Acute Stroke

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Acute Stroke

• A Neurological Emergency

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Acute Stroke

• Show stroke is an emergency
• Discuss stroke subtypes
• Appropriate investigations

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Acute stroke

• Benefits of treatment
• Acute therapy
• inpatient and outpatient
• Prevention
• primary and secondary

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Acute Stroke

• Common
• Serious
• Preventable
• Treatable

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Acute Stroke

• Medical Emergencies
• Rapid onset
• Poor prognosis
• Need for prompt treatment

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Acute StrokeA Medical Emergency

• Comes on quickly
• Poor prognosis
• 12 mortality at 7 days
• 19 at 30 days
• 31 at one year
• Needs urgent treatment
• TIME BRAIN

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Is it a Stroke?

• Focal Signs
• Negative symptoms
• Sudden onset
• Appropriate context
• Older age group
• Vascular risk factors

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What kind of stroke?

• TACI
• PACI
• LACI
• POCI

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OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION
SYSTEM

• TACI
• Large cortical stroke
• MCA /- ACA territories
• Higher cerebral dysfunction
• Dysphasia
• Acalculia
• Neglect
• AND
• Hemianopia
• And
• 2/3 of face/arm/leg

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OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION
SYSTEM

• PACI
• 2 out of 3 of TACI
• OR
• motor/sensory deficit more restricted than LACI
• OR
• Higher centre dysfunction alone

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OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION
SYSTEM

• LACI
• Pure motor stroke
• Pure sensory stroke
• Sensorimotor stroke
• Ataxic hemiparesis
• Dysarthria-clumsy hand syndrome

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OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION
SYSTEM

• POCI
• Ipsilateral cranial nerve lesion with
  contralateral motor/sensory deficit
• Bilateral motor/sensory deficits
• Conjugate gaze palsy
• Pure cerebellar deficit
• Isolated homonymous visual field defect

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Investigations

• Is it a stroke?
• Difficult in 1st 6 hours
• Type of stroke dictates investigations and their
  urgency

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Investigations

• CT
• Fast
• Reliable
• Available
• Differentiates between ICH and ischaemic stroke
• May show alternate diagnosis

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Investigations

• CT
• When?
• As soon as practicable for most patients
• Haemorrhagic transformation and primary ICH can
  be difficult to differentiate

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Investigations

• ECG
• FBC
• Renal function
• BGL
• ESR or CRP
• Cholesterol

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Investigations

• TACI
• Few needed
• LACI
• As above
• POCI
• As above
• PACI
• Carotid duplex
• Possibly TOE

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Emergency Management

• Dr Christopher Trethewy
• Trelawney the unofficial Cornish anthem

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Acute stroke treatment
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Acute Stroke Treatment

• Does the patient qualify for thrombolytic
  therapy?
• Clearly defined time of onset
• Less than 3 hours
• No contraindications to thrombolysis
• Stroke not too mild nor too severe
• DIRECTLY TO ED, DO NOT PASS GO

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Acute Stroke Treatment

• Recombinant tissue plasminogen activator
• Given within 3 hours
• To patients with appropriate stroke and CT
• REDUCES DEATH and DISABILITY at 3/12
• NNT 18
• NNH 34

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Acute Stroke Treatment

• rTPA
• Expensive
• 5 of strokes
• High risk of harm if not ideal subjects

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Acute Stroke Treatment

• Stroke Units
• Coordinated, goal directed rehabilitation
• Oxygenation
• Fever management
• Early mobilization
• BGL management
• PATHWAYS DON'T HELP

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Acute Stroke Treatment

• Aspirin
• Started within 48 hours
• Reduces death, disability, recurrent stroke
• Improves recovery
• NNT 111
• NNH
• 2 ICH per 1 000
• 4 bleeds per 1 000

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Acute Stroke Treatment

• BP reduction
• Possibly harmful early
• Neuroprotection
• No proven benefit to date

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Prevention

• BP lowering
• Possibly ACE-I esp in diabetes
• Smoking cessation
• Lipid lowering (maybe)
• Anticoagulation for Afib if other risk factors
• Aspirin if other vascular disease

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Secondary prevention

• Aspirin (and modified release dipyridamole)
• Anticoagulation if Afib
• CEA if symptomatic stenosis gt70
• BP lowering
• Smoking cessation
• Lipid lowering

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Stroke an emergency

• Early hospitalisation if moderate stroke
• Aspirin within 48 hours if not for TPA
• Stroke Unit
• Aspirin plus vascular risk management