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Acute Stroke

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Acute Stroke A Neurological Emergency Acute Stroke Show stroke is an emergency Discuss stroke subtypes Appropriate investigations Acute stroke Benefits of treatment ... – PowerPoint PPT presentation

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Title: Acute Stroke


1
Acute Stroke
  • A Neurological Emergency

2
Acute Stroke
  • Show stroke is an emergency
  • Discuss stroke subtypes
  • Appropriate investigations

3
Acute stroke
  • Benefits of treatment
  • Acute therapy
  • inpatient and outpatient
  • Prevention
  • primary and secondary

4
Acute Stroke
  • Common
  • Serious
  • Preventable
  • Treatable

5
Acute Stroke
  • Medical Emergencies
  • Rapid onset
  • Poor prognosis
  • Need for prompt treatment

6
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

7
Is it a Stroke?
  • Focal Signs
  • Negative symptoms
  • Sudden onset
  • Appropriate context
  • Older age group
  • Vascular risk factors

8
What kind of stroke?
  • TACI
  • PACI
  • LACI
  • POCI

9
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

10
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

11
OXFORDSHIRE COMMUNITY STROKE SUBCLASSIFICATION
SYSTEM
  • LACI
  • Pure motor stroke
  • Pure sensory stroke
  • Sensorimotor stroke
  • Ataxic hemiparesis
  • Dysarthria-clumsy hand syndrome

12
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

13
Investigations
  • Is it a stroke?
  • Difficult in 1st 6 hours
  • Type of stroke dictates investigations and their
    urgency

14
Investigations
  • CT
  • Fast
  • Reliable
  • Available
  • Differentiates between ICH and ischaemic stroke
  • May show alternate diagnosis

15
Investigations
  • CT
  • When?
  • As soon as practicable for most patients
  • Haemorrhagic transformation and primary ICH can
    be difficult to differentiate

16
Investigations
  • ECG
  • FBC
  • Renal function
  • BGL
  • ESR or CRP
  • Cholesterol

17
Investigations
  • TACI
  • Few needed
  • LACI
  • As above
  • POCI
  • As above
  • PACI
  • Carotid duplex
  • Possibly TOE

18
Emergency Management
  • Dr Christopher Trethewy
  • Trelawney the unofficial Cornish anthem

19
Acute stroke treatment
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43
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

44
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

45
Acute Stroke Treatment
  • rTPA
  • Expensive
  • 5 of strokes
  • High risk of harm if not ideal subjects

46
Acute Stroke Treatment
  • Stroke Units
  • Coordinated, goal directed rehabilitation
  • Oxygenation
  • Fever management
  • Early mobilization
  • BGL management
  • PATHWAYS DON'T HELP

47
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

48
Acute Stroke Treatment
  • BP reduction
  • Possibly harmful early
  • Neuroprotection
  • No proven benefit to date

49
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

50
Secondary prevention
  • Aspirin (and modified release dipyridamole)
  • Anticoagulation if Afib
  • CEA if symptomatic stenosis gt70
  • BP lowering
  • Smoking cessation
  • Lipid lowering

51
Stroke an emergency
  • Early hospitalisation if moderate stroke
  • Aspirin within 48 hours if not for TPA
  • Stroke Unit
  • Aspirin plus vascular risk management
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