Stroke: A Presentation

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Neurology Migraine ALS ParkinsonƎs Headache Seizures Neuropathy

Cardiology

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Heart attack Arrhythmias Heart failure Valvular disease

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ectives ±

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Highlight some important differences and similarities etween heart attack and stroke Motivate you to prevent a stroke

How is a stroke different from a heart attack? ±

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A stroke is a sudden neurological deficit caused y a lood vessel pro lem 2 types ± ±

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Ischemic strokes Hemorrhagic strokes

The effects of a stroke are extremely varied

hy is heart attack easier to recognize than stroke ? ±

Painful

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Pu lic and health care providers commonly recognize symptoms and need for action

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Vften painless the stroke itself often affects awareness of symptoms Poor recognition of symptoms and need for action

~espondents una le to name 1 warning sign or risk factor for stroke

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hich of the following are warning signs of stroke? A.

Sudden weakness or num ness of the face, arm or leg, especially on one side of the ody

B.

Sudden confusion, trou le speaking or understanding

C.

Sudden chest pain

D.

Sudden trou le seeing in one or oth eyes

E.

Sudden trou le walking, dizziness, loss of alance or coordination

F.

Sudden, severe headache with no known cause

A.

Sudden weakness or num ness of the face, arm or leg, especially on one side of the ody

B.

Sudden confusion, trou le speaking or understanding

C.

Sudden chest pain

D.

Sudden trou le seeing in one or oth eyes

E.

Sudden trou le walking, dizziness, loss of alance or coordination

F.

Sudden, severe headache with no known cause

Is heart attack easier to diagnose than stroke? ±

Diagnosis is relatively easy. EKG and cardiac enzymes readily availa le.

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Diagnosis is difficult. Many things can mimic stroke. There is no lood test for stroke. M~I not readily availa le.

M~I with diffusion weighted imaging

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here is the stroke?

CT scan of arteries of neck and head

Are the causes of heart attack and stroke different? ±

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Cause is usually rupture of a plaque within a coronary artery So the diagnostic and treatment strategy is fairly straightforward (find the lockage and open it up!)

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Atherosclerosis is important, ut there are many other causes Determining the cause in an individual is often a deductive process

There are many potential causes of stroke

Stroke is not
ust a rain disease and often the rain is
ust an innocent ystander ±

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Usually caused y diseases that are affect the entire vascular system (atherosclerosis) Material locking rain arteries usually comes from outside the rain (atrial fi rillation, carotid artery disease)

How is a Cardiologist different than a Neurologist ±

Basically a plum er or electrician

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Diagnostician Detective Daredevil

Case ±

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Healthy 61 yearyear-old man developed confused speech 1 day after falling out of a tree. August 11th, topping a tree, fell and sustained a left collar one fracture and small puncture of the lung. Next night suddenly developed confused speech.

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Trauma (fall out of a tree) Vascular pro lem (leg vein in
ury) Blood disorder (hypercoagula ility) Congenital heart anomaly (patent foramen ovale)

How are heart attack and stroke SIMILA~? Time is critical ± The first priority is to save tissue at risk ±

Kidwell 2004

ñou need to call 911 ASAP for oth heart attack and stroke! ±

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There is a 3 hour time limit for the medication t-PA, and the sooner itƎs given the etter! Future strokes may e prevented if we identify the cause of stroke ASAP People rought y am ulance are treated faster Neurological deterioration and other complications may e prevented if a patient is hospitalized earlier

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wune 2006 7AM: A 75 yearyear-old woman collapsed at home, rought to her local emergency room. She cannot move her right side or speak. The doctors there are not comforta le using tt-PA so transfer to DHMC is requested. 1:02 PM: Arrival DHMC ED.

4:49 PM artery is opened

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The system needs to e very coordinated

P~EPA~ED

~APID EVALUATIVN

INDIVIDUALIZED CA~E

Improving Stroke Care at DHMC

A TEAM APP~VACH

P~VTVCVLS TV DEC~EASE E~~V~S

ays everyone here can prevent a stroke ± ±

Identify and control risk factors If a warning sign of stroke occurs, get attention

10y risk 88% !

10y risk 13% !

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

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

2004: 144 pts ~x t-PA 50% had t-PA started at 1 of 47 referring hospitals >50% of these have <60 eds

MGH TeleStroke

Effectiveness of Stroke Prevention A solute risk reduction in a year: Strategy ± ± ± ± ± ±

arfarin for atrial fi rillation Carotid endarterctomy for symptomatic dz Smoking cessation Antihypertensive therapy if BP elevated Cholesterol lowering medications Aspirin

A~~ (%) 8 4 2 2 2 1-2

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anticoag

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Stroke arning Signs ±

Sudden weakness or num ness of the face, arm or leg, especially on one side of the ody

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Sudden confusion, trou le speaking or understanding

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Sudden trou le seeing in one or oth eyes

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Sudden trou le walking, dizziness, loss of alance or coordination

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Sudden, severe headache with no known cause

hat is a TIA ? ±

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Transient Ischemic Attack=Stroke symptoms that resolve with a short time. Can e 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 e estimated.

ABCD2 Tool ~isk of stroke following TIA A

Age> or = 60

1

B

Blood pressure >140/90

1

C

Clinical features

D2

unilateral weakness

2

speech impairment

1

Duration > 60 min

2

10-59 min

1

Dia etes

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hich action would you take if you thought someone was having a heart or stroke? A. B. C. D. E.

take the person a hospital advise the person to call a doctor call 911 call a spouse or family mem er do something else

hich action would you take if you thought someone was having a heart or stroke? A. B. C. D. E.

Take the person a hospital Advise the person to call a doctor Call 911 Call a spouse or family mem er Do something else

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Bleeding into the heart doesnƎt occur

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Brain hemorrhage is common

CT scan: ischemic stroke

Intracere ral hemorrhage at 1 hour and 6 hours

Intra--arterial throm olysis Intra Time window=6 hours

High resolution M~I to identify the u
 plaque

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ñou need to open the artery

Like with heart disease, the treatment and prevention of stroke needs to e individualized! ±

A 65 yo man attends a vascular disease prevention fair and an ultrasound shows a lockage of his left carotid artery. He is told to speak to his doctor ASAP and he ecomes worried that there is a Ɛtime om  ticking in his neck.