Age-Related Health Care

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• Age-Related Health Care
• Adelaide and Meath Hospital Dublin
• incorporating the National Childrens Hospital

Dept of Medical Gerontology Trinity College Dublin
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Stroke in Ireland

• Kills more people than breast cancer, lung cancer
  and bowel cancer combined

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Stroke is...

• a focal or global neurological deficit
• of presumed vascular origin
• lasting more than 24 hours
• or causing death within 24 hours

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A TIA is...

• a focal or global neurological deficit
• of presumed vascular origin
• lasting less than 24 hours

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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

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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

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Biggest advance in Stroke Care
Not, not, not
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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
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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

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Hospital nurses
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3 tasks

• Was it a stroke?
• What did the stroke cause?
• Cognitive impairment
• Dysphagia
• Gait disorder
• Sensory
• Inattention
• What caused the stroke?

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Vulnerable Tissue Work Fast!
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Brain attack

• ABC
• Diagnosis
• Stabilize
• BP, O2, Temp, glucose
• Swallow
• Positioning
• Stroke Service

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History

• Patient
• Collateral/witness

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Cincinnati Prehospital Stroke Scale

• Facial droop
• Arm drift
• Speech

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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

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Differential

• Tumour
• Meningitis/encephalitis
• Seizure
• Epilepsy
• Migraine
• Metabolic causes
• MS

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TIAs

• 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

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ABCD of TIA treatment

• 10 stroke risk within one week 30 if high
  score
• ABCD Score
• Age - gt60 1
• Blood Pressure - Syst gt 140 or Diast gt 90 1
• Clinical
• Motor 2
• Speech 1
• Duration
• gt 1 hour 2
• 10-59 min 1

Rothwell, Lancet 2005
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Urgent investigations

• Glucose
• FBC
• U E
• ECG

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Urgent CT

• Head injury
• Suspicion sub-arachnoid
• Headache
• Meningism
• Neurological deterioration
• Possibility of thrombolysis

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BP

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

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Stabilize

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

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First 12 hours

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

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Pharmacological

• Anti-platelets
• NSA, Asantin R, clopidrogel

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Strategies who can benefit?

• 150-250 strokes yearly in a Dublin hospital
• Stroke Unit 100
• Aspirin 80
• Neuroprotective strategies 90
• Thrombolysis 5

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iv Thrombolysis

• 3 Streptokinase terminated
• European r-TPA no overall change
• NINDS r-TPA modest improvement

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NINDS rt-PA regime

• Within 3 hours (mean 90 mins)
• 0.9 mg/kg (max 90mg)
• 10 bolus
• 90 over one hour
• Systolic lt185, Diastolic lt110
• BP managed by algorithm

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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

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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

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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

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Acute treatment

• Aspirin
• LMW Heparin
• Thrombolysis

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Neuroprotective

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

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Management issues

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

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Unmet needs post-stroke

• 38 no personal contact GP
• 46 attended DH
• 79 had health concerns
• 64 required Rx advice
• 18 had resumed smoking Martin Scot Med 2002

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6 Months after discharge

• 58 in the community
• 87 had seen GP
• 48 reviewed in OPD

Crowe IMJ 2002
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Remediable risk factors

• Smoking
• Alcohol
• Exercise
• Obesity, DM
• Psychosocial

• BP
• Lipids
• Homocysteine
• Infections
• Inflammation, thrombosis

Sem Vasc Med 2002, 2, 229-445
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Fibrinogen

• Adds to likelihood of event
• Reduce inflammation?
• Flu vaccine
• Reduces stroke hospitalization by 16

Nichol NEJM 3 April 2003
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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
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• Antithrombotics
• BP reduction
• Cholesterol
• Diet and DM
• Exercise/rehabilitation
• Forget smoking/Flu jabs

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Antiplatelets

• 25 reduction in all events
• CHD
• Stroke
• VTE
• Revascularization

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BP reduction

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

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Statins

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

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Carotid endarterectomy

• Carotid territory stroke TIA in last 6 months
• gt70 stenosis (about 5 of our patients)
• NNT 15 to prevent death or disability over 2-6
  years
• Surgically fit patients
• Surgeons with lt6 complication rates

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