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Tuesday, March 18, 2008

Stroke Victims: All you need to know

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Stroke Victims: All you need to know Slideshow Transcript
Slide 1: Get B rain S mart!

Slide 2: Neurology Cardiology Migraine ALS Heart attack Arrhythmias Parkinson’s Headache Stroke Heart failure Valvular disease Seizures Neuropathy

Slide 3: Everything you ever wanted to know about stroke (but were afraid to ask)

Slide 4: e strok

Slide 5: Objectives  Highlight some important differences and similarities between heart attack and stroke  Motivate you to prevent a stroke

Slide 6: How is a stroke different from a heart attack?  A stroke is a sudden neurological deficit caused by a blood vessel problem  2 types  Ischemic strokes  Hemorrhagic strokes  The effects of a stroke are extremely varied

Slide 8: Why is heart attack easier to recognize than stroke ?  Painful  Often painless  the stroke itself often  Public and health affects awareness of care providers symptoms commonly  Poor recognition of recognize symptoms and need symptoms and for action need for action

Slide 9: Respondents unable to name 1 warning sign or risk factor for stroke Pancioli, A. M. et al. JAMA 1998;279:1288-1292. Copyright restrictions may apply.

Slide 10: Which of the following are warning signs of stroke? A. Sudden weakness or numbness of the face, arm or leg, especially on one side of the body B. Sudden confusion, trouble speaking or understanding C. Sudden chest pain D. Sudden trouble seeing in one or both eyes E. Sudden trouble walking, dizziness, loss of balance or coordination F. Sudden, severe headache with no known cause

Slide 11: A. Sudden weakness or numbness of the face, arm or leg, especially on one side of the body B. Sudden confusion, trouble speaking or understanding C. Sudden chest pain D. Sudden trouble seeing in one or both eyes E. Sudden trouble walking, dizziness, loss of balance or coordination F. Sudden, severe headache with no known cause

Slide 12: Is heart attack easier to diagnose than stroke?  Diagnosis is  Diagnosis is relatively easy. difficult. Many EKG and cardiac things can mimic enzymes readily stroke. There is no blood test for available. stroke. MRI not readily available.

Slide 14: MRI with diffusion weighted imaging Isolated weakness right index finger JS Kim, Neurology, 2002

Slide 15: Where is the stroke?

Slide 17: CT scan of arteries of neck and head

Slide 18: Are the causes of heart attack and stroke different?  Cause is usually  Atherosclerosis is rupture of a plaque important, but there within a coronary are many other artery causes  So the diagnostic and  Determining the treatment strategy is cause in an individual fairly straightforward is often a deductive (find the blockage process and open it up!)

Slide 19: There are many potential causes of stroke

Slide 20: Stroke is not just a brain disease and often the brain is just an innocent bystander  Usually caused by diseases that are affect the entire vascular system (atherosclerosis)  Material blocking brain arteries usually comes from outside the brain (atrial fibrillation, carotid artery disease)

Slide 21: How is a Cardiologist different than a Neurologist  Basically a plumber or  Diagnostician electrician  Detective  Daredevil

Slide 22: Case  Healthy 61 year-old man developed confused speech 1 day after falling out of a tree.  August 11th, topping a tree, fell and sustained a left collar bone fracture and small puncture of the lung.  Next night suddenly developed confused speech.

Slide 27:  Trauma (fall out of a tree)  Vascular problem (leg vein injury)  Blood disorder (hypercoagulability)  Congenital heart anomaly (patent foramen ovale)

Slide 28: How are heart attack and stroke SIMILAR?  Time is critical  The first priority is to save tissue at risk

Slide 29: Kidwell 2004

Slide 30: You need to call 911 ASAP for both heart attack and stroke!  There is a 3 hour time limit for the medication t- PA, and the sooner it’s given the better!  Future strokes may be prevented if we identify the cause of stroke ASAP  People brought by ambulance are treated faster  Neurological deterioration and other complications may be prevented if a patient is hospitalized earlier

Slide 32:  June 2006 7AM: A 75 year-old woman collapsed at home, brought to her local emergency room. She cannot move her right side or speak. The doctors there are not comfortable using t-PA so transfer to DHMC is requested.  1:02 PM: Arrival DHMC ED.

Slide 35: 4:49 PM artery is opened

Slide 38:  The system needs to be very coordinated

Slide 40: PREPARED RAPID EVALUATION INDIVIDUALIZED CARE Improving Stroke Care at DHMC PROTOCOLS TO DECREASE ERRORS A TEAM APPROACH

Slide 41: Ways everyone here can prevent a stroke  Identify and control risk factors  If a warning sign of stroke occurs, get attention

Slide 44: 10y risk 88% !

Slide 45: 10y risk 13% !

Slide 46:  Preventing a heart attack or stroke is MUCH more effective (and safer) than a procedure!

Slide 50: HJM Barnett 1999

Slide 51: The medical and surgical 5-year Kaplan-Meier curves of freedom from ipsilateral stroke and perioperative stroke and death indicate a 5.9% difference favoring endarterectomy at 5 years in the Asymptomatic Carotid Atherosclerosis Study (ACAS) Barnett, H. J. M. et al. Arch Neurol 2000;57:40-45. Copyright restrictions may apply.

Slide 52: Kaplan-Meier 5-year risks of ipsilateral ischemic stroke for NASCET patients according to gender and degree of internal carotid artery stenosis in the medical and surgical groups Alamowitch, S. et al. Stroke 2005;36:27-31 Copyright ©2005 American Heart Association

Slide 55: 18/111 (16%) received t-PA Average cost for transportation $4,623

Slide 56: 2004: 144 pts Rx t-PA 50% had t-PA started at 1 of 47 referring hospitals >50% of these have <60 beds

Slide 58: Meyer 2005

Slide 59: MGH TeleStroke

Slide 60: Effectiveness of Stroke Prevention Absolute risk reduction in a year: Strategy ARR (%)  Warfarin for atrial fibrillation 8  Carotid endarterctomy for symptomatic dz 4  Smoking cessation 2  Antihypertensive therapy if BP elevated 2  Cholesterol lowering medications 2  Aspirin 1-2

Slide 61: Schaebitz W-R, 2000

Slide 63: anticoag RG Hart 2003

Slide 64: Stroke Diagnosis 40 years ago

Slide 65: Stroke Warning Signs  Sudden weakness or numbness of the face, arm or leg, especially on one side of the body  Sudden confusion, trouble speaking or understanding  Sudden trouble seeing in one or both eyes  Sudden trouble walking, dizziness, loss of balance or coordination  Sudden, severe headache with no known cause

Slide 66: What is a TIA ?  Transient Ischemic Attack=Stroke symptoms that resolve with a short time.  Can be a warning sign of impending stroke.  The highest risk period of stroke following a TIA is the first 2 weeks.  The risk of stroke soon after a TIA can now be estimated.

Slide 67: ABCD2 Tool risk of stroke following TIA A Age> or = 60 1 B Blood pressure >140/90 1 C Clinical features unilateral weakness 2 speech impairment 1 D2 Duration > 60 min 2 10-59 min 1 Diabetes 1

Slide 70: A B C D E F Systolic BP* 95-105 130-148 130-148 130-148 130-148 130-148 Diabetes No No Yes Yes Yes Yes Cigarettes No No No Yes Yes Yes Prior Atrial Fib. No No No No Yes Yes Prior CVD No No No No No Yes *BP in millimeters of mercury (mmHg) Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318.

Slide 71: Which action would you take if you thought someone was having a heart or stroke? A. take the person a hospital B. advise the person to call a doctor C. call 911 D. call a spouse or family member E. do something else

Slide 72: Which action would you take if you thought someone was having a heart or stroke? A. take the person a hospital B. advise the person to call a doctor C. call 911 D. call a spouse or family member E. do something else

Slide 73:  Bleeding into the  Brain heart doesn’t hemorrhage is occur common

Slide 74: CT scan: ischemic stroke

Slide 75: Intracerebral hemorrhage at 1 hour and 6 hours

Slide 76: Intra-arterial thrombolysis Time window=6 hours

Slide 77: High resolution MRI to identify the unstable plaque Chu B, Circulation 2005

Slide 78: You need to open the artery

Slide 80: Like with heart disease, the treatment and prevention of stroke needs to be individualized!  A 65 yo man attends a vascular disease prevention fair and an ultrasound shows a blockage of his left carotid artery. He is told to speak to his doctor ASAP and he becomes worried that there is a “time bomb” ticking in his neck.







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