Acute Stroke: Principles of Modern Management A program of the American Academy of Neurology The AAN Acute Stroke Management courses are supported in part by unrestricted educational grants from Abbott Laboratories, Genentech, Inc., Janssen Pharmaceutical, and Wyeth-Ayerst Pharmaceutica.

Overview of the Course

GOALS OF THE COURSE Review management of patients with acute stroke.  Diagnosis  Treatment of ischemic stroke  Treatment of hemorrhagic stroke Review in-hospital management. Review management to prevent stroke or recurrent stroke.

STROKE FACTS Third leading cause of death in the United States Common cause of disability and long-term institutionalized care Economic consequences more than $40 billion annually Affects not only the patient but the entire family

STROKE AS A PUBLIC HEALTH PROBLEM WHO – increased importance of stroke during next 50 years  Developing countries  Industrial societies including U.S. Decline in stroke incidence to be reversed Increase due to aging of population People who survive severe heart disease at high risk

STROKE EPIDEMIOLOGY Advancing age is the premier predictor of stroke –Stroke is an important cause of death in children –Strokes are relatively common in young adults More women die from stroke than do men More women die from stroke than from cancer of breast Stroke accounts for 10% of maternal deaths during pregnancy or the peripartum period

Under the age of 45, more women die from stroke than from heart attack Approximately 60% of patients with SAH are women Atrial fibrillation is an important risk factor for stroke among women older than 75

African-American Hispanic American AgeMenWomen STROKE IN MINORITIES Survey of Stroke Mortality in Texas Rate-Ratio in Comparison to Non-Hispanic Whites Morgenstern et al Stroke, 1997, 28:5-18

SUBTYPES OF STROKE HEMORRHAGIC STROKE – 20% of cases –Subarachnoid hemorrhage –Intracerebral hemorrhage ISCHEMIC STROKE – 80% of cases –Large artery atherosclerosis –Cardioembolism –Small artery occlusion (lacunes) –Non-atherosclerotic vasculopathies –Hypercoagulable state

CURRENT STRATEGIES MANAGEMENT OF CEREBROVASCLAR DISEASE Treatment of risk factors in large populations Treatment of highest risk persons Management of acute stroke Prevention and treatment of medical and neurological complications Rehabilitation Prevention of recurrent stroke

TREATABLE RISK FACTORS IN PREVENTION OF STROKE Hypertension Smoking Hypercholesterolemia Hyperhomocysteinemia Diabetes mellitus Alcohol abuse Drug abuse Co-developing heart disease

ANTITHROMBOTIC THERAPIES TO PREVENT ISCHEMIC STROKE Oral anticoagulants Antiplatelet agents –Aspirin –Aspirin and dipyridamole –Clopidogrel –Ticlopidine

SURGICAL MEASURES TO PREVENT ISCHEMIC STROKE Carotid endarterectomy Extracranial/intracranial bypass Other reconstructive operations Angioplasty and stenting Cardiovascular operations

IMPORTANCE OF ACUTE MANAGEMENT OF STROKE Medical and surgical interventions lower risk of stroke, but they do not eliminate stroke entirely Some patients have a stroke as their first symptom Some causes of stroke are not amenable to preventive therapies

BRAIN ATTACK The causes and effects of acute stroke (brain attack) are similar to those that cause acute myocardial ischemia (heart attack) Secondary to arterial diseases and life- threatening Potential for serious medical or neurological complications Mandate emergent interventions to limit effects Can be treated successfully and improving outcomes

TIME IS BRAIN Components of Modern Management  Prompt recognition  Call 911 or seek attention  Speedy transport (EMS)  Rapid evaluation  Urgent treatment

Pre and Post Course Self Assessment Goal:To assess patterns of physician behavior change as a result of attending the AAN Acute Stroke Management Course. This goal will be achieved by measurement of knowledge at the following intervals: at the beginning of the course; at the end of the course; six months after the course. 1.Pre Course Self Assessment 8:40 AM – 9:00 AM Complete pre course self assessment AAN staff will pick-up 2.Post Course Self Assessment 4:10 PM – 4:30 PM Complete post course self assessment AAN staff will pick-up 3.Six-month follow-up Assessment tool sent to all participants 6 months after the course