Age-Related Health Care Adelaide and Meath Hospital Dublin

1. Age-Related Health Care Adelaide and Meath Hospital Dublin incorporating the National Children’s Hospital Dept of Medical Gerontology Trinity College Dublin

2. Stroke in Ireland • Kills more people than breast cancer, lung cancer and bowel cancer combined

3. Stroke is…... • a focal or global neurological deficit • of presumed vascular origin • lasting more than 24 hours • or causing death within 24 hours

4. A TIA is…... • a focal or global neurological deficit • of presumed vascular origin • lasting less than 24 hours

5. Stroke burden • 9,250 acute strokes/year • 25% die in first year • 30,000 with residual disability • 48% hemiparesis • 22% cannot walk • 24-53% need help in ADLs • 12-18% aphasic

6. Impact • Personal: • “..more impact than my wedding, or the birth of my first child” • 2nd most expensive illness • Most common cause of acquired physical disability • Most expensive single DRG medically

7. Stroke Units  Thrombolysis  Biggest advance in Stroke Care Not, not, not

8. Stroke Units • Reduce death, disability, institutionalization • Reduce death and disability by 25% • NNT • 33 to save a death • 20 to regain independence • 20 to prevent institutionalize • Save 2-11 days hospital • If this were a tablet……….. Cochrane 2005

9. Stroke Units • Direct care of a specialist in stroke care and interdisciplinary team • Clearly defined continuum of care • Geographical unit preferable • CT/MRI on site • Main base general hospital • Take all patients referred

10. Person with stroke Public Health Vascular surgeon Carer Radiologist Rehabilitationist Neurologist Geriatrician GP Physiotherapy Clinical nutrition Occupational therapy Psychology Social work Speech therapy PHN Hospital nurses

11. 3 tasks Was it a stroke? What did the stroke cause? Cognitive impairment Dysphagia Gait disorder Sensory Inattention What caused the stroke?

13. Vulnerable Tissue: Work Fast!

14. Brain attack • ABC • Diagnosis • Stabilize • BP, O2, Temp, glucose • Swallow • Positioning • Stroke Service

15. History • Patient • Collateral/witness

16. Cincinnati Prehospital Stroke Scale • Facial droop • Arm drift • Speech

17. 4 level neuro Ax • End of the bed • Alertness (GCS), language, cognition • Classical neuro examination • Cranial nn • PTCS • Reflexes • ‘Parietal’ signs • Inattention/neglect • Agnosia • Apraxia

18. Differential • Tumour • Meningitis/encephalitis • Seizure • Epilepsy • Migraine • Metabolic causes • MS

19. TIA’s • 38% 'true' TIA • 10% had migraine • 9% had faints • 9% had possible TIAs, 9% had 'funny turns’ • 6% had epilepsy • 6% had vertigo • 0.8% had hypoglycaemia • 0.4% had brain tumours

20. ABCD of TIA treatment • 10% stroke risk within one week: 30% if high score • ABCD Score • Age - >60 = 1 • Blood Pressure - Syst > 140 or Diast > 90 = 1 • Clinical • Motor = 2 • Speech = 1 • Duration • > 1 hour = 2 • 10-59 min = 1 Rothwell, Lancet 2005

21. Urgent investigations • Glucose • FBC • U + E • ECG

22. Urgent CT • Head injury • Suspicion sub-arachnoid • Headache • Meningism • Neurological deterioration • Possibility of thrombolysis

23. BP • Ischaemic stroke - dangerous to treat if not > 220/140 • Sub-arachnoid - neurology advice - nimodipine and normal blood pressure

24. Stabilize • Keep euglycaemic • Antipyretics for pyrexia • O2: avoid hypoxia • NPO until swallow assessed • Early advice on positioning

25. First 12 hours • Stroke Service • Book CTB (within 48 hours) • Book other tests as appropriate: • Carotid dopplers • Holter monitor • ECHO • ……..

26. Pharmacological • Anti-platelets • NSA, Asantin R, clopidrogel

27. Strategies: who can benefit? • 150-250 strokes yearly in a Dublin hospital • Stroke Unit 100% • Aspirin 80% • Neuroprotective strategies 90% • Thrombolysis 5%

28. iv Thrombolysis • 3 Streptokinase: terminated • European r-TPA: no overall change • NINDS r-TPA: modest improvement

29. NINDS rt-PA regime • Within 3 hours (mean 90 mins) • 0.9 mg/kg (max 90mg) • 10% bolus • 90% over one hour • Systolic <185, Diastolic <110 • BP managed by algorithm

30. Contra-indications • PUD • Recent surgery • Recent arterial puncture • Abnormal coagulation • BP not manageable to 185/110 • No sign of established stroke on CT - NB difficult

31. Cochrane review • Excess of deaths • 23% thrombolysis • 18% controls • Reduction death and disability • 45% thrombolysis • 51% controls • Treat 16 patients to avoid one death/disability

32. The real world....Chiu, Stroke 1998 • 6% receive rt-PA • Those who don't: • Time 37% • ICH 22% • Minor/rapidly resolving symptoms 19% • Nonstroke Dx 12%

33. Acute treatment • Aspirin • LMW Heparin • Thrombolysis

34. Neuroprotective • Nimodipine • Glutamate antagonists • Na channel antagonists/glycine antagonists • Opioid antagonists • Antoxidants/Free radical scavengers

35. Management issues • Reducing delay • Stroke unit approach • CT access and expertise (?telemedicine) • Neuro-ICU

37. Unmet needs post-stroke • 38% no personal contact GP • 46% attended DH • 79% had health concerns • 64% required Rx advice • 18% had resumed smokingMartin Scot Med 2002

38. 6 Months after discharge • 58% in the community • 87% had seen GP • 48% reviewed in OPD Crowe IMJ 2002

39. Smoking Alcohol Exercise Obesity, DM Psychosocial BP Lipids Homocysteine Infections Inflammation, thrombosis Remediable risk factors Sem Vasc Med 2002, 2, 229-445

40. Fibrinogen • Adds to likelihood of event • Reduce inflammation? • Flu vaccine • Reduces stroke hospitalization by 16% Nichol NEJM 3 April 2003

41. Healthy lifestyle is anticoagulant and anti-inflammatory • Weight loss, exercise • Reduce vascular inflammation and insulin resistance • So, stop smoking, keep walking! Esposito, JAMA, April 9, 2003

42. Antithrombotics • BP reduction • Cholesterol • Diet and DM • Exercise/rehabilitation • Forget smoking/Flu jabs

43. Antiplatelets • 25% reduction in all events • CHD • Stroke • VTE • Revascularization

44. BP reduction • Diuretics and ACE-Inhibitor • Primary prevention trials suggest drug equivalence • Cave postural symptoms!

45. Statins • All patients with stroke • Fire and forget • Highest effective dose • Simvastatin 40 • Pravastatin 40 • Atorvostatin 10

47. Carotid endarterectomy • Carotid territory stroke TIA in last 6 months • >70% stenosis (about 5% of our patients) • NNT 15 to prevent death or disability over 2-6 years • Surgically fit patients • Surgeons with <6% complication rates

48. Antithrombotics • BP reduction • Cholesterol • Diet and DM • Exercise/rehabilitation • Forget smoking/Flu jabs