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NurseReview.Org - Everything About Stroke Victims NurseReview.Org - Everything About Stroke Victims Presentation Transcript

  • Get Brain Smart!
    • Neurology
    • Migraine ALS
    • Parkinson’s Headache
    • Seizures Neuropathy
    • Cardiology
    Stroke Heart attack Arrhythmias Heart failure Valvular disease
  • Everything you ever wanted to know about stroke (but were afraid to ask) Timothy Lukovits, M.D.
  • stroke
  • Objectives
    • Highlight some important differences and similarities between heart attack and stroke
    • Motivate you to prevent a stroke
  • How is a stroke different from a heart attack?
    • A stroke is a sudden neurological deficit caused by a blood vessel problem
    • 2 types
      • Ischemic strokes
      • Hemorrhagic strokes
    • The effects of a stroke are extremely varied
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  • Why is heart attack easier to recognize than stroke ?
    • Painful
    • Public and health care providers commonly recognize symptoms and need for action
    • Often painless
    • the stroke itself often affects awareness of symptoms
    • Poor recognition of symptoms and need for action
  • Copyright restrictions may apply. Pancioli, A. M. et al. JAMA 1998;279:1288-1292. Respondents unable to name 1 warning sign or risk factor for stroke
  • Which of the following are warning signs of stroke?
    • Sudden weakness or numbness of the face, arm or leg, especially on one side of the body
    • Sudden confusion, trouble speaking or understanding
    • Sudden chest pain
    • Sudden trouble seeing in one or both eyes
    • Sudden trouble walking, dizziness, loss of balance or coordination
    • Sudden, severe headache with no known cause
    • Sudden weakness or numbness of the face, arm or leg, especially on one side of the body
    • Sudden confusion, trouble speaking or understanding
    • Sudden chest pain
    • Sudden trouble seeing in one or both eyes
    • Sudden trouble walking, dizziness, loss of balance or coordination
    • Sudden, severe headache with no known cause
    • Diagnosis is relatively easy. EKG and cardiac enzymes readily available.
    • Diagnosis is difficult. Many things can mimic stroke. There is no blood test for stroke. MRI not readily available.
    Is heart attack easier to diagnose than stroke?
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  • MRI with diffusion weighted imaging Isolated weakness right index finger JS Kim, Neurology, 2002
  • Where is the stroke?
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  • CT scan of arteries of neck and head
    • Cause is usually rupture of a plaque within a coronary artery
    • So the diagnostic and treatment strategy is fairly straightforward (find the blockage and open it up!)
    • Atherosclerosis is important, but there are many other causes
    • Determining the cause in an individual is often a deductive process
    Are the causes of heart attack and stroke different?
  • There are many potential causes of stroke
  • Stroke is not just a brain disease and often the brain is just an innocent bystander
    • Usually caused by diseases that are affect the entire vascular system (atherosclerosis)
    • Material blocking brain arteries usually comes from outside the brain (atrial fibrillation, carotid artery disease)
  • How is a Cardiologist different than a Neurologist
    • Basically a plumber or electrician
    • Diagnostician
    • Detective
    • Daredevil
  • Case
    • Healthy 61 year-old man developed confused speech 1 day after falling out of a tree.
    • August 11 th , topping a tree, fell and sustained a left collar bone fracture and small puncture of the lung.
    • Next night suddenly developed confused speech.
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    • Trauma (fall out of a tree)
    • Vascular problem (leg vein injury)
    • Blood disorder (hypercoagulability)
    • Congenital heart anomaly (patent foramen ovale)
  • How are heart attack and stroke SIMILAR?
    • Time is critical
    • The first priority is to save tissue at risk
  • Kidwell 2004
  • You need to call 911 ASAP for both heart attack and stroke!
    • There is a 3 hour time limit for the medication t-PA, and the sooner it’s given the better!
    • Future strokes may be prevented if we identify the cause of stroke ASAP
    • People brought by ambulance are treated faster
    • Neurological deterioration and other complications may be prevented if a patient is hospitalized earlier
  •  
    • June 2006 7AM: A 75 year-old woman collapsed at home, brought to her local emergency room. She cannot move her right side or speak. The doctors there are not comfortable using t-PA so transfer to DHMC is requested.
    • 1:02 PM: Arrival DHMC ED.
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  • 4:49 PM artery is opened
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    • The system needs to be very coordinated
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  • Improving Stroke Care at DHMC PREPARED INDIVIDUALIZED CARE PROTOCOLS TO DECREASE ERRORS A TEAM APPROACH RAPID EVALUATION
  • Ways everyone here can prevent a stroke
    • Identify and control risk factors
    • If a warning sign of stroke occurs, get attention
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  • 10y risk 88% !
  • 10y risk 13% !
    • Preventing a heart attack or stroke is MUCH more effective (and safer) than a procedure!
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  • HJM Barnett 1999
  • Copyright restrictions may apply. Barnett, H. J. M. et al. Arch Neurol 2000;57:40-45. The medical and surgical 5-year Kaplan-Meier curves of freedom from ipsilateral stroke and perioperative stroke and death indicate a 5.9% difference favoring endarterectomy at 5 years in the Asymptomatic Carotid Atherosclerosis Study (ACAS)
  • Copyright ©2005 American Heart Association Alamowitch, S. et al. Stroke 2005;36:27-31 Kaplan-Meier 5-year risks of ipsilateral ischemic stroke for NASCET patients according to gender and degree of internal carotid artery stenosis in the medical and surgical groups
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  • 18/111 (16%) received t-PA Average cost for transportation $4,623
  • 2004: 144 pts Rx t-PA 50% had t-PA started at 1 of 47 referring hospitals >50% of these have <60 beds
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  • Meyer 2005
  • MGH TeleStroke
  • Effectiveness of Stroke Prevention Absolute risk reduction in a year:
            • Strategy ARR (%)
    • Warfarin for atrial fibrillation 8
    • Carotid endarterctomy for symptomatic dz 4
    • Smoking cessation 2
    • Antihypertensive therapy if BP elevated 2
    • Cholesterol lowering medications 2
    • Aspirin 1-2
  • Schaebitz W-R, 2000
  •  
  • anticoag RG Hart 2003
  • Stroke Diagnosis 40 years ago
  • Stroke Warning Signs
    • Sudden weakness or numbness of the face, arm or leg, especially on one side of the body
    • Sudden confusion, trouble speaking or understanding
    • Sudden trouble seeing in one or both eyes
    • Sudden trouble walking, dizziness, loss of balance or coordination
    • Sudden, severe headache with no known cause
  • What is a TIA ?
    • Transient Ischemic Attack=Stroke symptoms that resolve with a short time.
    • Can be 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 be estimated.
  • ABCD 2 Tool risk of stroke following TIA A Age> or = 60 1 B Blood pressure >140/90 1 C Clinical features unilateral weakness 2 speech impairment 1 D 2 Duration > 60 min 2 10-59 min 1 Diabetes 1
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  • A B C D E F Systolic BP* 95-105 130-148 130-148 130-148 130-148 130-148 Diabetes No No Yes Yes Yes Yes Cigarettes No No No Yes Yes Yes Prior Atrial Fib. No No No No Yes Yes Prior CVD No No No No No Yes Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318. *BP in millimeters of mercury (mmHg)
  • Which action would you take if you thought someone was having a heart or stroke?
    • take the person a hospital
    • advise the person to call a doctor
    • call 911
    • call a spouse or family member
    • do something else
  • Which action would you take if you thought someone was having a heart or stroke?
    • take the person a hospital
    • advise the person to call a doctor
    • call 911
    • call a spouse or family member
    • do something else
    • Bleeding into the heart doesn’t occur
    • Brain hemorrhage is common
  • CT scan: ischemic stroke
  • Intracerebral hemorrhage at 1 hour and 6 hours
    • Intra-arterial thrombolysis
    • Time window=6 hours
  • High resolution MRI to identify the unstable plaque Chu B, Circulation 2005
    • You need to open the artery
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  • Like with heart disease, the treatment and prevention of stroke needs to be individualized!
    • A 65 yo man attends a vascular disease prevention fair and an ultrasound shows a blockage of his left carotid artery. He is told to speak to his doctor ASAP and he becomes worried that there is a “time bomb” ticking in his neck.
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  • 11/30/06