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STROKE DISEASE

STROKE DISEASE. In a nutshell. The Prevention and Management of Stroke. by Dr Irfan Shakir. Size of the Problem. 110,000 new strokes every year 10,000 under 55 years of which 1,000 under 30 years In addition 30,000 repeat strokes Incident higher in Africans and South Asians

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STROKE DISEASE

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  1. STROKE DISEASE In a nutshell

  2. The Prevention and Management of Stroke by Dr Irfan Shakir

  3. Size of the Problem • 110,000 new strokes every year • 10,000 under 55 years of which 1,000 under 30 years • In addition 30,000 repeat strokes • Incident higher in Africans and South Asians • Third most common cause of death, 30% mortality at one month most die within first 10 days

  4. Size of the Problem • 85% of the strokes infarcts • 15% haemorrhagic

  5. Size of the Problem • Biggest cause of long term disability • Though 65% of survivors can live independently • 35% are significantly disabled of these 5% need residential care

  6. Risk Factors Lifestyle • Poor diet(Salt and fat intake too high, not enough fruit and vegetables) • Low level of physical activity • Alcohol misuse • Smoking

  7. Individual Risk Factors • Previous stroke or TIA • Hypertension • Atrial fibrillation(AF) • Coronary heart disease(CHD) • Peripheral vascular disease(PVD) • Carotid stenosis • Metabolic diseases(diabetes, hyperlipidaemia, obesity)

  8. Management Transient Ischaemic Attack(TIA) Definition:Focalneurological symptoms and signs of sudden onset of presumed vascular origin which completely resolve within 24 hours(i.e. hemiparesis, hemipraesthesia, dysphasia, amaurosis fugax), consider other diagnosis if loss of consciousness, dizziness, funny turn, or unexplained collapse

  9. Management(TIA) Refer for specialist assessment Use ABCD2 Score to stratify

  10. ABCD2 Score for Transient Ischaemic Attack • A (Age); 1 point for age >60 years, • B (Blood pressure > 140/90 mmHg); 1 point for hypertension at the acute evaluation. • C (Clinical features); 2 points for unilateral weakness, or 1 for speech disturbance alone • D (symptom Duration); 1 point for 10–59 minutes,or 2 points for >60 minutes. • D (Diabetes); 1 point

  11. ABCD2 Score for Transient Ischaemic Attack • Score 1-3: Low risk • Score 4-5: Medium risk • Score >5 :High risk

  12. ABCD2 Score for Transient Ischaemic Attack Department of Health • Score 1-3 see and investigate within one week • Score 4 or above see and investigate within 24 hours

  13. Hypertension Coronary Heart Disease Diabetes Hyperlipidaemia Current smoker Alcohol Atrial Fibrillation Family history Migraine Management(TIA)Risk Factors

  14. Management(TIA)Investigations 1 All Patients(if possible before attendance at the clinic) • Full Blood Count(FBC) • Urea and Electrolytes(U&E’s) • ESR • Fasting Sugar • Fasting Lipids

  15. Management(TIA)Investigations 2 As appropriate • ECG • Echocardiograph • Carotid Doppler • CT head • MR head and angiogram • Auto-antibody screen • Thrombophilia screen

  16. Treatment(TIA) Antiplatelets • Aspirin • Clopidogrel Add ons • Dipyridamole • ? Clopidogrel

  17. Treatment(TIA)

  18. Treatment(TIA) Anticoagulation • No benefit unless source of embolism present • Consider in all patients in AF as increased risk 3-7 fold but advantage over Aspirin not that large Absolute Risk Reduction(ARR) 2.9% (95% CI 0.9-4.9%) Number Needed to Treat (NNT) 34

  19. Anticoagulation in (AF)

  20. Treatment(TIA) Carotid Stenosis Symptomatic 70-99% stenosis benefits from carotid endarterectomy ARR 6.7% NNT 15 over 3 years

  21. Treatment(TIA) Hypertension • Compared with CHD evidence not as strong but 37% risk reduction has been reported if BP lowered to 140/85. • About 50% of deaths in stroke survivors due to cardiac events

  22. Treatment(TIA) Cholesterol Evidence is not as strong as in CHD. Reduction has to be larger than CHD. As majority have CHD and PVD treatment is important. Lower it if cholesterol > 3.5 ? Upper age limit because of side-effects

  23. Stroke Diagnosis • Focal neurological symptoms and signs of sudden onset which persists for more than 24 hours. • Diagnosis is primarily clinical

  24. Fast Test for Stroke

  25. ROSIER Scale for Stroke • Has there been loss of consciousness or syncope? Yes (-1) No (0) • Has there been seizure? Yes (-1) No(0) Is there a NEW ACUTE onset (or on awakening from sleep) • Asymetrical facial weakness Yes (+1) No (0) • Asymetrical arm weakness Yes (+1) No (0) • Asymetrical leg Weakness Yes (+1) No (0) • Speech disturbance Yes (+1) No (0) • Visual field defect Yes (+1) No (0) Total Score ____ (-2 to +5) Stroke is likely if total scores are > 0. Scores of </=0 have a low possibility of stroke but not completely excluded.

  26. Stroke Care Who to Admit to Hospital • All with disabling stroke • Minor disability stroke patients can be looked after at home if investigations and full multidisciplinary assessment can be done rapidly followed by specialised rehabilitation

  27. Stroke Care HOW IN HOSPITAL • All patients should be admitted to a dedicated acute stroke care area as soon as diagnosis has been made. • Acute Stroke Unit care is better for outcome. NNT = 20

  28. Stroke Care How in hospital: Rehab Stroke Units NNT 9-16

  29. Stroke Care Stroke Units(evidence)

  30. Stroke Care Stroke Assessment • Good history and clinical examination • Investigations to confirm diagnosis • Risk factors • Multidisciplinary assessment

  31. Stroke Care Neurological Examination • Power • Sensation • Visual fields • Visuo-spatial disturbance • Speech • Swallowing

  32. Stroke Care Clinical Classification • TACS=Total Anterior Circulation Stroke • PACS=Partial Anterior Circulation Stroke • LACS=Lacunar Stroke • POCS=Posterior Circulation Stroke

  33. Stroke Classification TACS • Hemi-motor and sensory deficit • Hemianopia • Cortical Dysfunction a) Dysphasia or b) Visuo-spatial disturbance

  34. Stroke Classification PACS Any two of the following • Hemi-motor and sensory deficit • Hemianopia • Cortical Dysfunction a) Dysphasia or b) Visuo-spatial disturbance

  35. Stroke Classification LACS • Pure motor hemiplegia • Pure sensory loss • Motor and sensory loss

  36. Stroke Classification POCS • Vertigo • Diplopia • Ataxia • Isolated hemianopia

  37. Stroke Classification

  38. Stroke Investigations • Full Blood Count(FBC) • Urea and Electrolytes(U&E’s) • ESR or Plasma viscosity • Fasting Sugar • Fasting Lipids • ECG • INR if on anticoagulation or clotting abnormality suspected

  39. Stroke Investigations Imaging • CT head immediately to deliver thrombolysis or as soon as possible with view to start antiplatelet treatment but no later than 24 hours • On anticoagulant immediately if haemorrhage seen give treatment to reverse • Chest X-ray if cardiac or chest disease present or suspected

  40. Stroke Investigations Consider • Carotid Doppler • Auto-antibody Screen • Thrombophylia Screen • Echocardiograph • Coagulation Screen

  41. Stroke Care Acute Stroke Unit • Give 300mg Aspirin as soon as haemorrhage excluded unless suitable for thrombolysis • Dysphagia screen • Manage hydration • Control blood sugar • Manage pyrexia • Manage hypoxia

  42. Stroke Care Acute Stroke Unit • Hypertension: Observe for 2-3 days unless diastolic persistently above 115 or evidence of accelerated hypertension. Lower BP using drugs which do not cause sudden drop.

  43. Stroke Care Multidisciplinary Team • THERAPISTS • OCCUPATIONAL THERAPIST • PHYSIOTHERAPIST • SPEECHTHERAPIST • DIETICIAN • PSYCHOLOGIST • SOCIAL WORKER • PHARMACIST • NURSE • DOCTOR

  44. Stroke Care Multidisciplinary Assessment Within 24- 48 hours of admission using protocols to have documented assessment of: • Consciousness level • Swallowing • Pressure sores risk

  45. Stroke Care Multidisciplinary Assessment • Nutritional status • Cognitive impairment • Communication • Moving and handling

  46. Stroke Care(Rehabilitation) Manage Using protocols • Continence • Nutrition • Shoulder pain • Discharge planning

  47. Stroke Care(Rehabilitation) Goal Setting • Must involve patient • Family if appropriate

  48. Stroke Care(Rehabilitation) Carers and Families • Give information on nature of stroke and treatment available • Assess and reduce stress • Give individual psychological support

  49. Stroke Care(Rehabilitation) Ongoing Care Once patient can transfer from bed to chair specialist stroketeams are effective in any of the following settings • Home • Day hospital • Nursing Home • Residential Home

  50. Stroke CareSecondary Prevention As for Transient Ischaemic Attack (TIA) • Lifestyle (diet,exercise, smoking, alcohol) • Antiplatelets • Anticoagulation in AF • Carotid Stenosis • Hypertension • Metabolic Diseases(diabetes, cholesterol, obesity)

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