What neurologist may add to
the care and cure of of stroke
patients, or…
Peter Sandercock
Perugia December
2007
What is th...
In America…to perform many
expensive investigations?
In the UK…to
diagnose a rare
cause of stroke
by clinical
examination?
Role of neurologist in acute
phase of stroke
Acute care: the neurologist will often be
involved at all points in the ‘path of acute care’
Acute brain attack
If neurologist finds NO clinical evidence of
‘stroke mimic’, e.g.: epileptic seizure,
migraine, Hypo- o...
NIHSS helps distinguish ‘stroke’ from ‘non-
stroke mimic’
NIHSS and ‘stroke’
vs ‘not stroke’
• About one third of patients with
NIHSS 1-4 do not have an acute
stroke
• NIHSS > 4 is...
If CT or MR excludes blood and ‘stroke
mimic’ neurologist decides
Probably ELIGIBLE for thrombolysis’
• Known time of onse...
Some clinical problems, where
neurologist very helpful
? POCI
• Man 75 years, arrives
at ER 3.5 hrs after,
sudden onset
‘dizziness’ and
unsteadiness
• Exam: Unsteady when
standi...
What to do?
• MR and angiography not available
• ‘Outside 3 hour window’: iv thrombolysis
not approved
• If this is a basi...
Migraine or ischaemic stroke?
This 53-year-old female patient with acute headache and right-sided
hemianopia. Not treated ...
Initial CT (A to C) show a hyperattenuating
posterior cerebral artery (arrow in B). On follow-
up (D to F), a large PCA in...
Blood on CT can be
a) missed if not looked for
carefully
b) Have disappeared if the
patient presents a day or
more after t...
Patient has clinical diagnosis of ‘acute
stroke’ but CT is normal.
• The time of onset of stroke symptoms is known
precisely
• You have an experienced stroke physician/stroke
neurologist ab...
‘Telephone neurology’ in acute stroke
to patient / family: confirm diagnosis, seek
consent. Neurologist to general physici...
Role in prevention
Neurologists and ‘dizzy turns’
• a 50 year old woman (depressed, just
started on anti-depressant) has an episode
where spe...
Neurologist asks about other symptoms: the
day before she describes a brief episode of
loss of vision in the left eye (ama...
The correct diagnosis
• An ocular and a cerebral TIA in
the distribution of the left internal
carotid artery
• High early ...
High early risk of stroke after TIA
0
2
4
6
8
10
12
14
0 7 14 21 28
Days
Riskofstroke(%)
OXVASC
OCSP
Lancet 2005; 366: 29-...
Management
• Start dual antiplatelet therapy, statin
and anti-hypertensive immediately
• Immediate carotid ultrasound stud...
Overall, 62% of patients referred with
‘TIA’ were found to have other
diagnoses
migraine
syncope/pre-syncope
‘funny turn’ ...
Neurologist organises management of
TIA and minor stroke
• Urgent brain imaging if symptoms persist > 1-2
hours
• high ABC...
Role of
neurologist
in care of
stroke
patients?
The neurologist is often the leader of
the multi-disciplinary team on the
stroke unit
Research led by neurologists
identified effective stroke
treatments
• Treatment acute ischaemic stroke
– Aspirin,
– Thromb...
• Diagnosis of in acute phase
• Management in the acute phase
• Lead multidisciplinary team on stroke
unit
• Co-ordinate s...
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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

    1. 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. 2. In America…to perform many expensive investigations?
    3. 3. In the UK…to diagnose a rare cause of stroke by clinical examination?
    4. 4. Role of neurologist in acute phase of stroke
    5. 5. Acute care: the neurologist will often be involved at all points in the ‘path of acute care’
    6. 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. 7. NIHSS helps distinguish ‘stroke’ from ‘non- stroke mimic’
    8. 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. 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. 10. Some clinical problems, where neurologist very helpful
    11. 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. 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. 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. 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. 15. Blood on CT can be a) missed if not looked for carefully b) 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. 16. Patient has clinical diagnosis of ‘acute stroke’ but CT is normal.
    17. 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. 18. ‘Telephone neurology’ in acute stroke to patient / family: confirm diagnosis, seek consent. Neurologist to general physician: advice, IST-3 helpline
    19. 19. Role in prevention
    20. 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. 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. 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. 23. High early risk of stroke after TIA 0 2 4 6 8 10 12 14 0 7 14 21 28 Days Riskofstroke(%) OXVASC OCSP Lancet 2005; 366: 29-36 10% risk of stroke by 7 days
    24. 24. Management • Start dual antiplatelet therapy, statin and anti-hypertensive immediately • Immediate carotid ultrasound study - often performed by neurologist
    25. 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. 26. Neurologist organises management of TIA and minor stroke • Urgent brain imaging if symptoms persist > 1-2 hours • high ABCD2 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. 27. Role of neurologist in care of stroke patients?
    28. 28. The neurologist is often the leader of the multi-disciplinary team on the stroke unit
    29. 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. 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

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