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An overview of stroke
 

An overview of stroke

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    An overview of stroke An overview of stroke Presentation Transcript

    • An overview of stroke Dr Shankar Hippargi Consultant Emergency Physician MMHRC
    • An overview of stroke• Stroke & TIA definition• Epidemiology• Classification• Challenges in India• Risk factors• Treatment options
    • Stroke• Stroke is a syndrome characterised by rapidly developing clinical signs of focal (or global) neurological disturbance lasting 24 hours or longer or leading to death with no apparent cause other than vascular origin. Includes: Excludes: • Subarchanoid • TIA hemorrhage • Subdural Hemorrhage • Tumor or infection causing hemorrhage or infarction
    • In stroke "Time lost is brain lost" • Every second 32,000 neurons die • In a minute • 1.9 million neurons die • Brain loses 14 billion synapses • 12 KM of myelinated fibers are lost • The ischemic brain ages 3.6 years each hour
    • Facts about stroke...• Globally approximately 20 million people suffer stroke each year• Of these 5 million wont survive• Male : Female = 3 : 1• Developing countries account for 85% of stroke related deaths
    • ...Facts about stroke • Leading cause of functional impairment • 20% survivors require institutinal care • 15-30% permanently disabled • 50% of stroke victims feel major stroke is worse than death
    • ...Facts about stroke• Every 40 seconds, someone in the United States has a stroke• Every 4 minutes someone dies of stroke• Prevalent in 3% of US population• The incidence is declinng overtime in developed nations Circulation- 2011 AHA
    • Indian scenario• Age-adjusted annual incidence • 334-424/1,00,000 in urban community • 84-262/1,00,000 in rural community• Relatively more hemorrhagic strokes (32%)• 1.2% of all deaths are due to stroke (all age groups)* Neurology Asia 2006; 11 : 1 – 4
    • Indian scenario• 12% of strokes in age <40 years• Male : Female ratio is 7:1• With increasing life expectancy & life style changes, incidence of stroke is expected to rise in India * Stroke in India
    • Challenges...• Lack of organised stroke services in government sector• 70% rural population- No access to Rx• Most stroke care centers are private & in urban areas• With infectious diseases still endemic, non-communicable diseases are given low priority
    • Median time to arrival tohospital after stroke onset • 7.6 hours in urban areas • Only 25% reached within 3 hours • Affordability??? • 34 +/- 6 hours rural areas
    • Types of stroke • 85% are ischemic • 10% are intracerebral hemorrhage • 5% are subarachnoid hemorrhage strokes
    • Types of stroke I s c h e m ic H e m o r r h a g ic 85% 15%L a rg e V e s s e l C a r d io e m b o lic Lacunar O th e r IC H SAH 35% 25% 20% 5% 10% 5%
    • Intra Cerebral Hemorrhage • Incidence of Hemorrhagic stroke has increased 18% in the past 10 years • Old age • Anticoagulation • Antiplatelets • Thrombolytic therapy
    • Transient Ischemic Attack• A neurological event with the signs and symptoms of a stroke, which resolve completely within 24 hours• TIAs typically last 2 to 30 minutes and can produce problems with vision, dizziness, weakness or trouble speaking• Mini stroke, Warning stroke
    • TIA• Short term risk of stroke following TIA is 3- 10% at 2 days, 9-17% at 90 days• Approximately 1/3 of all strokes are preceded by a TIA• Approximately half of all patients who experience a TIA fail to report it
    • TIAOne third of episodescharacterized as TIAs according tothe classic definition (ie, focaldeficits that resolve within 24hours) would be consideredinfarctions on the basis ofdiffusion-weighted MRI findings
    • ABCD2 scoring for TIASymbol Clinical feature Criterion PointA Age >= 60 1B Blood pressure >= 140/90 mmHg 1C Clinical features of the TIA unilateral weakness 2 speech disturbance without weakness 1D1 Duration of symptoms >= 60 min 2 10-59 min 1 <10 min 0D2 Diabetes diagnosed with diabetes? 1
    • ABCD2 scoring for TIAABCD2 Score Risk of stroke in 2 days 0-3 1% 4-5 4% 6-7 8%
    • Mortality• Every 4 minutes someone dies of stroke• 1 in every 18 deaths is due to stroke• Third leading cause of death next to cardiac problems and cancers• 30 days mortality decreased significantly in men (from 23% to 14 %) but not in women (21% to 20%)
    • Death rate after different types of stroke 30days 1 year 5 yearsIschemic 10 23 52 stroke ICH 52 62 70 SAH 45 48 52
    • Risk factorsNon-modifiable: Modifiable:• Age • Hypertension• Sex • Diabetes• Family history • Atrial fibrillation • Smoking• Race • High cholesterol • Excess Alcohol • Stress & Depression • Sedantary life style • Over weight • Poor diet
    • Stroke in women• Women between 45-54 years twice more likely to have stroke than men• Lifetime risk of stroke is greater in women compared with men because of their higher life expectancy• 44% increased risk in post-menopausal women on HRT
    • Stroke in women• Risk of stroke 2.4 times greater during pregnancy and until 6 weeks post natal period• Stroke is more severe in women, with 30 days case fatality of 24.7% compared with 19.7% for men**Sex Differences in Stroke Epidemiology, AHA journal
    • Stroke in children• Can occur in-utero, perinatal or later• Annual incidence 6.4/100000 children• Prevalence of perinatal stroke 29/100000 live births• A history of infertility, preeclampsia, prolonged rupture of membranes, and chorioamnionitis were found to be independent risk factors• Cerebral arteriopathy most common cause followed by Sickle cell disease and Congenital Heart Disease
    • • 12 years old• Left hemiplegia• BP 200/120• GCS 15/15
    • Signs & symptoms of stroke• Weakness or numbness of arm / leg or both• Facial muscle weakness• Difficulty speaking• Co-ordination problems• Dizziness• Visual problems• Sudden headache• Altered sensorium / Loss of consciousness
    • EMS
    • Magical agents in ER• Dextrose• Adenosine• Amiadarone• Calcium Gluconate• DC shock• Tissue plasminogen activator (Altepllase)
    • Recombinant Tissue Plasminogen Activator- Alteplase • The only approved durg for treatment of ischemic stroke • Should be given within 4.5 hours of onset, earlier the better • Category C in pregnancy • Dosage: • 0.9 mg/kg (up to a max total dose of 90 mg) • 10% of the dose given as a bolus over 1 min • 90% of the dose by infusion over 60 minutes
    • Intra-arterial thrombolysis • Better rate of recanalization • Larger therapeutic window ( 6 hours) • Can be given post- operatively (except post craniotomy) • Lower hemorrhage rate • Lower dose • Done by Interventional Neuroradiologist
    • Mechanical thrombolysis • 3-8 hours after stroke • Clot is mechanically extracted from the blood vessel • Done by Interventional Neuroradiologist
    • Neuro-surgical intervention • For malignant middle cerebral artery infarction • Large IC bleed • Bleed difficult to reach- Endovascular treatment
    • Rise of machines RP 7
    • Rehabilitation• Will I be able to lead a normal life?• Stroke recovery is a life time process• Needs a dedicated team work • Physiotherapist • Psychologist • Occupational therapist • Speech therapist• Should be customised to each patient
    • Prevention• Primary prevention: • 80% of strokes can be prevented by eating a healthy diet, regular exercise and avoiding smoking and excessive consumption of alcohol • Early recognition & Rx of hypertension • Anticoagulation for atrial fibrillation• Secondary Prevention: • 43% risk of second stroke • Compliance to medications most important • Life style modification
    • The Myths & Reality• Myth: Stroke is unpreventable• Reality: Stroke is largely preventable• Myth: Stroke cannot be treated• Reality: Stroke requires emergency treatment• Myth: Stroke only strikes the elderly• Reality: Stroke can happen to anyone• Myth: Stroke recovery happens only for a few months following a stroke• Reality: Stroke recovery continues throughout life
    • Race Against Time Thank You