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Stroke. Mark Sudlow Consultant and Senior Lecturer Stroke Northumbria/NHCT/University of Newcastle. Money talks. NAO estimates of cost of stroke £7 billion annually Of which £2.2 billion are direct costs to NHS Cf £1.9 billion for coronary heart disease

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stroke

Stroke

Mark Sudlow

Consultant and Senior Lecturer

Stroke Northumbria/NHCT/University of Newcastle

money talks
Money talks
  • NAO estimates of cost of stroke £7 billion annually
    • Of which £2.2 billion are direct costs to NHS
    • Cf £1.9 billion for coronary heart disease
  • Incidence the same as coronary heart disease – but greater associated disability
  • Recommend ways to save money
  • DOH obliged to make formal response via Public Accounts Committee
  • NAO to review progress
nao recommend
NAO Recommend
  • Faster access to specialist care for patients with TIA
    • High risk on same day
    • Lower risk within a week maximum
  • Faster access to specialist stroke care
    • Acute stroke units
    • Early scanning – 24 hours maximum
    • Thrombolysis - ?10% target and timed benchmarks for onset to needle
  • Better long term care provision
response from doh
Response from DOH
  • Stroke is no longer under Elderly or Long Term Conditions but under Vascular Disease
  • Working parties set up to look at recommendations on changing provision of care
  • NICE asked to fast track guidelines
  • Intercollegiate Acute Stroke and TIA Guidelines
transient ischaemic attack

Transient Ischaemic Attack

High early risk and effective early treatment

risk in transient ischaemic attack
Risk in Transient Ischaemic Attack
  • Risk of completed stroke within a week = 10%
  • Risk > 20% if
    • More than one TIA in 7 days
    • 3 or more of
      • BP > 140/90
      • Unilateral weakness of speech disturbance
      • Duration > 60 mins
      • Diabetes
  • The unstable angina of the brain
effective treatment
Effective treatment
  • Aspirin 75 mg od – reduces risk by 25%
  • Dipyridamole MR 200mg bd – reduces risk by further 20% when added to aspirin
  • Cholesterol reduction
  • Blood pressure reduction
  • Smoking
  • Exercise
  • Alcohol
what to do
What to do ..
  • Identify high risk patients and refer for urgent admission
    • More than one TIA in 7 days
    • 3 or more of
      • BP > 140/90
      • Unilateral weakness of speech disturbance
      • Duration > 60 mins
      • Diabetes
  • Refer lower risk patient urgently to TIA clinic
  • Start aspirin and consider dipyridamole
what we will do
What we will do ..
  • Admit high risk patients
    • Start treatment
    • Arrange urgent imaging
    • Refer to vascular surgery – where they will be seen within a couple of days
  • See lower risk patients within a week of referral
    • Start treatment
    • Information
    • Lifestyle advice
    • Arrange imaging
    • Refer to vascular surgery – where they will be seen within two weeks
acute stroke

Acute Stroke

FAST response allows life saving treatment

evidence for specialist care
Evidence for specialist care
  • Clear evidence that hospitalisation and treatment by a coordinated specialist team improves mortality and outcome
    • Absolute improvement of 10%
  • Increasing evidence that early specialist care is the key
evidence for early aspirin
Evidence for early aspirin
  • 1% absolute reduction in recurrence and mortality if given within 24 hours
  • Requires CT scan to exclude haemorrhage
evidence for thrombolysis
Evidence for thrombolysis
  • Within 3 hours of onset of symptoms
  • With CT scan showing no haemorrhage
  • 10% absolute improvement in number of patients with minimal disability
what to do1
What to do ..
  • If a patient presents or calls with symptoms suggesting acute stroke
  • Call an ambulance
what we will do1
What we will do..
  • If a patient presents with stroke within thrombolysis window
    • Immediate referral to stroke specialist
    • Immediate scanning
    • Thrombolysis
  • If a patient present outside that window
    • Admit to specialist stroke ward
    • CT scan within 24 hours
    • Preventative treatment started early
    • Coordinated specialist assessment and rehabilitation
    • Information
    • Lifestyle advice
secondary prevention

Secondary Prevention

Need for risk reduction as for any high risk vascular disease

With a few minor additions

slide18
Risk of MI, cardiac death and further stroke is similar to after MI
  • Strategies are broadly similar
slide19
Aspirin
  • Statin
  • Blood pressure – best evidence is for ACE and thiazide
stroke specific
Stroke specific
  • Dipyridamole MR 200 mg bd for at least 2 years
  • Risk of further stroke is particularly high with atrial fibrillation
    • 15% absolute per annum
    • Benefits of warfarin highest in this group
  • Risk of further stroke is particularly high with carotid stenosis
    • Carotid ultrasound and intervention if good recovery
    • Particularly important in partial anterior circulation strokes
what to do2
What to do ..
  • Annual check
    • Antiplatelets
    • Blood pressure
    • Cholesterol
    • Lifestyle
what we will do2
What we will do ..
  • Arrange ongoing rehabilitation
  • Outpatient check at 6 weeks (as an inpatients if not discharged)
  • Outpatient check at six months
life after stroke

Life After Stroke

Isolation and Dependency

slide24
Information
  • Inclusion of function and mood in annual screening
  • Access to social services and rehabilitation review
presentation
Presentation
  • 64 year old man
  • Sudden onset at 11 am of
    • Complete loss of speech
    • Total paralysis of right arm and leg
  • Called GP surgery
    • Advised to call 999 ambulance
  • Arrives hospital 11.28
    • No speech
    • Right hemianopia
    • Right face, arm and leg paralysis
slide29
CT scan 12.00
  • Thrombolysis 13.00
  • Statin that night
  • Aspirin and dipyridamole start the next day
slide31
Carotid doppler on day 7
  • 95% stenosis of left carotid artery
  • Urgent referral to vascular surgery
  • Seen in vascular outpatients 2 days later and arranged for urgent admission
  • Carotid stenting 2 weeks after stroke
slide32
Out of stroke unit by 10 days
  • Out after carotid intervention by 2 weeks after stroke
  • On treatment with
    • Aspirin
    • Dipyridamole
    • Simvastatin
    • Perindopril
    • Bendroflumethiazide
slide33
Cholesterol 3.2
  • Blood pressure 128/76
  • Stopped smoking
  • Complete recovery
  • Minimal ongoing risk
slide34
With a coordinated approach from
    • Ambulance service
    • Primary care
    • Emergency care
    • Stroke service
    • Vascular surgeons
  • We can do this
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