Stroke & the Emergency Department. Dr. Barry Moynihan, March 2 nd, 2012

Transcription

1 Stroke & the Emergency Department Dr. Barry Moynihan, March 2 nd, 2012

2 Outline Primer Stroke anatomy & clinical syndromes Diagnosing stroke Anterior / Posterior Thrombolysis Haemorrhage The London model

3 My stroke mental process Stroke is a vascular disease with common syndromes Infarction 85% Haemorrhage 15% Process Stroke (Y/N) - Infarct/Bleed - Territory - Mechanism - Treatment

4 Carotid & Vertebral Arteries The anterior and posterior circulation

5 Circle of Willis

6 Intracranial arteries Anterior Ophthalmic Anterior cerebral (ACA) Middle cerebral (MCA) Posterior Basilar (brainstem) Cerebellar arteries (SCA, AICA, PICA) Posterior cerebral (PCA)

7 Large or small vessel occlusion

8 MCA and ACA territories Pattern of weakness Dysphasia (Broca s and Wernicke s areas are in the MCA territory)

9 Summary basic syndromes MCA ACA PCA Lacune Weakness Face, arm Leg No Face, arm and leg Dysphasia Yes No No No Hemianopi a Inattention/ neglect Yes No Yes No Yes No No No

10 Stroke diagnosis in practice: FAST Facial weakness - can the person smile? Has their mouth or eye drooped? Arm weakness - can the person raise both arms? Speech problems - can the person speak clearly and understand what you say?

11 Figure 1. Circle graph shows final hospital discharge diagnoses of patients admitted through the emergency department with a diagnosis of stroke or transient ischemic attack (n=441). Kothari R U et al. Stroke 1995;26: Copyright American Heart Association

12 ROSIER Recognition of stroke in the ER

13 ROSIER score and diagnosis in 357 patients

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16 Diagnostic aids Sudden onset is key Focal deficits Posterior circulation strokes 30% of strokes, FAST and ROSIER are poor Visual symptoms & ataxia are key posterior Sx Head impulse test useful in acute vertigo MRI often required for posterior circulation stroke diagnosis

17 Thrombolysis

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19 tpa - time is brain

20 Figure 2 NNT and time after stroke Donnan, G. A. et al. (2011) How to make better use of thrombolytic therapy in acute ischemic stroke Nat. Rev. Neurol. doi: /nrneurol

21 Table 1 Trials of intravenous thrombolysis beyond 3 h after stroke Donnan, G. A. et al. (2011) How to make better use of thrombolytic therapy in acute ischemic stroke Nat. Rev. Neurol. doi: /nrneurol

22 EMJ, Nov 2011

23 Thrombolysis models

24 The importance of tpa Acute treatment, not just rehabilitation FAST campaign 50% of our patients arrive < 3hours from onset Change in patient (and doctor) expectations

25 ICH - Background Hypertension major risk factor 50-70% of lobar bleeds in elderly due to amyloid 15-20% anticoagulation related 2% vascular malformations

26 Prognostic indicators Haematoma volume 60 mls GCS score 8 } 30-day case fatality 90%

27 Warfarin related ICH Haematoma expansion more likely: 54% vs 16% Median period of expansion longer: 21 hr vs 8 hr Flibotte et al, Neurology 2004

28 London HASU model Timely access to tpa Co-ordinated vascular surgery 7 day imaging 7 day Consultant ward rounds

29 HASU, Stroke and TIA Units

30 St. George s 2000 admissions per year 1100 strokes 133 thrombolysed 13 IA tpa/clot retrieval Door to needle times 40 minutes Average LOS 9 days Average wait for CEA 5 days 90% spend all their time on a stroke bed 500 patients entered into trials Mortality now 6% at 30 days

31 The post-90 day 5-year risk of recurrent stroke after a first-ever TIA or non-disabling ischaemic stroke in the same population in and during

32 Stroke what s coming next? Intra-arterial thrombolysis/clot-retrieval Cooling Ambulance delivered therapies? ED delivered thrombolysis?

33 Example case 1 71M Dense left hemiplegia and dysphasia PMHx Pachymeningitis and brain biopsy

34 Example case 1

35 Example case 1 No bridging IV thrombolysis Time from ictus to recanalisation: 3h43m (223m) No residual weakness or dysphasia

36 Conclusions Stroke is now an acute care specialty Treatment works (tpa, Stroke Units) Early diagnosis is crucial FAST & ROSIER Posterior circulation strokes are often FAST ve Acute care is becoming more interventional