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Stroke and TIA


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Stroke and TIA

  1. 1. NICE Hot TopicsNICE Hot Topics Stroke and TIAStroke and TIA Dr Louise ShawDr Louise Shaw Consultant Stroke PhysicianConsultant Stroke Physician Royal United Hospital, BathRoyal United Hospital, Bath
  2. 2. Now is an exciting timeNow is an exciting time to be working in stroke !to be working in stroke ! National Audit Office Report 2005National Audit Office Report 2005 National Stroke Strategy Dec 2007National Stroke Strategy Dec 2007 Top priority for SW SHA in 2009Top priority for SW SHA in 2009 NICE Stroke Clinical Guideline JulyNICE Stroke Clinical Guideline July 20082008
  3. 3. Why has this happened?Why has this happened?  Stroke = major health problem for UKStroke = major health problem for UK  11% UK deaths11% UK deaths  Significant morbidity in survivorsSignificant morbidity in survivors  Substantial health & resource burdenSubstantial health & resource burden
  4. 4. What does the guidelineWhat does the guideline cover?cover?  Interventions in the acute stage ofInterventions in the acute stage of stroke and TIA: mostly 1stroke and TIA: mostly 1stst 48 hours48 hours  Key areas shown to improve outcome:Key areas shown to improve outcome: – Rapid diagnosisRapid diagnosis – Admission to specialist stroke unitAdmission to specialist stroke unit – Immediate brain imagingImmediate brain imaging – Thrombolysis where indicatedThrombolysis where indicated
  5. 5. NICE and TIANICE and TIA TIA is defined as stroke symptoms andTIA is defined as stroke symptoms and signs that resolve within 24 hourssigns that resolve within 24 hours Rapid assessment for risk ofRapid assessment for risk of subsequent stroke after a TIA allowssubsequent stroke after a TIA allows appropriate treatment to be initiated toappropriate treatment to be initiated to reduce the likelihood of strokereduce the likelihood of stroke occurringoccurring
  6. 6. Patient-centred carePatient-centred care  Stroke has a sudden and oftenStroke has a sudden and often dramatic impact on the person anddramatic impact on the person and their familytheir family  Good communication is essentialGood communication is essential  Patients, their families and carersPatients, their families and carers should all be involved in decisionsshould all be involved in decisions about their treatment and careabout their treatment and care  Consent and capacity issuesConsent and capacity issues
  7. 7. Rapid recognition ofRapid recognition of symptoms and diagnosissymptoms and diagnosis  Outside hospital use FASTOutside hospital use FAST  Exclude hypoglycaemia as cause ofExclude hypoglycaemia as cause of sudden-onset neurological symptomssudden-onset neurological symptoms  In ED, establish the diagnosis rapidlyIn ED, establish the diagnosis rapidly using a validated tool eg ROSIERusing a validated tool eg ROSIER (Recognition Of Stroke In Emergency(Recognition Of Stroke In Emergency Room)Room)
  8. 8. Emergency treatment forEmergency treatment for Acute StrokeAcute Stroke  Admit anyone with suspected strokeAdmit anyone with suspected stroke directly to a specialist acute stroke unitdirectly to a specialist acute stroke unit after assessment from either theafter assessment from either the community or EDcommunity or ED  i.e. Direct Admissions to ASUi.e. Direct Admissions to ASU
  9. 9. Emergency treatmentEmergency treatment componentscomponents  Confirm diagnosisConfirm diagnosis  Immediate or within 24 hours imagingImmediate or within 24 hours imaging  Thrombolysis if indicatedThrombolysis if indicated  Early mobilisationEarly mobilisation  Swallow managementSwallow management  Aspirin unless C/IAspirin unless C/I  Malnutrition screenMalnutrition screen
  10. 10. Immediate brain imagingImmediate brain imaging  For thrombolysis/early anticoagulationFor thrombolysis/early anticoagulation  On anticoagulantsOn anticoagulants  Known bleeding tendencyKnown bleeding tendency  Depressed LOC (GCS<13)Depressed LOC (GCS<13)  Unexplained progressive/fluctuatingUnexplained progressive/fluctuating symptomssymptoms  Papilloedema, neck stiffness or feverPapilloedema, neck stiffness or fever  Severe headache at onset of symptomsSevere headache at onset of symptoms
  11. 11. Rationale forRationale for Thrombolysis (I)Thrombolysis (I)  Occlusion of a cerebral artery leads to anOcclusion of a cerebral artery leads to an immediate drop in blood flowimmediate drop in blood flow  Effect depends on site and size of theEffect depends on site and size of the occlusion, and collateral circulationocclusion, and collateral circulation  If flow is reduced to 20ml/100g/min (40% ofIf flow is reduced to 20ml/100g/min (40% of normal value), neuro. symptoms occurnormal value), neuro. symptoms occur  Flow below 10ml/100g/min causes infarctFlow below 10ml/100g/min causes infarct  Brain tissue with flow 10-20ml/100g/minBrain tissue with flow 10-20ml/100g/min may survive a few hours but then diesmay survive a few hours but then dies unless flow is re-establishedunless flow is re-established
  12. 12. Rationale forRationale for Thrombolysis (II)Thrombolysis (II)  Spontaneous reperfusion may occurSpontaneous reperfusion may occur through endogenous release ofthrough endogenous release of plasminogen activatorplasminogen activator  For larger occlusions this is insufficientFor larger occlusions this is insufficient to induce reperfusion in timeto induce reperfusion in time  rt-PA administration via ivi enhancesrt-PA administration via ivi enhances this endogenous procedurethis endogenous procedure
  13. 13. Thrombolytic therapy forThrombolytic therapy for acute ischaemic strokeacute ischaemic stroke  rt-PA (alteplase) is licensed for use inrt-PA (alteplase) is licensed for use in UKUK  0.9mg/kg body weight (max 90mg)0.9mg/kg body weight (max 90mg) infused over 1 hour with 10% of totalinfused over 1 hour with 10% of total dose administered as an i.v. bolusdose administered as an i.v. bolus  Patients must be assessed andPatients must be assessed and treated within 3 hours of onset oftreated within 3 hours of onset of acute ischaemic strokeacute ischaemic stroke
  14. 14. Causes of Ischaemic Stroke
  15. 15. HistoryHistory  First attemptFirst attempt – Sussman BJ, Fitch TSP. Thrombolysis withSussman BJ, Fitch TSP. Thrombolysis with fibrinolysin in cerebral arterial occlusion.fibrinolysin in cerebral arterial occlusion.  JAMA 1958;167:1705-1709. JAMA 1958;167:1705-1709.   First human trials 1993First human trials 1993 – Japan (Mori E) 31 pts <6hrsJapan (Mori E) 31 pts <6hrs – USA (Haley E) 27 pts < 90minsUSA (Haley E) 27 pts < 90mins  First human RCT publishedFirst human RCT published – USA NINDS 333 pts <3hrsUSA NINDS 333 pts <3hrs
  16. 16. NINDS Trial Study DesignNINDS Trial Study Design  624 acute stroke patients randomized to624 acute stroke patients randomized to treatment with t-PA/placebo stratified ontreatment with t-PA/placebo stratified on centre and time from symptom onset tocentre and time from symptom onset to treatment (0-90 & 91-180 minutes)treatment (0-90 & 91-180 minutes)  Favorable outcome defined asFavorable outcome defined as normal/near normal @ 90 days using:normal/near normal @ 90 days using: Barthel Index, Rankin Scale, GCS & NIHSSBarthel Index, Rankin Scale, GCS & NIHSS
  17. 17. Risk of death dependency and goodRisk of death dependency and good functional outcome in randomised trialsfunctional outcome in randomised trials of rt-PA given within 3 hours of acuteof rt-PA given within 3 hours of acute strokestroke 17.3 18.4 36.4 51.4 44.3 30.2 0% 20% 40% 60% 80% 100% Thrombolysis Control Alive and independant alive but dependant Dead Cochrane September 1999
  18. 18. Other statisticsOther statistics  NNT 3.1 NNH 30.1NNT 3.1 NNH 30.1 – 10 times more likely to help than harm10 times more likely to help than harm  30% more likely to recover with no30% more likely to recover with no disabilitydisability  Rx 16 to prevent ‘poor outcome’Rx 16 to prevent ‘poor outcome’  Providing follow strict Rx criteria!Providing follow strict Rx criteria!
  19. 19. Favorable Outcome vsFavorable Outcome vs OnsetOnset
  20. 20. The New EnglandThe New England Journal MedicineJournal Medicine 20082008 Thrombolysis with Alteplase 3 toThrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic4.5 Hours after Acute Ischemic StrokeStroke ECASS InvestigatorsECASS Investigators
  21. 21. ECASS III ResultsECASS III Results  821 patients821 patients  Median time to Rx = 3hrs 59minutesMedian time to Rx = 3hrs 59minutes  Favourable outcome 52% v 45%Favourable outcome 52% v 45%  No significant difference in mortalityNo significant difference in mortality  Any I/C haemorrhage 27% v 17%Any I/C haemorrhage 27% v 17%  Clinically significant haemorrhage inClinically significant haemorrhage in 2.4% v 0.2%2.4% v 0.2%
  22. 22. What is in the pipeline?What is in the pipeline?  Intra-cerebral arterial workIntra-cerebral arterial work – Direct perfusion low dose alteplase intoDirect perfusion low dose alteplase into occluded arteryoccluded artery – Retrieval of the clot with cage/aspirationRetrieval of the clot with cage/aspiration +/- low dose alteplase+/- low dose alteplase – Stenting +/- low dose alteplaseStenting +/- low dose alteplase – Angioplasty +/- low dose alteplaseAngioplasty +/- low dose alteplase – Ultrasound/laser thrombolysis +/- lowUltrasound/laser thrombolysis +/- low dose alteplasedose alteplase
  23. 23. Developments inDevelopments in imagingimaging  MRI diagnostic tool for differentiatingMRI diagnostic tool for differentiating salvageable versus irreversiblysalvageable versus irreversibly damaged brain tissuedamaged brain tissue
  24. 24. MRI DWI PWI Better Patient Selection by Dynamic MRI? 2.5 hours after onset, NIHSS 15
  25. 25. MRI DWI PWI Better Patient Selection by Dynamic MRI? at 24 h, NIHSS 5
  26. 26.  Cerebral embolectomyCerebral embolectomy successful recanalisation insuccessful recanalisation in 69 /141 (48%)69 /141 (48%)  In combination with rtPA inIn combination with rtPA in 17 cases17 cases  Procedural complicationsProcedural complications 7.1%7.1%  Could extend time windowCould extend time window to 8 hoursto 8 hours Mechanical clot retrievalMechanical clot retrieval The MERCI TrialThe MERCI Trial
  27. 27. Patients treated at RUHPatients treated at RUH  15 patients since June 200815 patients since June 2008  12 men 3 women12 men 3 women  Age range 46 (x2) to 77Age range 46 (x2) to 77  Average age 62Average age 62
  28. 28. RUH Patient OutcomesRUH Patient Outcomes  5 patients discharged fully recovered5 patients discharged fully recovered  6 patients discharged with mild6 patients discharged with mild residual neurological deficitresidual neurological deficit  2 patients still inpatients with2 patients still inpatients with moderate-severe disabilitymoderate-severe disability  2 patients died: 1 following2 patients died: 1 following hemicraniectomy (not related to Rx)hemicraniectomy (not related to Rx)
  29. 29. RUH Patient OutcomesRUH Patient Outcomes  3 patients treated outside 3 hour3 patients treated outside 3 hour window: 2 poor outcome, 1 goodwindow: 2 poor outcome, 1 good  No patients with haemorrhage onNo patients with haemorrhage on repeat CT at 24 hoursrepeat CT at 24 hours
  30. 30. First patient!First patient!  66yrs male66yrs male  Previously F&WPreviously F&W  Sudden onset right hemiparesis 14:30Sudden onset right hemiparesis 14:30  Arrived ED 16:15Arrived ED 16:15  Dysphasia and dysarthriaDysphasia and dysarthria  NIHSS 7NIHSS 7  CT scan 16:30 early L parietal infarctCT scan 16:30 early L parietal infarct
  31. 31. 11stst patient outcomepatient outcome  Thrombolysed 16:55Thrombolysed 16:55  Door to needle time 40minsDoor to needle time 40mins  Symptoms to needle time 2hrs 25 minSymptoms to needle time 2hrs 25 min  45 min into treatment: speech45 min into treatment: speech improved, facial palsy improvedimproved, facial palsy improved  Then said “look I can lift my arm”Then said “look I can lift my arm”  NIHSS @ 2hrs = 2: at 24 hours = 0NIHSS @ 2hrs = 2: at 24 hours = 0
  32. 32. A story of 2 halvesA story of 2 halves  18 Nov 2008: two 46 yr old men18 Nov 2008: two 46 yr old men admitted same morning with strokeadmitted same morning with stroke  The 1The 1stst , NH had symptoms at 07:15, NH had symptoms at 07:15  Arrived RUH 08:39Arrived RUH 08:39  Dense hemi, sensory loss, aphasiaDense hemi, sensory loss, aphasia  NIHSS 18NIHSS 18  CT scan 08:54 showed hyperdense LCT scan 08:54 showed hyperdense L MCA and loss of insular ribbon on LMCA and loss of insular ribbon on L
  33. 33. NH outcomeNH outcome  Thrombolysed at 09:50Thrombolysed at 09:50  Symptoms to needle time 2hr 35 minSymptoms to needle time 2hr 35 min  Gradual but striking improvement overGradual but striking improvement over next few daysnext few days  NIHSS at 7 days = 2NIHSS at 7 days = 2  Discharged at 1 week: independentlyDischarged at 1 week: independently mobile, still moderate dysphasiamobile, still moderate dysphasia
  34. 34. The other 46 year oldThe other 46 year old  Symptoms at 08:00Symptoms at 08:00  Arrived ED 10:43Arrived ED 10:43  Dense left hemiparesisDense left hemiparesis  CT 10:50 normal:CT 10:50 normal:
  35. 35. RL outcomeRL outcome  No family: time to clarify story withNo family: time to clarify story with boss from workboss from work  Thrombolysed at 11:30Thrombolysed at 11:30  No change following treatmentNo change following treatment  CT at 24 hours shows R MCA infarct,CT at 24 hours shows R MCA infarct, but no post-thrombolysis haemorrhagebut no post-thrombolysis haemorrhage
  36. 36. RL outcome (2)RL outcome (2)  48 hours after admission rapid48 hours after admission rapid deteriorationdeterioration  Deteriorating GCS, dilated pupilDeteriorating GCS, dilated pupil  Repeat CT showed malignant R MCARepeat CT showed malignant R MCA infarct with significant oedema, massinfarct with significant oedema, mass effect, prominent midline shift to left:effect, prominent midline shift to left:
  37. 37. RL outcome (3)RL outcome (3)  Ventilated and transferred to FrenchayVentilated and transferred to Frenchay  Emergency hemicraniectomyEmergency hemicraniectomy  Deteriorated and diedDeteriorated and died
  38. 38. One last example SFOne last example SF  51 female SALT on holiday in Bath51 female SALT on holiday in Bath from Sussex, Sat 2 Mayfrom Sussex, Sat 2 May  normally fit and well except migrainenormally fit and well except migraine  Dysphasia, dysarthria, R hemiparesisDysphasia, dysarthria, R hemiparesis  NIHSS 11: treated at 4 hoursNIHSS 11: treated at 4 hours  CT scan early subtle left MCA infarctCT scan early subtle left MCA infarct  NIHSS at 2 hours =6: 24 hours =5NIHSS at 2 hours =6: 24 hours =5  Today: mild arm weakness/modToday: mild arm weakness/mod
  39. 39. “I’m very lucky; I could have been in hospital for a long time or not made a recovery. “The paramedics and doctors who treated me were excellent and the ‘miracle drug’ helped me make a full recovery. “Hopefully, I’ll continue leading a normal life. I’m a fit and active person, so it’s wonderful that I can continue walking and cycling. “Having a stroke is a terrible thing to go through. I was aware of what was going on, but couldn’t do anything about it.”
  40. 40. TIATIA  Start daily aspirin 300mg immediatelyStart daily aspirin 300mg immediately  Other secondary prevention as soonOther secondary prevention as soon as diagnosis is confirmedas diagnosis is confirmed  Discuss individual risk factorsDiscuss individual risk factors  Assess subsequent stroke risk ABCD2Assess subsequent stroke risk ABCD2  Use DWMRI not CT for imagingUse DWMRI not CT for imaging
  41. 41. ABCD2 (max score 7)ABCD2 (max score 7)  AgeAge >60>60 1 point; <60 0 points1 point; <60 0 points  BPBP >140/85 1 point>140/85 1 point  Clinical featuresClinical features – unilateral weakness 2 pointsunilateral weakness 2 points – speech disturbance 1 pointspeech disturbance 1 point – other (eg amaurosis) 0 pointsother (eg amaurosis) 0 points  Duration of symptomsDuration of symptoms – >60 min 2 points; 10-60 1 point>60 min 2 points; 10-60 1 point  Diabetes 1 point
  42. 42. High risk TIAHigh risk TIA  ABCD2 > or = 4ABCD2 > or = 4  2 or more TIAs in 1 week2 or more TIAs in 1 week  Specialist assessment within 24 hoursSpecialist assessment within 24 hours of symptom onsetof symptom onset  Urgent brain imaging if vascularUrgent brain imaging if vascular territory or pathology uncertainterritory or pathology uncertain
  43. 43. Lower risk TIALower risk TIA  ABCD2 of 3 or belowABCD2 of 3 or below  presenting > 1 week after symptomspresenting > 1 week after symptoms have resolvedhave resolved  Specialist assessment within 1 weekSpecialist assessment within 1 week  Brain imaging (non-urgent) if vascularBrain imaging (non-urgent) if vascular territory/pathology uncertainterritory/pathology uncertain
  44. 44. Carotid imaging and TIACarotid imaging and TIA or non-disabling strokeor non-disabling stroke  Carotid imaging within 1 week ofCarotid imaging within 1 week of symptom onsetsymptom onset  >70% symptomatic stenosis refer for>70% symptomatic stenosis refer for carotid endarterectomy (CEA) within 1carotid endarterectomy (CEA) within 1 week of symptom onsetweek of symptom onset  Perform CEA within 2 weeksPerform CEA within 2 weeks  < 70% stenosis offer best medical< 70% stenosis offer best medical treatmenttreatment
  45. 45. RUH rapid access TIARUH rapid access TIA clinicclinic  Now runs 4 or 5 days a weekNow runs 4 or 5 days a week  3-6 slots a day3-6 slots a day  same day carotid/CT imaging, ECGsame day carotid/CT imaging, ECG  usually sees patients within 1 weekusually sees patients within 1 week  new pathway required for high-risk TIAnew pathway required for high-risk TIA patientspatients  Fax referrals on TIA clinic formFax referrals on TIA clinic form
  46. 46. What’s afoot in RUH?What’s afoot in RUH?  New stroke unit opening march 2010New stroke unit opening march 2010  7 hyperacute beds7 hyperacute beds  43 acute stroke and neurology beds43 acute stroke and neurology beds  direct admission to hyper-acute areadirect admission to hyper-acute area  intensive physiological monitoringintensive physiological monitoring  rolling out thrombolysis 24/7rolling out thrombolysis 24/7  improved staffing levelsimproved staffing levels
  47. 47. What’s afoot in BANESWhat’s afoot in BANES PCT?PCT?  New Community Stroke Team rollingNew Community Stroke Team rolling out for early supported discharge andout for early supported discharge and long term follow uplong term follow up  FAST training for surgery staffFAST training for surgery staff  local advertising campaignlocal advertising campaign  BANES GP stroke/TIA standardsBANES GP stroke/TIA standards  AF auditAF audit