STROKE UPDATE ANTHEA PARRY MAY 2010

Transcription

1 STROKE UPDATE ANTHEA PARRY MAY 2010

2 Delivery of stroke care Clinical presentations Management

3 Health Care for London plan 8 HASU (hyperacute) units 20 stroke units TIA services

4 Hyperacute stroke units All patients who are suspected of having a stroke Implementation will be complete by July 2010 Travel time<30mins LOS up to 72hours, then repatriated to local stroke unit depending on post code

5 Acute care. Principles that lie behind are the restoration of normal blood flow and salvage of the ischaemic penumbra. Thrombolysis Maintenance of normal physiological environment.

6 Acute stroke timeline Time of onset= last time seen normal Is this a stroke? Is this patient suitable for thrombolysis Thrombolysis can be given hours from onset of symptoms Send immediately to HASU

7 Intravenous TPA Pivotal NINDS trial (0-3hours) 30% increase in minimal or no disability at 90 days Symptomatic haem increased %, half were serious and fatal No change in mortality

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10 WHO IS THROMBOLYSIS FOR? Ischaemic stroke with significant disability (only 80%) Rate in UK <1%( Sentinel Audit 2009) 2 in 10 patients who present with a FAST positive event will have a stroke mimic Significant number of exclusions

11 Impact of established treatments Treatment NNT Benefit/100 TPA 3 32 Stroke unit Aspirin 77 1

12 STROKE v TIA A stroke is a clinical syndrome of rapid onset of focal or sometimes global cerebral deficit with a vascular cause lasting more than 24hrs or leading to death. The distinction between TIA and stroke is an arbitrary one at 24 hours.

13 TIA Most TIAs last only minutes (70% last less than 30 mins.) 25% of patients whose TIAS last >5 hours have infarcts on their CTscans Proportion of patients with MR-DWI abnormality ranged from 25-58%

14 SYMPTOMS TIA % Stroke % Diplopia 6 6 Ataxia Hemianopia 6 16 Speech Sensory Motor 50 81

15 LIKELY SYMPTOMS Acute Negative ie loss of function Vascular risk factors NB the clumsy hand

16 UNLIKELY SYMPTONS LOC DIZZINESS ( in isolation) CONFUSION ( distinguish from dysphasia)

17 Prevalence of Risk factors OCPS BP 50% Age<45 20% IHD 33% Smoker 27% 45% PVD 25% TIA 12% Diabetes 10% 11% 2%

18 THE BIG THREE Transient focal neurological deficit TIA Seizure Complicated migraine

19 START 300MG OF ASPIRIN IMMEDIATELY

20 TIA 15 % of strokes are preceded by a TIA OXVACS study showed the risk of recurrence was 7 days 10% 28 days 18% Highest rate of recurrence occurred in those with LAA (Rothwell Lancet2007)

21 MANAGEMENT No clinical way of differentiating which patients will go on to have a stroke. Risk stratification score Speed of treatment

22 ABCD 2 RISK STRATIFICATION SCORE Age> 60 1 Duration of symptoms.60mins 2 Bp >140/ <10 0 Clinical features Unilat weakness 2 Diabetes 1 Speech 1 Other 0

23 ABCD2 scoring system ABCD score is highly predictive of risk of stroke at 7 and 30 days ABCD score of 5 and 6 was an independent predictor of subsequent stroke (7/90day risk 30 and 35% respectively)

24 Risk of Stroke at 7 days by ABCD ABCD score % risk(95%ci) < (0-3.3) (4.2-20) (16-46)

25 Urgency of treatment Express study (Rothwell Lancet 2007) Early initiation of treatment was associated with an 80% reduction of stroke in the risk of early recurrence(90 days)

26 Express study Rapid access Same day referral Same day initiation of treatment if diagnosis confirmed Aspirin 300mg Simvastatin 40mg BP therapy, perindopril/indapamide

27 ABCD2 score and risk High risk 4 seen assessed and treated within 24 hours from first contact with doctor Low risk <4 Seen,assessed and treated within 7days from first contact with doctor

28 TIA SERVICE AT HILLINGDON Standardised referral form throughout NW London Fax /ring Stroke specialist nurse 3-4 clinics a week CT scan,carotid doppler and MRI same day access

29 HIGH RISK Refer directly to stroke specialist nurse Cathy Mason Bleep number 5447 Patient will be seen same day

30 HIGH RISK ABCD 4 Headache, neck pain prominent feature Age < 45 More than 2 TIA in a week On anticoagulation

31 Approach to stroke/tia treatment Anticoagulation Antiplatelets Modification of risk factors

32 Antiplatelets agents Aspirin 300mg-75mg DipyridamoleMR 200mg bd ESPS-2 and ESPRIT (Lancet 5/06) Clopidogrel 75mg MATCH (Lancet7/04) FASTER (Lancet neurol10/07)

33 PROFESS TRIAL(NEJM9/08) Randomised double blind trial of Dipyridamole v Clopidogrel 20,000 patients with ischaemic stroke Recurrent 4 yearly events D =C Composite of stroke, MI and vasc death 13.1% in each Major haem rates higher with dipyridamole

34 Anti platelet options If aspirin naive Aspirin If already on aspirin Add dipyridamole? Or single agent clopidogrel If on 2 agents or clop???

35 Approach to stroke/tia treatment Acute stroke therapy? Anticoagulation Antiplatelets Modification of risk factors

36 Indications for anticoagulation Atrial fibrillation Some cardioembolic sources Thrombus in the heart?ef<35% Vertebral and? carotid dissection Rare hypercoaguable states

37 Approach to stroke/tia treatment Acute stroke therapy? Anticoagulation Antiplatelets Modification of risk factors

38 Hypertension Number one risk factor, effects in both primary and secondary prevention. PROGRESS and LIFE trials show that stroke risk reduction is proportional to the degree of reduction and not absolute level. Some evidence that ACE inhibitors have added benefit..

39 Hypercholesterolemia HPS shows same affect for cholesterol and statins Statins for (almost ) all SPARCL (NEJM 8/06), 80mg atorvastatin in stroke TIA if LDL>100

40 Summary of Treatment Aspirin 300mg for2/52, then 75mg Dipyridamole in addition or clopidogrel Statin Blood pressure lowering Assessment of carotid and cardiac disease NO DRIVING FOR 1 MONTH

41 What treatment for TIA? Aggressive medical management Carotid Endartectomy Carotid stenting

42 Carotid Endarterectomy NASCET and ECAS trials showed that surgery is beneficial in symptomatic stenosis >70% Selected patients with 50-60%, male with events within last 2 weeks and specific plaque morphology

43 Case 5 61 year old man with hypertension comes to surgery with 5 min episode of right arm weakness and dysphasia which have resolved Bp 150/90 Not diabetic

44 Management ABCD 5 Ring SSN If overnight then admit needs to be investigated and treated within 24 hours

45 Case 6 42 year old man presents with episode of visual loss Smoker No vascular risk factors BP 130/80

46 Management ABCD 1 Start on aspirin 300mg Tell patient not to drive Refer TIA clinic Form/Stroke specialist nurse Low risk so needs to be seen within a week

47 Case 4 30 year old man presents with 15 mins of aphasia and R upper limb weakness All symptoms have resolved No vascular risk factors Examination is normal Patient reports history of neck pain after vomiting

48 CASE 7 60 year old man presents with an episode of collapse While getting out of the shower Wife thinks there may have been a facial droop Hypertensive on 3 medications ABCD2 2

49 Case 8 88 year old Lives in a nursing home Dementia Carer noticed that patient was not responsive. Vomited once No neurological signs

50 What is the diagnosis and what would you do? Unlikely TIA Given comorbidities GP should start aspirin No TIA referral