1. Stroke - the size of the problem

2. What is a stroke? What is a transient ischaemic attack? What is the size of the problem?

3. What is a stroke? What is a transient ischaemic attack? What is the size of the problem?

4. Stroke = “brain attack” = Rapid onset of focal (or at times global) cerebral deficit, lasting at least 24 hours (or leading to earlier death), and for which there is no cause other than a vascular one

5. 3 main pathological types ~ 80% ischaemic ~ 15% primary intracerebral haemorrhage ~ 5% subarachnoid haemorrhage

6. What is a stroke? What is a transient ischaemic attack? What is the size of the problem?

7. “Mini stroke” Definition as for stroke except lasts < 24 hours (and not fatal) Vast majority are ischaemic TIA (transient ischaemic attack) = “brain attack” =

8. What is a stroke? What is a transient ischaemic attack? What is the size of the problem?

9. Measuring the burden of stroke mortality incidence prevalence outcome cost

10. Causes of death worldwide in 1990: WHO / World Bank Global Burden of Disease Study

11. Millions All causes 50.5 Coronary heart disease 6.3 (12% of total) Cancer (all types) 6.1 (12% of total) Cerebrovascular disease4.4 (9% of total)

12. Global burden of stroke - mortality 4.4 million deaths worldwide in 1990 2/3 of these deaths in developing countries Stroke deaths likely to double by 2020 3rd commonest cause of death after coronary heart disease and cancer Mortality data do not tell the whole story, since most strokes are not fatal Major burden of stroke is chronic disability

13. Incidence of first-ever-in-a-lifetime stroke in the Oxfordshire Community Stroke Project (Bamford et al 1990)

14. Cumulative percentage of first-ever-in-a- lifetime strokes by age in the Oxfordshire Community Stroke Project, 1981-1984 years Three quarters of the strokes occur in > 65 year olds Half the strokes occur in > 75 year olds

15. Age and sex standardised annual incidence of stroke, age 45 to 84 years, in 10 ‘ideal’ community- based studies in the 1980s and 1990s (Sudlow and Warlow 1997)

16. Stroke in the UK population ~ 60 million 125,000 strokes each year GP (list = 2000) would see ~ 4 per year 250,000 disabled stroke survivors GP would have ~ 7 such patients on list

17. Outcome after a stroke Describing the effects on an patient: (Death) WHO classification: Impairment Disability Handicap

18. Outcome after a stroke About 20% will die within one month By one year over half will be either dead (30%) or dependent (25%) After a 1st stroke, 10% will have another stroke in the first year, and 5% per year thereafter Also at risk of serious vascular disease elsewhere. About half eventually die of coronary heart disease

19. % of patients with different outcomes one year after first-ever stroke (Oxfordshire Community Stroke Project, n = 675) 0 20 40 60 80 100 All typesPICHSAHIschaemic stroke % Independent Dependent Dead

20. Cost of stroke Accounts for about 6% of NHS and Social Services expenditure = £2.3 billion per year

21. Percentage of hospital costs spent on different aspects of stroke care (Western General Hospital, Edinburgh) 81% 14% 5% Doctoring 19% Therapy 31% Drugs 10% Investigations 40% Other Nursing Overheads