Stroke

Dr Paul Davies

Cumberland Infirmary

Carlisle

Introduction

• Prevention– Hypertension– AF– TIA

• Management of new stroke symptoms

• Complications of stroke

Hypertension NICE Clinical Guideline 127 (2011)

• Major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death.

• Untreated hypertension can cause vascular and renal damage leading to a treatment-resistant state.

• Each 2 mmHg rise in systolic blood pressure associated with increased risk of mortality:– 7% from heart disease – 10% from stroke.

Definitions

•Stage 1 hypertension:• Clinic blood pressure (BP) is 140/90 mmHg or higher and• ABPM or HBPM average is 135/85 mmHg or higher.

•Stage 2 hypertension: • Clinic BP 160/100 mmHg is or higher and• ABPM or HBPM daytime average is 150/95 mmHg or higher.

•Severe hypertension: • Clinic BP is 180 mmHg or higher or• Clinic diastolic BP is 110 mmHg or higher.

If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.

Diagnosis (1)

ABPM:–at least two measurements per hour during the person’s usual waking hours, average of at least 14 measurements to confirm diagnosis

HBPM:–two consecutive seated measurements, at least 1 minute apart–blood pressure is recorded twice a day for at least 4 days and preferably for a week–measurements on the first day are discarded – average value of all remaining is used.

Diagnosis (2)

Step 4

Summary of antihypertensive

drug treatment

Aged over 55 years or black person of African or Caribbean family origin of any age

Aged under55 years

CA

A + C

A + C + D

Resistant hypertension

A + C + D + consider further diuretic, or alpha- or

beta-blocker

Consider seeking expert advice

Step 1

Step 2

Step 3KeyA – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic

Lifestyle interventionsOffer guidance and advice about:

– diet (including sodium and caffeine intake) and exercise

– alcohol consumption

– smoking.

Patient education and adherenceProvide:

– information about benefits of drugs and side effects

– details of patient organisations

– an annual review of care.

Additional recommendations

The ABCDE of TIA

Dr DP Davies

Cumberland Infirmary

Carlisle

What is a TIA?

• Classic definition– Sudden, focal neurological deficit that lasts for

less than 24 hours, is presumed to be of vascular origin and is confined to an area of brain or eye perfused by a specific artery

Non-Focal Neurological symptoms

• Generalised weakness and / or sensory disturbance

• Light-headedness• Feint• “Blackouts” • Incontinence• Confusion• Ringing in ears• Headaches

AAAARGH!

• Syncope is a loss of consciousness with no focal neurological signs

• A TIA is a focal neurological event with no change in consciousness

Features in the history from a patient with a possible TIA

• What was the nature of the symptoms• Were the neurological symptoms focal? • Were the focal neurological symptoms negative?• Was the onset of focal neurological symptoms

sudden?• What was the anatomical extent of the symptoms• What was the patient doing at the time?• How long did the focal neurological symptoms last?

Duration of TIA and Amaurosis Fugax

The majority of TIAs last less than 1 hour.

Incidence

• Incidence of 0.4/1000 population

• Approximately 30% of stroke are preceded by a TIA

• High immediate risk of stroke

Risk of stroke after TIA

Coull AJ et al. BMJ 2004;328: 326-8

ABCD2E Score Criteria Score

Age > 60 years 1

Blood Pressure >140 mmHg systolic and /or > 90 mmHg diastolic

1

Clinical features Focal, unilateral motor weakness or speech disturbance

Other

21

0

Duration > 60 mins

10-59 mins

< 10 mins

2

1

0

Diabetes Known diabetes 1

Events More than 2 in a week 6

Short term risk of stroke by ABCD2 Score

Claiborne Johnstone et al. Lancet 2007; 369:283-92

Carotid Ultrasound / Doppler

• Only necessary if:

• Anterior circulation ischaemic stroke / TIA / Transient Monocular blindness

• Virtually complete recovery from stroke

• Fit for Operation

• Within 4 weeks of the event

Absolute risk reduction from Carotid Endarterectomy

Rothwell et al. Lancet 2004;363: 915-24

TIA

• If clearly a TIA from history– Sudden onset– Focal neurological symptoms– Negative symptoms– No altered consciousness– Check for AF– Check if on Warfarin

TIA

• Refer to Neurovascular Clinic Immediately

• If on Warfarin admit even if symptoms are mild

• If in doubt use the stroke phone

Accessing Stroke Services in North Cumbria

Cumberland Infirmary

Neurovascular Clinic

Cumberland Infirmary

Carlisle

• Fax 01228 634008• Stroke phone• 07827 083620

Reviewing the patient following Stroke

Dr Paul Davies

North Cumbria Acute Hospitals NHS Trust

Cumberland Infirmary

Carlisle

GM-SAT

Stroke Follow up

• To assess potential for further rehabilitation

• To optimise secondary prevention

• To identify and manage complications

• To help in process of return to work

• To assess ability for return to driving

• To answer unanswered questions

Potential for further rehabilitation

• Patients frequently lose some functional ability following discharge

• Patients frequently lose function if unwell for other reasons

• Patients improve and have higher level goals to address

Secondary Prevention

• BP target ≤130 / 80

• Cholesterol target < 4.0 mMol

• Infarcts– Clopidogrel 75 mg

• Atrial Fibrillation– Anticoagulation if haemorrhagic stroke

excluded

Stroke Review

• Dysphagia– May be able to modify diet

• PEG tubes– Regular follow up– Review of U+E, magnesium, phosphate and

Calcium– Review if tube can be removed

Stroke Review

• Language problems– Usually followed up by SLT– Excellent communication between

departments

Stroke Review

• Incontinence– Find the cause– Are they aware of when to go?– Are they constipated?– Are they only wet at night?– Charting frequency and volume– Bladder scan– Involve district continence services

Incontinence

Unaware

Try toileting by the clock

Aim to void every 3-4 hours

Often need pads too

Poor mobility

Are chairs right height?

Why are transfers poor?

Do they need more aids and appliances?

Pain

• Shoulder pain– Subluxed shoulder– High-tone shoulder– Frozen shoulder

Post Stroke Central Pain

• Usually thalamic involvement

• Severe searing, burning neuropathic pain

• Unilateral

• Triggered by touch

• Can fluctuate in severity

• Can be very disabling

Return to Work

• Can be many problems

• Loss of physical function

• Loss of cognitive function

• Loss of confidence

• Risk

Case 1

• 55 year old man

• Right hemisphere infarct

• Atrial fibrillation

• Good physical recovery

• Some dyspraxia

• Chain saw

Case 1

• Occupation– Circular-saw blade sharpener

• Risk++

• District employment officer

Spasticity

• Positive features– High tone– Exaggerated reflexes– Clonus– Spasms (flexor and

extensor)– Mass synergy

patterns

• Negative features– Weak– Slow– Fatigue

Upper motor neurone syndrome

Spasticity

• Identify treatable causes– Pain, infection, impaction, urinary retention

• Posture

• Positioning

• Splinting

Spasticity

• Baclofen

• Gabapentin

• Botulinum Toxin

Botulinum Toxin

• Prevents release of Acetylcholine at motor

end plate

• Effects last around 3 months

• Needs repeating

• Injected directly into muscles

Return to Driving

• DVLA Guidance

Process

• Ensure visual fields are complete– Refer to ophthalmologists or optician

• Make an assessment of physical recovery

• Make an assessment of cognitive function for driving– Stroke driving assessment

• Refer to Mobility Centre in Newcastle

The unanswered questions

• Will it happen again?

• Can I go on holiday?

Review

• Hypertension

• TIA

• Review clinics