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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 l.jpg

Stroke diagnosis

Caroline Lawson

Consultant Nurse - stroke


Aims objectives l.jpg
Aims & objectives

  • Overview of stroke & TIA

  • Key risk factors

  • Initial treatment plan

  • Case studies


The impact on the future l.jpg
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


What is a stroke l.jpg

A disruption to the blood supply in the brain resulting in the brain not working normally

What is a Stroke?


Types of stroke l.jpg
Types of Stroke the brain not working normally

Ischaemic

Haemorrhagic


Slide6 l.jpg
TIA the brain not working normally

  • 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 l.jpg
Amaurosis Fugax the brain not working normally

  • Painless visual loss in one eye that is secondary to retinal ischaemia


What happens post stroke l.jpg
What happens post stroke the brain not working normally

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 l.jpg

Diffusion-weighted imaging the brain not working normally

TIA

Major stoke

Minor stroke


Risk factor modification l.jpg

Factor the brain not working normally

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 l.jpg
Risk of Recurrent Stroke the brain not working normally

  • 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 l.jpg
Cumulative risk of stroke after TIA the brain not working normally

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 l.jpg
HRT the brain not working normally

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 l.jpg
Primary stroke prevention through the brain not working normallyrisk 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 l.jpg

30 the brain not working normally

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 l.jpg
Stroke in young adults the brain not working normally

  • Cardiac problems – hole in heart

  • Clotting problems / sickle cell

  • Illicit drugs


Slide20 l.jpg

  • Heroin the brain not working normally –

    • 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 l.jpg

    • Amphetamine the brain not working normally

      • 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 l.jpg

    • Glue / Solvents the brain not working normally

      • 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 l.jpg
    Secondary prevention the brain not working normally

    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 l.jpg
    Link between ED & atherosclerosis the brain not working normally

    • 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 l.jpg
    ED & atherosclerosis the brain not working normally

    • 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 l.jpg

    Spironolactone the brain not working normally

    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


    Stroke diagnosis27 l.jpg
    Stroke diagnosis the brain not working normally


    Typical stroke mimics l.jpg
    Typical stroke mimics the brain not working normally

    • Seizures 24%

    • Syncope 23%

    • Sepsis 10%

    • Somatisation 7%

    • Migraine 6%

    • Labyrinthitis 4%

    • Tumour 3%

    • Low BM 3%


    Slide30 l.jpg

    BP:___/____ the brain not working normally

    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


    Agitation and distress l.jpg
    Agitation and distress… the brain not working normally


    Headache l.jpg
    Headache… the brain not working normally


    Nausea and vomiting l.jpg
    Nausea and vomiting… the brain not working normally


    Acute hypertension l.jpg
    Acute hypertension… the brain not working normally


    Cerebral bleed l.jpg
    Cerebral the brain not working normally bleed…


    Confusion l.jpg
    Confusion… the brain not working normally


    Visual disturbances l.jpg
    Visual disturbances… the brain not working normally


    Slide40 l.jpg

    • Loss or decrease power the brain not working normally

    • Loss or altered sensation

    • Speech difficulty

    • Loss of vision

    • Loss of balance or dizziness


    Following confirmation of clinical diagnosis l.jpg

    Following confirmation of clinical diagnosis the brain not working normally


    Slide42 l.jpg

    Brain imaging the brain not working normally

    CT Normal


    Lacunar strokes l.jpg
    Lacunar Strokes the brain not working normally

    • 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 l.jpg
    Secondary prevention the brain not working normally

    Antiplatelet

    • Relative risk reduction of 18%

    • Adding MR dipyridamole RRR ↑ 37%

    • Clopidogrel


    Anticoagulation warfarin l.jpg
    Anticoagulation (Warfarin) the brain not working normally

    • 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 l.jpg

    Cholesterol Reduction the brain not working normally

    • 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 l.jpg
    Carotid endarterectomy the brain not working normally

    • 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 l.jpg
    Carotid Artery Stenosis the brain not working normally

    External Carotid

    Stenosis at bifurcation of Internal Carotid

    Common Carotid


    Benefit from carotid surgery number of strokes prevented by 100 operations l.jpg
    Benefit from carotid surgery the brain not working normallynumber 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 l.jpg

    Rapid treatment of symptomatic patients the brain not working normally

    No. of Strokes prevented per 1000 CEAs at 3 years

    adapted from

    Rothwell 2004

    time from last event to randomisation


    Tia clinic l.jpg
    TIA clinic the brain not working normally

    • 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 l.jpg
    Cumulative risk of stroke after TIA the brain not working normally

    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


    Abcd 2 score l.jpg
    ABCD the brain not working normally2 Score


    Slide57 l.jpg

    Patient admitted with a diagnosis of TIA the brain not working normally

    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


    Case studies example ct scans l.jpg
    Case studies & example CT scans the brain not working normally


    Slide59 l.jpg

    • Age 46 the brain not working normally

    • Onset : Sudden

    • Outcome : organ transplant


    75 year old 2 hours post symptoms of left sided weakness l.jpg
    75 year old. 2 hours post symptoms of left sided weakness the brain not working normally

    NIHSS – 13

    Sensation

    Partial facial weakness

    Left sided weakness

    Partial hemianopia

    GP wife

    Haematologist son


    24hrs later l.jpg
    24hrs later the brain not working normally

    NIHSS = 1

    Mild facial weakness

    Discharged home Day 5

    Entered into CLOTs

    Risk factors not identified


    75 year old 2 hour history nihss 24 l.jpg
    75 year old. 2 hour history. NIHSS 24 the brain not working normally


    Slide64 l.jpg

    Deterioration: the brain not working normally

    • Mild GI Bleed

    • Dropped GCS

    • Rescan 11.00

    • Care of Dying pathway. Died that evening

    • Family request donation to ITU


    Reperfusion the holy grail of acute ischaemic stroke l.jpg
    Reperfusion: the Holy Grail of Acute Ischaemic Stroke the brain not working normally

    Occluded proximal MCA


    History 77 y old found collapsed at his nursing home 2 hours earlier l.jpg
    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 l.jpg

    BASP CT Training hours earlier.

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

    R

    L

    Farrall, Kane, Wardlaw



    89 man severe headache worsening vision decline in mobility69 l.jpg

    BASP CT Training mobility

    89 man - severe headache, worsening vision & decline in mobility

    R

    L

    Farrall, Kane, Wardlaw


    44 year old l.jpg
    44 year old mobility

    • Fit & healthy

    • Marathon runner

    • Multiple TIAs


    17 year old l.jpg
    17 year old mobility

    • left sided weakness

    • Sudden onset


    60 year old female l.jpg
    60 year old female mobility

    • Smoker


    47 year old male l.jpg
    47 year old male mobility

    • Smoker

    • Low social situation

    • Aphasia & dyspraxia


    54 year old l.jpg
    54 year old mobility

    • TIA previous week

    • Carotid duplex NAD

    • Out of area

    • Progressive RHS weakness

    • Echo NAD



    Money l.jpg
    MONEY mobility

    £105 million over 3 years

    £32m NHS

    £45m local authority

    £12m public awareness

    £16m training & education


    Public awareness l.jpg
    Public awareness mobility

    • 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 l.jpg
    Summary mobility

    • 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 £££