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Stroke diagnosis. Caroline Lawson Consultant Nurse - stroke. Aims & objectives. Overview of stroke & TIA Key risk factors Initial treatment plan Case studies. The impact on the future.

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stroke diagnosis

Stroke diagnosis

Caroline Lawson

Consultant Nurse - stroke

aims objectives
Aims & objectives
  • Overview of stroke & TIA
  • Key risk factors
  • Initial treatment plan
  • Case studies
the impact on the future
The impact on the future
  • Due to the demographic composition of the population, although mortality is reducing, the overall incidence of stroke is likely to rise over the next 20 years
  • It is estimated that between 1983 and 2023, there will be a 30% increase in first ever strokes
  • This is going to have a major impact on service provision and should be influencing service development now
types of stroke
Types of Stroke

Ischaemic

Haemorrhagic

slide6
TIA
  • A syndrome of
    • sudden onset
    • focal neurological deficit
      • Loss or decrease power
      • Loss or altered sensation
      • Speech difficulty
      • Loss of vision
      • Loss of balance or dizziness
    • lasting less than 24 hours
    • Vascular origin
amaurosis fugax
Amaurosis Fugax
  • Painless visual loss in one eye that is secondary to retinal ischaemia
what happens post stroke
What happens post stroke

Infarct or Haemorrhage

Core Ischemic Zone Ischaemic Penumbra

↓ ↓

Blood flow severely depleted Blood flow moderately depleted

↓ ↓

Oxygen & glucose depleted Collateral circulation supplies

↓ ↓

Necrosis of neurons & if no reperfusion = necrosis

glial cells

slide12

Diffusion-weighted imaging

TIA

Major stoke

Minor stroke

risk factor modification
Factor

Hypertension (raised blood pressure)

Smoking

Diabetes

Blocked carotid artery

Raised cholesterol

Atrial fibrillation ( irregular heart beat)

Risk reduction with treatment

38%

50% within one year; baseline after 5

years

44% reduction with tight blood pressure

control in patients with diabetes and

hypertension

50%

20-30% with statins in patients with

known CHD

68% when treated with warfarin

Non-modifiable:Age, gender, race/ethnicity, heredity

Risk factor modification
risk of recurrent stroke
Risk of Recurrent Stroke
  • People who have already suffered an ischemic stroke or TIA are at highest risk of a second stroke or death
  • Approximately 17% of strokes are second strokes
  • Second stroke risk is highest in the 7 daysfollowing the event

American Heart Association. Heart Disease and Stroke Statistics 2003 update.

Sacco RL et al. Stroke. 1998; 29(10): 2118-24.

German Stroke Databank.

cumulative risk of stroke after tia
Cumulative risk of stroke after TIA

14

2002-2004

1981-1984

12

10

8

Risk of stroke (%)

6

4

2

0

0

7

14

21

28

Days

Lancet 2005; 366: 29-36

slide16
HRT

Women have a lower risk of CVE than men but the risk rises post menopause

HRT increases risk by 30%

CVE – 20% increased risk

Venous thrombotic event – 50%

Dual HRT – doubles risk of VTE

primary stroke prevention through risk factor modification
Primary stroke prevention throughrisk factor modification

A

246,500

B

61,500

Key

A = Hypertension

B = Cigarette smoking

C = Atrial fibrillation

D = Heavy alcohol use

E = Hypercholesterolaemia

C

47,000

D

23,500

E

100,000

0

100,000

150,000

200,000

50,000

Estimated potential number of strokes prevented out of a total of 500,000

strokes annually in the USA

slide18

30

Non-fatal stroke

Non-fatal myocardial infarction

Non-fatal acute peripheral vascular events

20

Rates per 1000 population per year

10

0

< 35

35 - 44

45 - 54

55 - 64

65 - 74

75 - 84

≥ 85

Age (years)

Age-specific rates of non-fatal stroke vs myocardial infarction vs acute PVD events in OXVASC

Lancet 2005; 366: 1773-83

stroke in young adults
Stroke in young adults
  • Cardiac problems – hole in heart
  • Clotting problems / sickle cell
  • Illicit drugs
slide20
Heroin –
      • Slows respiratory rate, Slows heart rate
      • Lowers blood pressure
      • Infective endocarditis
  • Cocaine –
      • Narrows blood vessels – rise in BP
      • 23 fold increase in risk of heart attack in hour post use
      • Long term BP alteration causes atheroma build up – resulting in coronary artery disease
      • US – 1 in 4 of all MI in age group of 18-45 linked to cocaine use

Quereshi et al 1999 Circulation 99:2731-41

slide21
Amphetamine
      • Adrenaline-type effect on body –
      • Increases heart rate
      • Increases BP – risk of Stroke
      • Alters electrical activity of heart – arrthymia
  • Ecstasy
      • Related to amphetamine
      • Sudden arrthymia
      • Risk of Stroke
slide22
Glue / Solvents
      • Heart rhythm disturbances – causing sudden death
      • Cardiomyopathy
  • Cannabis
      • low dose - Fast heart rate
      • large dose - Slow heart rate , lower blood pressure
      • Risk of sudden death (no associated other cause)
      • Heart attack - 4 fold higher within the hour following cannabis use

Mittleman et al 2001 Circulation 103: 2805-9

secondary prevention
Secondary prevention

General population: Smoke 27% Obese 25% Alcohol 28% Exercise 70%

QOF in N Ireland:

Anticoag of AF : 90% patients

BP < 150/90 : 70%

Chol < 5 : 60%

Antiplat for TIA/ Stroke: 90%

link between ed atherosclerosis
Link between ED & atherosclerosis
  • 39% - 59% of men with heart disease experience ED
  • Atherosclerosis affects main vessels and peripheral arteries
  • Penile arteries 1- 2mm in diameter.
  • Carotid arteries 5 -7 mm
  • Plaque build up can show as chronic problem
  • ED 3 times more likely to have a stroke than those without ED
ed atherosclerosis
ED & atherosclerosis
  • Montorsi et al 2006:

93% of pts with ED and CAD - ED came before the CAD symptoms an average 2 years earlier

  • 2003: N = 300 Prevalence of ED 49%
  • Of these 67% developed ED 3 years prior to A C S
  • Moderate to severe ED (not mild)
  • 10yr relative risk of CAD increased by 65%
    • Stroke 43%
drugs with s e of impotence
Spironolactone

Doxazosin

Indapamide

Bendroflumethiazide

Felodipine

Amlodipine

Nifedipine

Enalapril

Darifenacin

Nebivolol

Lansoprazole

Atrovastatin

Ramipril

Lisinopril

Gabapentin

Amioderone

Omeprazole

Ranitidine / Cimetidine

Carbamazipine

Haloperidole

Drugs with S.E. of impotence
typical stroke mimics
Typical stroke mimics
  • Seizures 24%
  • Syncope 23%
  • Sepsis 10%
  • Somatisation 7%
  • Migraine 6%
  • Labyrinthitis 4%
  • Tumour 3%
  • Low BM 3%
slide30

BP:___/____

GCS: ____

BM:____

If BM <3.5 mmol/L treat & reassess when normal

Has there been loss of consciousness or syncope?

Has there been seizure activity?

Is there NEW ACUTE onset – or on waking from sleep?:

1. Asymmetric facial weakness

2. Asymmetric hand weakness

3. Asymmetric arm weakness

4. Asymmetric leg weakness

5. Speech disturbance

6. Visual field defect

Y (-1)

Y (-1)

Y (+ 1)

Y (+ 1)

Y (+ 1)

Y (+ 1)

Y (+ 1)

Y (+ 1)

N (0)

N (0)

N (0)

N (0)

N (0)

N (0)

N (0)

N (0)

If score totals > 0 assume diagnosis of Stroke

If score 0, -1 or -2 stroke diagnosis is unlikely but not excluded. Patient should be discussed with Stroke Physician or Stroke Nurse Consultant if stroke diagnosis still thought to be likely

slide40
Loss or decrease power
  • Loss or altered sensation
  • Speech difficulty
  • Loss of vision
  • Loss of balance or dizziness
lacunar strokes
Lacunar Strokes
  • Likely to present in TIA clinic
  • Account for 25% of all strokes
  • <1.5-2cm diameter
  • 20% due to embolic pathology
  • Different epidemiology than most strokes therefore low risk of early reoccurrence, mortality
  • > likely to have intrinsic SVD ? Vasospasm, microatheroma leading to occlusion, endothelical dysfunction or leak leading to oedema
secondary prevention44
Secondary prevention

Antiplatelet

  • Relative risk reduction of 18%
  • Adding MR dipyridamole RRR ↑ 37%
  • Clopidogrel
anticoagulation warfarin
Anticoagulation (Warfarin)
  • Should be started in every patient in AF unless contraindicated
  • RRR in secondary prevention of 66% v placebo
  • Should not be started until haemorrhage excluded, and 14 days have passed since onset of symptoms
  • Should also be considered if the IS stroke is associated with mitral valve disease or prosthetic heart valves
slide47
Cholesterol Reduction
  • Evidence suggests the lower the cholesterol the better
  • All patients should be advised to reduce saturated fat in their diet
  • RCP recommend treatment with a statin for patients with total cholesterol >3.5mmol/L
  • Different patients require different therapies
carotid endarterectomy
Carotid endarterectomy
  • Carotid ultrasound should be performed on any patient considered for carotid endarterectomy
  • Surgery would be considered where carotid stenosis is greater than 70%
  • Smoking cessation
  • Reduction in alcohol intake
  • Healthy diet & weight reduction
carotid artery stenosis
Carotid Artery Stenosis

External Carotid

Stenosis at bifurcation of Internal Carotid

Common Carotid

benefit from carotid surgery number of strokes prevented by 100 operations
Benefit from carotid surgerynumber of strokes prevented by 100 operations

Severity of narrowing

Delay to surgery Severe Moderate

Less than 2 weeks: 32 15

2 – 4 weeks: 16 3

4 – 12 weeks: 10 0

More than 12 weeks: 8 -3

Lancet 2004; 363: 915-24

slide53

Rapid treatment of symptomatic patients

No. of Strokes prevented per 1000 CEAs at 3 years

adapted from

Rothwell 2004

time from last event to randomisation

tia clinic
TIA clinic
  • Treat seriously – regardless of duration of symptoms
  • Investigate & treat – quickly
  • Driving -same laws as with a stroke

- For multiple TIAs 3 months cessation rather than 1 month

cumulative risk of stroke after tia55
Cumulative risk of stroke after TIA

14

2002-2004

1981-1984

12

10

8

Risk of stroke (%)

6

4

2

0

0

7

14

21

28

Lancet 2005; 366: 29-36

Days

slide57

Patient admitted with a diagnosis of TIA

Symptoms lasting >6 hours or residual symptoms

Symptoms TOTALLY resolved

Refer to medical team

Take blood

ECG

CXR

Admit for CT

In hours:

Refer to CL – Consultant Stroke Nurse (bleep 2826)

Refer to DG - research Nurse (bleep 2556)

If scanned and assessed safe for discharge (social and medical):

CT normal or infarct

Give Aspirin 300mg stat

Daily Aspirin 75mg & Dipyridamole 200mg MR BD

Simvastatin 20mg if Cholesterol > 5

Patient info leaflet

Advice not to drive one month

Refer to TIA clinic. (fax form)

Patient will be seen within one 7 days

ABCD Score < 4

ABCD Score 4 or more

Refer to KAR or on call medical registrar:

Consider in-patient CT scan

If seen & for discharge:

Take bloods / investigations

Stat Aspirin 300mg

Continue Aspirin 75mg until clinic

Patient info leaflet

Advice not to drive 1/12

Refer to TIA clinic. (fax form)

Patient will be seen within 7days

Discharge home:

Take bloods / Investigations

Stat Aspirin 300mg

Continue Aspirin 75mg until clinic

Patient info leaflet

Advice not to drive for one month

Refer to TIA clinic. (fax form)

Patient to expect wait of 1-2 weeks

slide59
Age 46
  • Onset : Sudden
  • Outcome : organ transplant
75 year old 2 hours post symptoms of left sided weakness
75 year old. 2 hours post symptoms of left sided weakness

NIHSS – 13

Sensation

Partial facial weakness

Left sided weakness

Partial hemianopia

GP wife

Haematologist son

24hrs later
24hrs later

NIHSS = 1

Mild facial weakness

Discharged home Day 5

Entered into CLOTs

Risk factors not identified

slide64
Deterioration:
  • Mild GI Bleed
  • Dropped GCS
  • Rescan 11.00
  • Care of Dying pathway. Died that evening
  • Family request donation to ITU
history 77 y old found collapsed at his nursing home 2 hours earlier
History: 77 y old found collapsed at his nursing home 2 hours earlier.

F.

R

L

Farrall, Kane, Wardlaw

further history 24 hrs later gcs fell partial seizure activity r arm and r face eyes deviated r

BASP CT Training

Further History: 24 hrs later, GCS fell: partial seizure activity R arm and R face; eyes deviated R.

R

L

Farrall, Kane, Wardlaw

44 year old
44 year old
  • Fit & healthy
  • Marathon runner
  • Multiple TIAs
17 year old
17 year old
  • left sided weakness
  • Sudden onset
47 year old male
47 year old male
  • Smoker
  • Low social situation
  • Aphasia & dyspraxia
54 year old
54 year old
  • TIA previous week
  • Carotid duplex NAD
  • Out of area
  • Progressive RHS weakness
  • Echo NAD
money
MONEY

£105 million over 3 years

£32m NHS

£45m local authority

£12m public awareness

£16m training & education

public awareness
Public awareness
  • 60% general public unable to recognise 3 symptoms of stroke
  • 30% would call 999
  • 50% GPs would refer to A&E immediately

Stroke Association

Re TIA: 33% seen within 1 week. If increase to review in 24 hours then reduce risk of CVE by 18%

£12 million / 3 years for increased national awareness

summary
Summary
  • Stroke is becoming a greater problem – increased costs with relatively poor outcomes
  • Early diagnosis & treatment is essential
  • CT scans can give false normal results
  • Identification of underlying cause is not always possible
  • Not just what happens to the elderly
  • Now is the “time” for stroke – there is £££
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