1. Management of Stroke and TIA Dr Anthony G Hemsley BMedSci MD FRCP Stroke Physician Lead Clinician Elderly Care

2. Big Numbers

3. INCIDENCE 140,000 new cases / year in UK

4. MORTALITY 3rd leading cause of death in UK

5. MORBIDITY THE LEADING cause of disability in UK

6. ECONOMIC 2.6m Acute hospital bed days / year

7. ECONOMIC £2.8b Direct care costs

8. ECONOMIC £2.4b Informal care costs

9. ECONOMIC £1.8b Lost productivity

10. History  Hippocrates  Apoplexy (Gk) “Struck down with violence” “Struck down with violence” The term “stroke” used as a synonym for apoplectic seizure (1599) The term “stroke” used as a synonym for apoplectic seizure (1599)

11. Historical Perspective Stroke has been seen as an inevitable risk of growing old, with little to be done for those who suffer a stroke other than trying to make them comfortable “Fatalism has long blighted stroke services in England” Professor Roger Boyle, National Director for Heart Disease and Stroke

12. Acute Stroke in the UK – an emergency?  Stroke has not been regarded as an emergency  Therapeutic nihilism  Category B or C for the ambulance service

13. National Recognition

15. National Audit Office Stroke is a Treatable Disease

16. National Audit Office  Fast and effective access to appropriate care  Suspected stroke should be treated as a medical emergency (QM 1)  Rapid access to brain scanning (QM 5,7,8)  Greater uptake of thrombolysis  Rapid admission to stroke unit (QM 9)

18. Stroke

19. NEURONAL LOSS 1.9m Neurones lost each minute a stroke goes untreated

20. TIME CRITICAL TIME IS BRAIN

22. The 17 th Century Service  Put to bed with head well raised  Bleed freely (1-2 pints)  Apply warm mustard poultices  Open bowels quickly and freely  Throw up a turpentine clyster  Cut off the hair  Apply rags of vinegar (or gin) and water  8-10 leeches on temple opposite paralysed side

23. Stroke Thrombolysis – The Evidence  12% absolute increase in the number of patients “cured”  More effective in stroke than in acute MI  The benefit is critically time dependent:  NNT:@ 60 mins = 2/3 @ 120 mins = 6 @ 180 mins = 25

24. STROKE THROMBOLYSIS 12% cured

25. AIM >1,500 Patients fully recovering from their strokes per year

26. AIM £16m Savings to the health service in direct care costs per year

27. NICE Technology Appraisal Guidance 122

29. Stroke Imaging  Revolutionised stroke management  Redefined stroke as a dynamic and evolving process  Vital in aiding an accurate diagnosis  Facilitates safe, rapid and appropriate management

30. Quality Marker 7 Timely imaging for acute stroke

31. Imaging for Acute Stroke  Urgent indication Next scan slot and certainly within 60 minutes NICE Quality Standard 2010  Non-urgent Within 24 hours

32. CT Scanning for Stroke – Why is it an Issue?  CT scanning seen as costly?  Radiologists in short supply?  Perceived lack of an effective stroke treatment?  General lack of interest in stroke?  Stroke not regarded as a medical priority?

34. “But how will it change your management?”  Clinical examination cannot distinguish between ischaemic and haemorrhagic stroke  Early use of antiplatelet agents in IS increases independent survival  Haematoma expansion and death in PICH is worsened by antithrombotic therapy  Appropriate early management of those who have not had a stroke

35. Does Treating Acute Stroke Make a Difference?

36. 6 Stroke Thrombolysis 18 Acute Cardiac Revascularisation 20 Stroke Units 33 Cardiac Thrombolysis 62 Clopidogrel 100 Aspirin ??? Coronary Care Units NNT to Benefit One Patient

37. STROKE UNIT CARE 18% Reduction in death 22% Reduction in dependency 20% Reduction in institutionalisation

38. ASPIRIN  After exclusion of ICH by imaging:  300mg ASA as soon as possible and within 24 hours NICE CG Acute Stroke 2008 National Clinical Guideline for Stroke 2008

39. TIA

40. Daily Stroke Clinic  Stroke or TIA is a major indicator of a high risk of further occlusive vascular event  Risk of stroke following a TIA – front loaded: 20%

41. Daily Stroke Clinic  Specialist assessment  Accurate diagnosis (40-50% of all clinic referrals are non-neurovascular)  Identification of the vascular territory  Appropriate investigations  Assessment and management of vascular risk factors (QM 2)

42. Evidence for the DSC  The early use of EXisting PREventative Strategies for Stroke (EXPRESS) Prospective sequential comparison study  SOS-TIA Prospective observational study

43. STROKE CLINICS 80% reduction in recurrent stroke

44. Quality Marker 5  Immediate referral of patients with TIA / minor disabling stroke  Brain imaging within 24 hours  Carotid intervention within 48 hours

45. Take Home Message  Stroke / TIA is a medical emergency  All patients benefit from rapid assessment  Thrombolysis  Direct ASU admission  Imaging has become a cornerstone of stroke management

46. Thank you for your attention