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Stroke & Society : Dr Vijay Sardana Stroke & Society : Dr Vijay Sardana Presentation Transcript

  • STROKE & SOCIETY Vijay Sardana MD;DM Professor & Head Deptt of Neurology Medical college, KOTA
  • Stroke Definition
    • Clinical syndrome characterized by sudden onset symptom and sign of focal (at time global) cerebral dysfunction of vascular origin lasting more than 24 hrs or leading to death
  • Stroke
    • 2 nd commonest cause of death
    • Most common cause of disability
  • STROKE Epidemiology
    • 5 – 6 million die of stroke worldwide annually
    • Reducing trend in western countries – change in life style
    • 87% of all strokes occur in underdeveloped and developing countries
    • Stroke is second common killer
    • 29 th October as world stroke day (WFN,WHO,WSO) theme for 2008, “ Little Strokes, Big Trouble”
  • Stroke : India
    • Stroke incidence – 163/1,00,000
    • Population/yr.
    • Stroke prevalence – 545/1.00.000
    • Ischemic stroke incidence- 14.43.539/yr (80% of all) - 2005
  • Stroke India Annual incidence
    • 145/1,00,000/per year (India)
    • 29/1,00,000 Sri Lanka
    • 370/1,00,000 China
    • 523/1,000 Japan
  • Stroke Prevalence
    • India 57 - 843/1,00,000
    • China 620 - 1,1,00/1,00,000
    • Japan 398 – 3540/1,00,000
  • WHO – Global Stroke Mortality Projections 2003 to 2030
    • 2005 - 16 million first ever Stroke
    • - 62 million Stroke Survivors
    • - 51 million Disability Adjusted Life year (DALYs)
    • - 5.7 million Stroke Deaths
    • Same year India - 53% of all deaths Including Stroke from ch. Diseases
    • By 2015 - 18 millions First Ever Stroke
    • - 6.5 ,, ,, Deaths
    • By 2030 - 23 million First Ever Stroke
    • - 7.8 million Deaths
  • Stroke: India
    • 73%- don’t realize that symptoms are due to cerebral stroke
    • Low threat perception of stroke in comparison to ‘heart attack”
    • Most of rural patients – not aware of Time window
  • Raised Stroke burden in India
    • Smoking
    • Increased longitivity
    • 41.2yrs (1951-61)
    • 61.4yrs (1991-96)
    • Change in lifestyle accompanying urbanization
    • Genetic syndrome
    • Centra obesity
    • High triglyceride
    • Low HDL +/- glucose intlerance
  • Stroke & community
    • 75% Stroke managed offside academic medical centre
    • Need to optimize stroke care in the community setting
  • Stroke care in community
    • Stroke awareness
    • Emergency Medical Services transport V/S Personal transport
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  • Stroke: India
    • 7-24% present to hosp. within 3 hrs (Indian urban based study)
    • Major factor for early advise – living within 10 km radius (Pandian et al 2006)
    • Major factor for delay – non availability of transport
  • STROKE MORTALITY IN INDIA
    • 1990(WHO)-6,19,000/90,40,000 total deaths
    • 73/1,00,000 population
    • Stroke deaths
    • equal to IHD
    • 20 times more than malaria
    • 1.5 times Tuberculosis
  • Stroke outcome
    • One third independent in ADL
    • More than one fifth- bed ridden
    • Rest – in between
  • Inevitable Stroke epidemic
  • STROKE SPECIFIC TO INDIA
    • YOUNG STROKE-20-25%
    • CVT
    • RHD
    • ARTERITIS
  • Stroke- what needs to be done
    • Imparting physicians knowledge about stroke management, importance of window period & thrombolytic therapy
    • Educating public
    • stroke warning symptoms
    • risk factors
    • mortality & dependence
    • importance of time window
    • Stroke units
  • Run For Stroke at Kota
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  • Stroke care in community
    • F -Face weakness
    • A -Arm weakness
    • S -Speech disturbance
    • T -Time
  • Stroke care in Community issues
    • Hospital readiness
        • Ship & Drip
        • Drip & Ship
        • Role of Telemedicine
  • Ischemic st roke Time window in Brain
    • ATP exhaustion : 2 min
    • First neuronal damage : 5 min
    • Infarction begins : 1-2 hrs
    • Infarction continues to enlarge : 6 -12 hrs
    • Re-establishment of circulation in less than one hour leads to restoration of physiological and biochemical functions
  • Ischaemic Stroke Brain Oedema
    • Onset 1 – 3 hrs
    • Max 2 days
    • Resolve 2 weeks
  • Diagnostic evaluation Stroke mimics Hypoglycemia Hyperglycemia Hepatic encephalopathy Seizures Hemiplegic migraine SDH Brain abcess Hypertensive encephalopathy MS Hysterical Stroke chameleons Acute confusional states Seizures with acute strokes Sensory symptoms Movement disorders
    • Uncommon manifestations of common clinical problems are more common than common manifestations of uncommon clinical problems
  • Ischaemic Stroke
    • Risk Factors
    • * Hypertension * Atrial fibrillation
    • * Diabetes * Myxomatous Deg. Mit. Valve
    • * Smoking * Deficient ant thrombin iii
    • * Antiphoshpholipid * Protin - S
    • Antibodies * Protin - C
    • * Lupus anticoagulant * Aging
    • Anticardiolipin * Hyperhomocystenemia
  • Ischaemic Stroke
    • Cerebral circulation – regulation – pathophysiolgy
    • Blood flow & glucose consumption 1/5 resting cardiac output
    • Gray matter > white
    • No metabolic reserve
    • Normal CBF 55ml/100gm/mt.
    • Critical 23ml/100gm/mt
    • Infarction 8-9ml/100gm/mt
    • Ischaemic Penumbra 8-23ml/100gm/mt
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  • Ischaemic Stroke
    • Complete : Persistence neuro deficit
    • > 24 hrs
    • TIA : Transient neuro deficit <24hrs
  • Time of onset of isch stroke
    • Time % cases
    • 12 am - 4 am 18
    • 4 am – 8 am 23
    • 8 am – 12 noon 25
    • 12 noon – 4 pm 13
    • 4 pm – 8 pm 19
    • 8 pm – 12 pm 12
  • Ischaemic Stroke Focal Cerebral Aetiology
        • Vascular Disorders
        • Atherosclerosis-
        • Moyamoya synd Fibro muscular dysplasia
        • - Lacunar infarction
        • Vascular dissection
        • - CVT
        • Cardiac Disorders
        • Mural thromb - RHD, Prosth valve
        • Arrhythmias - Endocarditis
        • Haematologic Disorders
        • Hypercoag state, Thrombocytosis
  • Ischaemic Stroke
    • Infarct size depends upon
    • Collaterals
    • Blood viscosity
    • Mean arterial B.P.
    • CSF pressure
  • Ischaemic Stroke
    • Ring around infracted centre, Penumbra
    • CBF in this area
    • Partial Ischaemic state
    • Functional activity
    • Preserved structural integrity
  • Stroke - Diagnosis
    • Is it a stroke ?
    • Which type of stroke ?
    • - Ischaemic
    • - Hemorrhagic
    • If ischaemic stroke :
    • - What is the event ?
    • - Which is the territory
    • - What is the aetiology
  • Cardioembolic Stroke Criteria
    • Clinical
    • - Young adult, onset deficit with no antecedent TIA
    • - Involvement of multiple vascular territories
    • - Cardiac source
    • Diagnostic studies
    • - CT or MRI : ischaemic bland / haemorrhagic infarcts in multiple vascular territories
    • - Echocardiography : cardiogenic emboli
    • - Angiography : no significant stenosis
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  • Stroke early CT Signs
    • Hyperdense MCA Sign – (sensitivity 27-34%)
    • Loss of gray White diffrentiation in the insular ribbon at the lat. margin of insula (loss of the insular ribbon sign)
    • Sylvian dot sign specificity 38-46%
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  • Management of Ischaemic Stroke
    • Phase I Acute Management
    • Phase II Rehabilitation
    • Phase III Prevention of rec.
  • Stroke Management - Variations
    • Availability of technology
    • Affordability
    • Type of Medical practice (Public v/s private)
    • Difference in Philosophy of practice (evidence based or not)
  • RAPID CLINICAL EVALUATION
    • Reperfuse Ischemic brain
    • Act within a time limit of the penumbra
    • NIHSS evaluation
      • Non-Neurologists and Neurologists
      • Identifies
            • Candidates for thrombolysis
            • Patients with increase risk of
            • hemorrhagic complications
    NIHSS <10: 60-70% Favorable outcome after 1 yr ;3% chance of ICH NIHSS >20: 4-16% have favorable outcome; 17% chance of ICH
  • EMERGENCY ROOM
    • Obtain vitals
    • Ensure ABC
    • Cannulate (0.9 N sal at 50ml /hr)
    • Spot sugar
    • BP
    • EKG
    • Send BT, CT, Platelet Ct
    • O 2 at 2L/ min (nasal cannula)
    • Intubation (Poor ventilatory drive)
    • Brain CT Non Contrast
    • If potential thrombolysis-DO NOT GIVE ASP./ ANTICOAGULATION
    • Treat as any other emergency
    • (eg. Unstable Trauma, AMI)
  • NINDS – Recommended stroke evaluation target for Thrombolysis
    • Task Time target (min)
    • Door to Doctor 10
    • Door to CT completion 25
    • Door to CT read 45
    • Door to Department 60
    • Access to Neurological expertise 15
    • Access to Neurosurgical expertise 120
    • Admit to Monitored bed 180
  • Ischaemic Stroke
    • Medical Treatment : General
    • Rapid  BP. - Don’t treat - 10days
    • Unless V.high dias - 120
    • Nasogastric intubations if vomiting
    • Frequent turning
    • Air ways
    • Diet
  • Stroke – what needs to be done
    • Imparting physicians knowledge about stroke management, importance of window period & thrombolytic therapy
    • Educating public
      • stroke warning symptoms
      • risk factors
      • mortality & dependence
      • importance of time window
      • Stroke units
  • Stroke units
    • 20% reduction in mortality & dependency as compared to gen ward
    • Stroke unit patients- at 1 yr
    • more likely to be alive
    • independent
    • living at home
  • Stroke unit : 100
    • 3 additional would survive
    • 3 additional would avoid long term hosp. care
    • 6 additional would return home physically independent
  • Stroke : India
    • Dr. P.M. Dalal – specialized stroke Management concept
    • mortality 33% - 12%
    • Late Sh. Nagi Reddi
    • Dr. T.J. Cherian – First Stroke unit in private sector in 1985
  • Stroke service in developing countries Brazil Iran China Pakistan India Neurologist 5000 420 20,000 60 1500 Neurology deptt. 90 24 1500 15 40 Stroke units 35 20 150 5 100 Stroke Prevalence /1,00,000 128 43 400 48 545
  • Stroke unit- Aims
    • Giving patients rapid access to wide range of modern clinical & radiological facilities
    • Providing facility for safe administration & monitoring of hyper acute treatment
    • Early rehabilitation & patient education
  • Stroke unit
    • ICU beds
    • Cardiac monitors
    • Ventilators
    • Defibrillators
    • Rehab equipment
    • Central gas supply
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  • Kota Med college Stroke unit : policies
    • 12 beds
    • Admission – adults where stroke is major clinical problem
    • SAH – NS – back
    • Exclusion
    • Major medical co morbidity
    • Requirement of other ongoing surgical & other medical treatment
    • Major preexisting psychiatric disorder
    • TIA
  • Stroke Therapy - Breakthrough
    • 1996 – thrombolytic Therapy
  • Thrombolysis
    • Less than 5% patients
    • Few hundred in India
  • Ischaemic Stroke Thrombolytic Therapy
    • Intravenous tPA
    • Intra-arterial tPA/ urokinase
  • Ischaemic Stroke Thrombolytic agents
    • IV recanalization - 30-40%
    • I.A. recanalization - 60-70%
    • V. good but potentially dangerous for clot lyses
    • Must adopt strict guidelines exclusion / inclusion criteria
    • Emergency CT essential
    • Neurosurgery back up essential for ICH
  • Eligibility Criteria for iv TPA
    • Inclusion criteria
    • Onset of symptom to drug administration time is below 3 hours
    • Patient has significant neurological deficit
    • No hemorrhage on CT scan
  • Exclusion criteria
    • Stroke or server head trauma in last three month
    • Major surgery in last 14 days
    • Systolic BP. Above 185 mm of Hg or diastolic BP above 110 of mm of Hg
    • If Patient is rapidly improving or has minor symptoms
    • Symptoms suggest SAH
    • Hematuria, Malena, hemoptysis within last 21 days
    • Seizure at the onset of stroke
    • Prothrombin time>15sec
    • Platelet count 1,00,000/mm3
    • Glucose<50 or >400 mg/DI
  • Thrombolysis - advantage with Kota
    • Nearby districts within window period
    • Population density
    • Vigilant & relatively health conscious people
    • Relative economic vibrancy
  • TPA cost in developing country
    • India- Rs. 55,000 (1217 USD)
    • China – 9586 Yuan Remuinbi (1269 USD)
    • Argentina – 4810 Argentina Peso (1586 USD)
    • Mexico -24059 Mexico Peso (2306 USD)
    • Turkey – 1919 Lira (1480 USD)
  • Acute Ischaemic Stroke Medical Therapy
    • Antithrombotic Therapy
    • - Antiplatelet drugs – Aspirin; clopidogrel
    • - Anticoagulants – Heparin; Warfarin
    • Reperfusion Therapy
    • - Thrombolytic Drugs – Streptokinase; tPA
    • Neuronal Protection
    • - Ca Channel Antigonissts – Nimodipine
    • Nicardipine
  • Ischaemic Stroke
    • Anti convulsants
    • Vasodilators
    • - Poor benefit
    • - May produce intracerebral steal / damage infracted area
    • Volume expanders
    • Low mol. Wt. Dextran - mixed result
    • Pentoxicyfyline
    • Barbiturates - poor value
    • Ca Chh.inhib. - mixed result
  • Ischaemic Stroke
    • Antioedema agents
    • Corticosteroids - less effective
    • use only if patient - Obtundation
    • - Coma
    • - Herniation
    • Dexamethasone - 10mg bolus 4mg IV 4-6 hrly
    • Mannitol/glycerol
  • Treatment of Acute Ischaemic Stroke
    • Acute Therapy Maintanence Therapy
    • Thrombolytics * Antiplatelets
    • Antiplatelets * Antithrombotics
    • Antithrombotics * Statins
    • * Ace Inhibitors
    • * ARB-II Blockers
    • * Folic Acid/ Vitamins
    • Risk Factors Modification
  • Ischaemic Stroke Antiplatelet Agents
    • Aspirin – inhibit thromboxane A2 30-325 mg
    • Dipyrimadole (persantine) less effective (ESPS)
    • 200mg slow release BD
    • Combined Aspirin + Dipyrimadole (ESPS 2)
    • Clopidogrel 75mg OD (CAPRIE)
  • Ischaemic Stroke - Clopidogrel
    • Similar efficiency as Aspirin
    • ESP2
    • - Aspirin – Risk reduction 18%
    • - Aspirin and Dipyarimadole
    • Risk reduction 37%
  • Ischaemic Stroke Anticoagulation
    • Indications
    • - Cardioembolic strokes
    • - Strokes in evolution
    • - Posterior circulation stroke (basilar artery thrombosis)
    • - Recurrent TIA with tight stenosis
    • - Carotid / Vertebrobasilar dissection
  • Ischaemic Stroke
    • Anticoagulants : Controversial
    • - Large infarct Avoid
    • - Non compliment patient
    • - Can not be followed up
    • - Bleeding diatheses
    • - Peptic ulcer
    • - Liver disease
  • Management of Acute Ischaemic Stroke
    • Use of Heparin may still be used in certain subgroups
    • Acute MI
    • AF
    • Intracardiac thrombus
    • Critical Stenosis of supplying arteries
    • Recent acute basilar occlusion
  • Ischaemic Stroke Prevention After first Stroke
    • Statin Therapy
    • Reduce 10 year stroke recurrence, improves survival
    • 794 consecutive first ever acute Ischaemic Stroke
    • 10 year Follow up
    • Recurrence with statin _ 7.5%
    • Recurrence without statin – 16.3%
    • Milionis et al – Neurology 2009 : 72 : 1816 - 1822
  • Ischaemic Stroke Prevention Atrial Fibrillation
    • Average stroke risk 4.5% / year
    • High risk if additional factors present
    • - Age > 75 years
    • - Recent stroke or TIA
    • - Systolic HT
    • - Diabetes
    • Anticoagulation (Warfarin) reduces risk by 70%
    • Aspirin may be used in patients under 65 year without risk factors
  • We have a dream
    • Population knows about sign & symptom of stroke
    • “ Brain attack” is taken as seriously as “Heart attack”
    • Patient are brought to hospital early
    • Stroke centers are established at every distrct of the country
  • We have a dream
    • More patients receive Thrombolytic therapy
    • Technology should be used for Tele-consultation of stroke patient to compensate for shortage of stroke specialits
    • National programme on Stroke
  • Thanks