Transcript Acute Stroke Diagnosis: science and art

What neurologist may add to
the care and cure of of stroke
patients, or…
What is the place of the neurologist in stroke
medicine?
Peter Sandercock
Perugia December
2007
In America…to perform many
expensive investigations?
In the UK…to
diagnose a rare
cause of stroke
by clinical
examination?
Role of neurologist in acute
phase of stroke
Acute care: the neurologist will often be
involved at all points in the ‘path of acute care’
Acute brain attack
If neurologist finds NO clinical evidence of
‘stroke mimic’, e.g.: epileptic seizure,
migraine, Hypo- orhyper-glycaemia, or other
obvious non-stroke diagnosis -> do CT
Non-stroke pathology
CT/MR Scan
Subdural, tumour
Scan: Normal, Infarct,
intracerebral bleed,
SAH
NIHSS helps distinguish ‘stroke’ from ‘nonstroke mimic’
NIHSS and ‘stroke’
vs ‘not stroke’
• About one third of patients with
NIHSS 1-4 do not have an acute
stroke
• NIHSS > 4 is a useful indicator that
the deficit is due to a stroke
If CT or MR excludes blood and ‘stroke
mimic’ neurologist decides
Probably ELIGIBLE for thrombolysis’
• Known time of onset
• Unilateral neurological signs
• Increasing NIH score (>4)
• Abnormal vascular signs (AF, PVD)
Probably NOT ELIGIBLE
• Deficit first noted on waking from sleep
• Prior cognitive impairment
• Loss of consciousness at/soon after onset
• Seizure
• Can walk now ( too mild)
Some clinical problems, where
neurologist very helpful
? POCI
• Man 75 years, arrives
at ER 3.5 hrs after,
sudden onset
‘dizziness’ and
unsteadiness
• Exam: Unsteady when
standing
• No limb ataxia
• NIHSS = 2
• ? POCI
?Hyper-attenuating
basilar artery?
What to do?
• MR and angiography not available
• ‘Outside 3 hour window’: iv thrombolysis
not approved
• If this is a basilar thrombosis, could he
deteriorate rapidly if not treated?
• Randomised in IST-3
Migraine or ischaemic stroke?
This 53-year-old female patient with acute headache and right-sided
hemianopia. Not treated with thrombolysis, because significance of
abnormality not appreciated
Krings et al, Stroke. 2006;37:399-403.)
Initial CT (A to C) show a hyperattenuating
posterior cerebral artery (arrow in B). On followup (D to F), a large PCA infarction is now visible.
Subarachnoid haemorrhage with focal deficit
(eg hemiparesis) due to delayed cerebral
ischaemia
Blood on CT can be
a) missed if not looked for
carefully
b) Have disappeared if the
patient presents a day or
more after the
haemorrhage
Patient has clinical diagnosis of ‘acute
stroke’ but CT is normal.
Can you diagnose ‘acute ischaemic
stroke suitable for thrombolysis’ without
DWI MR? Yes, if:
• The time of onset of stroke symptoms is known
precisely
• You have an experienced stroke physician/stroke
neurologist able to see the patient urgently in
A&E or at CT scan room
• Urgent non-contrast CT scan is interpreted by
someone with expertise in acute stroke CT
• -> MRI not essential; its place in routine acute
stroke care yet to be determined
‘Telephone neurology’ in acute stroke
to patient / family: confirm diagnosis, seek
consent. Neurologist to general physician: advice,
IST-3 helpline
Role in prevention
Neurologists and ‘dizzy turns’
• a 50 year old woman (depressed, just
started on anti-depressant) has an episode
where speech is ‘dizzy and confused’.
• At emergency department: BP 180/90.
Normal examination.
• diagnosis ‘?reaction to anti-depressant;’
• Management ‘stop drug and go home’, but
does refer neurologist
Neurologist asks about other symptoms: the
day before she describes a brief episode of
loss of vision in the left eye (amaurosis
fugax).
The correct diagnosis
• An ocular and a cerebral TIA in
the distribution of the left internal
carotid artery
• High early risk of stroke
• Immediate action required
High early risk of stroke after TIA
Risk of stroke (%)
14
OXVASC
OCSP
12
10
8
6
10% risk of stroke by 7
days
4
2
0
0
Lancet 2005; 366: 29-36
7
14
Days
21
28
Management
• Start dual antiplatelet therapy, statin and
anti-hypertensive immediately
• Immediate carotid ultrasound study often performed by neurologist
Overall, 62% of patients referred with
‘TIA’ were found to have other
diagnoses
migraine
syncope/pre-syncope
‘funny turn’ (= event it is not possible to
categorise)
vertigo or dizziness only
epilepsy
transient global amnesia
cerebral tumour
Oxfordshire Community Stroke Project: of 542 patients referred
with possible TIAs, in 317 (62%) the diagnosis was not a TIA
Neurologist organises management of
TIA and minor stroke
• Urgent brain imaging if symptoms persist > 1-2
hours
• high ABCD2 score, ?admit to hospital for treatment
& investigation
• Aspirin
• Add dipyridamole in high-risk cases
• Statin to lower cholesterol
• Blood pressure lowering: diuretic and angiotensin
converting enzyme (ACE) inhibitor
• Urgent non-invasive carotid imaging ->
endarterectomy < 2 weeks if severe stenosis
Role of
neurologist
in care of
stroke
patients?
The neurologist is often the leader of
the multi-disciplinary team on the
stroke unit
Research led by neurologists
identified effective stroke
treatments
• Treatment acute ischaemic stroke
– Aspirin,
– Thrombolysis
• Prevention
– Anticoagulants in AF
– Antiplatelet for secondary prevention after
TIA/stroke
– Carotid surgery for symptomatic stenosis
The neurologist has many
roles in cure and care of stroke
• Diagnosis of in acute phase
• Management in the acute phase
• Lead multidisciplinary team on stroke
unit
• Co-ordinate stroke services, including
secondary prevention
• Lead research