age-related health care adelaide and meath hospital dublin
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Age-Related Health Care Adelaide and Meath Hospital Dublin incorporating the National Children’s Hospital. Dept of Medical Gerontology Trinity College Dublin. Stroke in Ireland. Kills more people than breast cancer, lung cancer and bowel cancer combined. Stroke is…. - PowerPoint PPT PresentationTRANSCRIPT
http://indigo.ie/~arhc
Age-Related Health CareAdelaide and Meath Hospital Dublin
incorporating the National Children’s Hospital
Dept of Medical GerontologyTrinity College Dublin
http://indigo.ie/~arhc
Stroke in Ireland
•Kills more people than breast cancer, lung cancer and bowel cancer combined
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Stroke is…...
• a focal or global neurological deficit• of presumed vascular origin• lasting more than 24 hours• or causing death within 24 hours
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A TIA is…...
• a focal or global neurological deficit• of presumed vascular origin• lasting less than 24 hours
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Stroke burden
• 9,250 acute strokes/year• 25% die in first year• 30,000 with residual disability
– 48% hemiparesis– 22% cannot walk– 24-53% need help in ADLs– 12-18% aphasic
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Impact
• Personal: – “..more impact than my wedding, or the
birth of my first child”
• 2nd most expensive illness• Most common cause of acquired
physical disability• Most expensive single DRG medically
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Biggest advance in Stroke Care
Not, not, not
Thrombolysis
Stroke Units
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Stroke Units• Reduce death, disability,
institutionalization• Reduce death and disability by 25%• NNT
– 33 to save a death– 20 to regain independence– 20 to prevent institutionalize
• Save 2-11 days hospital• If this were a tablet………..
Cochrane 2005
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Stroke Units• Direct care of a specialist in stroke care
and interdisciplinary team• Clearly defined continuum of care• Geographical unit preferable• CT/MRI on site• Main base general hospital• Take all patients referred
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Vascular surgeon
Radiologist
Public Health
Geriatrician
RehabilitationistNeurologist
GP
PHN
Person with stroke
Carer
Hospital nurses
Physiotherapy
Occupational therapySpeech therapySocial workPsychology
Clinical nutrition
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3 tasks•Was it a stroke?•What did the stroke cause?
–Cognitive impairment–Dysphagia–Gait disorder–Sensory–Inattention
•What caused the stroke?
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http://indigo.ie/~arhc
Vulnerable Tissue:
Work Fast!
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Brain attack• ABC• Diagnosis• Stabilize
• BP, O2, Temp, glucose
• Swallow• Positioning• Stroke Service
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History
• Patient• Collateral/witness
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Cincinnati Prehospital Stroke Scale
• Facial droop• Arm drift• Speech
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4 level neuro Ax• End of the bed• Alertness (GCS), language, cognition• Classical neuro examination
– Cranial nn– PTCS– Reflexes
• ‘Parietal’ signs– Inattention/neglect– Agnosia– Apraxia
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Differential
• Tumour• Meningitis/encephalitis• Seizure• Epilepsy• Migraine• Metabolic causes• MS
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TIA’s• 38% 'true' TIA• 10% had migraine• 9% had faints• 9% had possible TIAs, 9% had 'funny turns’• 6% had epilepsy• 6% had vertigo• 0.8% had hypoglycaemia• 0.4% had brain tumours
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ABCD of TIA treatment• 10% stroke risk within one week: 30% if high
score• ABCD Score
– Age - >60 = 1– Blood Pressure - Syst > 140 or Diast > 90 = 1– Clinical
• Motor = 2• Speech = 1
– Duration• > 1 hour = 2• 10-59 min = 1
Rothwell, Lancet 2005
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Urgent investigations
• Glucose• FBC• U + E• ECG
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Urgent CT
• Head injury• Suspicion sub-arachnoid
– Headache– Meningism
• Neurological deterioration• Possibility of thrombolysis
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BP
• Ischaemic stroke - dangerous to treat if not > 220/140
• Sub-arachnoid - neurology advice - nimodipine and normal blood pressure
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Stabilize
• Keep euglycaemic• Antipyretics for pyrexia
• O2: avoid hypoxia
• NPO until swallow assessed• Early advice on positioning
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First 12 hours
• Stroke Service• Book CTB (within 48 hours)• Book other tests as appropriate:
– Carotid dopplers– Holter monitor– ECHO– ……..
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Pharmacological
• Anti-platelets– NSA, Asantin R, clopidrogel
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Strategies: who can benefit?
• 150-250 strokes yearly in a Dublin hospital– Stroke Unit 100%– Aspirin 80%– Neuroprotective strategies 90%– Thrombolysis 5%
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iv Thrombolysis
• 3 Streptokinase: terminated• European r-TPA: no overall change• NINDS r-TPA: modest improvement
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NINDS rt-PA regime
• Within 3 hours (mean 90 mins)• 0.9 mg/kg (max 90mg)• 10% bolus• 90% over one hour• Systolic <185, Diastolic <110• BP managed by algorithm
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Contra-indications
• PUD• Recent surgery• Recent arterial puncture• Abnormal coagulation• BP not manageable to 185/110• No sign of established stroke on CT - NB
difficult
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Cochrane review
• Excess of deaths – 23% thrombolysis– 18% controls
• Reduction death and disability– 45% thrombolysis– 51% controls
• Treat 16 patients to avoid one death/disability
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The real world....Chiu, Stroke 1998
• 6% receive rt-PA• Those who don't:
– Time 37%– ICH 22%– Minor/rapidly resolving symptoms 19%– Nonstroke Dx 12%
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Acute treatment
• Aspirin• LMW Heparin• Thrombolysis
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Neuroprotective
• Nimodipine• Glutamate antagonists• Na channel antagonists/glycine
antagonists• Opioid antagonists• Antoxidants/Free radical scavengers
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Management issues
• Reducing delay• Stroke unit approach• CT access and expertise (?
telemedicine)• Neuro-ICU
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http://indigo.ie/~arhc
Unmet needs post-stroke
• 38% no personal contact GP• 46% attended DH• 79% had health concerns• 64% required Rx advice• 18% had resumed smoking
Martin Scot Med 2002
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6 Months after discharge
• 58% in the community• 87% had seen GP• 48% reviewed in OPD
Crowe IMJ 2002
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Remediable risk factors
• Smoking• Alcohol• Exercise• Obesity, DM• Psychosocial
• BP• Lipids• Homocysteine• Infections• Inflammation,
thrombosis
Sem Vasc Med 2002, 2, 229-445
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Fibrinogen
•Adds to likelihood of event•Reduce inflammation?
– Flu vaccine– Reduces stroke hospitalization by 16%
Nichol NEJM 3 April 2003
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Healthy lifestyle is anticoagulant and anti-
inflammatory
• Weight loss, exercise• Reduce vascular inflammation and
insulin resistance
• So, stop smoking, keep walking!
Esposito, JAMA, April 9, 2003
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• Antithrombotics
• BP reduction
• Cholesterol
• Diet and DM
• Exercise/rehabilitation
• Forget smoking/Flu jabs
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Antiplatelets
• 25% reduction in all events• CHD• Stroke• VTE• Revascularization
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BP reduction
• Diuretics and ACE-Inhibitor• Primary prevention trials suggest drug
equivalence• Cave postural symptoms!
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Statins
• All patients with stroke• Fire and forget• Highest effective dose• Simvastatin 40• Pravastatin 40• Atorvostatin 10
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http://indigo.ie/~arhc
Carotid endarterectomy
• Carotid territory stroke TIA in last 6 months
• >70% stenosis (about 5% of our patients)
• NNT 15 to prevent death or disability over 2-6 years
• Surgically fit patients• Surgeons with <6% complication rates
http://indigo.ie/~arhc
• Antithrombotics
• BP reduction
• Cholesterol
• Diet and DM
• Exercise/rehabilitation
• Forget smoking/Flu jabs