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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

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acute stroke
Acute Stroke
  • A Neurological Emergency
acute stroke2
Acute Stroke
  • Show stroke is an emergency
  • Discuss stroke subtypes
  • Appropriate investigations
acute stroke3
Acute stroke
  • Benefits of treatment
  • Acute therapy
    • inpatient and outpatient
  • Prevention
    • primary and secondary
acute stroke4
Acute Stroke
  • Common
  • Serious
  • Preventable
  • Treatable
acute stroke5
Acute Stroke
  • Medical Emergencies
    • Rapid onset
    • Poor prognosis
    • Need for prompt treatment
acute stroke a medical emergency
Acute StrokeA 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
Is it a Stroke?
  • Focal Signs
  • Negative symptoms
  • Sudden onset
  • Appropriate context
    • Older age group
    • Vascular risk factors
what kind of stroke
What kind of stroke?
  • TACI
  • PACI
  • LACI
  • POCI
oxfordshire community stroke subclassification system
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 system10
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 system11
OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION SYSTEM
  • LACI
    • Pure motor stroke
    • Pure sensory stroke
    • Sensorimotor stroke
    • Ataxic hemiparesis
    • Dysarthria-clumsy hand syndrome
oxfordshire community stroke subclassification system12
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
Investigations
  • Is it a stroke?
    • Difficult in 1st 6 hours
  • Type of stroke dictates investigations and their urgency
investigations14
Investigations
  • CT
    • Fast
    • Reliable
    • Available
    • Differentiates between ICH and ischaemic stroke
    • May show alternate diagnosis
investigations15
Investigations
  • CT
    • When?
    • As soon as practicable for most patients
      • Haemorrhagic transformation and primary ICH can be difficult to differentiate
investigations16
Investigations
  • ECG
  • FBC
  • Renal function
  • BGL
  • ESR or CRP
  • Cholesterol
investigations17
Investigations
  • TACI
    • Few needed
  • LACI
    • As above
  • POCI
    • As above
  • PACI
    • Carotid duplex
    • Possibly TOE
emergency management
Emergency Management
  • Dr Christopher Trethewy
    • Trelawney – the unofficial Cornish anthem
acute stroke treatment43
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 treatment44
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 treatment45
Acute Stroke Treatment
  • rTPA
    • Expensive
    • 5% of strokes
    • High risk of harm if not ideal subjects
acute stroke treatment46
Acute Stroke Treatment
  • Stroke Units
    • Coordinated, goal directed rehabilitation
    • Oxygenation
    • Fever management
    • Early mobilization
    • BGL management
    • PATHWAYS DON'T HELP
acute stroke treatment47
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 treatment48
Acute Stroke Treatment
  • BP reduction
    • Possibly harmful early
  • Neuroprotection
    • No proven benefit to date
prevention
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
Secondary prevention
  • Aspirin (and modified release dipyridamole)
  • Anticoagulation if Afib
  • CEA if symptomatic stenosis >70%
  • BP lowering
  • Smoking cessation
  • Lipid lowering
stroke an emergency
Stroke: an emergency
  • Early hospitalisation if moderate stroke
  • Aspirin within 48 hours if not for TPA
  • Stroke Unit
  • Aspirin plus vascular risk management