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 Preventable Treatable

Acute Stroke

Medical Emergencies

Rapid onset Poor prognosis Need for prompt treatment

Acute Stroke
A Medical Emergency

Comes on quickly Poor prognosis

12% mortality at 7 days 19% at 30 days 31% at one year TIME = BRAIN

Needs urgent treatment

Is it a Stroke?

Focal Signs Negative symptoms Sudden onset Appropriate context

Older age group Vascular risk factors

What kind of stroke?

TACI PACI LACI POCI

OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION SYSTEM

TACI

Large cortical stroke MCA +/- ACA territories Higher cerebral dysfunction

Dysphasia Acalculia Neglect Hemianopia

2/3 of face/arm/leg

AND

And

OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION SYSTEM

PACI

2 out of 3 of TACI OR

motor/sensory deficit more restricted than LACI Higher centre dysfunction alone

OR

OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION SYSTEM

LACI

Pure motor stroke Pure sensory stroke Sensorimotor stroke Ataxic hemiparesis Dysarthria-clumsy hand syndrome

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

Is it a stroke?

Difficult in 1st 6 hours

Type of stroke dictates investigations and their urgency

Investigations

CT

Fast Reliable Available Differentiates between ICH and ischaemic stroke May show alternate diagnosis

Investigations

CT

When? As soon as practicable for most patients

Haemorrhagic transformation and primary ICH can be difficult to differentiate

Investigations

ECG FBC Renal function BGL ESR or CRP Cholesterol

Investigations

TACI

Few needed As above As above

LACI

POCI

PACI

Carotid duplex Possibly TOE

Emergency Management

Dr Christopher Trethewy

Trelawney the unofficial Cornish anthem

Acute stroke treatment

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 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 Treatment

rTPA

Expensive 5% of strokes High risk of harm if not ideal subjects

Acute Stroke Treatment

Stroke Units

Coordinated, goal directed rehabilitation Oxygenation Fever management Early mobilization BGL management PATHWAYS DON'T HELP

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 Treatment

BP reduction

Possibly harmful early No proven benefit to date

Neuroprotection

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

Aspirin (and modified release dipyridamole) Anticoagulation if Afib CEA if symptomatic stenosis >70% BP lowering Smoking cessation Lipid lowering

Stroke: an emergency

Early hospitalisation if moderate stroke Aspirin within 48 hours if not for TPA Stroke Unit Aspirin plus vascular risk management