gp lecture programme 3 february 2010 dr stephen louw stroke physician rvi newcastle upon tyne
TRANSCRIPT
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GP Lecture Programme3 February 2010
Dr Stephen Louw
Stroke Physician
RVI Newcastle upon Tyne
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Population Relative Risk for Stroke
• High ABCD2 score: 8% chance in next 2 days• AF 5 – 17x (if >2 risk factors, 18% stroke p.y.)• Hypertension 3-4• Alcohol 4 • Migraine: 2.16• IHD 2-4• CCF 2-4• Diabetes 2-4 • Smoking 1.5-2.9• Hyperlipidaemia – uncertain as a sole risk• PFO 26% of general population have a PFO.
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Commonest TIAs
Middle Cerebral Artery Territory• Total or partial anterior Circulation TIA
– Hemiplegia/hemianaeasthesia
– Homonymous hemi-anopia
– Cortical problem: dysphasia/visual or sensory neglect
• Lacunar-type: pure motor or sensory or mixed• Amaurosis fugax• Post circulation (difficult to diagnose)
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Middle Cerebral Artery TerritoryThe focus of ABCD2 scale
Validation and refinement of scores to predict very early stroke risk after TIA: Johnston SC, Rothwell PM et al. Lancet 2007. Jan. 27:369:283-92.
ABCD2
Score
2-day risk 7-day risk 90-day risk
5 4.1% 5.9 9.8
7 8.1% 11.7 17.8
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Middle Cerebral Artery TerritoryThe focus of ABCD2 scale
The focus of investigations in hospital:
• Identify patients with critical internal carotid artery stenosis
• Rapid referral for carotid endarterectomy
• CEA– Benefits: reduces stroke risk by 50%– Risks: immediate death or stroke: 2 – 3%
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Carotid Endarterectomy European Carotid Surgery Trialists’ Collaboration Group (ECTST) The Lancet
1998;351:1379-87 CLASSIC PAPER
• Patients with recent TIA or stroke and 70 – 99% carotid stenosis clearly benefit in terms of stroke prevention. Confirmed NASCET (1991)
• Pts with <70% stenosis were harmed by CEA.• NNT (surgery) 14 pts to prevent a major
ipsilateral carotid territory stroke over the next 5 years.
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Limb shaking TIA
• 1-2 min duration• Usually severe carotid
stenosis• Often good surgical
candidates• Differential diagnosis• Partial seizure• Tremor
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Capsular warning TIAGeoffrey Donnan (Australia) Neurology 1993;43:957
• 4.5% of TIAs • Ischemia due to
haemodynamic phenomena in a diseased, single, small penetrating vessel
• Leads to lacunar infarct and involved a single penetrating vessel
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Posterior Circulation TIA
POCS TIA is more likely if:
true diplopia
DDK
past pointing
Dysarthria
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Posterior Circulation TIA
Low predictive rate for POCS TIA if:
Isolated features of• ‘Dizziness’,• unsteadiness,• vertigo or• ‘ataxia’.
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Transient Global Amnesia
• Sudden onset of disorientation – amnesia for immediate events
• Speech intact
• No other focal neurology
• Resolves within minutes
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Unusual types of Migraine
Ocular migraine• Transient loss of
vision• Usually with headache
Basilar type migraine• Affects both sides• Rarely motor signs• Aura may include:
– Blindness– Vertigo– Diplopia– Dysarthria– Ataxia
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Stroke
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Rapid recognition of symptoms and diagnosis
Reproduced with permission from The Stroke Association
– Use the FAST tool to screen for stroke or TIA outside hospital
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How accurate is FAST?Diagnostic Accuracy of Stroke Referrals…J Harbison, O Hossain, D Jenkinson, J Davis, SJ Louw, GA Ford.Stroke 2003;34:71-76
• 487 patients; 356 stroke/TIA• FAST used by ambulance paramedics
– 23% = non-stroke– 46% admitted within 3 hours
• Primary Care Doctors– 29% = non-stroke– 14% admitted within 3 hours
• ER– 29% = non-stroke
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Limitations of FAST
• Does not take pre-existing disability into account
• Low sensitivity for posterior circulation strokes: – occipital lobes (vision)– cerebellum (often no weakness)– brain stem (sensory deficit, cranial nerve
lesions)
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TIME IS BRAINTime window: stroke to needle 4.5 hrs
Suspectedstroke?
Within 3.5
hours?
Call 999: blue light patient into stroke unit
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Time-windows for thrombolysis
• A limit (not a ‘target’)
• Anterior circulation strokes– 4.5 hours
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Reason for time-limit
• For every 3 patients we thrombolyse, one will have a significantly less marked level of impairment.
but…..• One in 30 patients we thrombolyse, will be
harmed (including death) due to symptomatic bleeding (including intracranial).
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r-TPA in Newcastle upon Tyne
• In total 4 major bleeds – 2 deaths
PH 2
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Time-windows for thrombolysis
• A limit (not a ‘target’)
• Anterior circulation strokes– 4.5 hours
• Anterior circulation strokes in very young people – 6 hours (intra-arterial thrombolysis)
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Time-windows for thrombolysis
• A limit (not a ‘target’)• Anterior circulation strokes
– 4.5 hours
• Anterior circulation strokes in very young people – 6 hours (intra-arterial thrombolysis)
• Posterior circulation strokes– 12 hours (intra-arterial thrombolysis)
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Fast track system: Newcastle
• All cases blue lighted by ambulance to Acute Medical Unit (AMU)
• Ambulance paramedics notify before setting off from patient’s home
• AMU SpR/Senior Nurse phones Stroke Consultant and Notifies CT scan personnel
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Cases NOT for 999 referral
• Low likelihood of benefit from rTPA– poor pre-stroke functional level
– dementia, Nursing Home
– uncertain onset time (e.g. “woke up with stroke”)
– seizure
• High risk of bleeding complix from rTPA– surgery/major trauma within the last 2 weeks
– on warfarin, bleeding tendency
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Common Stroke Mimics
• Seizure – Todd’s paralysis
• Cardiovascular collapse
• Migraine
• Labyrinthine disorders
• Infection- related delirium (“?dysphasia with no other focal neurological deficit”)
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Improving stroke services in the North East
• Primary prevention– FATS 5 guidelines– Anticoagulation for AF– Hypertension
• Secondary prevention: Spotting TIAs
• Rapid referral of acute stroke
• Enhanced rehabilitation services