the role of the neurologist in the care and cure of patients
TRANSCRIPT
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What neurologist may add to the care and cure of of stroke
patients, or…
Peter Sandercock
Perugia December
2007
What is the place of the neurologist in stroke medicine?
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In America…to perform many expensive investigations?
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In the UK…to diagnose a rare cause of stroke
by clinical examination?
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Role of neurologist in acute phase of stroke
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Acute care: the neurologist will often be involved at all points in the ‘path of acute care’
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Acute brain attack
If neurologist finds NO clinical evidence of ‘stroke mimic’, e.g.: epileptic seizure, migraine, Hypo- orhyper-glycaemia, or other obvious non-stroke diagnosis -> do CT
CT/MR Scan Non-stroke pathologySubdural, tumour
Scan: Normal, Infarct, intracerebral bleed, SAH
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NIHSS helps distinguish ‘stroke’ from ‘non-stroke mimic’
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NIHSS and ‘stroke’ vs ‘not stroke’
• About one third of patients with NIHSS 1-4 do not have an acute stroke
• NIHSS > 4 is a useful indicator that the deficit is due to a stroke
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If CT or MR excludes blood and ‘stroke mimic’ neurologist decides
Probably ELIGIBLE for thrombolysis’• Known time of onset • Unilateral neurological signs • Increasing NIH score (>4)• Abnormal vascular signs (AF, PVD)
Probably NOT ELIGIBLE• Deficit first noted on waking from sleep• Prior cognitive impairment• Loss of consciousness at/soon after onset• Seizure• Can walk now ( too mild)
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Some clinical problems, where neurologist very helpful
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? POCI
• Man 75 years, arrives at ER 3.5 hrs after, sudden onset ‘dizziness’ and unsteadiness
• Exam: Unsteady when standing
• No limb ataxia• NIHSS = 2• ? POCI
?Hyper-attenuating basilar artery?
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What to do?
• MR and angiography not available
• ‘Outside 3 hour window’: iv thrombolysis not approved
• If this is a basilar thrombosis, could he deteriorate rapidly if not treated?
• Randomised in IST-3
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Migraine or ischaemic stroke?
This 53-year-old female patient with acute headache and right-sided hemianopia. Not treated with thrombolysis, because significance of
abnormality not appreciated
Krings et al, Stroke. 2006;37:399-403.)
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Initial CT (A to C) show a hyperattenuating posterior cerebral artery (arrow in B). On follow-up (D to F), a large PCA infarction is now visible.
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Blood on CT can be
a) missed if not looked for carefully
b) Have disappeared if the patient presents a day or more after the haemorrhage
Subarachnoid haemorrhage with focal deficit
(eg hemiparesis) due to delayed cerebral ischaemia
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Patient has clinical diagnosis of ‘acute stroke’ but CT is normal.
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• The time of onset of stroke symptoms is known precisely
• You have an experienced stroke physician/stroke neurologist able to see the patient urgently in A&E or at CT scan room
• Urgent non-contrast CT scan is interpreted by someone with expertise in acute stroke CT
• -> MRI not essential; its place in routine acute stroke care yet to be determined
Can you diagnose ‘acute ischaemic stroke suitable for thrombolysis’ without
DWI MR? Yes, if:
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‘Telephone neurology’ in acute stroketo patient / family: confirm diagnosis, seek
consent. Neurologist to general physician: advice, IST-3 helpline
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Role in prevention
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Neurologists and ‘dizzy turns’
• a 50 year old woman (depressed, just started on anti-depressant) has an episode where speech is ‘dizzy and confused’.
• At emergency department: BP 180/90. Normal examination.
• diagnosis ‘?reaction to anti-depressant;’
• Management ‘stop drug and go home’, but does refer neurologist
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Neurologist asks about other symptoms: the day before she describes a brief episode of
loss of vision in the left eye (amaurosis fugax).
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The correct diagnosis
• An ocular and a cerebral TIA in the distribution of the left internal carotid artery
• High early risk of stroke
• Immediate action required
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High early risk of stroke after TIA
0
2
4
6
8
10
12
14
0 7 14 21 28
Days
Ris
k o
f st
roke
(%
)
OXVASC
OCSP
Lancet 2005; 366: 29-36
10% risk of stroke by 7 days
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Management• Start dual antiplatelet therapy, statin
and anti-hypertensive immediately
• Immediate carotid ultrasound study - often performed by neurologist
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Overall, 62% of patients referred with ‘TIA’ were found to have other
diagnoses
migrainesyncope/pre-syncope‘funny turn’ (= event it is not possible to categorise)vertigo or dizziness onlyepilepsytransient global amnesiacerebral tumour
Oxfordshire Community Stroke Project: of 542 patients referred with possible TIAs, in 317 (62%) the diagnosis was not a TIA
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Neurologist organises management of TIA and minor stroke
• Urgent brain imaging if symptoms persist > 1-2 hours
• high ABCD2 score, ?admit to hospital for treatment & investigation
• Aspirin• Add dipyridamole in high-risk cases• Statin to lower cholesterol• Blood pressure lowering: diuretic and angiotensin
converting enzyme (ACE) inhibitor• Urgent non-invasive carotid imaging ->
endarterectomy < 2 weeks if severe stenosis
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Role of neurologist in care of stroke patients?
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The neurologist is often the leader of the multi-disciplinary team on the
stroke unit
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Research led by neurologists identified effective stroke
treatments• Treatment acute ischaemic stroke
– Aspirin, – Thrombolysis
• Prevention– Anticoagulants in AF– Antiplatelet for secondary prevention after
TIA/stroke– Carotid surgery for symptomatic stenosis
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• Diagnosis of in acute phase
• Management in the acute phase
• Lead multidisciplinary team on stroke unit
• Co-ordinate stroke services, including secondary prevention
• Lead research
The neurologist has many roles in cure and care of stroke