor The Tamilnadu Dr. M.G.R. Medical University Former Head Institute of Neurology, Madras Medical College 20-1-11

  2. Is survival a mere stroke of Luck? Cerebrovascular Emergencies “My Opinions are founded on knowledge but modified by experience”

  3. Every minute matters: ‘time is brain’ Expert is one who think to his chosen mode of ignorance

  4. INTRODUCTION • Perceptual Sense (Observation) • Word Sense (Recording) • Common Sense (Thinking) • Will lead you to get - Clinical Sense “ He who cannot forgive others destroys the bridge over which he himself must pass” - Annoy

  5. Cerebrovascular disease – Mind boggling facts • World wide incidence: 2/1000 population/annum1 • Incidence in people aged 45 – 84 years: about 4/10001 • Incidence in India: was 36/100,000 for the year 1998-19993 in a study in Calcutta • Incidence of mortality due to stroke (India: WHO study): 73/100,000 per year2 CVD is the most disabling of all neurologic diseases. 50% of survivors have a residual neurologic deficit. Greater than 25% require chronic care. 1.A practical approach to management of stroke patients; 1996; 360-384 2. Epidemology of cerebrovascular disorders in India; 1999; 4-19 3. Neuroepidemiology 2001;20:201-207 If you think you can or you can’t You are always right

  6. Annual risk CVD, MI, vascular death following TIA, minor CVD • CVD 6.7 % • MI 2.5 % • Death 7.2 % • CVD, MI, Vascular death 8.6 % • CVD, MI, Death 10.3 % Experience can be defined as yesterday’s answer to today’s problems

  7. Indian scenario 1880 death / day due to stroke in India Equal to 6 Boeings 737 crashes every day

  8. Indian scenario Number of deaths due to stroke • 22 times that due to malaria • 4 times that due to RHD • 1.4 times that due to TB • Almost equal to deaths due to IHD

  9. Comparison India vs. established market economies (Age adjusted stroke mortality) • Indian immigrants to England have higher risk or dying due to stroke than local population 2 to 3 times stroke mortality higher in India

  10. Comparison • USA – stroke mortality decline since 1940’s • India likely to increase • Increase life expectancy (aging population) • Urbanization

  11. Acute stroke interventions – reasonable evidence • Stroke units • Aspirin • Thrombolysis • Heparin

  12. Stroke • Neurologists Vascular event due to atherosclerosis Relevant to all of us • Cardiologists • Physicians

  13. Stroke disability worldwide • Limb weakness – 77% • Urinary disturbance – 48% • Dysphagia – 45% • Cognitive deficit – 44% 35% functionally dependent at 1 year

  14. Acute stroke interventions – evidence based medicine • Stroke care units vs general wards • 9% relative risk reduction • 56 deaths or dependency avoided / 1000 acute strokes treated / year • Aspirin • 3% relative risk reduction • 12 deaths or dependency avoided / 1000 active strokes treated / year

  15. Acute stroke interventions – evidence based medicine • Thrombolysis – (even in USA only 1% of strokes are thrombolysed) • 10% relative risk reduction • 63 deaths or dependency avoided (91 early deaths due to haemorrhage) • Heparin • No benefit

  16. Conclusion • People who survive stroke – 90% are left with deficit – minimal / mild / moderate / severe • None of the presently available therapy has any major impact hence prevention is critical

  17. New role of doctors “Managers of Change” “Preventors of Change” (Health ill health)

  18. Global 15 million deaths globally every year due to vascular disease (30% of all deaths)

  19. Global By 2020 – stroke and myocardial infarction will constitute leading cause of death / disability

  20. Lowering blood pressure • Primary prevention – 17 randomised trials – reduction of 5 to 6 mmHg diastolic and 10.12 mmHg systolic BP – 38% reduction of stroke • Secondary prevention – have we made PROGRESS

  21. Common Stroke Mimics • Hypoglycemia • Post ictal state • Drug overdose • Concussion with neck injury • Migrainous accompaniment • Encephalopathies with focal signs • Hyponatremia • Subdural hematoma, Empyema • Focal Encephalitis: Herpes Being ignorant is not so much a shame as being unwilling to learn

  22. Guidelines for 24 hrs – Mandatory Level of Evidence Level A: Based on RCT or Meta analysis of RCT Level B: Based on Robust Experiment or Observation Studies Level C: Based on Expert opinion. “The True Art of Memory is The Art of Attention” - S.Johnson

  23. 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 4. Rule out stroke mimics “ We Sometimes think we have forgotten something when in fact we never really learned it in the first place”Imp.Your Memory Skills

  24. Guideline: 3 (B) - CPR • CPR is rarely successful in the setting of stroke – Sneeder 1993. • Guideline: 4(B) Investigations:(Sagar 1995)- 435 PTS) • Chest x-ray 16% ABN • Only 4% change clinical management • Order x-ray chest if weight loss or chest symptoms present Through Action You Create your Own Education - D.B. ELLIS

  25. Guideline 5: (B) ECG: • Cardiac cause of Death (30 days) Ebrahim 1990. • All conscious patients to have ECG • Guideline 6: (C) CT: • Routine CT Head is a must • King’s fund forum(1988) gives useful framework • Weir 1994 Clinical scoring cannot distinguish • CT done if: a) Uncertainty of Stroke b) If Anticoagulation or Anti Platelet treatment contemplated c) IV rtPA Thought is the labour of the intellect Reverie is its pleasure

  26. Guideline 7:(B) M.R.I. • Mohr 1995, - Unclear for Implications for clinical practice • 2004 – PWI > DWI – IV rtPA very useful Whatever the Mind can conceive and Believe, the mind can Achieve -Napoleon Hill

  27. Imagination is more Important than Knowledge • Guideline 8: (B) ECHO no Routine • Echo in Acute Stroke – Cardiac cause/Thrombus LV • TEE is superior to TTE • Amer Heart Asson (1997) - same conclusion • Yield is very low. (Leung 1993; Chambors 1997) • Only when abnormal ECGS - change clinical management

  28. Guideline9: (A) – Doppler scan for selected patients • > 80% stenosis benefits from Endarterectomy • Subst Storke -Good recovery - do doppler • Useful in posterior circulation A open foe may prove a curse ; but a pretended friend is worse

  29. Guideline 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 - 1997) Check ABG only if Hypoxia suspected. It is a great misfortune not to possess sufficient wit to speak well nor sufficient judgment to keep silent - La Broyers character

  30. You are what you think and not what you think you are • Guideline 11: (A) Steroids and Hyperosmolar agents Unproven treatment – • Tumor oedma responds but not cytotoxic stroke oedma qialbash 1997 - No effect on survival or improv. In funct. Outcome • Mannitol - (Boysen 1997) - short term effective statistically in conclusive

  31. We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts R.B. Schmeck • Guideline 12: (B) - Blood Pressure • Defer - acute reduction of BP - 10 days unless HT Encephalopathy or aortic dissection present • Moris 1997 - 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 1994 - HT - Prim. stroke prevent • Neal 1996 (Current RCT) - HTs in stroke survivors -study needed • Acute reduction of BP only if thrombolysis considered

  32. Guideline13: (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 Discipline Weighs ounces; Regret weighs Tons

  33. A great many people think they are thinking when they are merely re arranging their prejudicesW. James • Guideline 14:(B/C) - Blood sugar • Weir (1997) > 8 mm d/Lit - Poor outcome • Acute MI + 11 mm d/Lit - Intensive Insulin - improved (Malmberg 1997)

  34. Many Ideas grow better when transplanted into another mind than in the one where they sprang UPO.W. Holmos • Guideline15: (A) Cholesterol • Prosp. Study collob.: 1993 - Epidem study do not support • Blaun 1997: Metranauetic - Chollest & statin 30% decrease - stroke in CAHD patients. • Sacks 1996 - Tot chol: decrease to 4.8 mmol/Lit benefits

  35. Guideline 16: (A/C) Deep vein thrombosis • Kalra 1995 - 10 days - stroke Pts - 50% • Sandercock 1993 - Pul embol 6-16% only • Ist 1997 - 5000 IV or 12500 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. A woman’s desire for revenge outlasts all her other emotions

  36. Every discovery contains an irrational element or 4 creative intuition • Guideline17: (A/B) Pressure sure • Event health care (1995) specialised low pressure mattress systems to be used than stand Hospital - mattress

  37. I have never let my Medical schooling interfere with my education Mark Twain • Management of infarction • Guideline18: (A) • Aspirin 75 - 150 /Day • 3 yrs 40% reduces of vascular events in 1000 pts (APTC - 1994) • Stroke sub type value ? (TACI, PACI, LACI, POCI) • Dienners - 1996, synergy possible with Clopidogrel Ticlopidine etc.

  38. Anti Coagulation • Warfarin - AF • In sinus rhythm - uncertain • Spirit 1997 low dose ABP + Warfarin in TIA & Minor stroke - Stopped of HE • Heparin (IST 1997) – Significant reduction in early death (12 fewer in 1000) not better than aspirin • So avoid Heparin (A) “ He who cannot forgive others destroys the bridge over which he himself must pass” - Annoy

  39. When they tell you to grow up, they mean stop growing Piccaso • Thrombolysis (A) • Warlow 1997 - Uncertain clinical benefit • 2004 – NINDS – Thrombolysis conclusively proved its efficacy – first 3 hrs

  40. A (Neurologist’s) life is like a piece of paper on which everyone who passes by leaves an impression- Chines proverb • Guideline 20: (I) Hemorrhage • Hankey and hon 1997: Supra tentorial evacuation for ICH is controversial - Avoid • Infra tentorial - Yes • Main Indication - Deteriorating or depressed consciousness

  41. A medical school should not be a preparation for life. A school should be life Guideline21 : Ventilation -Decreased level of consciousness - increased mortality and poor final outcome - Absent pupillary light responses - poor prognosis

  42. PITFALLS • Basing treatment of stoke on brain imaging along without a vascular work-up • Missing early infarct signs on CT • Underestimating the time of symptom onset for patients who wake up with a stoke • Overtreatment of hypertension in acute stoke Three can be seen in the divisions of a human in mind, body and spirit

  43. PITFALLS • Overuse of carotid endarterectomy in asymptomatic patients • Not investigating both extracranial and intracranial circulations • Failure to distinguish severe cartid stenosis from total occlusion • Not obtaining spinal fluid for patients with suspected subarachnoid hemorrhage “Social Isolation is in itself a pathogenicFactor for disease production”

  44. PITFALLS • Not treating patients with large artery ischmic stroke indefinitely with antiplatelet terapy • Failure to recognize lacunar stoke • Inadequate use and dosing ofHMG Co-A reductase inhibitors (statins) inpatients with cerebrovascular disease Through Action You Create your Own Education - D.B. ELLIS

  45. PROGNOSTIC PEARLS • 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 “By Nature All Men/ Women are alike butby Education widely different”

  46. STOKE MYTHOLOGY • GENERAL MYTHS • DIAGNOSTIC MYTHS • THERAPEUTIC MYTHS Serious, sincere, systematic study surely secures supreme success

  47. GENERAL MYTHS • PHYSICIAN + MRI = NEUROLOGIST • MINISTROKE • CVA CHAOTIC COMMUNICATION Discipline Weighs ounces Regret weighs Tons

  48. DIAGNOSTIC MYTHS • Self evident cause • Ischaemic stroke + AF • Lacunes, Lacunar infarcts and small vessel disease • Cryptogenic stroke • PFO and Cardiogenic stroke Experience can be defined as yesterday’s answer to today’s problems

  49. Ultrasound Diagnosis • In skilled hands, ultrasound may show: • Carotid occlusion or stenosis • MCA occlusion or stenosis • Vertebrobasilar occlusion • Extracranial dissection The secret of walking on water is Knowing where the stones are

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