Stroke diagnosis

1. Stroke diagnosis Caroline Lawson Consultant Nurse - stroke

2. Aims & objectives • Overview of stroke & TIA • Key risk factors • Initial treatment plan • Case studies

3. The impact on the future • Due to the demographic composition of the population, although mortality is reducing, the overall incidence of stroke is likely to rise over the next 20 years • It is estimated that between 1983 and 2023, there will be a 30% increase in first ever strokes • This is going to have a major impact on service provision and should be influencing service development now

4. A disruption to the blood supply in the brain resulting in the brain not working normally What is a Stroke?

5. Types of Stroke Ischaemic Haemorrhagic

6. TIA • A syndrome of • sudden onset • focal neurological deficit • Loss or decrease power • Loss or altered sensation • Speech difficulty • Loss of vision • Loss of balance or dizziness • lasting less than 24 hours • Vascular origin

7. Amaurosis Fugax • Painless visual loss in one eye that is secondary to retinal ischaemia

8. What happens post stroke Infarct or Haemorrhage Core Ischemic Zone Ischaemic Penumbra ↓ ↓ Blood flow severely depleted Blood flow moderately depleted ↓ ↓ Oxygen & glucose depleted Collateral circulation supplies ↓ ↓ Necrosis of neurons & if no reperfusion = necrosis glial cells

12. Diffusion-weighted imaging TIA Major stoke Minor stroke

13. Factor Hypertension (raised blood pressure) Smoking Diabetes Blocked carotid artery Raised cholesterol Atrial fibrillation ( irregular heart beat) Risk reduction with treatment 38% 50% within one year; baseline after 5 years 44% reduction with tight blood pressure control in patients with diabetes and hypertension 50% 20-30% with statins in patients with known CHD 68% when treated with warfarin Non-modifiable:Age, gender, race/ethnicity, heredity Risk factor modification

14. Risk of Recurrent Stroke • People who have already suffered an ischemic stroke or TIA are at highest risk of a second stroke or death • Approximately 17% of strokes are second strokes • Second stroke risk is highest in the 7 daysfollowing the event American Heart Association. Heart Disease and Stroke Statistics 2003 update. Sacco RL et al. Stroke. 1998; 29(10): 2118-24. German Stroke Databank.

15. Cumulative risk of stroke after TIA 14 2002-2004 1981-1984 12 10 8 Risk of stroke (%) 6 4 2 0 0 7 14 21 28 Days Lancet 2005; 366: 29-36

16. HRT Women have a lower risk of CVE than men but the risk rises post menopause HRT increases risk by 30% CVE – 20% increased risk Venous thrombotic event – 50% Dual HRT – doubles risk of VTE

17. Primary stroke prevention throughrisk factor modification A 246,500 B 61,500 Key A = Hypertension B = Cigarette smoking C = Atrial fibrillation D = Heavy alcohol use E = Hypercholesterolaemia C 47,000 D 23,500 E 100,000 0 100,000 150,000 200,000 50,000 Estimated potential number of strokes prevented out of a total of 500,000 strokes annually in the USA

18. 30 Non-fatal stroke Non-fatal myocardial infarction Non-fatal acute peripheral vascular events 20 Rates per 1000 population per year 10 0 < 35 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 ≥ 85 Age (years) Age-specific rates of non-fatal stroke vs myocardial infarction vs acute PVD events in OXVASC Lancet 2005; 366: 1773-83

19. Stroke in young adults • Cardiac problems – hole in heart • Clotting problems / sickle cell • Illicit drugs

20. Heroin – • Slows respiratory rate, Slows heart rate • Lowers blood pressure • Infective endocarditis • Cocaine – • Narrows blood vessels – rise in BP • 23 fold increase in risk of heart attack in hour post use • Long term BP alteration causes atheroma build up – resulting in coronary artery disease • US – 1 in 4 of all MI in age group of 18-45 linked to cocaine use Quereshi et al 1999 Circulation 99:2731-41

21. Amphetamine • Adrenaline-type effect on body – • Increases heart rate • Increases BP – risk of Stroke • Alters electrical activity of heart – arrthymia • Ecstasy • Related to amphetamine • Sudden arrthymia • Risk of Stroke

22. Glue / Solvents • Heart rhythm disturbances – causing sudden death • Cardiomyopathy • Cannabis • low dose - Fast heart rate • large dose - Slow heart rate , lower blood pressure • Risk of sudden death (no associated other cause) • Heart attack - 4 fold higher within the hour following cannabis use Mittleman et al 2001 Circulation 103: 2805-9

23. Secondary prevention General population: Smoke 27% Obese 25% Alcohol 28% Exercise 70% QOF in N Ireland: Anticoag of AF : 90% patients BP < 150/90 : 70% Chol < 5 : 60% Antiplat for TIA/ Stroke: 90%

24. Link between ED & atherosclerosis • 39% - 59% of men with heart disease experience ED • Atherosclerosis affects main vessels and peripheral arteries • Penile arteries 1- 2mm in diameter. • Carotid arteries 5 -7 mm • Plaque build up can show as chronic problem • ED 3 times more likely to have a stroke than those without ED

25. ED & atherosclerosis • Montorsi et al 2006: 93% of pts with ED and CAD - ED came before the CAD symptoms an average 2 years earlier • 2003: N = 300 Prevalence of ED 49% • Of these 67% developed ED 3 years prior to A C S • Moderate to severe ED (not mild) • 10yr relative risk of CAD increased by 65% • Stroke 43%

26. Spironolactone Doxazosin Indapamide Bendroflumethiazide Felodipine Amlodipine Nifedipine Enalapril Darifenacin Nebivolol Lansoprazole Atrovastatin Ramipril Lisinopril Gabapentin Amioderone Omeprazole Ranitidine / Cimetidine Carbamazipine Haloperidole Drugs with S.E. of impotence

27. Stroke diagnosis

28. Typical stroke mimics • Seizures 24% • Syncope 23% • Sepsis 10% • Somatisation 7% • Migraine 6% • Labyrinthitis 4% • Tumour 3% • Low BM 3%

30. BP:___/____ GCS: ____ BM:____ If BM <3.5 mmol/L treat & reassess when normal Has there been loss of consciousness or syncope? Has there been seizure activity? Is there NEW ACUTE onset – or on waking from sleep?: 1. Asymmetric facial weakness 2. Asymmetric hand weakness 3. Asymmetric arm weakness 4. Asymmetric leg weakness 5. Speech disturbance 6. Visual field defect Y (-1) Y (-1) Y (+ 1) Y (+ 1) Y (+ 1) Y (+ 1) Y (+ 1) Y (+ 1) N (0) N (0) N (0) N (0) N (0) N (0) N (0) N (0) If score totals > 0 assume diagnosis of Stroke If score 0, -1 or -2 stroke diagnosis is unlikely but not excluded. Patient should be discussed with Stroke Physician or Stroke Nurse Consultant if stroke diagnosis still thought to be likely

33. Agitation and distress…

34. Headache…

35. Nausea and vomiting…

36. Acute hypertension…

37. Cerebral bleed…

38. Confusion…

39. Visual disturbances…

40. Loss or decrease power • Loss or altered sensation • Speech difficulty • Loss of vision • Loss of balance or dizziness

41. Following confirmation of clinical diagnosis

42. Brain imaging CT Normal

43. Lacunar Strokes • Likely to present in TIA clinic • Account for 25% of all strokes • <1.5-2cm diameter • 20% due to embolic pathology • Different epidemiology than most strokes therefore low risk of early reoccurrence, mortality • > likely to have intrinsic SVD ? Vasospasm, microatheroma leading to occlusion, endothelical dysfunction or leak leading to oedema

44. Secondary prevention Antiplatelet • Relative risk reduction of 18% • Adding MR dipyridamole RRR ↑ 37% • Clopidogrel

45. Anticoagulation (Warfarin) • Should be started in every patient in AF unless contraindicated • RRR in secondary prevention of 66% v placebo • Should not be started until haemorrhage excluded, and 14 days have passed since onset of symptoms • Should also be considered if the IS stroke is associated with mitral valve disease or prosthetic heart valves

47. Cholesterol Reduction • Evidence suggests the lower the cholesterol the better • All patients should be advised to reduce saturated fat in their diet • RCP recommend treatment with a statin for patients with total cholesterol >3.5mmol/L • Different patients require different therapies

48. Carotid endarterectomy • Carotid ultrasound should be performed on any patient considered for carotid endarterectomy • Surgery would be considered where carotid stenosis is greater than 70% • Smoking cessation • Reduction in alcohol intake • Healthy diet & weight reduction

49. Carotid Artery Stenosis External Carotid Stenosis at bifurcation of Internal Carotid Common Carotid