1. Accuracy of Stroke Identification TRACS Feb 2016 David Blacker Neurologist and stroke physician SCGH Clinical Professor of Neurology UWA Medical Director WANRI

2. Accurate identification Why the need?  Correct, prompt treatment  Treatment at the most appropriate location  Implications for patient  Implications for service delivery  Stroke journey from onset to treatment

3. ACUTE STROKE- EVERY MINUTE COUNTS 1 minute= 1.9 million neurons 14 billion synapses 7.5 miles of myelinated fibres

4. How common is stroke? Stroke: more common than myocardial infarction But…….. Only 49% of AUS able to name a Sx of stroke (without prompting)-2003 1 in 6 do not know any warning signs of stroke 1 in 10 confuse stroke and heart attack NSF data 2006 Oxford Vascular Study. Rothwell et al., Lancet 2005;366:1773

6. Copyright ©2003 American Heart Association Harbison, J. et al. Stroke 2003;34:71-76 Face Arm Speech Test and Instructions for Use in Training Package

7. Copyright ©2005 American Heart Association Circulation 2005;112:IV-111-120IV-

8. Copyright ©2005 American Heart Association Circulation 2005;112:IV-111-120IV-

9. Australian Public’s Awareness of Stroke Warning Signs Improves After National Multimedia Campaigns by Janet E. Bray, Roslyn Johnson, Kym Trobbiani, Ian Mosley, Erin Lalor, and Dominique Cadilhac Stroke Volume 44(12):3540-3543 November 25, 2013 Copyright © American Heart Association, Inc. All rights reserved.

10. The proportion of respondents (weighted and unweighted) aware of stroke advertising by year (campaign). Janet E. Bray et al. Stroke. 2013;44:3540-3543 Copyright © American Heart Association, Inc. All rights reserved.

11. Trends in the proportion of unprompted stroke warning signs recalled with time. Janet E. Bray et al. Stroke. 2013;44:3540-3543 Copyright © American Heart Association, Inc. All rights reserved.

12. Trends in unprompted recall of the most common stroke warning signs with time stratified by awareness of campaigns. Janet E. Bray et al. Stroke. 2013;44:3540-3543 Copyright © American Heart Association, Inc. All rights reserved.

13. Ambulance services and stroke  Call centre  Prioritization of call (priority 1 v others)  Assessments at scene  Dispatch to appropriate hospital- service configuration  Pre-hospital therapies

16. Paramedic stroke scores  Cincinnati  LA  Ontario  Melbourne  All approx 85-90% sensitivity  Not much difference to 1990s studies

17. Paramedic Diagnosis of Stroke by Janet E. Bray, Kelly Coughlan, Bill Barger, and Chris Bladin Stroke Volume 41(7):1363-1366 July 1, 2010 Copyright © American Heart Association, Inc. All rights reserved.

18. Figure. Flow chart of methods. Janet E. Bray et al. Stroke. 2010;41:1363-1366 Copyright © American Heart Association, Inc. All rights reserved.

19. Stroke services organisation  Bypass and direct to stroke centre  “Drip and ship” 2008- Impact of ambulance diversion strategy on delivery of patients to stroke units % patients admitted to stroke units (SCGH, RPH, Fremantle), 3 months before and after 292/408 (71.6%) cf 258/387 (66.7%), and 211/307 (68.7%) prior year

20. Stroke services organisation  Continues to be critical  Plans for SCGH and FSH thrombectomy service  24 hour service?  Future other metro and rural

21. Design and Validation of a Prehospital Stroke Scale to Predict Large Arterial Occlusion by Natalia Pérez de la Ossa, David Carrera, Montse Gorchs, Marisol Querol, Mònica Millán, Meritxell Gomis, Laura Dorado, Elena López-Cancio, María Hernández-Pérez, Vicente Chicharro, Xavier Escalada, Xavier Jiménez, and Antoni Dávalos Stroke Volume 45(1):87-91 December 23, 2013 Copyright © American Heart Association, Inc. All rights reserved.

22. RACE score  Facial palsy  Arm motor  Leg motor  Head and gaze deviation  Aphasia  Agnosia All 0-2 points (except gaze) Score of > 5 85% sensitive, 65% specific,

23. Sensitivity (squares) and specificity (circles) of different cutoff values of the Rapid Arterial oCclusion Evaluation (RACE) scale for the detection of large vessel occlusion. Natalia Pérez de la Ossa et al. Stroke. 2014;45:87-91 Copyright © American Heart Association, Inc. All rights reserved.

24. Proportion of patients with ischemic stroke with large vessel occlusion (LVO; black), ischemic stroke without LVO (gray), hemorrhagic stroke (dashed), or stroke mimic (white) for every Rapid Arterial oCclusion Evaluation (RACE) scale score. Natalia Pérez de la Ossa et al. Stroke. 2014;45:87-91 Copyright © American Heart Association, Inc. All rights reserved.

25. At the hospital

27. Typical presentations  Abrupt onset  Focal, anatomically-localising  “-ve symptoms”

28. Atypical presentations  Not localising- eg psychiatric, confusion (NB dysphasia), impaired consciousness  +ve Sx- abnormal movements (limb shaking TIAs)  “Peripheral” looking cortical hand  NB vascular risk factors  NB- SAH and CVST

29. Mimic- over Dx of stroke; 20-25%  Seizure (20%)  Syncope (15%)  Sepsis (12%)  Functional (9%)  Headache- migraine (9%)  AND; tumor, metabolic, peripheral vestibulopathy, neuropathy, dementia, SDH, drugs, TGA, other

30. Stroke MRI: The Concept Mismatch MRA Vessel Occlusion T2* Rule out ICH Tissue at Risk Impaired Perfusion PWI DWI-Core of Infarct Schellinger PD, Fiebach JB. In Fiebach JB, Schellinger PD 2003; 6: 31-34.

31. tPA opens vessels

32. Advanced imaging  May help confirm Dx  “Encourage” use of tPA when unsure, or at prolonged time interval  Selection in “wake up” strokes – more soon!  Not yet used to “rule out” in the early time frame

33. Acute decisions tPA in 10minutes!

34. Type I v type II decisons

35. Implications for missed Dx Stroke Dx missed  Isolated vertigo due to inferior cerebellar infarction  Treatment opportunity missed  Medico-legal

36. Implications for misdiagnosis Stroke wrongly Dx instead of mimic  IV tPA- probably safe in mimics!  Unlikely to get thrombectomy  Missed treatment of other conditions; NB PPM, sepsis  Driving implications  Work implications  Hospital coding implications

37. Other questions  Stroke v TIA  “Treated stroke” with no deficit- nomenclature