The Prevention and Management of Stroke by pptfiles



  In a nutshell
 The Prevention and
Management of Stroke

  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
   Third most common cause of death, 30%
    mortality at one month most die within first
    10 days
        Size of the Problem

   85% of the strokes infarcts

   15% haemorrhagic
          Size of the Problem

   Biggest cause of long term disability
   Though 65% of survivors can live
   35% are significantly disabled of these
    5% need residential care
                 Risk Factors

   Poor diet(Salt and fat intake too high, not
    enough fruit and vegetables)
   Low level of physical activity
   Alcohol misuse
   Smoking
        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,
     Transient Ischaemic Attack(TIA)

Definition:Focal neurological 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

Refer for specialist assessment
Use ABCD2 Score to stratify
    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
     ABCD2 Score for Transient
        Ischaemic Attack

   Score 1-3: Low risk
   Score 4-5: Medium risk
   Score >5 :High risk
    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
Management(TIA)Risk Factors

   Hypertension         Alcohol
   Coronary Heart       Atrial Fibrillation
    Disease              Family history
   Diabetes
                         Migraine
   Hyperlipidaemia
   Current smoker
          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
            Investigations 2
                 As appropriate

   ECG
   Echocardiograph
   Carotid Doppler
   CT head
   MR head and angiogram
    Auto-antibody screen
   Thrombophilia screen
   Aspirin
   Clopidogrel

Add ons
 Dipyridamole

 ? Clopidogrel

   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
Anticoagulation in (AF)

          Carotid Stenosis

Symptomatic 70-99% stenosis benefits
 from carotid endarterectomy ARR 6.7%
 NNT 15 over 3 years

   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

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

   Focal neurological symptoms and signs
    of sudden onset which persists for
    more than 24 hours.
   Diagnosis is primarily clinical
Fast Test for Stroke
       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)
1.    Asymetrical facial weakness Yes (+1) No (0)
2.    Asymetrical arm weakness Yes (+1) No (0)
3.    Asymetrical leg Weakness Yes (+1) No (0)
4.    Speech disturbance              Yes (+1) No (0)
5.    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.
               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
                 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
             Stroke Care
How in hospital: Rehab Stroke Units

NNT 9-16
 Stroke Care
Stroke Units(evidence)
                 Stroke Care
                Stroke Assessment
   Good history and clinical examination
   Investigations to confirm diagnosis
   Risk factors
   Multidisciplinary assessment
               Stroke Care
          Neurological Examination
   Power
   Sensation
   Visual fields
   Visuo-spatial disturbance
   Speech
   Swallowing
               Stroke Care
           Clinical Classification
   TACS=Total Anterior Circulation Stroke
   PACS=Partial Anterior Circulation Stroke
   LACS=Lacunar Stroke
   POCS=Posterior Circulation Stroke
       Stroke Classification
   Hemi-motor and sensory deficit
   Hemianopia
   Cortical Dysfunction
              a) Dysphasia or
              b) Visuo-spatial disturbance
           Stroke Classification
Any two of the following
   Hemi-motor and sensory deficit
   Hemianopia
   Cortical Dysfunction
                  a) Dysphasia or
                  b) Visuo-spatial disturbance
         Stroke Classification

   Pure motor hemiplegia
   Pure sensory loss
   Motor and sensory loss
         Stroke Classification

   Vertigo
   Diplopia
   Ataxia
   Isolated hemianopia
       Stroke Classification
             6month       3 month
             mortality   recurrence
TACS           50%         LOW
PACS           10%         HIGH
LACS            7%         LOW
POCS           14%         HIGH
         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
         Stroke Investigations
   CT head immediately to deliver thrombolysis
    or as soon as possible with view to start
    antiplatelet treatment but no later than 24
   On anticoagulant immediately if haemorrhage
    seen give treatment to reverse
   Chest X-ray if cardiac or chest disease
    present or suspected
         Stroke Investigations

   Carotid Doppler
   Auto-antibody Screen
   Thrombophylia Screen
   Echocardiograph
   Coagulation Screen
               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
                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
                Stroke Care
            Multidisciplinary Team



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

   Nutritional status
   Cognitive impairment
   Communication
   Moving and handling
  Stroke Care(Rehabilitation)

Using protocols
 Continence

 Nutrition

 Shoulder pain

 Discharge planning
    Stroke Care(Rehabilitation)

                Goal Setting

   Must involve patient
   Family if appropriate
    Stroke Care(Rehabilitation)
            Carers and Families

   Give information on nature of stroke
    and treatment available
   Assess and reduce stress
   Give individual psychological support
  Stroke Care(Rehabilitation)
               Ongoing Care
 Once patient can transfer from bed to
  chair specialist stroke teams are
  effective in any of the following settings
 Home

 Day hospital

 Nursing Home

 Residential Home
            Stroke Care
        Secondary Prevention
    As for Transient Ischaemic Attack (TIA)
   Lifestyle (diet,exercise, smoking, alcohol)
   Antiplatelets
   Anticoagulation in AF
   Carotid Stenosis
   Hypertension
   Metabolic Diseases(diabetes, cholesterol,

To top