Stroke

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Stroke

• Mark Sudlow
• Consultant and Senior Lecturer
• Stroke Northumbria/NHCT/University of Newcastle

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Money talks

• NAO estimates of cost of stroke 7 billion
  annually
• Of which 2.2 billion are direct costs to NHS
• Cf 1.9 billion for coronary heart disease
• Incidence the same as coronary heart disease
  but greater associated disability
• Recommend ways to save money
• DOH obliged to make formal response via Public
  Accounts Committee
• NAO to review progress

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NAO Recommend

• Faster access to specialist care for patients
  with TIA
• High risk on same day
• Lower risk within a week maximum
• Faster access to specialist stroke care
• Acute stroke units
• Early scanning 24 hours maximum
• Thrombolysis - ?10 target and timed benchmarks
  for onset to needle
• Better long term care provision

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Response from DOH

• Stroke is no longer under Elderly or Long Term
  Conditions but under Vascular Disease
• Working parties set up to look at recommendations
  on changing provision of care
• NICE asked to fast track guidelines
• Intercollegiate Acute Stroke and TIA Guidelines

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Transient Ischaemic Attack

• High early risk and effective early treatment

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Risk in Transient Ischaemic Attack

• Risk of completed stroke within a week 10
• Risk gt 20 if
• More than one TIA in 7 days
• 3 or more of
• BP gt 140/90
• Unilateral weakness of speech disturbance
• Duration gt 60 mins
• Diabetes
• The unstable angina of the brain

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Effective treatment

• Aspirin 75 mg od reduces risk by 25
• Dipyridamole MR 200mg bd reduces risk by
  further 20 when added to aspirin
• Cholesterol reduction
• Blood pressure reduction
• Smoking
• Exercise
• Alcohol

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What to do ..

• Identify high risk patients and refer for urgent
  admission
• More than one TIA in 7 days
• 3 or more of
• BP gt 140/90
• Unilateral weakness of speech disturbance
• Duration gt 60 mins
• Diabetes
• Refer lower risk patient urgently to TIA clinic
• Start aspirin and consider dipyridamole

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What we will do ..

• Admit high risk patients
• Start treatment
• Arrange urgent imaging
• Refer to vascular surgery where they will be
  seen within a couple of days
• See lower risk patients within a week of referral
• Start treatment
• Information
• Lifestyle advice
• Arrange imaging
• Refer to vascular surgery where they will be
  seen within two weeks

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Acute Stroke

• FAST response allows life saving treatment

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Evidence for specialist care

• Clear evidence that hospitalisation and treatment
  by a coordinated specialist team improves
  mortality and outcome
• Absolute improvement of 10
• Increasing evidence that early specialist care is
  the key

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Evidence for early aspirin

• 1 absolute reduction in recurrence and mortality
  if given within 24 hours
• Requires CT scan to exclude haemorrhage

14
Evidence for thrombolysis

• Within 3 hours of onset of symptoms
• With CT scan showing no haemorrhage
• 10 absolute improvement in number of patients
  with minimal disability

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What to do ..

• If a patient presents or calls with symptoms
  suggesting acute stroke
• Call an ambulance

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What we will do..

• If a patient presents with stroke within
  thrombolysis window
• Immediate referral to stroke specialist
• Immediate scanning
• Thrombolysis
• If a patient present outside that window
• Admit to specialist stroke ward
• CT scan within 24 hours
• Preventative treatment started early
• Coordinated specialist assessment and
  rehabilitation
• Information
• Lifestyle advice

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Secondary Prevention

• Need for risk reduction as for any high risk
  vascular disease
• With a few minor additions

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• Risk of MI, cardiac death and further stroke is
  similar to after MI
• Strategies are broadly similar

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• Aspirin
• Statin
• Blood pressure best evidence is for ACE and
  thiazide

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Stroke specific

• Dipyridamole MR 200 mg bd for at least 2 years
• Risk of further stroke is particularly high with
  atrial fibrillation
• 15 absolute per annum
• Benefits of warfarin highest in this group
• Risk of further stroke is particularly high with
  carotid stenosis
• Carotid ultrasound and intervention if good
  recovery
• Particularly important in partial anterior
  circulation strokes

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What to do ..

• Annual check
• Antiplatelets
• Blood pressure
• Cholesterol
• Lifestyle

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What we will do ..

• Arrange ongoing rehabilitation
• Outpatient check at 6 weeks (as an inpatients if
  not discharged)
• Outpatient check at six months

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Life After Stroke

• Isolation and Dependency

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• Information
• Inclusion of function and mood in annual
  screening
• Access to social services and rehabilitation
  review

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How it should be
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Presentation

• 64 year old man
• Sudden onset at 11 am of
• Complete loss of speech
• Total paralysis of right arm and leg
• Called GP surgery
• Advised to call 999 ambulance
• Arrives hospital 11.28
• No speech
• Right hemianopia
• Right face, arm and leg paralysis

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Expected outcome
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• CT scan 12.00
• Thrombolysis 13.00
• Statin that night
• Aspirin and dipyridamole start the next day

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• Carotid doppler on day 7
• 95 stenosis of left carotid artery
• Urgent referral to vascular surgery
• Seen in vascular outpatients 2 days later and
  arranged for urgent admission
• Carotid stenting 2 weeks after stroke

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• Out of stroke unit by 10 days
• Out after carotid intervention by 2 weeks after
  stroke
• On treatment with
• Aspirin
• Dipyridamole
• Simvastatin
• Perindopril
• Bendroflumethiazide

33

• Cholesterol 3.2
• Blood pressure 128/76
• Stopped smoking
• Complete recovery
• Minimal ongoing risk

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• With a coordinated approach from
• Ambulance service
• Primary care
• Emergency care
• Stroke service
• Vascular surgeons
• We can do this

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• And save money