Dr Lindsay Erwin RAH Paisley STROKE REVIEW Dr Lindsay Erwin RAH Paisley

Definition

TRANSIENT MONOCULAR BLINDNESS Sudden onset of focal or global loss of cerebral function OR TRANSIENT MONOCULAR BLINDNESS

CORTEX ANATOMY

CORTEX MAP

Stroke mimics Seizure Mass lesion Migraine Hypoglycemia Systemic infection Toxic-metabolic encephalopathy Multiple sclerosis Intracranial (sub / epidural) hematoma

CLASSIFICATION Different Mechanisms / Aetiology + Outcome Taci – Total Anterior Circulation Paci – Partial Anterior Circulation Laci - Lacunar Poci – Posterior Circulation Different Mechanisms / Aetiology + Outcome

CLASSIFICATION 1 unilateral weakness (and / or sensory deficit) affecting face. 2 unilateral weakness (and / or sensory deficit) affecting arm 3 unilateral weakness (and / or sensory deficit) affecting hand 4 unilateral weakness (and / or sensory deficit) affecting leg 5 unilateral weakness (and / or sensory deficit) affecting foot 6 Dysphasia, dyslexia, dysgraphia, (i.e. dominant hemisphere cortical) 7 Visuospatial disorder / inattention / neglect (i.e. non – dominant hemisphere) 8 Homonomous hemianopias/ or quadrantopia 9 Brainstem / cerebellar signs other than ataxic hemiparesis 10 Other deficit TACS 1+2+3+4+5+6+7 LACS 1+2+3+4+5 OR 1+2+3 OR 2+3+4+5 POCS 8 OR 9 OR 8 +9 PACS Other combinations excluding 9 and 10

Small vessel block

Big vessel block – good collateral

Big vessel block – no collateral

Stroke Types Bleeds - 20% - subdural - subarachnoid - intracerebral Infarcts - 80% - atheroembolic - borderzone - vasculitis

Stroke Types - subdural Trauma usual cause

Stroke Types - subarachnoid Aneurysm rupture common cause. “Worst headache”

Stroke Types - intracerebral bleed OFTEN HAVE HEADACHE, DROWSINESS, HBP AT ONSET

Stroke Types - Infarct sources Atheroembolic; source anywhere from heart to intracranial vessels

Stroke Types - borderzone Low flow - usually hypotension; blood loss / cardiac arrest

Stroke Types - vasculitis Primary vasculitis: Giant cell Takayasu’s Polyarteritis nodosa Churg Strauss Wegener’s Secondary vasculitis Lupus Rheumatoid Sjogren’s Drug induced immune

Risk factors / etiology HBP Hypotension Lipids AF Endocarditis Smoking / alcohol Diabetes Drugs Trauma Genetics

HBP

Risk factors / etiology Lipids

Atheroma

Risk factors - Lipids Primary prevention

Risk factors - Lipids Stroke prevention -SPARCL

Risk factors / etiology AF AF affects 5% of people > 65

Atrial Fibrillation Aspirin minimally effective - 22% risk reduction Warfarin best protection - 62% risk reduction Need tight INR control -- INR 2 - 3. How to make it safe??

C ONGESTIVE FAILURE 1 AF - CHADS2 H YPERTENSION 1 A GE > 75 1 D IABETES 1 S TROKE OR TIA 2

AF – CHADS risk score

Risk factors / etiology Hypotension Smoking / alcohol Diabetes Drugs Trauma Genetics Cardioembolism

PFO May allow paradoxical embolism. Risk higher if PFO and atrial septal aneurysm.

Getting the blood to flow!

Representation of Penumbra in Acute Stroke. Thomas, S. H. et al. N Engl J Med 2006;354:2263-2271

ACUTE CARE Time of onset. Any fluctuation in symptoms? Previous stroke, TIA, recent head injury or fall? Witness report if anyone available. Confirm current drugs, especially antiplatelet agents and anticoagulants. Check Baseline Bloods U/E, FBC and GLUCOSE. Immediate CT if any possibility of thrombolysis, fluctuating GCS, pyrexia, patient on warfarin. ECG & Chest X-ray

Next Steps If no bleed, start aspirin. If on aspirin, stop Hypoxic patients (saturation <95%) should have Oxygen Start I.V. saline as necessary. Avoid dextrose on day 1. Swallow assessment ASAP. NBM till then. If no bleed, start aspirin. If on aspirin, stop on admission, and resume if no bleed. Rectal aspirin if unable to swallow. Blood Pressure should not be lowered unless encephalopathy or aortic dissection or BP VERY high

Next Steps 2 Hyperglycaemia – treat if diabetic. Avoid hypo; DVT prophylaxis – If leg paralysis, heparin is not indicated unless there is co-existing DVT or PE. Pyrexia over 37 C must be treated at once by oral or rectal paracetamol. Nursing Assessments – pressure area risks, fluid balance, weight. Avoid catheter unless critical for measuring output or to relieve retention.

Continuing Management Refer to Stroke Team within 24 hours of admission Transfer to Stroke Unit / Stroke \Team Care same day if possible Why?

Continuing Management – Stroke Unit Meta-analysis by the Stroke Unit Trialist's collaboration 18% + reduction in death or dependence death or need of institutional care. Absolute changes were a 3% reduction in all cause mortality (NNT 33), a 3% reduction in the need for nursing home care, and a 6% increase in the number of independent survivors (NNT 16). Also 14 days less hospital stay

Acute Treatment Easy – early aspirin for almost all. 10 in 1000 extra will walk out Harder – thrombolysis for a few. 1 in 10 extra will walk out

Will it work? Per 1000 treated Intracranial bleed NNH 22 Death NNT 236 Death / Dependent NNT 10 1 or more point >mRS NNT 3 THE EARLIER THE BETTER

Bleeds Reverse coagulopathy Refer neurosurgery for cerebellar bleeds Less evidence for other sites ? > 30ml near the surface.

TRANSIENT MONOCULAR BLINDNESS Is it a TIA? Sudden onset of focal or global loss of cerebral function OR TRANSIENT MONOCULAR BLINDNESS

Is it a stroke /TIA? POSITIVE FEATURES - TIA LESS LIKELY TINGLING rather than numbness Flashing lights rather than loss of vision Jerking rather than paralysis Depends on a good history / witness statement

Is it a stroke / TIA? 23% of strokes preceded by TIA stroke risk after TIA: 2 days - 3.1% 7 days - 5.2% 90 days - 10.5%

ABCD2 Score A) Age 60 or older = 1 B) Raised BP – systolic > 140 / diastolic > 90 = 1 C) Unilateral weakness = 2 Speech disturbance without weakness = 1 other = 0 D) Duration > 60 min = 2 10 - 59 min = 1 < 10 min = 0 D) Diabetes = 1 3 or over is significant 6/7 may need admitted.

ABCD 2 SCORE - risk prediction

Is the ABCD Score Useful…… TRIAGE of TIA with MRI MRI DWI +ve scans thought to be extra useful

STROKE RATE after TIA EXPRESS study Before After Risk of recurrent stroke after first seeking medical attention in patients with TIA ROTHWELL, The Lancet 2007;370:1432-144

INITIAL MANAGEMENT OF TIA Establish diagnosis / Check risk factors: Aspirin Cholesterol Blood Pressure AF Diabetes Ischaemic Heart Disease PVD Carotid disease Cardioembolic source If “classic” TIA < 20 min, may give aspirin till seen at OPC.

Risk factor reduction Blood pressure to target ~ 130 / 80 Cholesterol to target ~ <4.0 mmol/l Antiplatelet drugs: Anticoagulation for AF Lifestyle advice

Drug treatment Blood pressure: diuretic / ACE combination Cholesterol - simvaststatin / atorvastatin Antiplatelet: aspirin 300 mg for 2 weeks, then 75mg; clopidogrel 75 mg or aspirin + dipyridamole retard Anticoagulation for AF - INR 2 - 3

BLEEDS: 20 - 42 % DEATH RATE AT 1 MONTH Recurrence VASCULAR DEATH % 1 month 1yr 2 yrs 3yr 11.4 17.1 20.7 26.7 REINFARCTS: 12 % FIRST YR 4-5% / YR AFTER BLEEDS: 20 - 42 % DEATH RATE AT 1 MONTH (worst in men >75)

Road to Recovery - Sitting balance first, standing unsupported, walking, then independence

Why did it get worse? Stroke in progression Vessel re-embolises / dissects Bleed into infarcted area Seizure Hypoxia Underperfusion

If only I had / hadn’t……… Usually not true - inevitable. The usual ONLYwarning is a TIA. Long term primary prevention best ….even then Could prevent only half of all stroke.

Is that his last slide??

Lindsay.erwin at rah scot nhs uk Dr Lindsay Erwin RAH Paisley Lindsay.erwin at rah scot nhs uk