logging in or signing up Stroke 06 001 Maurizio Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINTLite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 859 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: February 04, 2008 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Slide1: Age-Related Health Care Adelaide and Meath Hospital Dublin incorporating the National Children’s Hospital Dept of Medical Gerontology Trinity College DublinStroke in Ireland: Stroke in Ireland Kills more people than breast cancer, lung cancer and bowel cancer combinedStroke is…...: Stroke is…... a focal or global neurological deficit of presumed vascular origin lasting more than 24 hours or causing death within 24 hoursA TIA is…...: A TIA is…... a focal or global neurological deficit of presumed vascular origin lasting less than 24 hoursStroke burden: Stroke burden 9,250 acute strokes/year 25% die in first year 30,000 with residual disability 48% hemiparesis 22% cannot walk 24-53% need help in ADLs 12-18% aphasicImpact: Impact Personal: “..more impact than my wedding, or the birth of my first child” 2nd most expensive illness Most common cause of acquired physical disability Most expensive single DRG medicallyBiggest advance in Stroke Care: Biggest advance in Stroke Care Not, not, notStroke Units: Stroke Units Reduce death, disability, institutionalization Reduce death and disability by 25% NNT 33 to save a death 20 to regain independence 20 to prevent institutionalize Save 2-11 days hospital If this were a tablet……….. Cochrane 2005Stroke Units: Stroke Units Direct care of a specialist in stroke care and interdisciplinary team Clearly defined continuum of care Geographical unit preferable CT/MRI on site Main base general hospital Take all patients referredSlide10: Hospital nurses3 tasks: 3 tasks Was it a stroke? What did the stroke cause? Cognitive impairment Dysphagia Gait disorder Sensory Inattention What caused the stroke?Slide13: Vulnerable Tissue: Work Fast!Brain attack: Brain attack ABC Diagnosis Stabilize BP, O2, Temp, glucose Swallow Positioning Stroke ServiceHistory: History Patient Collateral/witnessCincinnati Prehospital Stroke Scale: Cincinnati Prehospital Stroke Scale Facial droop Arm drift Speech4 level neuro Ax: 4 level neuro Ax End of the bed Alertness (GCS), language, cognition Classical neuro examination Cranial nn PTCS Reflexes ‘Parietal’ signs Inattention/neglect Agnosia ApraxiaDifferential: Differential Tumour Meningitis/encephalitis Seizure Epilepsy Migraine Metabolic causes MSTIA’s: TIA’s 38% 'true' TIA 10% had migraine 9% had faints 9% had possible TIAs, 9% had 'funny turns’ 6% had epilepsy 6% had vertigo 0.8% had hypoglycaemia 0.4% had brain tumours ABCD of TIA treatment: ABCD of TIA treatment 10% stroke risk within one week: 30% if high score ABCD Score Age - >60 = 1 Blood Pressure - Syst > 140 or Diast > 90 = 1 Clinical Motor = 2 Speech = 1 Duration > 1 hour = 2 10-59 min = 1 Rothwell, Lancet 2005Urgent investigations: Urgent investigations Glucose FBC U + E ECGUrgent CT: Urgent CT Head injury Suspicion sub-arachnoid Headache Meningism Neurological deterioration Possibility of thrombolysisBP: BP Ischaemic stroke - dangerous to treat if not > 220/140 Sub-arachnoid - neurology advice - nimodipine and normal blood pressureStabilize: Stabilize Keep euglycaemic Antipyretics for pyrexia O2: avoid hypoxia NPO until swallow assessed Early advice on positioningFirst 12 hours: First 12 hours Stroke Service Book CTB (within 48 hours) Book other tests as appropriate: Carotid dopplers Holter monitor ECHO ……..Pharmacological: Pharmacological Anti-platelets NSA, Asantin R, clopidrogelStrategies: who can benefit?: Strategies: who can benefit? 150-250 strokes yearly in a Dublin hospital Stroke Unit 100% Aspirin 80% Neuroprotective strategies 90% Thrombolysis 5%iv Thrombolysis: iv Thrombolysis 3 Streptokinase: terminated European r-TPA: no overall change NINDS r-TPA: modest improvementNINDS rt-PA regime: NINDS rt-PA regime Within 3 hours (mean 90 mins) 0.9 mg/kg (max 90mg) 10% bolus 90% over one hour Systolic <185, Diastolic <110 BP managed by algorithmContra-indications: Contra-indications PUD Recent surgery Recent arterial puncture Abnormal coagulation BP not manageable to 185/110 No sign of established stroke on CT - NB difficultCochrane review: Cochrane review Excess of deaths 23% thrombolysis 18% controls Reduction death and disability 45% thrombolysis 51% controls Treat 16 patients to avoid one death/disabilityThe real world....Chiu, Stroke 1998: The real world....Chiu, Stroke 1998 6% receive rt-PA Those who don't: Time 37% ICH 22% Minor/rapidly resolving symptoms 19% Nonstroke Dx 12%Acute treatment: Acute treatment Aspirin LMW Heparin ThrombolysisNeuroprotective: Neuroprotective Nimodipine Glutamate antagonists Na channel antagonists/glycine antagonists Opioid antagonists Antoxidants/Free radical scavengersManagement issues: Management issues Reducing delay Stroke unit approach CT access and expertise (?telemedicine) Neuro-ICUUnmet needs post-stroke: Unmet needs post-stroke 38% no personal contact GP 46% attended DH 79% had health concerns 64% required Rx advice 18% had resumed smoking Martin Scot Med 20026 Months after discharge: 6 Months after discharge 58% in the community 87% had seen GP 48% reviewed in OPD Crowe IMJ 2002Remediable risk factors: Remediable risk factors Smoking Alcohol Exercise Obesity, DM Psychosocial BP Lipids Homocysteine Infections Inflammation, thrombosis Sem Vasc Med 2002, 2, 229-445Fibrinogen: Fibrinogen Adds to likelihood of event Reduce inflammation? Flu vaccine Reduces stroke hospitalization by 16% Nichol NEJM 3 April 2003Healthy lifestyle is anticoagulant and anti-inflammatory: Healthy lifestyle is anticoagulant and anti-inflammatory Weight loss, exercise Reduce vascular inflammation and insulin resistance So, stop smoking, keep walking! Esposito, JAMA, April 9, 2003Slide42: Antithrombotics BP reduction Cholesterol Diet and DM Exercise/rehabilitation Forget smoking/Flu jabsAntiplatelets: Antiplatelets 25% reduction in all events CHD Stroke VTE RevascularizationBP reduction: BP reduction Diuretics and ACE-Inhibitor Primary prevention trials suggest drug equivalence Cave postural symptoms!Statins: Statins All patients with stroke Fire and forget Highest effective dose Simvastatin 40 Pravastatin 40 Atorvostatin 10Carotid endarterectomy: Carotid endarterectomy Carotid territory stroke TIA in last 6 months >70% stenosis (about 5% of our patients) NNT 15 to prevent death or disability over 2-6 years Surgically fit patients Surgeons with <6% complication ratesSlide48: Antithrombotics BP reduction Cholesterol Diet and DM Exercise/rehabilitation Forget smoking/Flu jabs You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Stroke 06 001 Maurizio Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINTLite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 859 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: February 04, 2008 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript Slide1: Age-Related Health Care Adelaide and Meath Hospital Dublin incorporating the National Children’s Hospital Dept of Medical Gerontology Trinity College DublinStroke in Ireland: Stroke in Ireland Kills more people than breast cancer, lung cancer and bowel cancer combinedStroke is…...: Stroke is…... a focal or global neurological deficit of presumed vascular origin lasting more than 24 hours or causing death within 24 hoursA TIA is…...: A TIA is…... a focal or global neurological deficit of presumed vascular origin lasting less than 24 hoursStroke burden: Stroke burden 9,250 acute strokes/year 25% die in first year 30,000 with residual disability 48% hemiparesis 22% cannot walk 24-53% need help in ADLs 12-18% aphasicImpact: Impact Personal: “..more impact than my wedding, or the birth of my first child” 2nd most expensive illness Most common cause of acquired physical disability Most expensive single DRG medicallyBiggest advance in Stroke Care: Biggest advance in Stroke Care Not, not, notStroke Units: Stroke Units Reduce death, disability, institutionalization Reduce death and disability by 25% NNT 33 to save a death 20 to regain independence 20 to prevent institutionalize Save 2-11 days hospital If this were a tablet……….. Cochrane 2005Stroke Units: Stroke Units Direct care of a specialist in stroke care and interdisciplinary team Clearly defined continuum of care Geographical unit preferable CT/MRI on site Main base general hospital Take all patients referredSlide10: Hospital nurses3 tasks: 3 tasks Was it a stroke? What did the stroke cause? Cognitive impairment Dysphagia Gait disorder Sensory Inattention What caused the stroke?Slide13: Vulnerable Tissue: Work Fast!Brain attack: Brain attack ABC Diagnosis Stabilize BP, O2, Temp, glucose Swallow Positioning Stroke ServiceHistory: History Patient Collateral/witnessCincinnati Prehospital Stroke Scale: Cincinnati Prehospital Stroke Scale Facial droop Arm drift Speech4 level neuro Ax: 4 level neuro Ax End of the bed Alertness (GCS), language, cognition Classical neuro examination Cranial nn PTCS Reflexes ‘Parietal’ signs Inattention/neglect Agnosia ApraxiaDifferential: Differential Tumour Meningitis/encephalitis Seizure Epilepsy Migraine Metabolic causes MSTIA’s: TIA’s 38% 'true' TIA 10% had migraine 9% had faints 9% had possible TIAs, 9% had 'funny turns’ 6% had epilepsy 6% had vertigo 0.8% had hypoglycaemia 0.4% had brain tumours ABCD of TIA treatment: ABCD of TIA treatment 10% stroke risk within one week: 30% if high score ABCD Score Age - >60 = 1 Blood Pressure - Syst > 140 or Diast > 90 = 1 Clinical Motor = 2 Speech = 1 Duration > 1 hour = 2 10-59 min = 1 Rothwell, Lancet 2005Urgent investigations: Urgent investigations Glucose FBC U + E ECGUrgent CT: Urgent CT Head injury Suspicion sub-arachnoid Headache Meningism Neurological deterioration Possibility of thrombolysisBP: BP Ischaemic stroke - dangerous to treat if not > 220/140 Sub-arachnoid - neurology advice - nimodipine and normal blood pressureStabilize: Stabilize Keep euglycaemic Antipyretics for pyrexia O2: avoid hypoxia NPO until swallow assessed Early advice on positioningFirst 12 hours: First 12 hours Stroke Service Book CTB (within 48 hours) Book other tests as appropriate: Carotid dopplers Holter monitor ECHO ……..Pharmacological: Pharmacological Anti-platelets NSA, Asantin R, clopidrogelStrategies: who can benefit?: Strategies: who can benefit? 150-250 strokes yearly in a Dublin hospital Stroke Unit 100% Aspirin 80% Neuroprotective strategies 90% Thrombolysis 5%iv Thrombolysis: iv Thrombolysis 3 Streptokinase: terminated European r-TPA: no overall change NINDS r-TPA: modest improvementNINDS rt-PA regime: NINDS rt-PA regime Within 3 hours (mean 90 mins) 0.9 mg/kg (max 90mg) 10% bolus 90% over one hour Systolic <185, Diastolic <110 BP managed by algorithmContra-indications: Contra-indications PUD Recent surgery Recent arterial puncture Abnormal coagulation BP not manageable to 185/110 No sign of established stroke on CT - NB difficultCochrane review: Cochrane review Excess of deaths 23% thrombolysis 18% controls Reduction death and disability 45% thrombolysis 51% controls Treat 16 patients to avoid one death/disabilityThe real world....Chiu, Stroke 1998: The real world....Chiu, Stroke 1998 6% receive rt-PA Those who don't: Time 37% ICH 22% Minor/rapidly resolving symptoms 19% Nonstroke Dx 12%Acute treatment: Acute treatment Aspirin LMW Heparin ThrombolysisNeuroprotective: Neuroprotective Nimodipine Glutamate antagonists Na channel antagonists/glycine antagonists Opioid antagonists Antoxidants/Free radical scavengersManagement issues: Management issues Reducing delay Stroke unit approach CT access and expertise (?telemedicine) Neuro-ICUUnmet needs post-stroke: Unmet needs post-stroke 38% no personal contact GP 46% attended DH 79% had health concerns 64% required Rx advice 18% had resumed smoking Martin Scot Med 20026 Months after discharge: 6 Months after discharge 58% in the community 87% had seen GP 48% reviewed in OPD Crowe IMJ 2002Remediable risk factors: Remediable risk factors Smoking Alcohol Exercise Obesity, DM Psychosocial BP Lipids Homocysteine Infections Inflammation, thrombosis Sem Vasc Med 2002, 2, 229-445Fibrinogen: Fibrinogen Adds to likelihood of event Reduce inflammation? Flu vaccine Reduces stroke hospitalization by 16% Nichol NEJM 3 April 2003Healthy lifestyle is anticoagulant and anti-inflammatory: Healthy lifestyle is anticoagulant and anti-inflammatory Weight loss, exercise Reduce vascular inflammation and insulin resistance So, stop smoking, keep walking! Esposito, JAMA, April 9, 2003Slide42: Antithrombotics BP reduction Cholesterol Diet and DM Exercise/rehabilitation Forget smoking/Flu jabsAntiplatelets: Antiplatelets 25% reduction in all events CHD Stroke VTE RevascularizationBP reduction: BP reduction Diuretics and ACE-Inhibitor Primary prevention trials suggest drug equivalence Cave postural symptoms!Statins: Statins All patients with stroke Fire and forget Highest effective dose Simvastatin 40 Pravastatin 40 Atorvostatin 10Carotid endarterectomy: Carotid endarterectomy Carotid territory stroke TIA in last 6 months >70% stenosis (about 5% of our patients) NNT 15 to prevent death or disability over 2-6 years Surgically fit patients Surgeons with <6% complication ratesSlide48: Antithrombotics BP reduction Cholesterol Diet and DM Exercise/rehabilitation Forget smoking/Flu jabs