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Stroke

Heart attack Arrhythmias Heart failure Valvular disease

Everything you ever wanted to know about stroke (but were afraid to ask)
Timothy Lukovits, M.D.

Objectives

Highlight some important differences and similarities between heart attack and stroke Motivate you to prevent a stroke

How is a stroke different from a heart attack?

A stroke is a sudden neurological deficit caused by a blood vessel problem 2 types

Ischemic strokes Hemorrhagic strokes

The effects of a stroke are extremely varied

Why is heart attack easier to recognize than stroke ?

Painful
Public and health care providers commonly recognize symptoms and need for action

Often painless the stroke itself often affects awareness of symptoms Poor recognition of symptoms and need for action

Respondents unable to name 1 warning sign or risk factor for stroke

Pancioli, A. M. et al. JAMA 1998;279:1288-1292.

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Which of the following are warning signs of stroke?

A.

Sudden weakness or numbness of the face, arm or leg, especially on one side of the body
Sudden confusion, trouble speaking or understanding

B.

C.
D. E.

Sudden chest pain

Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause

F.

A.

Sudden weakness or numbness of the face, arm or leg, especially on one side of the body

B.

Sudden confusion, trouble speaking or understanding

Sudden chest pain

C.

D.
E.

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination

F.

Sudden, severe headache with no known cause

Is heart attack easier to diagnose than stroke?

Diagnosis is relatively easy. EKG and cardiac enzymes readily available.

Diagnosis is difficult. Many things can mimic stroke. There is no blood test for stroke. MRI not readily available.

MRI with diffusion weighted imaging

Isolated weakness right index finger

JS Kim, Neurology, 2002

Where is the stroke?

CT scan of arteries of neck and head

Are the causes of heart attack and stroke different?

Cause is usually rupture of a plaque within a coronary artery So the diagnostic and treatment strategy is fairly straightforward (find the blockage and open it up!)

Atherosclerosis is important, but there are many other causes Determining the cause in an individual is often a deductive process

There are many potential causes of stroke

Stroke is not just a brain disease and often the brain is just an innocent bystander

Usually caused by diseases that are affect the entire vascular system (atherosclerosis) Material blocking brain arteries usually comes from outside the brain (atrial fibrillation, carotid artery disease)

How is a Cardiologist different than a Neurologist

Basically a plumber or electrician

Diagnostician Detective Daredevil

Case

Healthy 61 year-old man developed confused speech 1 day after falling out of a tree. August 11th, topping a tree, fell and sustained a left collar bone fracture and small puncture of the lung. Next night suddenly developed confused speech.

Trauma (fall out of a tree) Vascular problem (leg vein injury) Blood disorder (hypercoagulability) Congenital heart anomaly (patent foramen ovale)

How are heart attack and stroke SIMILAR?

Time is critical The first priority is to save tissue at risk

Kidwell 2004

You need to call 911 ASAP for both heart attack and stroke!

There is a 3 hour time limit for the medication t-PA, and the sooner its given the better! Future strokes may be prevented if we identify the cause of stroke ASAP People brought by ambulance are treated faster Neurological deterioration and other complications may be prevented if a patient is hospitalized earlier

June 2006 7AM: A 75 year-old woman collapsed at home, brought to her local emergency room. She cannot move her right side or speak. The doctors there are not comfortable using t-PA so transfer to DHMC is requested. 1:02 PM: Arrival DHMC ED.

4:49 PM artery is opened

The system needs to be very coordinated

PREPARED

RAPID EVALUATION

Improving Stroke Care at DHMC

INDIVIDUALIZED CARE

A TEAM APPROACH

PROTOCOLS TO DECREASE ERRORS

Ways everyone here can prevent a stroke

Identify and control risk factors If a warning sign of stroke occurs, get attention

10y risk 88% !

10y risk 13% !

Preventing a heart attack or stroke is MUCH more effective (and safer) than a procedure!

The medical and surgical 5-year Kaplan-Meier curves of freedom from ipsilateral stroke and perioperative stroke and death indicate a 5.9% difference favoring endarterectomy at 5 years in the Asymptomatic Carotid Atherosclerosis Study (ACAS)

Barnett, H. J. M. et al. Arch Neurol 2000;57:40-45.

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Kaplan-Meier 5-year risks of ipsilateral ischemic stroke for NASCET patients according to gender and degree of internal carotid artery stenosis in the medical and surgical groups

Alamowitch, S. et al. Stroke 2005;36:27-31

Copyright 2005 American Heart Association

2004: 144 pts Rx t-PA 50% had t-PA started at 1 of 47 referring hospitals >50% of these have <60 beds

MGH TeleStroke

Effectiveness of Stroke Prevention Absolute risk reduction in a year:

Strategy

ARR (%)
8 4 2 2 2 1-2

Warfarin for atrial fibrillation Carotid endarterctomy for symptomatic dz Smoking cessation Antihypertensive therapy if BP elevated Cholesterol lowering medications Aspirin

Schaebitz W-R, 2000

anticoag

Stroke Diagnosis 40 years ago

Stroke Warning Signs

Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination

Sudden, severe headache with no known cause

What is a TIA ?

Transient Ischemic Attack=Stroke symptoms that resolve with a short time. Can be a warning sign of impending stroke. The highest risk period of stroke following a TIA is the first 2 weeks. The risk of stroke soon after a TIA can now be estimated.

Risk of stroke following TIA A Age> or = 60 1

ABCD2 Tool

B
C

Blood pressure >140/90

Clinical features unilateral weakness

1
2

speech impairment
D2 Duration > 60 min 10-59 min Diabetes

1
2 1 1

30

Estimated 10-Year Rate (%)

27 22.4 Men W omen 14.8 19.1

25 20 15 10 5 0 2.6 4 1.1 2 5.4 3.5 8.4 6.3

B
A 95-105 No No No No B 130-148 No No No No

C
C 130-148 Yes No No No

D
D 130-148 Yes Yes No No

E
E 130-148 Yes Yes Yes No

F
F 130-148 Yes Yes Yes Yes

Systolic BP* Diabetes Cigarettes Prior Atrial Fib. Prior CVD

*BP in millimeters of mercury (mmHg)

Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS).

Which action would you take if you thought someone was having a heart or stroke?
A. B. C. D. E.

take the person a hospital advise the person to call a doctor call 911 call a spouse or family member do something else

Which action would you take if you thought someone was having a heart or stroke?
A. B. C. D. E.

Take the person a hospital Advise the person to call a doctor Call 911 Call a spouse or family member Do something else

Bleeding into the heart doesnt occur

Brain hemorrhage is common

CT scan: ischemic stroke

Intracerebral hemorrhage at 1 hour and 6 hours

Intra-arterial thrombolysis Time window=6 hours

You need to open the artery

Like with heart disease, the treatment and prevention of stroke needs to be individualized!

A 65 yo man attends a vascular disease prevention fair and an ultrasound shows a blockage of his left carotid artery. He is told to speak to his doctor ASAP and he becomes worried that there is a time bomb ticking in his neck.