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The role of the neurologist in the care and cure of patients

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  • This is a flow diagram to help you organise your acute assessment of patients with suspected stroke. It also includes a reminder about the common stroke mimics.

The role of the neurologist in the care and cure of patients Presentation Transcript

  • 1. What neurologist may add to the care and cure of of stroke patients, or… Peter Sandercock Perugia December 2007 What is the place of the neurologist in stroke medicine?
  • 2. In America…to perform many expensive investigations?
  • 3. In the UK…to diagnose a rare cause of stroke by clinical examination?
  • 4. Role of neurologist in acute phase of stroke
  • 5. Acute care: the neurologist will often be involved at all points in the ‘path of acute care’
  • 6. Acute brain attack If neurologist finds NO clinical evidence of ‘stroke mimic’, e.g. : epileptic seizure, migraine, Hypo- orhyper-glycaemia, or other obvious non-stroke diagnosis -> do CT CT/MR Scan Non-stroke pathology Subdural, tumour Scan: Normal, Infarct, intracerebral bleed, SAH
  • 7. NIHSS helps distinguish ‘stroke’ from ‘non-stroke mimic’
  • 8. NIHSS and ‘stroke’ vs ‘not stroke’
    • About one third of patients with NIHSS 1-4 do not have an acute stroke
    • NIHSS > 4 is a useful indicator that the deficit is due to a stroke
  • 9. If CT or MR excludes blood and ‘stroke mimic’ neurologist decides
    • Probably ELIGIBLE for thrombolysis’
    • Known time of onset
    • Unilateral neurological signs
    • Increasing NIH score (>4)
    • Abnormal vascular signs (AF, PVD)
    • Probably NOT ELIGIBLE
    • Deficit first noted on waking from sleep
    • Prior cognitive impairment
    • Loss of consciousness at/soon after onset
    • Seizure
    • Can walk now ( too mild)
  • 10. Some clinical problems, where neurologist very helpful
  • 11. ? POCI
    • Man 75 years, arrives at ER 3.5 hrs after, sudden onset ‘dizziness’ and unsteadiness
    • Exam: Unsteady when standing
    • No limb ataxia
    • NIHSS = 2
    • ? POCI
    ?Hyper-attenuating basilar artery?
  • 12. What to do?
    • MR and angiography not available
    • ‘ Outside 3 hour window’: iv thrombolysis not approved
    • If this is a basilar thrombosis, could he deteriorate rapidly if not treated?
    • Randomised in IST-3
  • 13. Migraine or ischaemic stroke? This 53-year-old female patient with acute headache and right-sided hemianopia. Not treated with thrombolysis, because significance of abnormality not appreciated Krings et al, Stroke. 2006;37:399-403.)
  • 14. Initial CT (A to C) show a hyperattenuating posterior cerebral artery (arrow in B). On follow-up (D to F), a large PCA infarction is now visible.
  • 15.
    • Blood on CT can be
    • missed if not looked for carefully
    • Have disappeared if the patient presents a day or more after the haemorrhage
    Subarachnoid haemorrhage with focal deficit (eg hemiparesis) due to delayed cerebral ischaemia
  • 16. Patient has clinical diagnosis of ‘acute stroke’ but CT is normal.
  • 17.
    • The time of onset of stroke symptoms is known precisely
    • You have an experienced stroke physician/stroke neurologist able to see the patient urgently in A&E or at CT scan room
    • Urgent non-contrast CT scan is interpreted by someone with expertise in acute stroke CT
    • -> MRI not essential; its place in routine acute stroke care yet to be determined
    Can you diagnose ‘acute ischaemic stroke suitable for thrombolysis’ without DWI MR? Yes, if:
  • 18. ‘ Telephone neurology’ in acute stroke to patient / family: confirm diagnosis, seek consent. Neurologist to general physician: advice, IST-3 helpline
  • 19. Role in prevention
  • 20. Neurologists and ‘dizzy turns’
    • a 50 year old woman (depressed, just started on anti-depressant) has an episode where speech is ‘dizzy and confused’.
    • At emergency department: BP 180/90. Normal examination.
    • diagnosis ‘?reaction to anti-depressant;’
    • Management ‘stop drug and go home’, but does refer neurologist
  • 21. Neurologist asks about other symptoms: the day before she describes a brief episode of loss of vision in the left eye (amaurosis fugax).
  • 22. The correct diagnosis
    • An ocular and a cerebral TIA in the distribution of the left internal carotid artery
    • High early risk of stroke
    • Immediate action required
  • 23. High early risk of stroke after TIA 0 2 4 6 8 10 12 14 0 7 14 21 28 Days Risk of stroke (%) OXVASC OCSP Lancet 2005; 366: 29-36 10% risk of stroke by 7 days
  • 24. Management
    • Start dual antiplatelet therapy, statin and anti-hypertensive immediately
    • Immediate carotid ultrasound study - often performed by neurologist
  • 25. Overall, 62% of patients referred with ‘TIA’ were found to have other diagnoses migraine syncope/pre-syncope ‘ funny turn’ (= event it is not possible to categorise) vertigo or dizziness only epilepsy transient global amnesia cerebral tumour Oxfordshire Community Stroke Project: of 542 patients referred with possible TIAs, in 317 (62%) the diagnosis was not a TIA
  • 26. Neurologist organises management of TIA and minor stroke
    • Urgent brain imaging if symptoms persist > 1-2 hours
    • high ABCD 2 score, ?admit to hospital for treatment & investigation
    • Aspirin
    • Add dipyridamole in high-risk cases
    • Statin to lower cholesterol
    • Blood pressure lowering: diuretic and angiotensin converting enzyme (ACE) inhibitor
    • Urgent non-invasive carotid imaging -> endarterectomy < 2 weeks if severe stenosis
  • 27. Role of neurologist in care of stroke patients?
  • 28. The neurologist is often the leader of the multi-disciplinary team on the stroke unit
  • 29. Research led by neurologists identified effective stroke treatments
    • Treatment acute ischaemic stroke
      • Aspirin,
      • Thrombolysis
    • Prevention
      • Anticoagulants in AF
      • Antiplatelet for secondary prevention after TIA/stroke
      • Carotid surgery for symptomatic stenosis
  • 30.
    • Diagnosis of in acute phase
    • Management in the acute phase
    • Lead multidisciplinary team on stroke unit
    • Co-ordinate stroke services, including secondary prevention
    • Lead research
    The neurologist has many roles in cure and care of stroke