Retrospective analysis of Trauma and Orthopaedics TIA & and post- multi Stroke surgery pre5th Year Revision

Trauma Centre status.

Samed Talibi, Vhaid Mushtaq, Osama Aweid, Shahbaz Malik, Deepa Bose

Dr Samed Talibi FY1 Department Mitchell MB BS Trauma and Orthopaedics Capt. James of Hospitals BirminghamMRCP University

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Objectives Revision Stroke and TIA basics Presentation Differentials Risk factors Investigation Treatment Pathophysiology Classification Relevant scoring systems Predominantly drawn out through Cases

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Bottom Line We want you to be effective house-officers in 6 months timeRecognise it

Effective clinical skills

Appropriate initial investigation and management

Know when to request senior help Safe management post stroke (ward cover)
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Bandwagon

Neurophobia

Article in JAMA 1994, Jozefowicz et al.

Endemic amongst medical students and junior doctors

Exposure likely to be the remedy

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Context
5 minutes in England 40 seconds in USA Third commonest cause of death in UK Lifetime risk 1 in 4 men 1 in 5 women (2-3 times higher than breast cancer) 1/3 all strokes in under 65s Largest cause of complex disability in 1/20/13 adults

CASE 1
A 79 year old woman
HPc

Unable to rise up from her bed on waking Weakness of her right arm & leg Confused Atrial fibrillation Hypertension Osteoarthritis Warfarin Amlodipine Ramipril Paracetamol

Mhx

Dhx

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On examination

she is fully conscious difficulty finding words unable to clearly express the course of events mild weakness in the right upper & lower limb

right homonymous hemianopia 1/20/13

What would you do next?

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Investigations to carry out

CT Head

Glucose and electrolytes and LFTS FBC ESR CXR and ECG Carotid doppler Cardiac echo Carotid ultrasound Young stroke screen
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What are you expecting to see on CT Head?

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Acute CT Head

emedici ne 1/20/13

Why do we do CTs?

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CT Head 24hrs+

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A.

If less than 3 hours since onset of stroke symptoms require thrombolysis If greater than 3 hours medical management
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A.

Acute Stroke Management

Thrombolysis of Stroke Intravenous tPA:
1. 2.

3. 4.

5. 6.

More than a minimal neurological deficit Stroke symptoms must be present for at least 30 minutes Not significantly improve before treatment Symptoms must be distinguishable from an episode of generalized ischaemia (i.e. syncope)/seizure/migraine disorder Time of onset <3 hours (At the Moment!) No CT scan evidence of ICH
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Thrombolysis Exclusion Criteria

Rapidly improving neurological signs Systolic blood pressure (SBP) greater than 185 mm Hg or diastolic blood pressure (DBP) greater than 110 mm Hg or aggressive (continuous intravenous) treatment required to lower BP to this range Seizure at stroke onset Symptoms suggestive of subarachnoid haemorrhage Suspected acute pericarditis Stroke or serious head trauma within 3 months Major surgery or serious bodily trauma within 2 weeks History of a prior ICH Intracranial neoplasm Arteriovenous malformation or aneurysm GI or urinary tract hemorrhage within 21 days Arterial puncture at a non-compressible site or lumbar puncture within 1 week Concomitant oral anticoagulant (INR>1.7) Platelet count <100 x 109/L Prothrombin time (PT) >15 (INR >1.7) Activated partial thromboplastin time (aPTT) elevated beyond reference range Glucose <50 mg/dL or >400 mg/dL Positive pregnancy test (in woman of childbearing age) Blood should be sent for type and screen in case transfusions are required

COMMON SENSE APPLIES 1/20/13

Stroke Intervention Early intervention is Essential

Penumbra salvageable with thrombolysis and/or neuro-protective agents Reperfusion injury and ischaemic cascade targeted by neuro-protective agents IV thrombolysis (t-PA) given within 3 hours improves functional outcome and reduces neurological impairment (twice as effective in first 1.5Hrs)
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Medical Acute Stroke Management

Aspirin 300 mg initially and for 2 weeks Then definitive long-term anti-thrombotic treatment -clopidogrel

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Common Stroke Unit Issues - Management

IV fluids avoid 5% Dextrose & excess fluid administration Swallowing Nil orally initially Assessment within first hour! SALT assessment + IV fluids Temporary NG feed if appropriate at 24hrs PEG placement if appropriate (rare!) Try to ensure nutrition in all patients O2 if Sa02 < 94 % Hypertension if >220mmMg, (180 post thrombolysis) GTN infusion Avoid hyperthermia PR/PO Paracetamol if necessary Blood glucose maintain normoglycaemia Statin after 48hrs Antidepressants shown to be useful in stroke related depression late Anticonvulsants where needed
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2 Stroke Prevention

Controlling hypertension Anti-platelet agent Statin Lifestyle changes

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Prognosis & Mortality

The mortality from the acute event is about 20 % Approximately 50 %of patients are alive after five years Death at 1 year

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Primary ICH TACI PACI LACI POCI

62% Worst 60% 16% 11% Least worst 19%

Case 2

80 Yr old man Wife woken in the night by thrashing and fell out of bed Speech disturbance What else in history is important?

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History

90%+ of neurological diagnosis Says it in the name STROKE NEGATIVE symptoms May evolve acutely though consider the differentials
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Examination

The next 9% of neurological diagnosis Formal neurological examination but targeted Involves:

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Specific examination points

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Specific examination points

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Differentials of Stroke

Numerous but there are the usual suspects: SAH Seizure Space occupying lesion Migraine equivalent Venous sinus thrombosis Infective
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Inflammatory

Differentials of Stroke - SAH

emedici ne 1/20/13

Differentials of Stroke - Seizure

Maybe in known epileptic or de-novo Partial versus Generalised Todds Paresis Think about triggers Think about underlying causes

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Differentials of Stroke - SOL

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Differentials of Stroke - Migraine

Mechanism is still unclear May present without headache History critical Positive symptoms/aura
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Differentials of stroke - Acute Venous Stroke

given full- dose anticoagulation treatment (initially full-dose heparin and then warfarin [INR 23]) unless there are comorbidities that preclude its use.

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Differentials of Stroke The Funnies

Lots of rare and esoteric causes

satisfying when diagnosis made but this is very much a process Simply keep an open mind, investigate appropriately, report what you find not what you think you should find
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Example - What do you see?

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Example - What do you see?

You dont always need to give the exact diagnosis or syndrome it is more helpful to describe the signs where complex or unclear

A&E SHO reported 6th nerve palsy A&E SpR reported 3rd MAU SHO reported 4th MAU senior review reverted to 3rd Who was right? Underlying cause?

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Stroke
Defined by WHO as a clinical syndrome consisting of

rapidly developing clinical signs of focal (at times global) disturbance of cerebral function lasting more than 24 h or leading to death no apparent cause other than that of vascular origin

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Case 2

80 Yr old man Wife woken in the night by thrashing and fell out of bed Speech disturbance

So what do we think is happening here?

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Classification

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Stroke (Bamford-Oxford) Classification 1 Total Anterior Circulation Infarct (TACI)

Large cortical stroke in middle / anterior cerebral artery areas

new higher cerebral dysfunction (e.g. dysphasia, visuospatial disorder) homonymous visual field defect ipsilateral motor and/or sensory deficit of at least two areas of face, arm and leg

Partial Anterior Circulation Infarct (PACI)

Cortical stroke in middle / anterior cerebral artery areas
Two of the three components of the TACI syndrome 1/20/13

Stroke (Bamford-Oxford) Classification 2

Posterior Circulation Infract (POCI)

One of 1. Cerebellar or brainstem syndromes 2. Loss of consciousness 3. Isolated homonymous hemianopia

Lacunar Infarct (LACI)

Subcortical stroke due to small vessel disease
One of:

Unilateral weakness (and/or sensory deficit) of face/arm/leg or all three Pure sensory stroke Ataxic hemiparesis

No higher dysphasia or visuospatial or hemianopia or vertebrobasilar 1/20/13 problems

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What was all that really about? Classification helps to direct management and prognostication but also LOCALISATION

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CASE 3 Friday evening 6pm

67 year old, type 2 diabetic, hypertensive Reports episode of left arm weakness, sudden onset that day, 20mins Resolved Neuro NAD, BP 134/88

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What would you do?

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If ABCD2 score > 4 aspirin (300 mg daily) started immediately specialist assessment and investigation within 24 hours of onset of symptoms measures for 2o prevention introduced as soon as the diagnosis is confirmed, including discussion of individual risk factors NICE guidance applies 1/20/13

ABCD2 score for patient

AGE 67 BP 134/88 Clinical weak L arm Duration 20 mins Diabetic Yes TOTAL ABCD2 score

1 0 1 1 1 5

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Risk of stroke after a TIA

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If the patient has AF, how would you calculate their risk factor for a stroke?

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Risk of Stroke with AF - CHADS-VASc

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CHADS-VASc Therapy

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Transient Ischaemic Attack (TIA)

Neurological deficit of presumed vascular origin lasting less than 24 hours Most really last minutes Brain Infarction occurs with ischaemia > 1 hour This is an area that is evolving If there is a deficit on examination at presentation likely a stroke
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TIA Risk

Transient cerebral ischaemia is a sign of impending the risk of a permanent neurological deficit rises dramatically after a patient has experienced a TIA Approximately 60 %of patients with a completed stroke have had premonitory TIAs TIA may be due to low flow with inadequate collateral blood supply embolic TIAs are usually single and more prolonged

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If the patient was having crescendo TIAs?

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Surgical Prevention of Stroke

Carotid stenosis measured by Carotid ultrasound 2 major trials North American Symptomatic Endarterectomy Trial (NASCET) European Carotid Surgery Trial (ECST) Carotid Endarterectomy advocated in fit patients with 70% - 99 % stenosis internal carotid artery Symptoms suggestive of TIA or non- disabling stroke in the corresponding vascular territory
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1 Prevention of Stroke

Most common treatable risk factor Direct relationship BP Stroke 5-6 mmHg drop reduces stroke by 42% Treatment of Systolic HTN in elderly reduced stroke by 37%

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1 and 2 Stroke Prevention and Antiplatelet Therapy

No clear evidence of aspirin in primary prevention of stroke (unlike MI) (not AF) Canadian study 1300 mg aspirin/ day showed 50% reduction in death / stroke in males only Low doses (75 mg, 81 mg) have been suggested to preferentially inhibit platelet TXA2 and not endothelial PGI2 Low doses have been shown to be equally effective MATCH trial ongoing looking at stroke prevention with combination Aspirin + Clopidogrel
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The mortality from the acute event is about 20 percent Approximately 50 percent of patients are alive after five years Irreversible damage begins at immediately at the core The surrounding area (penumbra) may be viable for up to 6 hours Process of stroke injury at cellular level called the ischaemic cascade ATP depletion, Membrane pumps fail, Calcium mediated cytotoxic reactions and release of excitatory neurotransmitters such as glutamate Another target for therapeutic interventions
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Complications Intracerebral Haemorrhage

ICH may be signaled by acute hypertension, headache, neurological deterioration, and nausea or vomiting. If ICH is suspected, obtain an emergent head CT scan and obtain PT, aPTT, platelet count, and fibrinogen. If ICH is present on CT scan, evaluate lab studies and administer, if needed, 6-8 units of cryoprecipitate containing fibrinogen and factor VIII, 6-8 units of platelets, and/or fresh frozen plasma. Seniors/Neurosurgery/Haematology

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1 Prevention of Stroke Overview

Aspirin reduces risk of stroke by 15-20%

Carotid endarterectomy (CEA) should be considered for patients with large vessel atherothrombotic disease in the internal carotid artery that causes low flow or embolic TIAs CEA should be done quickly 1-2/52 Virtually all patients with atrial fibrillation who have a history of stroke or TIA should be treated with warfarin in the absence of contraindications (60% RRR in AF) Falls not as great a risk as traditionally taught
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Final case

20 year old male, student

5 days history of headache associated with nausea and generally unwell

Any other relevant history? Examination? Poor co-ordination Eyes?

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Final case

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Final case
Cerebellar and other posterior circulation strokes present quite differently Many are very subtle Brainstem strokes often combine cranial nerve signs with long tract signs many syndromes Can present with dizziness/vertigo or impaired conciousness - TIA is not the most likely diagnosis in elderly with frequent episodes of vertigo or (pre) syncope!

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Summary
We have discussed the basics of stroke, presentation, history, examination, investigation and management

We have given an overview of the guidelines and scoring systems which give a framework to current clinical practice.

We have attempted to make this relevant to the expected standard of a good FY1

Further study needs to be tailored to your purpose not everyone needs to be a stroke physician

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Take home points

This was revision there is always more depth to any area of medicine you need to be competent in general for the population you are seeing Basic clinical skills and sound logical thought will get you a very long way whatever you are doing Never be afraid to escalate Finals MCQs generally dont cause problems practice Clinical skills it is blindingly obvious to an examiner when a student/doctor is not well versed NEUROPHOBIA!
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