How to Recognise a Stroke or Mini

How to Recognise a Stroke or MiniStroke
31st March 2011
Thomas Walsh, Consultant Stroke Geriatrician
Galway University Hospitals
STROKE & MINI STROKE –
Brain Attack
•Burden of Stroke
•What is a stroke or mini-stroke
•How to recognise a stroke or mini-stroke
•How can we treat stroke or mini-stroke
•Galway Stroke service
BURDEN OF STROKE
 Leading cause of adult disability globally
 2nd leading cause of death worldwide
 Ireland
 8,500 new strokes annually
 35,000 stroke survivors with disability
 West of Ireland
 1200 per year approx
 150 people would be saved from death or
dependency if adequate stroke treatments were
available
OUTCOME OF STROKE
Dead
15%
Major
Disability
10%
Full
Recovery
10%
Minor
Disability
25%
Moderate
Disability
40%
Heart and Stroke Foundation of Alberta, NWT and Nunavut 2007
Stroke
WHAT IS A STROKE?
 Stroke: sudden onset of arm, leg or face
weakness / sensory disturbance on one side of
the body, speech disturbance or vision loss in
one eye lasting more than 24 hours due to a
blocked or burst blood vessel
 Mini-Stroke (TIA): same as above but lasting
less than 24 hours
FAST Test
Assessment - History
Is it a stroke/mini-stroke?
• Onset: usually sudden
• Course: maximal at onset, occasionally evolves over
days
• Location of symptoms: were symptoms localised or
generalised?
• Nature of symptoms: loss of function usually
History
Symptoms unlikely to be mini-stroke or stroke
• Light headedness/ faintness
• ‘Blackouts’ with altered or loss of consciousness or
fainting
• Generalized weakness and/or generalized sensory
disturbance
• Incontinence of urine or faeces
• Episode of confusion
• Drop attacks
Examination
Left facial
droop
Medical management
of acute stroke
• Minimise brain damage - assess patient
suitability for thrombolysis (clot busting
drug)
• Exclude bleed in the brain with CT scan
• Get patient to an Acute Stroke Unit
• Prevent early stroke recurrence
Stroke Thrombolysis
Evolving Stroke
Minimising damage
RESTORATION OF BLOOD FLOW
Intravenous
thrombolytic
drugs can
accelerate
reopening of a
blocked artery
and thus
prevent
destruction of
brain cells
EVIDENCE FOR
THROMBOLYSIS
RESULTS OF 3 Randomised Controlled Trials
• For every 100 patients treated
– 32 will have a better final outcome
– 3 have a worse final outcome
– 65 will be unchanged
AHA Guidelines
ECASS-3 NEJM 2008
Results heavily influenced by time to treatment:
The quicker the better “TIME IS BRAIN”
Given up to 4 and a half hours only
Benefits of Thrombolysis are
time dependent
Current License
ECASS III
IST - 3
odds ratio
Confidence limits
3 hours
Stroke onset to treatment time (minutes)
6 hours
STROKE UNIT
Organised multidisciplinary care in a dedicated
stroke unit reduces the risk
of dependence, mortality, institutionalisation
Dependence: NNT 20
Mortality: NNT 30 Langhorne et al Lancet Neur 2009
WHY?
 Early mobilisation
 Prevention of complications
 Early recognition and treatment of complications
MINI-STROKE
“Brain Attack”
A MEDICAL EMERGENCY
WHAT IS A MINISTROKE (TIA)?
 Mini-Stroke: sudden onset of arm, leg or face
weakness / sensory disturbance on one side of
the body, speech disturbance or vision loss in
one eye lasting less than 24 hours due to a
temporarily blocked blood vessel
Mini-Stroke or TIA
Cumulative risk of stroke after TIA by time
Coull et al 2004 BMJ Feb OXVASC Study
TIMING OF TIA PRECEDING STROKE
35
4 studies
Percentage of patients
30
2416 patients with stroke
25
549 (23%) reported preceding TIA
20
15
10
5
0
0
1
2
3
Neurology 2005; 64: 817-20.
4
5
6
7
Days
8
9
10
11
12
13
14
RAPID TIA ASSESSMENT
Rapid Access Mini Stroke Clinic Study
90-day stroke risk after TIA/Minor Stroke
12
Phase 1
10
Risk of stroke (%)
8
6
p=0.0001
4
2
Phase 2
0
0
10
Lancet 2007; 370:1432-42
20
30
40
Days
50
60
70
80
90
Prevention of Recurrent
Stroke
• Carotid artery operation if relevant artery
narrowed
• Blood thinning drugs
• Atrial fibrillation (irregular heart beat) ?
warfarin
• Blood pressure control
• Cholesterol lowering
• Lifestyle factors
Galway Stroke Service
• Dedicated Acute Stroke Unit – St Rita’s
UCHG May 2010
• 24/7 consultant delivered thrombolysis –
June 2010
• Rapid Access Mini-Stroke clinics (Tues
& Friday)- based in MAU August 2010
• Stroke Rehabilitation ward – Unit 4
MPUH - in progress
Immediate Interventions
 Thrombolysis in selected patients (< 4.5 hrs)
 100% admitted to Acute Stroke Unit within 24 hrs
 Rapid exclusion of Carotid Artery narrowing
 Identification of atrial fibrillation (irregular heart
beat)
 Introduction of aspirin or warfarin (blood thinners)
 Refer to mini-stroke clinic rapidly
FAST Test
Do you feel lucky……?