Family Physician's Role in Managing Stroke Recovery

TERTIARY MANAGEMENT OF
STROKE :THE ROLE OF A FAMILY
PHYSCIAN
MOHAMMED LUKMAN ABOLAJI
DEPARTMENT OF FAMILY MEDICINE ,AKTH,KANO.
7/28/2021 1
MOHAMMED LUKMAN ABOLAJI, FAMILY MEDICINE,AKTH ,KANO

OUTLINE
INTRODUCTION
EPIDEMIOLOGY
PATHOPHYSIOLOGY
CLASSIFICATION
RISK FACTORS
CLINICAL FEATURES
SECONDARY PREVENTIONOF STROKE
COMPLICATIONS
TERTIARY MANAGEMENT OF STROKE
BURDEN OF STROKE ON CAREGIVERS
PROGNOSIS
ROLE OF FP IN MULTIDICIPLINARY CARE
CONCLUSION
REFRENCES
7/28/2021 MOHAMMED LUKMAN ABOLAJI, FAMILY MEDICINE,AKTH ,KANO 2

INTRODUCTION
Stroke; ‘Rapidly evolving focal (or global) disturbance of cerebral function,
lasting 24 hours or longer, or leading to death, with no apparent cause, other
than of vascular origin’ (WHO 1970)
Transient Ischemic attack (TIA);“Clinical syndrome of acute onset focal or global
disturbance of cerebral function of no apparent other than of vascular origin,
which completely resolves within 24 hours”
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INTRODUCTION
Definition-drawbacks
Time based: 24 hrs time, obsolete as permanent brain injury may occur sooner
Does not corroborate the mantra “time’s neurone”
Does not suggest stroke to be a medical emergency
Global cerebral dysfunction is seldom caused by CVD
Does not take into cognizance the use of IV thrombolytics within 3hours in CI or use of recombinant
activated factor VII within 4 hours in ICH
TIA is not benign [as it heralds stroke in 50% within 24 –48 hrs, 10% within one wk; 15% within one
mth, up to 20% devstroke within 90 days]
Most (90%) TIA lasts 10 mins; resolve in 30 mins. If symptoms last > I hr; chances of resolution only
15%
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INTRODUCTION
Stroke: Clinical syndrome typified by rapidly evolving focal disturbance of
cerebral function, of vascular origin with an objective neuroimaging evidence of
a lesion irrespective of duration of clinical symptoms.
AHA/ASA .Stroke. 2013;44:2064-2089
TIA: transient neurological dysfunction caused by focal brain, spinal cord, or
retinal ischemia without any objective evidence of an acute infarction.
AHA/ASA . Stroke.2009;40:2276–2293.
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INTRODUCTION
Common neurological emergency
Accounts for 1 out of every 14.8 deaths
47% of these deaths occur out of the hospital
Someone suffers a stroke every 53 seconds
Someone dies from stroke every 3.3 minutes
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EPIDEMIOLOGY
Major cause of death and disability worldwide
Incidence Increases with rising age (0.5/1000 at <40yrs, 10-12/1000 at 40 yrs, 70/1000 at 70yrs)
Stroke is the 4thmost common neurological disorder after headache, epilepsy and neuropathy.
Increasing incidence and prevalence of stroke in developing countries due to increasing life
expectancy & the adoption of unhealthy lifestyles
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EPIDEMIOLOGY
EPIDEMIOLOGY IN NIGERIA
Prevalence:58/100,000 (400-700/100,000)
Incidence: 26/100,000 (130-400/100,000)
Hospital data: 0.9 -4.9% of hospital admissions
6.5 –41% of CNS admissions
2.8 –8.4% of hospital deaths
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EPIDEMIOLOGY
Neurologic diseases comprise 15.6% of all medical admissions and stroke comprise 77.6%
[Owolabi et al. 2010]
29.3% of strokes were in patients aged ≤40 years, 17% presented within the first 6 hours of
onset of stroke with a case fatality in the first 24 and 72 hrs of 4.2% and 19.7% respectively
[Owolabi et al. 2012]
Young (Nigerians)
M:F -1.7:1
C . I. -7th decade
C . H. -6th decade
CI: 49 %; ICH :45%; SAH :6%.
Ogunet al.: Stroke 2005;36:1120-1122.)
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PATHOPHYSIOLOGY OF STROKE
Brain constitutes 2% of human body mass
Receives 20% of cardiac output
CBF 55ml/100g/min (75ml/100g in grey M and 30ml/100g white M)
Oxygen 3.5ml/100g/min
Glucose 5mg/100g/min
CBF 20-30mls/100g/min - Loss of electrical activity
CBF 10 mls /100g/min - Neuronal death
Exhausted in 2 mins & consciousness lost 8-10 sec
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PATHOPHYSIOLOGY
7/28/2021 11

PATHOPHYSIOLOGY
7/28/2021 12

CLASSIFICATION OF STROKE
ISCHEMIC (85%)
Cerebral infarct
Thrombotic
Embolic
Cryptogenic
Lacunar
Watershed
TIA
HEMORRHAGIC (15%)
SAH
ICH
Ventricular
Parenchyma
•Infratentoric
•Supratentoric
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RISK FACTORS
NON-MODIFIABLE
Old age (> 45yrs)
Male gender
Race (Black >> Asian > Caucasians)
Family history of stroke
Prior stroke/TIA
LBW
MODIFIABLE (Well Documented)
 Hypertension
 DM
Heart disease, esp. atrial fibrillation, CCF, VHD, IE,
CDM, CoHDx
Cigarette smoking
 Dyslipidemia
Physical inactivity/Sedentary lifestyle/Obesity
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RISKS FACTORS
MODIFIABLE (Less Well Documented)
 Alcohol intake [dose-related effect]
 Drug misuse [cocaine, heroin, amphetamines, cannabis, sympathomimetic]
 Infection* [EBV, H.pylori, Chlamydia, periodontitis]
 Environment – pollution, geography [stroke belt], climate
 Socioeconomic status [low]
 Others: Obstructive sleep apnea, depression, microalbuminuria
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CLINICAL FEATURES
Sudden onset
Focal neurological deficit
Progresses over minutes to hours
Headache, N/V, choking, convulsion , LOC
Acute hemiparesis or hemiplegia
 Complete or partial hemianopia, monocular
or binocular visual loss or diplopia
Dysarthria or aphasia
 Ataxia, vertigo or nystagmus
 Sudden decrease in consciousness
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INVESTIGATION
Hematologic studies (CBC, PT/PTTK, INR)
Serum electrolytes, osmolarity
Blood glucose
Chest x-ray
Renal and hepatic chemical analyses
Carotid Doppler
Brain CT scan
Electrocardiogram

MANAGEMENT OF STROKE
ABC of resuscitation
Focused history
Onset of symptoms
Recent episodes
 AMI
Trauma
Surgery
Bleeding
Medications
Insulin
Antihypertensive
 Anticoagulant
Antiplatelet
Risk factors/ Comorbidities
 HTN & DM
 Arrhythmias & Dyslipidemia
Alcoholism, smoking
Family history & Lifestyle

Clinical Examination ;
Physical
Neurological
CVS, RS etc.
Treatment;
IVF - N/S (non-hypoglycemic stroke) →within
48hrs.
Mannitol and furosemide →↑ICP or acute
Antiplatelet/anticoagulants (after CT or MRI)
Treat other comorbidities

Do not give antiHTN except;
BP >220/120mmHg
MAP >145mmHg
BP >200mmHg (with features of HTN
emergency)
BP >185/110mmHg ( for thrombolysis)
Acute Thrombolytic Therapy IV tissue
Plasminogen Activator: 0.9 mg/kg (with caution)
Criteria for thrombolysis:
< 3 hrs from onset
CH excluded by imaging
SBP < 185; DBP < 110 mm Hg
Platelets > 100,000
Patient not on anticoagulants, no recent surgery
or GI bleeding
No seizures at onset

SECONDARY PREVENTION OF STROKE
Blood pressure control
Diuretics +/-ACE inhibitors or ARBs, CCBs, BB
Diabetes Management
Smoking Cessation
Alcohol Moderation
Carotid Artery Interventions
Lipid Management (Statins)
Anti platelet agents
Anti coagulants
Diet± Weight Reduction ± Exercise

COMPLICATIONS OF STROKE
Early;
Infection (chest, UTI)
Dysphagia
Constipation/fecal incontinence
DVT
Convulsion
Motor deficits (total or partial)
Spasticity
Late;
Pressure ulcers
Pain; Allodynia, hyperalgesia
Falls/ fracture, Osteoporosis
Contracture
Sexual dysfunction
Sensory alterations – visual, smell, agnosia
Mood disorders – depression, anxiety
Cognitive disorders – dementia, memory impairment
Alteration of ADL

TERTIARY MANAGEMENT OF STROKE
Management of complications
Rehabilitation (social, physical & psychological)

Walking aids; Individual patients may gain confidence from using a walking aid. If walking aids
improve gait, balance, quality of life and independence, or reduce falls, after stroke, they could
provide a cost-effective intervention.
Gait-oriented physical fitness training; should be offered to all patients assessed as medically
stable and functionally safe to participate, when the goal of treatment is to improve functional
ambulation
Electromechanical assisted gait training
Repetitive task training.
Muscle strength training.
7/28/2021 25

COGNITION; Cognitive changes after a stroke may be general (eg slowing of information
processing), or may occur within specific domains (eg orientation, attention, memory,
visuospatial and visuoconstructive, mental flexibility, planning and organisation and language). It
should also be recognised that cognitive impairment may have existed before the stroke.
Cognitive rehabilitation concerns efforts to help patients understand their impairment and to
restore function or to compensate for lost function (eg by teaching strategies) in order to assist
adaptation and facilitate independence.
 VISUAL PROBLEM; There are many visual problems associated with stroke, including visual field
defects, disorders of eye movement and visuospatial neglect.
All stroke patients should be screened for visual problems, and referred appropriately
FP should ensure that patients have and correctly wear their prescribed eyewear.
7/28/2021 26

COMMUNICATION; Aphasia is an acquired multimodal language disorder. It can affect the
person’s ability to talk, write and understand spoken and written language leaving other
cognitive abilities relatively intact. Dysarthria is a motor speech impairment of varying severity
affecting clarity of speech, voice quality and volume, and overall intelligibility.
Aphasic and Dysarthric stroke patients should be referred for speech and language therapy.
NUTRITION AND SWALLOWING; Poor nutritional status post stroke increases the length of
hospital stay and risk of complications, and undernourishment on admission is an independent
marker of poor outcome at six months post stroke.
 Assessment of a patient’s nutritional risk should include an assessment of their ability to eat
independently and a periodic record of their food consumption. Ongoing monitoring of
nutritional status after a stroke should include biochemical measures (ie low pre-albumin,
impaired glucose metabolism),swallowing status, unintentional weight loss, eating assessment
and dependence, nutritional intake.
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Following nutritional screening, those identified as undernourished, and those at risk of
becoming undernourished, should be referred to a dietitian and considered for prescription of
oral nutritional supplements as part of their overall nutritional care plan.
Patients with dysphagia should have an oropharyngeal swallowing rehabilitation program that
includes restorative exercises in addition to compensatory techniques and diet modification
CONTINENCE; Incontinence of urine and feces is dramatically increased following stroke. The
prevalence of urinary incontinence is reported as 40-60% in patients.
Patients should have individualised bowel programmes that are patient-centred and the
assessment should include physical ability, availability of care, social setting, clinical issues,
dietary factors, medications.
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PAIN; Stroke patients are particularly prone to pain, most commonly associated with the
musculoskeletal ramifications of paralysis and immobility, and particularly involving the
hemiplegic shoulder.
In patients with central post-stroke pain unresponsive to standard treatment, and where
clinician and patient are aware of potential side effects, amitriptyline (titrated to a dose of 75
mg) may be considered. If amitriptyline is ineffective, or contraindicated, lamotrigine or
carbamazepine are alternatives although the high incidence of side effects should be
recognised.
POST-STROKE FATIGUE;. Fatigue is significantly associated with limitation in instrumental
activities of daily living but this association is mostly related to associated depression and
severity of the hemiparesis. Fatigue also impacts adversely on health-related quality of life.
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Patients with post-stroke fatigue should be screened for depression.
DISTURBANCES OF MOOD AND EMOTIONAL BEHAVIOUR; Mood disturbance is a very common
problem after stroke, although there is some uncertainty about just how frequent different types of
mood problems are, and about the precise psychosocial and physical factors associated with their
onset.
All stroke patients (including those cared for in primary care) should be screened for mood
disturbance. Appropriate referral to health and clinical psychology services should be considered for
patients and carers to promote good recovery/adaptation and prevent and treat abnormal adaptation
to the consequences of stroke.
SEXUALITY; The effects of stroke, such as motor or sensory impairment, urinary problems, perceptual
alterations, tiredness, anxiety, depression, and changes in self image, self confidence and self worth
can cause sexually-related difficulties. Medication, particularly antihypertensives, can also interfere
with sexual function. The most common fear is that resuming sex may cause another stroke.
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FP should provide advice and information to patients and partners about sexuality and sex after
stroke on an individualised basis.
INFECTIONS; Infections are relatively common during stroke rehabilitation, particularly chest
infection or urinary tract infection while in hospital.
 should recognise, assess, investigate and treat common infections such as chest or urinary
tract infections.
PRESSURE ULCER PREVENTION; With adequate nursing resources and expertise, pressure ulcers
should not develop during immobility after stroke. Risk assessment for pressure sores is a
generic nursing skill and should be a part of routine hospital nursing care and community care.
Guidance on the prevention and management of pressure ulcers is available
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Hospital managers should ensure that nursing expertise, staffing and equipment levels are
sufficient to prevent pressure ulcers. Hospitals should have up-to-date policies on risk
assessment, pressure ulcer prevention and treatment.
VENOUS THROMBOEMBOLISM; Patients at a particularly high risk of early DVT following an
ischaemic stroke (e.g those with a history of previous DVT, known thrombophilia or active
cancer) can be given prophylactic heparin. Low molecular weight heparin (LMWH) is
recommended in preference to unfractionated heparin (UFH).
Anticoagulant therapy in the first two weeks after ischaemic stroke can cause hemorrhagic
stroke or hemorrhagic transformation of the ischemic stroke and has no net benefit. Low dose
aspirin has been shown to be safe and effective in preventing deep vein thrombosis (DVT)and
pulmonary embolism
Early mobilization and good hydration
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FALL; Falls are a common feature for patients after stroke. As some falls can lead to devastating
complications, measures should be taken to minimize the risk of falling.
 Individually prescribed muscle strengthening and balance retraining program, withdrawal of
psychotropic medication and home hazard assessment and modification in people at high risk,
for example with severe visual impairment, have been shown to be of benefit in reducing falls.
RECURRENT STROKE; Recurrent stroke is outside the remit of this guideline as it is included in
Management of patients with stroke or TIA: assessment, investigation, immediate management
and secondary prevention.
7/28/2021 33

BURDEN OF STROKE ON CAREGIVERS
Caregiver of stroke survivors suffers in different form such as physical, psychological, social,
economic and spiritual, especially those with a higher level of disabilities.
Caring for a stroke survivors disrupts the integrity of the families and produces ill effect on the
quality of life of caregivers.
Economic constrains will force many patients to stay at home which creates lots of burden on
caregivers at home which deteriorates quality of life too.
7/28/2021 34

ANTICIPATORY GUIDANCE
Stairs and wells should be blocked to reduce the risk of injuries from falling.
 Cleaning supplies, medications, and other potential poisons need to be stored safely out of
reach of stoke px, preferably in locked cabinets.
Firearms should be stored safely, preferably unloaded and in locked cabinets or safe
Relatives should be counseled on keeping matches and lighters in a safe place out of the reach
of px
All families should be advised to have smoke detectors throughout the home, especially in
rooms where px sleep, and to keep the hot water heater set at or below 120°F to reduce the risk
of scald injuries.
When a pool or hot tub is accessible to px, a nearby telephone with emergency contacts should
beat poolside. All px should have supervision within arm's length at all times.
7/28/2021 35

PROGNOSIS
POOR PROGNOTIC INDICATOR
Hematoma volume/ expansion
Intraventricular hemorrhage
Very low GCS
ICH location (deep)
Age
Infection/ Hyperthermia
Hyperglycemia/Hypoglycemia
Tranformation
PROGNOSIS GENERALLY
25% of patients die after an acute stroke
40% will have moderate to severe impairment
and require special assistance/care
10% of stroke survivors recover completely.
25% recover with minor impairment
15% will experience a 2nd stroke in 5yrs.
7/28/2021 36

THE ROLE OF A FAMILY PHYSCIAN IN THE
MULTIDICIPLINARY MANAGEMENT OF STROKE
Early and accurate diagnosis of stroke
Continuous counselling
Monitoring
Management
Coordination of care
Referral
7/28/2021 37

CONCLUSION
Stroke is an emergency and early diagnosis and treatment with prompt referral is the key to
better outcome and prognosis.
Stroke management in Nigeria is suboptimal due to deficiencies in the provision of diagnostic,
treatment, rehabilitation and support services.
Limited resources, manpower shortage, lack of organized stroke unit, neuro-imaging facilities,
ambulance services, education of patients and their relatives, as well as impracticable use of
thrombolytics are contributory.
7/28/2021 38

REFRENCES
1.www.ninds.nih.gov -- National Institute of Neurological Disorders and Stroke (800-352-9424). Assessed
on 2/7/2020
2. Management of patients with stroke: REDS (Reach Early Discharge Scheme). NHS Evidence, 2012.
[Online] Available at: www.evidence.nhs.uk/ qipp Accessed 03/7/2020.
3. Bugge C, Alexander H, Hagen S (1999) Stroke patients’ informal caregivers. Patient, caregiver and service
factors that affect caregiver strain. Stroke. 30, 8, 1517-1523.
4. Lincoln NB, Francis VM, Lilley SA, Sharma JC, Summerfield M (2003) Evaluation of a stroke family support
organiser. A randomized controlled trial. Stroke. 34, 1, 116-121.
5. Murray J, Young J, Forster A. Review of longer-term problems after a disabling stroke. Rev Clin Gerontol.
2007;17(04):277–292.
7/28/2021 39

Special acknowledgement
DR ABDULLAHI IBRAHIM HARUNA
DR ABDULGAFFAR OLAWUMI LEKAN
DR UMAR TAHIR BOLORI

THANK YOU FOR LISTENING
7/28/2021 41

Family Physician's Role in Managing Stroke Recovery

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