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All About Strokes
Allan L Bernstein MD
Neurology
Definition of Stroke
Ischemic stroke:
Clot blocks
blood flow
through one
of the arteries
feeding the brain
Definition of Stroke
Hemorrhagic
stroke:
Weakened blood
vessel ruptures
allowing
bleeding into
brain
Definition of Stroke
Deprived of oxygen,
nerve cells in affected
area begin to die.
Body function lost
in part of body
controlled by
ischemic blood cells.
Residual Effects of Stroke
Survivors can be
left with paralysis,
inability to speak,
visual field deficits,
emotional
problems, etc.
Stroke Facts
Approx 50% of
stroke deaths
occur before the
patient reaches
the hospital
Impact of Stroke in the United
States
• Of all CVDs, stroke is the third leading cause of
death
• Annual incidence
– 780,000 strokes
• 600,000 first attacks
• 180,000 recurrent attacks
• 15% of strokes are heralded by TIA
• 90-day risk of stroke after TIA: 3%–17%
– Highest risk within the first 30 days
CVD = cardiovascular disease; MRI = magnetic resonance imaging
American Heart Association. Heart Disease and Stroke Statistics–2008 Update.
Dallas, Texas: American Heart Association; 2008
Rosamond W et al. Circulation. 2008;117(4);e25
Estimates of the Cost of Stroke
Mean lifetime cost
of ischemic stroke
• $140,048
Average cost of ischemic
stroke within 30 days
• $13,019 (mild)
• $20,346 (severe)
$65.5 billion* in 2008
*Estimated direct and indirect costs
American Heart Association. Heart Disease and Stroke Statistics–2008 Update.
Dallas, Texas: American Heart Association; 2008;
Rosamond W et al. Circulation. 2008;117(4);e25
Signs and Symptoms of a Stroke
Sudden numbness
or weakness
in face, arm, or leg
(especially one side
of body)
Signs and Symptoms of a Stroke
Sudden confusion,
trouble speaking
or understanding
Signs and Symptoms of a Stroke
Sudden trouble
seeing in one
or both
eyes
Signs and Symptoms of a Stroke
Sudden trouble
walking, dizziness,
loss of balance
or coordination
Signs and Symptoms of a Stroke
Facial droop
Arm drift
Risk Factors
Hypertension
Hyperlipidemia
Diabetes
Obesity
Smoking
Age
Family History
Atrial Fibrillation
Hx of TIAs
Decreased
physical activity
Acute stroke care
• VERY LIMITED TIME TO ACT
• Four and a half hours from onset of
symptoms to active treatment
• Must be an observed onset
• Must be seen at a facility where acute
stroke care is available
• Sonoma County is excellent for TPA but
has NO COMPREHENSIVE CENTER
“Clot Busting”
• rTPA (tissue plasminogen activator
– Dissolves clots and keeps new ones from
forming for up to 12 hours
– Good but dangerous.
– Brain tissue gets soft
– Other areas may also bleed
Role of a Stroke Center
• Acute care with appropriate access to
specialists
• Ongoing education of the entire stroke
team
• Rapid evaluation by imaging and lab
• Clear guidelines for prevention of
complications
Role of a Stroke Center
• Team approach to ensure safety while in
the hospital
– Prevent blood clots in the legs
– Prevent falls
– Prevent choking or aspiration
– Ensure appropriate control of diabetes and
blood pressure
– Prevent secondary infections
Role of a Stroke Center
Rehabilitation
•
•
•
•
•
•
Motor: physical therapy
Speech: speech and swallowing therapy
Occupational therapy
Depression-identify and plan treatment
Family involvement in all aspects of care
Prevention of next event
Role of a Stroke Center
Preventing the next event
• Discharge planning
– Antiplatelet medication
– Anti cholesterol/lipid medication
– Blood pressure control
– Education re: life style modifications
Risk Factors
Hypertension
Hyperlipidemia
Diabetes
Obesity
Smoking
Age
Family History
Atrial Fibrillation
Hx of TIAs
Decreased
physical activity
Risk Factors for Stroke Recurrence
Early stroke recurrence
Stroke subtype
– High for large artery, extra- and intracranial occlusive disease
• Elevated blood glucose
• HTN
Late stroke recurrence
•
•
•
•
Age
HTN
Heart disease (CHD, HF, AF)
DM and hyperglycemia
Prior stroke or TIA
AF = atrial fibrillation; CHD = coronary heart disease;
DM = diabetes mellitus; HF = heart failure; HTN = hypertension
Sacco RL et al. Neurology. 1999;53(7 suppl 4):S15
Defining Stroke Subtype Is an Important
Consideration in Recurrent Stroke
Prevention
Other
5%
Cryptogenic
30%
Cardiogenic
embolism
20%
Ischemic stroke
88%
Albers GW et al. Chest. 2004;126(3 suppl):438S
Thom T et al. Circulation. 2006;113(6):e85
Hemorrhagic stroke
12%
Atherosclerotic
cerebrovascular
disease
20%
Small vessel
disease
“lacunae”
25%
Recent TIA:
A Neurologic Emergency
• Risk of stroke after TIA
– 10.5% occurred within 90 days and half occurred within
2 days (Kaiser-Permanente HMO study)
• Risks may have been previously underestimated
– 1%─2% at 7 days and 2%─4% at 30 days
• True risk
– Up to 10% at 7 days and as high as 15% at 30 days
• Time window for prevention is brief
– 17% of TIAs occur on the day of stroke
– 43% during the 7 days prior to stroke
Rothwell PM. Nat Clin Pract Neurol. 2006;2(4):174
Prevention of Recurrent Stroke
• Evaluation for risk factors
– HTN, DM, hyperlipidemia
• Evaluation for cause
– Arterial diseases, heart diseases
– Coagulopathies
• Management of risk factors
– Lifestyle and medications
• Antithrombotic therapy
• Surgical or endovascular interventions
Sacco RL et al. Stroke. 2006;37(2):577
Johnston SC et al. Ann Neurol. 2006;60(3):301
Predicting Risk of Stroke After TIA:
ABCD2 Score for 2- or 7-Day Risk of Stroke
A Age
≥60 years
1 point
B Blood pressure
SBP >140 mm Hg or
DBP ≥90 mm Hg
1 point
Unilateral weakness
2 points
C Clinical features
Speech disturbance without
weakness
1 point
Duration of
D
symptoms
≥60 minutes
2 points
10–59 minutes
1 point
D Diabetes
Diabetes
Johnston SC et al. Lancet. 2007;369(9558):283
Rothwell PM et al. Lancet. 2005;366(9479):29
Maximum score
DBP = diastolic blood pressure; SBP = systolic blood pressure
1 point
7 points
National Stroke Association (NSA)
Guidelines for the Management of TIAs
Factor
Comment
Hospitalization
• Consider within 24–48 hours of first TIA
• Timely hospital referral of recent (within 1 week) TIA and hospital
admission is generally recommended in the case of crescendo TIAs,
symptoms longer than
1 hour, symptomatic carotid stenosis >50%, known cardiac-source
embolism, hypercoagulable state, or appropriate California or ABCD score
• Hospitals/practitioners should have local admission policy and referral
policy for specialists’ assessments
• Local written protocols for diagnostic testing
Clinical
evaluation
• Specialized clinic for rapid assessment and evaluation within 24–48 hours
• For recent TIA, need same-day access to imaging such as CT/CTA,
MRI/A, and/or CUS
• If not admitted to hospital, rapid (within 12 hours) access to urgent
assessment and investigation
• If TIA occurred in past 2 weeks and the patient was not hospitalized,
prompt
CT/CTA = computed tomography/computed
tomographic angiography
(24–48 hour) investigations (CUS, blood work, EKG, echocardiogram)
CUS = carotid ultrasound
Johnston SC et al. Ann
Neurol. 2006;60(3):301
needed
Timing of initial
assessment
NSA Guidelines for the
Management of TIAs: Evaluation
Factor
Comment
General
EKG, CBC, serum electrolytes, creatinine, fasting
blood glucose, lipids
Brain imaging
CT/CTA or MRI/A; TCD is complementary
Carotid
imaging
Doppler ultrasound; CTA and/or MRA for supra-aortic
vessels if Doppler not reliable or CEA considered;
conventional angiogram if Doppler and MRA/CTA
discordant or not feasible
Cardiac
evaluation
TTE or TEE in patients younger than 45 years when
neck, brain, and hematology studies negative for
cause
CBC = complete blood count
CEA = carotid endarterectomy
TCD = transcranial Doppler
TEE = transesophageal echocardiogram
TTE = transthoracic echocardiogram
Johnston SC et al. Ann Neurol. 2006;60(3):312