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Acute Stroke Acute Stroke ●

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Acute Stroke Acute Stroke ● Powered By Docstoc
					              Acute Stroke
●   A Neurological Emergency
               Acute Stroke
●   Show stroke is an emergency

●   Discuss stroke subtypes

●   Appropriate investigations
                   Acute stroke
●   Benefits of treatment

●   Acute therapy
       inpatient and outpatient

●   Prevention
       primary and secondary
              Acute Stroke
●   Common
●   Serious
●   Preventable
●   Treatable
                  Acute Stroke
●   Medical Emergencies
       Rapid onset
       Poor prognosis
       Need for prompt treatment
                  Acute Stroke
              A Medical Emergency
●   Comes on quickly
●   Poor prognosis
       12% mortality at 7 days
       19% at 30 days
       31% at one year
●   Needs urgent treatment
       TIME = BRAIN
                  Is it a Stroke?
●   Focal Signs
●   Negative symptoms
●   Sudden onset
●   Appropriate context
       Older age group
       Vascular risk factors
           What kind of stroke?
●   TACI
●   PACI
●   LACI
●   POCI
OXFORDSHIRE COMMUNITY STROKE
  SUBCLASSIFICATION SYSTEM
●   TACI
       Large cortical stroke
       MCA +/- ACA territories
       Higher cerebral dysfunction
         ●   Dysphasia
         ●   Acalculia
         ●   Neglect
       AND
         ●   Hemianopia
       And
         ●   2/3 of face/arm/leg
OXFORDSHIRE COMMUNITY STROKE
  SUBCLASSIFICATION SYSTEM
●   PACI
       2 out of 3 of TACI
       OR
         ●   motor/sensory deficit more restricted than LACI
       OR
         ●   Higher centre dysfunction alone
OXFORDSHIRE COMMUNITY STROKE
  SUBCLASSIFICATION SYSTEM
●   LACI
       Pure motor stroke
       Pure sensory stroke
       Sensorimotor stroke
       Ataxic hemiparesis
       Dysarthria-clumsy hand syndrome
OXFORDSHIRE COMMUNITY STROKE
  SUBCLASSIFICATION SYSTEM
●   POCI
       Ipsilateral cranial nerve lesion with contralateral
        motor/sensory deficit
       Bilateral motor/sensory deficits
       Conjugate gaze palsy
       Pure cerebellar deficit
       Isolated homonymous visual field defect
                   Investigations
●   Is it a stroke?
       Difficult in 1st 6 hours
●   Type of stroke dictates investigations and
    their urgency
                 Investigations
●   CT
       Fast
       Reliable
       Available
       Differentiates between ICH and ischaemic stroke
       May show alternate diagnosis
                    Investigations
●   CT
       When?
       As soon as practicable for most patients
         ●   Haemorrhagic transformation and primary ICH can be
             difficult to differentiate
              Investigations
●   ECG
●   FBC
●   Renal function
●   BGL
●   ESR or CRP
●   Cholesterol
                   Investigations
●   TACI
       Few needed
●   LACI
       As above
●   POCI
       As above
●   PACI
       Carotid duplex
       Possibly TOE
        Emergency Management
●   Dr Christopher Trethewy
       Trelawney – the unofficial Cornish anthem
Acute stroke treatment
         Acute Stroke Treatment
●   Does the patient qualify for thrombolytic
    therapy?
       Clearly defined time of onset
       Less than 3 hours
       No contraindications to thrombolysis
       Stroke not too mild nor too severe
●   DIRECTLY TO ED, DO NOT PASS GO
       Acute Stroke Treatment
●   Recombinant tissue plasminogen activator
●   Given within 3 hours
●   To patients with appropriate stroke and CT
●   REDUCES DEATH and DISABILITY at 3/12
●   NNT 18
●   NNH 34
         Acute Stroke Treatment
●   rTPA
       Expensive
       5% of strokes
       High risk of harm if not ideal subjects
         Acute Stroke Treatment
●   Stroke Units
       Coordinated, goal directed rehabilitation
       Oxygenation
       Fever management
       Early mobilization
       BGL management
       PATHWAYS DON'T HELP
         Acute Stroke Treatment
●   Aspirin
       Started within 48 hours
       Reduces death, disability, recurrent stroke
       Improves recovery
       NNT 111
       NNH
         ●   2 ICH per 1 000
         ●   4 bleeds per 1 000
         Acute Stroke Treatment
●   BP reduction
       Possibly harmful early
●   Neuroprotection
       No proven benefit to date
                    Prevention
●   BP lowering
       Possibly ACE-I esp in diabetes
●   Smoking cessation
●   Lipid lowering (maybe)
●   Anticoagulation for Afib if other risk factors
●   Aspirin if other vascular disease
         Secondary prevention
●   Aspirin (and modified release dipyridamole)
●   Anticoagulation if Afib
●   CEA if symptomatic stenosis >70%
●   BP lowering
●   Smoking cessation
●   Lipid lowering
         Stroke: an emergency
●   Early hospitalisation if moderate stroke
●   Aspirin within 48 hours if not for TPA
●   Stroke Unit
●   Aspirin plus vascular risk management

				
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posted:7/26/2011
language:English
pages:51