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Neurogenic pain and depression

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Neurogenic pain and depression

  1. 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
  2. 2. Cerebrovascular Emergencies Is survival a mere stroke of Luck?“My Opinions are founded on knowledge but modified by experience”
  3. 3. Every minute matters: ‘time is brain’ Expert is one who think to his chosen mode of ignorance
  4. 4. 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
  5. 5. 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 year2CVD 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
  6. 6. 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
  7. 7. Indian scenario 1880 death / day due to stroke in IndiaEqual to 6 Boeings 737 crashes every day
  8. 8. 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
  9. 9. 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
  10. 10. ComparisonUSA – stroke mortality decline since 1940’sIndia likely to increase– Increase life expectancy (aging population)– Urbanization
  11. 11. Acute stroke interventions – reasonable evidence Stroke units Aspirin Thrombolysis Heparin
  12. 12. Stroke Vascular event due to atherosclerosis Relevant to all of us Neurologists Cardiologists Physicians
  13. 13. Stroke disability worldwide  Limb weakness – 77%  Urinary disturbance – 48%  Dysphagia – 45%  Cognitive deficit – 44%35% functionally dependent at 1 year
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. New role of doctors“Managers of Change”“Preventors of Change”(Health ill health)
  18. 18. Global 15 million deaths globallyevery year due to vascular disease (30% of all deaths)
  19. 19. Global By 2020 – stroke and myocardialinfarction will constitute leading cause of death / disability
  20. 20. 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
  21. 21. 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
  22. 22. Guidelines for 24 hrs – MandatoryLevel of EvidenceLevel A: Based on RCT or Meta analysis of RCTLevel B: Based on Robust Experiment or Observation StudiesLevel C: Based on Expert opinion.“The True Art of Memory is The Art of Attention” - S.Johnson
  23. 23. 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
  24. 24.  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 presentThrough Action You Create your Own Education - D.B. ELLIS
  25. 25.  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
  26. 26.  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
  27. 27.  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
  28. 28.  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
  29. 29.  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
  30. 30.  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
  31. 31.  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
  32. 32.  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 - BleedingDiscipline Weighs ounces; Regret weighs Tons
  33. 33.  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
  34. 34.  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 benefitsMany Ideas grow better when transplanted into another mind than in the one where they sprang UP O.W. Holmos
  35. 35.  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
  36. 36.  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
  37. 37.  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
  38. 38. 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” -
  39. 39.  Thrombolysis (A)  Warlow 1997 - Uncertain clinical benefit  2004 – NINDS – Thrombolysis conclusively proved its efficacy – first 3 hrsWhen they tell you to grow up, they mean stop growing Piccaso
  40. 40.  Guideline 20: (I) Hemorrhage – Hankey and hon 1997: Supra tentorial evacuation for ICH is controversial - Avoid – Infra tentorial - Yes – Main Indication - Deteriorating or depressed consciousnessA (Neurologist’s) life is like a piece of paper on which everyone who passes by leaves an impression - Chines proverb
  41. 41. 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 final3 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 prognosisA medical school should not be a preparation for life. A school should be life
  42. 42. 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 stokeThree can be seen in the divisions of a human in mind, body and spirit
  43. 43. 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”
  44. 44. 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
  45. 45. 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”
  46. 46. STOKE MYTHOLOGY GENERAL MYTHS DIAGNOSTIC MYTHS THERAPEUTIC MYTHS Serious, sincere, systematic study surely secures supreme success
  47. 47. GENERAL MYTHS PHYSICIAN+ MRI = NEUROLOGIST MINISTROKE CHAOTIC CVA COMMUNICATION Discipline Weighs ounces Regret weighs Tons
  48. 48. 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
  49. 49. Ultrasound DiagnosisIn 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
  50. 50. UCLA Stroke CT ProtocolsSequence 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
  51. 51. 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
  52. 52. UCLA Stroke MRI ProtocolsSequence 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
  53. 53. 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
  54. 54. Other Diagnostic Tools -2Radionuclide SPECT Scanning1PET Scanning2Transesophageal 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.
  55. 55. 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
  56. 56. Thrombolysis in acute strokeDead/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
  57. 57. NINDS ConsensusDoor to MD evaluation 10 minDoor to CT completion 25 minDoor to CT read 45 minDoor to treatment 60 minAccess to neurological expertise 15 minAccess to neurosurgical expertise 2 hrsAdmit to monitored bed 3 hrs Memory, Pity and Beauty are short lived in life; But tinged with emotion persist in life
  58. 58. CONCLUSION • MYTHS • PITFALLS • PROGNOSTIC PEARLSIt is the disease of not listening, the malady of not marking, that I am troubled withal - Shakespeare
  59. 59. 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
  60. 60. Where are we ……? Call Stroke onset emergency Secondary prevention services Full recovery U RS Activated (15 minutes) Neuroprotective drug infusedDrugs 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
  61. 61. Dedicated to my family formaking everything worthwhile

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