Stroke

1. Stroke Mark Sudlow Consultant and Senior Lecturer Stroke Northumbria/NHCT/University of Newcastle

2. Money talks • NAO estimates of cost of stroke £7 billion annually • Of which £2.2 billion are direct costs to NHS • Cf £1.9 billion for coronary heart disease • Incidence the same as coronary heart disease – but greater associated disability • Recommend ways to save money • DOH obliged to make formal response via Public Accounts Committee • NAO to review progress

3. NAO Recommend • Faster access to specialist care for patients with TIA • High risk on same day • Lower risk within a week maximum • Faster access to specialist stroke care • Acute stroke units • Early scanning – 24 hours maximum • Thrombolysis - ?10% target and timed benchmarks for onset to needle • Better long term care provision

4. Response from DOH • Stroke is no longer under Elderly or Long Term Conditions but under Vascular Disease • Working parties set up to look at recommendations on changing provision of care • NICE asked to fast track guidelines • Intercollegiate Acute Stroke and TIA Guidelines

5. Transient Ischaemic Attack High early risk and effective early treatment

6. Risk in Transient Ischaemic Attack • Risk of completed stroke within a week = 10% • Risk > 20% if • More than one TIA in 7 days • 3 or more of • BP > 140/90 • Unilateral weakness of speech disturbance • Duration > 60 mins • Diabetes • The unstable angina of the brain

7. Effective treatment • Aspirin 75 mg od – reduces risk by 25% • Dipyridamole MR 200mg bd – reduces risk by further 20% when added to aspirin • Cholesterol reduction • Blood pressure reduction • Smoking • Exercise • Alcohol

9. What to do .. • Identify high risk patients and refer for urgent admission • More than one TIA in 7 days • 3 or more of • BP > 140/90 • Unilateral weakness of speech disturbance • Duration > 60 mins • Diabetes • Refer lower risk patient urgently to TIA clinic • Start aspirin and consider dipyridamole

10. What we will do .. • Admit high risk patients • Start treatment • Arrange urgent imaging • Refer to vascular surgery – where they will be seen within a couple of days • See lower risk patients within a week of referral • Start treatment • Information • Lifestyle advice • Arrange imaging • Refer to vascular surgery – where they will be seen within two weeks

11. Acute Stroke FAST response allows life saving treatment

12. Evidence for specialist care • Clear evidence that hospitalisation and treatment by a coordinated specialist team improves mortality and outcome • Absolute improvement of 10% • Increasing evidence that early specialist care is the key

13. Evidence for early aspirin • 1% absolute reduction in recurrence and mortality if given within 24 hours • Requires CT scan to exclude haemorrhage

14. Evidence for thrombolysis • Within 3 hours of onset of symptoms • With CT scan showing no haemorrhage • 10% absolute improvement in number of patients with minimal disability

15. What to do .. • If a patient presents or calls with symptoms suggesting acute stroke • Call an ambulance

16. What we will do.. • If a patient presents with stroke within thrombolysis window • Immediate referral to stroke specialist • Immediate scanning • Thrombolysis • If a patient present outside that window • Admit to specialist stroke ward • CT scan within 24 hours • Preventative treatment started early • Coordinated specialist assessment and rehabilitation • Information • Lifestyle advice

17. Secondary Prevention Need for risk reduction as for any high risk vascular disease With a few minor additions

18. Risk of MI, cardiac death and further stroke is similar to after MI • Strategies are broadly similar

19. Aspirin • Statin • Blood pressure – best evidence is for ACE and thiazide

20. Stroke specific • Dipyridamole MR 200 mg bd for at least 2 years • Risk of further stroke is particularly high with atrial fibrillation • 15% absolute per annum • Benefits of warfarin highest in this group • Risk of further stroke is particularly high with carotid stenosis • Carotid ultrasound and intervention if good recovery • Particularly important in partial anterior circulation strokes

21. What to do .. • Annual check • Antiplatelets • Blood pressure • Cholesterol • Lifestyle

22. What we will do .. • Arrange ongoing rehabilitation • Outpatient check at 6 weeks (as an inpatients if not discharged) • Outpatient check at six months

23. Life After Stroke Isolation and Dependency

24. Information • Inclusion of function and mood in annual screening • Access to social services and rehabilitation review

26. How it should be

27. Presentation • 64 year old man • Sudden onset at 11 am of • Complete loss of speech • Total paralysis of right arm and leg • Called GP surgery • Advised to call 999 ambulance • Arrives hospital 11.28 • No speech • Right hemianopia • Right face, arm and leg paralysis

28. Expected outcome

29. CT scan 12.00 • Thrombolysis 13.00 • Statin that night • Aspirin and dipyridamole start the next day

31. Carotid doppler on day 7 • 95% stenosis of left carotid artery • Urgent referral to vascular surgery • Seen in vascular outpatients 2 days later and arranged for urgent admission • Carotid stenting 2 weeks after stroke

32. Out of stroke unit by 10 days • Out after carotid intervention by 2 weeks after stroke • On treatment with • Aspirin • Dipyridamole • Simvastatin • Perindopril • Bendroflumethiazide

33. Cholesterol 3.2 • Blood pressure 128/76 • Stopped smoking • Complete recovery • Minimal ongoing risk

34. With a coordinated approach from • Ambulance service • Primary care • Emergency care • Stroke service • Vascular surgeons • We can do this

35. And save money