AN OVERVIEW OF STROKERecent perspectives

DR. A.V. SRINIVASAN

“Knowledge can be communicated but not Wisdom”- Hermann Hesse

Introduction

Improved technology and treatment for stroke has decreased mortality and prolonged survival but disability from stroke remain Major health care concern.

Although Rehabilitation is one of the oldest forms of treatment, it is least understood. Some physicians uneasiness with rehabilitation has its origin in Medical Training. Traditional Medical training emphasis on diagnosis and curative treatment. When cure is not possible patient needs Rehabilitation Therapy, Counseling and Support in the face of physical disability, feeling of failure and futility.

1. 45 85 yrs - Stroke occurs

2. Guidelines for 24hrs: MandatoryLevel of Evidence

Level A: Based on RCT or Meta analy. of RCT

Level B: Based on Robust Experiment or Observation Studies

Level C: Based on Expert opinion.

25% men

20% women

“The True Art of Memory is The Art of Attention” - S.Johnson

Injured Brain

According to WHO

Doctor assessment of Handicap may not coincide with Patients Assessment. Neurologist depends on physiotherapy, occupation therapy and speech therapy in rehabilitating the stroke patients.

NEUROLOGIC PREDICTORS.

Flaccid Paralysis for more than 96 hrs When tendon reflexes recover without return of voluntary

movement – prognosis poor Recovery of sensory less in usual to a degree. Postion

sense recovers but not pain and temperature Recovery from Dysphasia is never complete Dysarthria usual improves and Dysphagia never improves Diplopia due to brain stem is usually permanent Conjugate gaze – recovers Vertigo improves but hearing loss is permanent Pseudobulbar palsy permanent

REHABILITATION OF STROKE Assessment of function

Motor, postural, perceptual, cognitive, communication and autonomic

Independence and self-care Walking dressing washing, toileting and feeding

Available services Nursing Physiotherapy Occupational therapy Clinical psychology Medical social worker plus self-help groups (‘Stroke

Club’)

EARLY MANAGEMENT AND REHABILITATION

Consist of1. Skin care 2. IV therapy in disabled patients 3. Caution due to confusion 4. Auditory and visual deficit 5. Splint and braces 6. Complications include the following

Complications include the following:

A. Contractures

b. Treatment of Spasticity

TREATMENT MODALITIES FOR SPASTICITY Surgery

Nerve Blocks

Motor Point Blocks

Drugs: Dantrolene, Baclofen, Diazepam

Muscle Stretching Program

Prevention of Nociception

Complications include the following:

c.  Reflex sympathetic Dystrophy d. Physiological Deconditioning.

PHYSIOLOGICAL DECONDITIONING

Loss of Normal Postural Reflexes

Increased Resting Pulse RateCatabolic Nutritional State-Psychological Depression

Lower Vital CapacitySlowing of GI Tract

Venous StasisUrinary Stasis

Complications include the following:

e. Swallowing disordersf. CVD and Heterotrophic ossification

Complications include the following:

7. Psychological factors

FACTORS GOVERNING THE OUTCOME OF STROKE REHAB.

Good outcome – Mild to moderate neurologic damage

with mild moderate paresis not associated with sensory or visual problems

Patients not demented or depressed

Walking 150 feet without assistances (Goal ) Motor alone – 0.9 Motor Sensory Visual – 0.5 Barthal index score – 95 normal

• Motor alone- 0.6• Motor Sensory Visual – 0.5

FACTORS GOVERNING THE OUTCOME OF STROKE REHAB.

Motor deficits alone reach their goals within 12 weeks

Framinham study – recovery from stroke 3 months

Adams – recovery from stroke 2 years

FACTORS GOVERNING THE OUTCOME OF STROKE REHAB.

FUTURE TRENDS IN REHABILITATION (Sensory Modulation)

Anatomical Principles Somatosensory System Limbic System Visual System

Phantom Experiences The man who missed his foot for penis Gaze Tinnitus Ear Lobe stimulation produces as an eroatic

sensation in nipple Phantom Pain

Role of Parietal Lobe Clinical Implications

Synesthesia - Virtual reality box Allesthesia - Extinction of

referred sensation Caloric test - Disappearance of

Anosognosia

FUTURE TRENDS IN REHABILITATION (Sensory Modulation)

SUMMARY

The goal of rehabilitation is to permit a return to function. In pursuit of this goal, proper management of secondary disabilities is essential. Clinical objectives include: prevention of contractures, retardation of deconditioning, maximization of nutritional status, optimal treatment of associated medical problems, and providing appropriate psychological support to family and patients.

1.History And Examination

a.Stroke clerking Performa (1994) R.C.P.1. Improved patient Assessment2. Improved Management - not clear3. Improved outcome - not clear

b. Examination1. Secure Diag of Stroke2. Specify Impairment3. Identify sub type of Ischemic stroke

“ We Sometimes think we have forgotten something when in fact we never really learned it in the first place”

Imp.Your Memory Skills

Guide: 3 (B) - CPR Impaired Consciousness - From Stroke

Resuscitation is rarely successful Schneider 1993

Guide: 4(B) Investigations:(Sagar 1995)-435 PTS)

Chest x-ray 16% ABN Only 4% change clinical management Order x-ray chest if WT Loss or chest

symptoms present

Through Action You Create your Own Education- D.B. ELLIS

Guide 5: (B) ECG: Cardiac cause of Death (30 days) Ebrahim 1990. All conscious patients to have ECG

Guide 6: (C) CT: Routine CT Head is a Intell lazy approach King’s fund forum(1988) gives useful framework Weir 1994 Clinical scoring cannot distinguish Do CT if a) Uncertainty of Stroke

b) If Anticoagulation or Anti Platelet treatment contemplated

Guide 7:(B) M.R.I.

Moha 1995, - Unclear for Implications for clinical practice

No Routine MRI indication in Acute Stroke

Whatever the Mind can conceive and Believe, the mind can Achieve

Napoleon Hill

Imagination is more Important than Knowledge Guide 8: (B) ECHO no Routine

Echo in Acute Stroke TOE Vs. TTE Amer Heart Asson (1997) - same

conclusion Yield is very low. (Leung 1993;

Chambors 1997) Only when ABN ECGS - change clinical

management

Guide 9: (A) - Dopp scan for selected PTS: 80% > more benefits from

Endarterectomy Minor stroke -No disability Subst Storke -Good recovery do

doppler Medically fit

Guide 10: (B) Management: Fever (Worst Prog.) Reith 1996 Hypoxia ( Moroney 1996) - Exac. by seizures

Pneumonia and Arrythmias - Worst outcome Hyperbaric O2 ineffective (Nighoghossaln

1995) Haemodilut. Plasm Expanders; venesection No evidence for efficacy (As plund - 1997)Check ABG only if Hypoxia suspected.

Guide 11: (A) Steroids and Hyperosmolar agents Unproven treatment - should not be used Tumor oedma responds but not

cytotoxic stroke oedma qialbash 1997 - No effect on survival or improv. In funct. Outcome

Manntol - (Boysen 1997) - short term effective statistically in conclusive

You are what you think and not what you think you are

Annoymous

We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts

R.B. Schmeck

Guide 12: (B) - Blood Pressure Defer - acute reduction of BP - 10 days unless

HT Encephalopathy or adrtic dissection present

Moris 1997 - Increase BP - falls in 10 days UK - 5mm in D.B.P. 1/3 storke - Low BP prompt

correct of hypovoll. and withdrawal of hypotonic drugs

Collins 1994 - HT - Prim. stroke prevent Neal 1996 (Current RCT) - HTs in stroke

survivors -study needed

Guide 13: (A/B) - AF AF / ISCH Stroke/ Mild disability -

warfarin after 48 Hrs (Longer for larger) Aspirin for others

EAFT 1995 Less than 2 PT - No effect SPAF 1996 > 5 - Bleeding

A great many people think they are thinking when they are merely re arranging their prejudices

W. James

Guide 14:(B/C) - Blood sugar Weir (1997) > 8 mm d/Lit - Poor

outcome Acute MI + 11 mm d/Lit - Intensive

Insulin - improved (Malmberg 1997)

Many Ideas grow better when transplanted into another mind than in the one where they sprang UP

O.W. Holmos

Guide 15: (A) Cholesterol Prosp. Study collob.: 1993 - Epidem

study do not support Blaun 1997: Metranauetic - Chollest &

statin 30% decrease - stroke in CAHD patients.

Sacks 1996 - Tot chol: decrease to 4.8 mmol/Lit benefits

Guide 16: (A/C) Deep vein thrombosis Kalra 1995 - 10 days - stroke Pts - 50% Sandercock 1993 - Pul embol 6-16% only Ist 1997 - 5000 IV or 12500 twice daily -

Hemorrage greater Gradual stocking value - useful in Surg - pts

but its value not evaluated - (Wells 1994) Use with caution - if periph artery insuf. is

present hence do not use heparin on stockings.

Every discovery contains an irrational element or 4 creative intuition

Khrl Popper

Guide 17: (A/B) Pressure sure Event health care (1995) specialised

low pressure mattress systems to be used than stand Hospital - mattress

I have never let my Medical schooling interfere with my education

Mark Twain

Manag of infarction Guide 18: (A)

• Aspirin 75 - 150 /Day• 3 yrs 40% reduces of vascular events in

1000 pts (APTC - 1994)• Stroke sub type value ? (TACI, PACI, LACI,

POCI)• Dienners - 1996, synergy possibel with

clopidogrel ticlopidine etc.

Anti Coagulation Warfarin - AF

In sinus rhythm - uncertain Spirit 1997 low dose ABP + Warfarin in

TIA & Minorstorke - Stopped of HE Heparin (IST 1997) - Signif. reduction in

early death (12 fewor in 1000) not better than aspirin

So avoid Heparin (A)

When they tell you to grow up, they mean stop growing

P. Diccaso

Thrombolysis (A)

Warlow 1997 - Uncertain clinical benefit at the expense of greater hazard avoid - thrombolysis

A (Neurologist’s) life is like a piece of paper on which everyone who passes by leaves an impression

- Chines proverb

Guide 20: (I) Hemorrhage

Hankey and hon 1997: Supra tentorial evacuation for ICH is controversial - Avoid

Infra tentorial - Yes Main Indication - Deteriorating or

depressed consciousness

A medical school should not be a preparation for life. A school should be life

3 D ied

3 4 R ed tag

7 D ied

2 1 d isch ton ver h om e

3 D ied

8 D isc fo rp a llim a

1 D iscH om e

6 4 D isch ar 6 7 D ied

1 3 1In tu b a tion

9 3N ot In tu b

2 2 4 P ts Guide 21 : Ventilation -Decreased level of consciousness - increased mortality and poor final outcome - Absent pupillary light responses - poor prognosis

“By the deficits we may know the talentsBy the exception we may discern rulesBy studying the pathology,We construct the model of healthAnd tools we need to affect our own life mould our

destiny,Change ourselves and our societyIn ways that as yet we can only imagine”

- Lawrence Miller

STROKE-TO-DEMENTIA(Dr. A.V. Srinivasan, Dr. S. Balasubramanian,

Dr. R. Sowntharya, Dr. S. Rajesh)

Dr. A. V. Srinivasan

Addl. Prof. Of Neurology

Institute of Neurology,

Chennai.

Pathogenesis of dementia due to SIVD

1. Lacunar hypothesis2. Binswanger’s subtype of SIVD3. VaD with coexisting Alzheimer’s

disease

Expert is one who think to his chosen mode of ignorance

Two diverging/converging pathways associated with SIVD

Risk factor CVD Ischemic Brain injury MRI lesion Clinical syndrome

HTN

Arteriosclerosis 1. occlusion complete infarct lacune lacunnar state

Arteriosclerosis 2. Hypoperfusion incomplete infarct WHSM Bingswanger syndrome

Experience can be defined as

yesterday’s answer to today’s problems

Clinical syndromes

1. Lacunar state --- 85%2. Strategic infarct dementia(e.g.

thalamic dementia) --- unknown %3. Binswanger’s syndrome --- 10 – 15%

Take time to think; it is the source of power

Take time to read; it is the foundation of wisdomTake time to work; it the price of success

Features suggestive of vascular dementia

From the historyOnset associated with a strokeImprovement following acute eventAbrupt onset

From the examFindings typical of stroke e.g., hemiparesis, hemianopia

From imagingInfarct(s) above the tentorium

Every thing should be made as simple as possible; but not simpler

Categories of vascular DementiaCategory Clinical presentation

Lacunar infarctions Progressive dementia, focal deficits, or apathetic, frontal-lobe-like syndrome, may have no stroke history

Single strategic infarctions

Sudden onset aphasia, agnosia, anterograde amnesia, frontal lobe syndrome

Multiple infarctions Step-wise appearance of cognitive & motor deficits

Mixed AD – VaD Progressive dementia with remote or concurrent history of stroke

White matter infarctions (Binswanger’s disease)

Dementia, apathy, agitation, bilateral cortico-spinal/bulbar signs

NINDS-AIREN criteria for VaDProbable vascular dementia : cognitive

decline from a previously higher level in three areas of function including memory; evidence of cerebrovascular disease by neurologic exam and neuroimaging; onset of dementia either abruptly or within 3 months of a recognized stroke.

Possible vascular dementia : Dementia in the absence of either neuroimaging evidence of infarction or in the absence of a clear temporal relationships between dementia and stroke.

NATURE, TIME AND PATIENCE are the 3 great physicians

NINDS-AIREN criteria for VaD contd…

AD with cerebrovascular disease : Patients with possible AD who have imaging evidence for infarction, or clinical history of stroke, both of which appear incidental by clinical judgement

Definite vascular dementia : Probable vascular dementia plus histopathological evidence of infarction in the absence of other histological markers of dementia (e.g., plaques, tangles, pick bodies, etc.,)

Truth comes out of error sooner than that of confusion

Diagnostic criteria

1. Hachinski’s ischemic score2. DSM IV criteria3. ADDTC criteria4. NINDS – AIREN criteria5. Binswanger’s criteria

Opinion is ultimately determined by the feelings

and not by the intellect

Short comings1. Not interchangeable hence four fold rise in

frequency2. DSM IV R most liberal3. NINDS- AIREN criteria conservative4. Gold standard for VaD (pathological definition

difficult)5. Most of the criteria failed to distinguish

between small and large vessel subtypes

“Healthy Mind and Healthy expression of Emotion go hand in

Hand”

Diagnosis and prognosis

Risk factorsModifiable Non-modifiableHypertension AgeHyperglycemia Gender

Race Heredity

Discipline Weighs ounces Regret weighs Tons

Diagnosis and prognosis contd….

Vascular phenotype : “CVD” Arteriosclerosis Amyloid angiopathy Other small vessel disease

“You have got to be before you can do

and do before you can have”

Diagnosis and prognosis contd….Vascular

distributionMechanism of Brain injury

Pathological phenotype “Infarct”

Single arterySmall arteriole

Acute ischemia Multiple lacunar infarcts

Single artery Acute ischemia Single strategically placed lacunar infarct

Border zoneSmall arteriole

Chronic hypo perfusion

White matter demyelination and axonal loss

Diagnosis and prognosis contd….

Neuro imaging phenotype

CT lucency (lacunes and leukoariosis)

MRI hyper intensity (lacunes and WMSH)

A true commitment is a heart felt promise to yourself from which you will not back down -

D. Mcnally

Diagnosis and prognosis contd….

Localisation / neural network

Clinical phenotype or syndrome

Cortico-basal ganglia – thalamocortical loops

Lacunar stateApathy, depression, abulia Dysexecutive syndromeNormal visual fieldsparkinsonism

Cortico-basal ganglia thalamocortical loops

Strategic infarct dementiaDysexecutive syndromeFrontal lobe syndrome

Deep white matter connections

Binswanger’s syndromeSlowly progressive depression, bradykinesia, dysexecutive syndrome, gait apraxia, urinary incontinence

Prognosis

1. Risk factors Advanced age Education Lacunar subtype Lt. Hemisphere CVA Non white

Develops dementia following ischemic stroke

“Fools Admire but of men of sense approve”

- A. Pope

Prognosis contd….

2. In Lacunar stroke - Leukoariosis is a poor prognosis3. Recurrence of strokeHence Atrophy cognitive impairment WMSH are inter related in SIVD

“Social Isolation is in itself a pathogenic

Factor for disease production”

Prevention & Treatment

Primary preventionControl of risk factors in mid lifea. Framingham Heart Studyb. HASSc. ARIC d. Systolic hypertension in Europe double

blind trialAt twenty the will rules

At thirty the intellect

At forty Judgment

Prevention & Treatment contd…

Secondary prevention Below 135 mm of Hg cognitive impairment Presence of lacunes and white matter

changes may be used as a marker for high risk group

Little is known – for effectiveness in other risk factors

A woman’s desire for revenge outlasts all her other emotions

Prevention & Treatment contd…

Anti dementia drug trials (not based on subtype of VaD)

Alkaloid derivatives(hydergine or nicergoline)PentoxyfyllinePiracetamMemantineDonepezilGingko biloba

Modest benefit

Thought is the labour of the intellect

Reverie is its pleasure

Role of RIVASTIGMINE in SIVD

No.of patients : 10Age group : 50 – 80 yearsFemale : 4Male : 6Most of them had diabetes and hypertension Not based on subtype of VaD 30% showed remarkable cognitive, curative and

affective deficitFuture study needed

“ He who cannot forgive others destroys the bridge over which he

himself must pass” - Annoy

Strategies to prevent – STROKE-TO-DEMENTIA

Treat hypertension optimally Treat diabetes Control hyperlipidaemia Persuade patients to cease smoking and

decrease alcohol intake Prescribe anticoagulants for atrial fibrillation Provide antiplatelet therapy for high risk

patients

A open foe may prove a curse ; but

a pretended friend is worse

Strategies to prevent – STROKE-TO-DEMENTIA contd…

Perform carotid endarterectomy for severe (>70%) carotid stenosis

Use dietary control for diabetes, obesity and hyperlipidaemia

Recommend lifestyle changes (e.g., weight loss, exercise, reduce stress, decrease salt intake)

Intervene early for stroke and transient ischemic attacks with neuroprotective agents (e.g., propentofylline, calcium channel antagosists,

N-methyl-D-aspartate receptor antagonists, antioxidants)

Provide intensive rehabilitation after stroke

READ not to contradict or confuteNor to Believe and Take for Granted but TO WEIGH AND CONSIDER

THANK YOU