14. Stroke for local doctor

STROKE (For local doctor) Dr. Nguyen Anh Tuan Goals • Work up for TIA and stroke • Window time for TPA, recommendation • Treatment of hemorrhagic stroke • BP control in ICH • SAH: emergency treatment Introduction • Cerebrovascular disease is a major cause of mortality and morbidity in the world • Stroke of all types rank third as a cause of death and are surpassed only by heart disease and cancer • Incidence: 150-200/100.000 Stroke – incidence and prevalence 531.000 new cases of stroke and 200.000 recurrences of stroke each year in the US In 22 European countries with a combined population of approximately 500 million, almost one million strokes are estimated to occur each year 1. Cardiovascular disease 2. Cancer 3. Stroke Cause of death Sorelle R. Circulation 2000;102:E9047-9 Brainin M et al. Eur J Neurol 1999;7:5-10 Stroke – definitions • Interruption of blood flow (ischaemic stroke) or • Bleeding into or around the brain (haemorrhagic stroke) An injury to the brain caused by: Transient ischaemic attack (TIA) • Brief episode in which neurological deficits suddenly occur, then disappear; can persist up to 24 hours • Temporary arterial blockage, with no resultant brain damage PLEASE… Pay Attention to these symptoms • TIA’s should not be ignored – More that 1/3 of people will go on to have an actual stroke – 5% of strokes will occur within 1 month of the TIA or first stroke – 12% will occur within 1 year – 20% will occur within 2 years – 25% will occur within 3 years Stroke – aetiology • In Vietnam, haemorrhagic stroke rate maybe higher, up to 40% according to some recent data • Poorly control of hypertension in community can explain the difference 85% Ischaemic strokes 15% Haemorrhagic strokes Ischaemic strokes (85%)  Cerebrovascular disease  Embolism Haemorrhagic strokes (15%)  Hypertension  Aneurysms  Arteriovenous malformations Cerabral Embolism Task Force. Arch Neurol 1986;43:71-84 Risk factor • Hypertension • Diabetes Mellitus • Cardiac disease • Hyperlipidaemia • Smoking • Family history • Obesity ANATOMY: Blood supply to the brain [...]... After first stroke Acetylsalicylic acid (ASA)   Small benefit within 48 hours of stroke onset Delay for 24 hours if receiving thrombolytics After recurrent stroke with taking ASA  Consider clopidogrel or dipyramidole/aspirin • In patients who do not merit or qualify for aggressive acute thrombolytic treatment, therapy with ASA is warranted • ASA should be started within 48 hours of stroke onset... small perforating vessels, internal capsule, basal ganglia, thalamus, pons • Brainstem stroke Cerebral ischaemia Duration of ischaemia  Cerebral ischaemia can produce irreversible injury to highly vulnerable neurons in 5 minutes  If cerebral ischaemia persists for >6 hours, infarction of part or all of the involved vascular territory is completed  Clinical evidence depends on the location of stroke. .. 3 or 12 months Adverse effects (5%)  Significant brain haemorrhage Recomemdation for TPA • In patients with acute ischemic stroke in whom treatment can be initiated within 3 h of symptom onset, we recommend IV recombinant tissue plasminogen activator (rtPA) over no IV r-tPA (Grade 1A) • In patients with acute ischemic stroke in whom treatment can be initiated within 4.5 h but not within 3 h of symptom... rtPA over no IV r-tPA (Grade 2C) IV TPA vs IA TPA • In patients with acute ischemic stroke in whom treatment cannot be initiated within 4.5 h of symptom onset, recommend against IV r-tPA (Grade 1B) • In patients with acute ischemic stroke due to proximal cerebral artery occlusions who do not meet eligibility criteria for treatment with IV r-tPA, recommend intraarterial (IA) r-tPA initiated within 6... different signal intensities on T1- or T2-weighted images MRI scan Diffusion-weighted imaging (DWI) MRI image acute stroke  Best way to   Ischaemia can be visualised as early as within 30 minutes of stroke Relies on reduction of random diffusion (Brownian motion) of water after acute stroke MRI scan Features of ischaemic region  Swollen cells  Reduced extracellular space  Decrease in diffusion...Circle of Willis Stroke – diagnosis Stroke Common symptoms  Weakness and sensory loss down one side of the body  Disturbances of consciousness and confusion  Impariment of speech, vision and co-ordination of movement Computed... Duration of ischaemia (min) Zivin JA Neurology 1998;50:599–603 Ischaemic damage Determinants of damage  Duration of cerebral hypoperfusion  Degree of cerebral hypoperfusion Strokes are an EMERGENCY • If patients are having a Stroke come to the hospital right away – CALL 9-1-1 in US (115 in Vietnam) Case (continue…) • 7.15pm (45munutes after symptom onset) • Patient arrives in the ED, the nurse immediately... the Hospital • Diagnostic Testing – CT or MRI of the brain – EKG – Carotid Ultrasound – Echocardiogram Thrombolytics (t-PA) Some exclusion criteria for thrombolytics  Should preferably be given within 3 hours of symptom onset  No other likely explanation for the neurologic symptoms  No significant risk of bleeding  No evidence of bleeding on head CT scans  No evidence of early infarct sign on head... region Computed tomography (CT) scan A B Early ischaemic changes Chronic infarction Magnetic resonance imaging (MRI) Early ischaemic changes after occlusion of the left internal carotid artery ISCHEMIC STROKE Case • At 6.30pm, a female collapsed at a shopping mall • At 6.40 you find a woman sitting on the bench, she is confuse but response to verbal stimuli • Summary signs and symptoms: – – – – Regular... patients who do not merit or qualify for aggressive acute thrombolytic treatment, therapy with ASA is warranted • ASA should be started within 48 hours of stroke onset • In patients with a contraindication for ASA, dypiridamole or clopidogrel can be used  . STROKE (For local doctor) Dr. Nguyen Anh Tuan Goals • Work up for TIA and stroke • Window time for TPA, recommendation • Treatment of hemorrhagic stroke • BP control in. an actual stroke – 5% of strokes will occur within 1 month of the TIA or first stroke – 12% will occur within 1 year – 20% will occur within 2 years – 25% will occur within 3 years Stroke – aetiology •. 85% Ischaemic strokes 15% Haemorrhagic strokes Ischaemic strokes (85%)  Cerebrovascular disease  Embolism Haemorrhagic strokes (15%)  Hypertension  Aneurysms  Arteriovenous malformations Cerabral Embolism Task Force. Arch Neurol