Stroke & the Emergency Department Dr. Barry Moynihan, March 2 nd, 2012
Outline Primer Stroke anatomy & clinical syndromes Diagnosing stroke Anterior / Posterior Thrombolysis Haemorrhage The London model
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
Carotid & Vertebral Arteries The anterior and posterior circulation
Circle of Willis
Intracranial arteries Anterior Ophthalmic Anterior cerebral (ACA) Middle cerebral (MCA) Posterior Basilar (brainstem) Cerebellar arteries (SCA, AICA, PICA) Posterior cerebral (PCA)
Large or small vessel occlusion
MCA and ACA territories Pattern of weakness Dysphasia (Broca s and Wernicke s areas are in the MCA territory)
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
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?
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;26:2238-2241 Copyright American Heart Association
ROSIER Recognition of stroke in the ER
ROSIER score and diagnosis in 357 patients
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
Thrombolysis
tpa - time is brain
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:10.1038/nrneurol.2011.89
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:10.1038/nrneurol.2011.89
EMJ, Nov 2011
Thrombolysis models
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
ICH - Background Hypertension major risk factor 50-70% of lobar bleeds in elderly due to amyloid 15-20% anticoagulation related 2% vascular malformations
Prognostic indicators Haematoma volume 60 mls GCS score 8 } 30-day case fatality 90%
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
London HASU model Timely access to tpa Co-ordinated vascular surgery 7 day imaging 7 day Consultant ward rounds
HASU, Stroke and TIA Units
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
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 1981 86 and during 2002 10
Stroke what s coming next? Intra-arterial thrombolysis/clot-retrieval Cooling Ambulance delivered therapies? ED delivered thrombolysis?
Example case 1 71M Dense left hemiplegia and dysphasia PMHx Pachymeningitis and brain biopsy
Example case 1
Example case 1 No bridging IV thrombolysis Time from ictus to recanalisation: 3h43m (223m) No residual weakness or dysphasia
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