Slide1: Age-Related Health Care Adelaide and Meath Hospital Dublin incorporating the National Children’s Hospital Dept of Medical Gerontology Trinity College Dublin


Stroke in Ireland: Stroke in Ireland Kills more people than breast cancer, lung cancer and bowel cancer combined


Stroke is…...: Stroke is…... a focal or global neurological deficit of presumed vascular origin lasting more than 24 hours or causing death within 24 hours


A TIA is…...: A TIA is…... a focal or global neurological deficit of presumed vascular origin lasting less than 24 hours


Stroke 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% aphasic


Impact: 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 medically


Biggest advance in Stroke Care: Biggest advance in Stroke Care Not, not, not


Stroke 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 2005


Stroke 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 referred


Slide10: Hospital nurses


3 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 Service


History: History Patient Collateral/witness


Cincinnati Prehospital Stroke Scale: Cincinnati Prehospital Stroke Scale Facial droop Arm drift Speech


4 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 Apraxia


Differential: Differential Tumour Meningitis/encephalitis Seizure Epilepsy Migraine Metabolic causes MS


TIA’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 2005


Urgent investigations: Urgent investigations Glucose FBC U + E ECG


Urgent CT: Urgent CT Head injury Suspicion sub-arachnoid Headache Meningism Neurological deterioration Possibility of thrombolysis


BP: BP Ischaemic stroke - dangerous to treat if not > 220/140 Sub-arachnoid - neurology advice - nimodipine and normal blood pressure


Stabilize: Stabilize Keep euglycaemic Antipyretics for pyrexia O2: avoid hypoxia NPO until swallow assessed Early advice on positioning


First 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, clopidrogel


Strategies: 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 improvement


NINDS 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 algorithm


Contra-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 difficult


Cochrane 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/disability


The 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 Thrombolysis


Neuroprotective: Neuroprotective Nimodipine Glutamate antagonists Na channel antagonists/glycine antagonists Opioid antagonists Antoxidants/Free radical scavengers


Management issues: Management issues Reducing delay Stroke unit approach CT access and expertise (?telemedicine) Neuro-ICU


Unmet 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 2002


6 Months after discharge: 6 Months after discharge 58% in the community 87% had seen GP 48% reviewed in OPD Crowe IMJ 2002


Remediable risk factors: Remediable risk factors Smoking Alcohol Exercise Obesity, DM Psychosocial BP Lipids Homocysteine Infections Inflammation, thrombosis Sem Vasc Med 2002, 2, 229-445


Fibrinogen: Fibrinogen Adds to likelihood of event Reduce inflammation? Flu vaccine Reduces stroke hospitalization by 16% Nichol NEJM 3 April 2003


Healthy 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, 2003


Slide42: Antithrombotics BP reduction Cholesterol Diet and DM Exercise/rehabilitation Forget smoking/Flu jabs


Antiplatelets: Antiplatelets 25% reduction in all events CHD Stroke VTE Revascularization


BP 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 10


Carotid 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 rates


Slide48: Antithrombotics BP reduction Cholesterol Diet and DM Exercise/rehabilitation Forget smoking/Flu jabs