This document provides information on neurogenic pain and depression from Prof. A.V. Srinivasan. It discusses how neurogenic pain often results from central nervous system disorders and can lead to depression. Effective treatment of the underlying neurological condition may help reduce both the pain and depressive symptoms. Multidisciplinary management involving a neurologist, pain specialist, and mental health professional provides the best approach for patients suffering from neurogenic pain and associated depression.

1. Neurogenic Pain and Depression
Prof. A.V. SRINIVASAN,
MD, DM, Ph.D, F.A.A.N, F.I.A.N.D.Sc
Emeritus Professor
The Tamilnadu Dr. M.G.R. Medical University
Former Head
Institute of Neurology, Madras Medical College
20-1-11

3. Cerebrovascular
Emergencies
Is survival a mere stroke of Luck?
“My Opinions are founded on knowledge but modified by experience”

4. Every minute matters: ‘time is brain’
Expert is one who think to his
chosen mode of ignorance

5. INTRODUCTION
 Perceptual
Sense (Observation)
 Word Sense (Recording)
 Common Sense (Thinking)
– Will lead you to get - Clinical Sense
“ He who cannot forgive others destroys the bridge over
which he himself must pass” - Annoy

6. Cerebrovascular disease –
Mind boggling facts
 World wide incidence: 2/1000 population/annum 1
 Incidence in people aged 45 – 84 years: about 4/1000 1
 Incidence in India: was 36/100,000 for the year 1998-1999 3 in a
study in Calcutta
 Incidence of mortality due to stroke (India: WHO study):
73/100,000 per year2
CVD is the most disabling of all neurologic diseases.
50% of survivors have a residual neurologic deficit.
Greater than 25% require chronic care.
1.A practical approach to management of stroke patients; 1996; 360-384
2. Epidemology of cerebrovascular disorders in India; 1999; 4-19
3. Neuroepidemiology 2001;20:201-207
If you think you can or you can’t You are always right

7. Annual risk CVD, MI, vascular
death following TIA, minor CVD
• CVD 6.7 %
• MI 2.5 %
• Death 7.2 %
• CVD, MI, Vascular death 8.6 %
• CVD, MI, Death 10.3 %
Experience can be defined as yesterday’s answer to
today’s problems

8. Indian scenario
1880 death / day
due to stroke in India
Equal to 6 Boeings 737 crashes every day

9. Indian scenario
Number of deaths due to stroke
 22 times that due to malaria
 4 times that due to RHD
 1.4 times that due to TB
 Almost equal to deaths due to IHD

10. Comparison
India vs. established market economies
(Age adjusted stroke mortality)
2 to 3 times stroke
mortality higher in India
 Indian immigrants to England have higher
risk or dying due to stroke than local
population

11. Comparison
USA – stroke mortality decline since 1940’s
India likely to increase
– Increase life expectancy (aging population)
– Urbanization

12. Acute stroke interventions –
reasonable evidence
 Stroke units
 Aspirin
 Thrombolysis
 Heparin

13. Stroke
Vascular event due to atherosclerosis
Relevant to all of us
 Neurologists Cardiologists Physicians

14. Stroke disability worldwide
 Limb weakness – 77%
 Urinary disturbance – 48%
 Dysphagia – 45%
 Cognitive deficit – 44%
35% functionally dependent at 1 year

15. Acute stroke interventions –
evidence based medicine
 Stroke care units vs general wards
– 9% relative risk reduction
– 56 deaths or dependency avoided / 1000 acute
strokes treated / year
 Aspirin
– 3% relative risk reduction
– 12 deaths or dependency avoided / 1000 active
strokes treated / year

16. Acute stroke interventions –
evidence based medicine
 Thrombolysis – (even in USA only 1% of
strokes are thrombolysed)
– 10% relative risk reduction
– 63 deaths or dependency avoided
(91 early deaths due to haemorrhage)
 Heparin
– No benefit

17. Conclusion
 People who survive stroke – 90% are left
with deficit – minimal / mild / moderate /
severe
 None of the presently available therapy has
any major impact hence prevention is
critical

18. New role of doctors
“Managers of Change”
“Preventors of Change”
(Health ill health)

19. Global
15 million deaths globally
every year due to vascular disease
(30% of all deaths)

20. Global
By 2020 – stroke and myocardial
infarction will constitute leading cause
of death / disability

21. Lowering blood pressure
 Primary prevention – 17 randomised trials –
reduction of 5 to 6 mmHg diastolic and
10.12 mmHg systolic BP – 38% reduction
of stroke
 Secondary prevention – have we made
PROGRESS

22. Common Stroke Mimics
 Hypoglycemia
 Post ictal state
 Drug overdose
 Concussion with neck injury
 Migrainous accompaniment
 Encephalopathies with focal signs
 Hyponatremia
 Subdural hematoma, Empyema
 Focal Encephalitis: Herpes
Being ignorant is not so much a shame as being unwilling to learn

23. Guidelines for 24 hrs – Mandatory
Level of Evidence
Level A: Based on RCT or Meta analysis of
RCT
Level B: Based on Robust Experiment or
Observation Studies
Level C: Based on Expert opinion.
“The True Art of Memory is The Art of Attention” - S.Johnson

24. 1. History And Examination
a. Stroke clerking Performa (1994) R.C.P.
1. Improved patient Assessment
2. Improved Management - not clear
3. Improved outcome - not clear
b. Examination
1. Secure Diag of Stroke
2. Specify Impairment
3. Identify sub type of Ischemic stroke
4. Rule out stroke mimics
“ We Sometimes think we have forgotten something when
in fact we never really learned it in the first place”
Imp.Your Memory Skills

25.  Guideline: 3 (B) - CPR
– CPR is rarely successful in the setting of stroke – Sneeder
1993.
 Guideline: 4(B) Investigations:(Sagar 1995)-
435 PTS)
– Chest x-ray 16% ABN
– Only 4% change clinical management
– Order x-ray chest if weight loss or chest symptoms
present
Through Action You Create your Own Education - D.B. ELLIS

26.  Guideline 5: (B) ECG:
– Cardiac cause of Death (30 days) Ebrahim 1990.
– All conscious patients to have ECG
 Guideline 6: (C) CT:
– Routine CT Head is a must
– King’s fund forum(1988) gives useful framework
– Weir 1994 Clinical scoring cannot distinguish
– CT done if: a) Uncertainty of Stroke
b) If Anticoagulation or Anti Platelet
treatment contemplated
c) IV rtPA
Thought is the labour of the intellect
Reverie is its pleasure

27.  Guideline 7:(B) M.R.I.
– Mohr 1995, - Unclear for Implications for
clinical practice
– 2004 – PWI > DWI – IV rtPA very useful
Whatever the Mind can conceive and Believe,
the mind can Achieve -Napoleon Hill

28.  Guideline 8: (B) ECHO no Routine
– Echo in Acute Stroke – Cardiac cause/Thrombus LV
– TEE is superior to TTE
– Amer Heart Asson (1997) - same conclusion
– Yield is very low. (Leung 1993; Chambors 1997)
– Only when abnormal ECGS - change clinical
management
Imagination is more Important than Knowledge

29.  Guideline 9: (A) – Doppler scan for selected
patients
– > 80% stenosis benefits from Endarterectomy
– Subst Storke -Good recovery - do doppler
– Useful in posterior circulation
A open foe may prove a curse ; but a pretended friend is worse

30.  Guideline 10: (B) Management:
– Fever (Worst Prog.) Reith 1996
– Hypoxia (Moroney 1996) - Exac. by seizures
Pneumonia and Arrythmias - Worst outcome
– Hyperbaric O2 ineffective (Nighoghossaln 1995)
– Haemodilut. Plasm Expanders; venesection
– No evidence for efficacy (As plund - 1997)
Check ABG only if Hypoxia suspected.
It is a great misfortune not to possess sufficient wit to speak well
nor sufficient judgment to keep silent - La Broyers character

31.  Guideline
11: (A) Steroids and Hyperosmolar
agents Unproven treatment –
– Tumor oedma responds but not cytotoxic stroke
oedma qialbash 1997 - No effect on survival or
improv. In funct. Outcome
– Mannitol - (Boysen 1997) - short term effective
statistically in conclusive
You are what you think and not what you think you are

32.  Guideline 12: (B) - Blood Pressure
– Defer - acute reduction of BP - 10 days unless HT
Encephalopathy or aortic dissection present
– Moris 1997 - Increase BP - falls in 10 days
– UK - 5mm in D.B.P. 1/3 storke - Low BP prompt correct of
hypovoll. and withdrawal of hypotonic drugs
– Collins 1994 - HT - Prim. stroke prevent
– Neal 1996 (Current RCT) - HTs in stroke survivors -study
needed
– Acute reduction of BP only if thrombolysis considered
We learn by thinking and the quality of the learning outcome is
determined by the quality of our thoughts
R.B. Schmeck

33.  Guideline 13: (A/B) – AF
– AF / ISCH Stroke/ Mild disability - Warfarin after
48 Hrs (Longer for larger)
– Aspirin for others
 EAFT 1995 Less than 2 PT - No effect
 SPAF 1996 > 5 - Bleeding
Discipline Weighs ounces; Regret weighs Tons

34.  Guideline 14:(B/C) - Blood sugar
– Weir (1997) > 8 mm d/Lit - Poor outcome
– Acute MI + 11 mm d/Lit - Intensive Insulin - improved
(Malmberg 1997)
A great many people think they are thinking when they are
merely re arranging their prejudices
W. James

35.  Guideline 15: (A) Cholesterol
– Prosp. Study collob.: 1993 - Epidem study do
not support
– Blaun 1997: Metranauetic - Chollest & statin
30% decrease - stroke in CAHD patients.
– Sacks 1996 - Tot chol: decrease to 4.8
mmol/Lit benefits
Many Ideas grow better when transplanted into another mind than
in the one where they sprang UP
O.W. Holmos

36.  Guideline 16: (A/C) Deep vein thrombosis
– Kalra 1995 - 10 days - stroke Pts - 50%
– Sandercock 1993 - Pul embol 6-16% only
– Ist 1997 - 5000 IV or 12500 twice daily - Hemorrage greater
– Gradual stocking value - useful in Surg - pts but its value not
evaluated - (Wells 1994)
– Use with caution - if periph artery insuf. is present hence do
not use heparin on stockings.
A woman’s desire for revenge outlasts all her other emotions

37.  Guideline 17: (A/B) Pressure sure
– Event health care (1995) specialised low
pressure mattress systems to be used than stand
Hospital - mattress
Every discovery contains an irrational element or
4 creative intuition

38.  Management of infarction
– Guideline 18: (A)
 Aspirin 75 - 150 /Day
 3 yrs 40% reduces of vascular events in 1000 pts (APTC -
1994)
 Stroke sub type value ? (TACI, PACI, LACI, POCI)
 Dienners - 1996, synergy possible with Clopidogrel
Ticlopidine etc.
I have never let my Medical schooling interfere with my education
Mark Twain

39. Anti Coagulation
 Warfarin - AF
– In sinus rhythm - uncertain
– Spirit 1997 low dose ABP + Warfarin in TIA &
Minor stroke - Stopped of HE
– Heparin (IST 1997) – Significant reduction in
early death (12 fewer in 1000) not better than
aspirin
– So avoid Heparin (A)
“ H who cannot forgive others destroys the
e
bridge over which he himself must pass” -

40.  Thrombolysis (A)
 Warlow 1997 - Uncertain clinical benefit
 2004 – NINDS – Thrombolysis
conclusively proved its efficacy – first 3 hrs
When they tell you to grow up, they mean stop growing
Piccaso

41.  Guideline 20: (I) Hemorrhage
– Hankey and hon 1997: Supra tentorial
evacuation for ICH is controversial - Avoid
– Infra tentorial - Yes
– Main Indication - Deteriorating or depressed
consciousness
A (Neurologist’s) life is like a piece of paper on which everyone who
passes by leaves an impression
- Chines proverb

42. 2 2 4 P ts
Guideline 21 : Ventilation
131
I n t u b a tio n
93
N o t In tu b -Decreased level of
consciousness - increased
6 4 D is c h a r 6 7 D ie d
mortality and poor final
3 4 R e d ta g 2 1 d is c h t o
n ver h om e
8 D is c fo r
p a llim a
1 D is c
H om e outcome
- Absent pupillary light
3 D ie d 7 D ie d 3 D ie d
responses - poor prognosis
A medical school should not be a preparation for life.
A school should be life

43. PITFALLS
 Basing treatment of stoke on brain imaging
along without a vascular work-up
 Missing early infarct signs on CT
 Underestimating the time of symptom onset
for patients who wake up with a stoke
 Overtreatment of hypertension in acute
stoke
Three can be seen in the divisions of a human in mind, body and spirit

44. PITFALLS
 Overuse of carotid endarterectomy in
asymptomatic patients
 Not investigating both extracranial and
intracranial circulations
 Failure to distinguish severe cartid stenosis
from total occlusion
 Not obtaining spinal fluid for patients with
suspected subarachnoid hemorrhage
“Social Isolation is in itself a pathogenic
Factor for disease production”

45. PITFALLS
 Not treating patients with large artery
ischmic stroke indefinitely with antiplatelet
terapy
 Failure to recognize lacunar stoke
 Inadequate use and dosing ofHMG Co-A
reductase inhibitors (statins) inpatients with
cerebrovascular disease
Through Action You Create your Own Education - D.B. ELLIS

46. PROGNOSTIC PEARLS
 Flaccid Paralysis for more than 96 hrs
 When tendon reflexes recover without return of voluntary
movement – prognosis poor
 Recovery of sensory less in usual to a degree. Postion sense
recovers but not pain and temperature
 Recovery from Dysphasia is never complete
 Dysarthria usual improves and Dysphagia never improves
 Diplopia due to brain stem is usually permanent
 Conjugate gaze – recovers
 Vertigo improves but hearing loss is permanent
 Pseudobulbar palsy permanent
“ByNature All Men/W en are alike but
om
byEducation widelydifferent”

47. STOKE MYTHOLOGY
 GENERAL MYTHS
 DIAGNOSTIC MYTHS
 THERAPEUTIC MYTHS
Serious, sincere, systematic study surely secures supreme success

48. GENERAL MYTHS
 PHYSICIAN+ MRI = NEUROLOGIST
 MINISTROKE
CHAOTIC
 CVA
COMMUNICATION
Discipline Weighs ounces Regret weighs Tons

49. DIAGNOSTIC MYTHS
 Self evident cause
 Ischaemic stroke + AF
 Lacunes, Lacunar infarcts and small vessel
disease
 Cryptogenic stroke
 PFO and Cardiogenic stroke
Experience can be defined as
yesterday’s answer to today’s problems

50. Ultrasound Diagnosis
In skilled hands, ultrasound may show:
• Carotid occlusion or stenosis
• MCA occlusion or stenosis
• Vertebrobasilar occlusion
• Extracranial dissection
The secret of walking on water is
Knowing where the stones are

51. UCLA Stroke CT Protocols
Sequence Time CT CT CT CT CT Stroke
Stroke Stroke reduced
WWO Stroke
WWO reduced Dye
Diamox Dye WWO
Diamox
SCOUT 0’15” + + + + +
CT 0’30” + + + + +
CTA-COW - + + + +
16’
CTA-Neck - + + + +
CTP 20’ - + + + +
CTP W 30’ - - + - +
diamox
Post- 0’30” + - - - -
contrast

52. Magnetic Resonance Imaging (MRI)1
 High level of anatomic detail for precisely locating the
stroke and determining the extent of damage.
 Especially useful for small blood vessels due to high
sensitivity
 Advances in the early detection of stroke involve
using diffusion and perfusion weighted imaging.
1. Curr Opin Neurol. 2004 Aug;17(4):447-51
Memory, the daughter of attention, is the teeming
mother of knowledge - Martin Tupper

53. UCLA Stroke MRI Protocols
Sequence Time Brain TIA Stroke Thrombol Thrombol
WWO ysis 1 ysis 2
SCOUT 0’25” + + + + +
MRA-Neck 6’44” - + + - +
DWI 0’40” - + + + +
T2 3’42” + + + + +
MRA-COW 6’12” - + + + -
FLAIR 2’41” + - + + -
GRE 2’35” - - + + +
PWI 2’ - - - + +
T1 3’ + - - - -
T1 post 3’ + - - - -
Gad

54. Other Diagnostic Tools-1
 Magnetic Resonance Angiography1 (MRA)
 Carotid Duplex Scanning2:
 Transcranial Doppler (TCD)3
 Xenon CT Scanning4
1.Neurol Res. 2004 Jun;26(4):429-342. J Vasc Surg. 2003 Sep;38(3):422-30. 3. .Neurology.
2004 May 11;62(9):1468-81,4. Keio J Med. 2000 Feb;49 Suppl 1:A25-8
Science is below the mind; Spirituality is beyond the mind

55. Other Diagnostic Tools -2
Radionuclide SPECT Scanning1
PET Scanning2
Transesophageal Echocardiography3
1. AJNR Am J Neuroradiol. 2001 May;22(5):928-36
2.Neuroimaging Clin N Am. 2003 Nov;13(4):741-58
3. Heart Dis. 2003 Sep-Oct;5(5):320-2
Success is a prize to be won. Action is the road to it.
Chance is what may lurk in the shadows at the road side.

56. THERAPEUTIC MYTHS
 Evidence based medicine = Randomized Clinical
Trials
– Best Research Evidence
– Clinical Expertise
– Patient Values
 Systematic Escalation of anti thrombotic therapy
 Brain Hemorrhage Demands Neuro surgical
Consultation

57. Thrombolysis in acute stroke
Dead/dependent follow-up 62% vs 69% s.
Deaths by day 14 22% vs 12% s.
Deaths during follow-up 22% vs 19% s.
Deaths ordered by antithrombotic 40% 30% 17% 10%
Deaths ordered by thrombolytic 3% 20% ns.
Deaths ordered by stroke severity 11% 29% ns.
Symptomatic ICH by 14 dys 9.3% vs 2.5% s.
Fatal ICH by 14 dys 6% vs 1% s.
Dead/dependent follow-up < 3 hr. 55% vs 71% s.!
Dead follow-up < 3 hr. 20% vs 25% ns.
NATURE, TIME AND PATIENCE
are the 3 great physicians

58. NINDS Consensus
Door to MD evaluation 10 min
Door to CT completion 25 min
Door to CT read 45 min
Door to treatment 60 min
Access to neurological expertise 15 min
Access to neurosurgical expertise 2 hrs
Admit to monitored bed 3 hrs
Memory, Pity and Beauty are short lived in life;
But tinged with emotion persist in life

59. CONCLUSION
• MYTHS
• PITFALLS
• PROGNOSTIC PEARLS
It is the disease of not listening, the malady of not marking,
that I am troubled withal - Shakespeare

60. CVD – Prevention or Cure?
While number of curative methods are
available, preventive therapy is
undoubtedly the main strategy in the
management of CVD
Lijec Vjesn. 2003 Nov-Dec;125(11-12):322-8
The sign wasn’t placed there
By the Big Printer in the sky

61. Where are we ……?
Call
Stroke onset emergency
Secondary
prevention services
Full recovery
U RS
Activated
(15 minutes)
Neuroprotective
drug infused
Drugs administered
‘stroke-treatment’ 6-8 O during transport
cocktail H ER stroke team
Brain scan
The art of medicine is caring for the heart of the patient

63. Dedicated to my family for
making everything worthwhile