All About Strokes

Allan L Bernstein MD

Neurology

Definition of Stroke

Ischemic stroke:

Clot blocks

blood flow

through one

of the arteries

feeding the brain

Definition of Stroke

Hemorrhagic stroke:

Weakened blood vessel ruptures allowing bleeding into brain

Definition of Stroke

Deprived of oxygen,

nerve cells in affected

area begin to die.

Body function lost

in part of body

controlled by

ischemic blood cells.

Residual Effects of Stroke

Survivors can be

left with paralysis,

inability to speak,

visual field deficits,

emotional

problems, etc.

Stroke Facts

Approx 50% of

stroke deaths

occur before the

patient reaches

the hospital

Impact of Stroke in the United States

• Of all CVDs, stroke is the third leading cause of death

• Annual incidence– 780,000 strokes

• 600,000 first attacks• 180,000 recurrent attacks

• 15% of strokes are heralded by TIA• 90-day risk of stroke after TIA: 3%–17%

– Highest risk within the first 30 days

American Heart Association. Heart Disease and Stroke Statistics–2008 Update. Dallas, Texas: American Heart Association; 2008 Rosamond W et al. Circulation. 2008;117(4);e25

CVD = cardiovascular disease; MRI = magnetic resonance imaging

Estimates of the Cost of Stroke

$65.5 billion* in 2008

Average cost of ischemic stroke within 30 days

• $13,019 (mild)• $20,346 (severe)

Mean lifetime costof ischemic stroke

• $140,048

*Estimated direct and indirect costs

American Heart Association. Heart Disease and Stroke Statistics–2008 Update. Dallas, Texas: American Heart Association; 2008; Rosamond W et al. Circulation. 2008;117(4);e25

Signs and Symptoms of a Stroke

Sudden numbness

or weakness

in face, arm, or leg

(especially one side

of body)

Signs and Symptoms of a Stroke

Sudden confusion,

trouble speaking

or understanding

Signs and Symptoms of a Stroke

Sudden trouble

seeing in one

or both

eyes

Signs and Symptoms of a Stroke

Sudden trouble

walking, dizziness,

loss of balance

or coordination

Signs and Symptoms of a Stroke

Facial droop

Arm drift

Risk Factors

Hypertension

Hyperlipidemia

Diabetes

Obesity

Smoking

Age

Family History

Atrial Fibrillation

Hx of TIAs

Decreased

physical activity

Acute stroke care

• VERY LIMITED TIME TO ACT• Four and a half hours from onset of

symptoms to active treatment• Must be an observed onset• Must be seen at a facility where acute

stroke care is available• Sonoma County is excellent for TPA but

has NO COMPREHENSIVE CENTER

“Clot Busting”

• rTPA (tissue plasminogen activator– Dissolves clots and keeps new ones from

forming for up to 12 hours– Good but dangerous.– Brain tissue gets soft– Other areas may also bleed

Role of a Stroke Center

• Acute care with appropriate access to specialists

• Ongoing education of the entire stroke team

• Rapid evaluation by imaging and lab• Clear guidelines for prevention of

complications

Role of a Stroke Center

• Team approach to ensure safety while in the hospital– Prevent blood clots in the legs– Prevent falls– Prevent choking or aspiration– Ensure appropriate control of diabetes and

blood pressure– Prevent secondary infections

Role of a Stroke CenterRehabilitation

• Motor: physical therapy• Speech: speech and swallowing therapy• Occupational therapy • Depression-identify and plan treatment• Family involvement in all aspects of care• Prevention of next event

Role of a Stroke CenterPreventing the next event

• Discharge planning– Antiplatelet medication– Anti cholesterol/lipid medication– Blood pressure control– Education re: life style modifications

Risk Factors

Hypertension

Hyperlipidemia

Diabetes

Obesity

Smoking

Age

Family History

Atrial Fibrillation

Hx of TIAs

Decreased

physical activity

Risk Factors for Stroke Recurrence

Early stroke recurrenceStroke subtype

– High for large artery, extra- and intracranial occlusive disease• Elevated blood glucose• HTNLate stroke recurrence • Age • HTN• Heart disease (CHD, HF, AF) • DM and hyperglycemiaPrior stroke or TIA

Sacco RL et al. Neurology. 1999;53(7 suppl 4):S15

AF = atrial fibrillation; CHD = coronary heart disease; DM = diabetes mellitus; HF = heart failure; HTN = hypertension

Defining Stroke Subtype Is an Important Consideration in Recurrent Stroke

Prevention

Ischemic stroke88%

Hemorrhagic stroke12%Other

5%

Cryptogenic30%

Cardiogenicembolism

20%

Small vesseldisease

“lacunae” 25%

Atheroscleroticcerebrovascular

disease20%

Albers GW et al. Chest. 2004;126(3 suppl):438S Thom T et al. Circulation. 2006;113(6):e85

Recent TIA: A Neurologic Emergency

• Risk of stroke after TIA – 10.5% occurred within 90 days and half occurred within

2 days (Kaiser-Permanente HMO study)

• Risks may have been previously underestimated– 1%─2% at 7 days and 2%─4% at 30 days

• True risk– Up to 10% at 7 days and as high as 15% at 30 days

• Time window for prevention is brief– 17% of TIAs occur on the day of stroke– 43% during the 7 days prior to stroke

Rothwell PM. Nat Clin Pract Neurol. 2006;2(4):174

Prevention of Recurrent Stroke• Evaluation for risk factors

– HTN, DM, hyperlipidemia

• Evaluation for cause– Arterial diseases, heart diseases– Coagulopathies

• Management of risk factors– Lifestyle and medications

• Antithrombotic therapy• Surgical or endovascular interventions

Sacco RL et al. Stroke. 2006;37(2):577

Johnston SC et al. Ann Neurol. 2006;60(3):301

Predicting Risk of Stroke After TIA:ABCD2 Score for 2- or 7-Day Risk of Stroke

Johnston SC et al. Lancet. 2007;369(9558):283 Rothwell PM et al. Lancet. 2005;366(9479):29

A Age ≥60 years 1 point

B Blood pressureSBP >140 mm Hg or DBP ≥90 mm Hg 1 point

C Clinical featuresUnilateral weakness 2 points

Speech disturbance without weakness 1 point

D Duration of symptoms

≥60 minutes 2 points

10–59 minutes 1 point

D Diabetes Diabetes 1 pointMaximum score 7 points

DBP = diastolic blood pressure; SBP = systolic blood pressure

National Stroke Association (NSA) Guidelines for the Management of TIAsFactor Comment

Hospitalization • Consider within 24–48 hours of first TIA• Timely hospital referral of recent (within 1 week) TIA and hospital

admission is generally recommended in the case of crescendo TIAs, symptoms longer than 1 hour, symptomatic carotid stenosis >50%, known cardiac-source embolism, hypercoagulable state, or appropriate California or ABCD score

• Hospitals/practitioners should have local admission policy and referral policy for specialists’ assessments

• Local written protocols for diagnostic testing

Clinical evaluation

• Specialized clinic for rapid assessment and evaluation within 24–48 hours

Timing of initial assessment

• For recent TIA, need same-day access to imaging such as CT/CTA, MRI/A, and/or CUS

• If not admitted to hospital, rapid (within 12 hours) access to urgent assessment and investigation

• If TIA occurred in past 2 weeks and the patient was not hospitalized, prompt (24–48 hour) investigations (CUS, blood work, EKG, echocardiogram) needed

Johnston SC et al. Ann Neurol. 2006;60(3):301

CT/CTA = computed tomography/computed tomographic angiography CUS = carotid ultrasound

NSA Guidelines for the Management of TIAs: Evaluation

Factor Comment

GeneralEKG, CBC, serum electrolytes, creatinine, fasting blood glucose, lipids

Brain imaging CT/CTA or MRI/A; TCD is complementary

Carotid imaging

Doppler ultrasound; CTA and/or MRA for supra-aortic vessels if Doppler not reliable or CEA considered; conventional angiogram if Doppler and MRA/CTA discordant or not feasible

Cardiac evaluation

TTE or TEE in patients younger than 45 years when neck, brain, and hematology studies negative for cause

Johnston SC et al. Ann Neurol. 2006;60(3):312

CBC = complete blood countCEA = carotid endarterectomyTCD = transcranial Doppler TEE = transesophageal echocardiogramTTE = transthoracic echocardiogram