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NeurologyNeurology

Migraine ALSMigraine ALS

Parkinson’s HeadacheParkinson’s Headache

Seizures NeuropathySeizures Neuropathy

CardiologyCardiology

StrokeStrokeHeart attack ArrhythmiasHeart attack Arrhythmias

Heart failure Valvular Heart failure Valvular diseasedisease

Everything you ever wanted

to know about stroke

(but were afraid to ask)

Timothy Lukovits, M.D.Timothy Lukovits, M.D.

ObjectivesObjectives

Highlight some important differences Highlight some important differences and similarities between heart attack and similarities between heart attack and strokeand stroke

Motivate you to prevent a strokeMotivate you to prevent a stroke

How is a stroke different from How is a stroke different from a heart attack?a heart attack?

A stroke is a sudden neurological A stroke is a sudden neurological deficit caused by a blood vessel deficit caused by a blood vessel problemproblem

2 types2 types Ischemic strokesIschemic strokes Hemorrhagic strokesHemorrhagic strokes

The effects of a stroke are extremely The effects of a stroke are extremely variedvaried

Why is heart attack easier to Why is heart attack easier to recognize than stroke ?recognize than stroke ?

PainfulPainful

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

Often painlessOften painless the stroke itself the stroke itself

often affects often affects awareness of awareness of symptomssymptoms

Poor recognition of Poor recognition of symptoms and symptoms and need for actionneed for action

Copyright restrictions may apply.

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

Respondents unable to name Respondents unable to name 1 warning sign or risk factor for stroke1 warning sign or risk factor for stroke

Which of the following Which of the following are warning signs of are warning signs of

stroke?stroke?A.A. Sudden weakness or numbness of the face, arm Sudden weakness or numbness of the face, arm

or leg, especially on one side of the bodyor leg, especially on one side of the body

B.B. Sudden confusion, trouble speaking Sudden confusion, trouble speaking or understandingor understanding

C.C. Sudden chest painSudden chest pain

D.D. Sudden trouble seeing in one or both eyesSudden trouble seeing in one or both eyes

E.E. Sudden trouble walking, dizziness, loss of Sudden trouble walking, dizziness, loss of balance or coordinationbalance or coordination

F.F. Sudden, severe headache with no known causeSudden, severe headache with no known cause

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

B.B. Sudden confusion, trouble speaking Sudden confusion, trouble speaking or understandingor understanding

C.C. Sudden chest painSudden chest pain

D.D. Sudden trouble seeing in one or both eyesSudden trouble seeing in one or both eyes

E.E. Sudden trouble walking, dizziness, loss of Sudden trouble walking, dizziness, loss of balance or coordinationbalance or coordination

F.F. Sudden, severe headache with no known causeSudden, severe headache with no known cause

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

B.B. Sudden confusion, trouble speaking Sudden confusion, trouble speaking or understandingor understanding

C.C. Sudden chest painSudden chest pain

D.D. Sudden trouble seeing in one or both eyesSudden trouble seeing in one or both eyes

E.E. Sudden trouble walking, dizziness, loss of balance Sudden trouble walking, dizziness, loss of balance or coordinationor coordination

F.F. Sudden, severe headache with no known causeSudden, severe headache with no known cause

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

B.B. Sudden confusion, trouble speaking Sudden confusion, trouble speaking or understandingor understanding

C.C. Sudden chest painSudden chest pain

D.D. Sudden trouble seeing in one or both eyesSudden trouble seeing in one or both eyes

E.E. Sudden trouble walking, dizziness, loss of balance Sudden trouble walking, dizziness, loss of balance or coordinationor coordination

F.F. Sudden, severe headache with no known causeSudden, severe headache with no known cause

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

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

Is heart attack easier to Is heart attack easier to diagnose than stroke?diagnose than stroke?

Isolated weakness right index fingerJS Kim, Neurology, 2002

MRI with diffusion weighted MRI with diffusion weighted imagingimaging

Where is the stroke?Where is the stroke?

CT scan of arteries of CT scan of arteries of neck and headneck and head

Cause is usually Cause is usually rupture of a plaque rupture of a plaque within a coronary within a coronary arteryartery

So the diagnostic So the diagnostic and treatment and treatment strategy is fairly strategy is fairly straightforward (find straightforward (find the blockage and the blockage and open it up!) open it up!)

Atherosclerosis is Atherosclerosis is important, but important, but there are many there are many other causesother causes

Determining the Determining the cause in an cause in an individual is often a individual is often a deductive processdeductive process

Are the causes of heart attack Are the causes of heart attack and stroke different?and stroke different?

There are many potential There are many potential causes of strokecauses of stroke

Stroke is not just a brain Stroke is not just a brain disease and often the brain is disease and often the brain is

just an innocent bystanderjust an innocent bystander

Usually caused by diseases that are Usually caused by diseases that are affect the entire vascular system affect the entire vascular system (atherosclerosis) (atherosclerosis)

Material blocking brain arteries Material blocking brain arteries usually comes from outside the brain usually comes from outside the brain (atrial fibrillation, carotid artery (atrial fibrillation, carotid artery disease)disease)

How is a Cardiologist different How is a Cardiologist different than a Neurologistthan a Neurologist

Basically a plumber Basically a plumber or electricianor electrician

DiagnosticianDiagnostician DetectiveDetective DaredevilDaredevil

CaseCase

Healthy 61 year-old man developed Healthy 61 year-old man developed confused speech 1 day after falling confused speech 1 day after falling out of a tree.out of a tree.

August 11August 11thth, topping a tree, fell and , topping a tree, fell and sustained a left collar bone fracture sustained a left collar bone fracture and small puncture of the lung. and small puncture of the lung.

Next night suddenly developed Next night suddenly developed confused speech.confused speech.

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

foramen ovale)foramen ovale)

How are heart attack and How are heart attack and stroke SIMILAR?stroke SIMILAR?

Time is criticalTime is critical The first priority is to save tissue The first priority is to save tissue

at riskat risk

Kidwell 2004

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

There is a 3 hour time limit for the medication There is a 3 hour time limit for the medication t-PA, and the sooner it’s given the better! t-PA, and the sooner it’s given the better!

Future strokes may be prevented if we Future strokes may be prevented if we identify the cause of stroke ASAPidentify the cause of stroke ASAP

People brought by ambulance are treated People brought by ambulance are treated fasterfaster

Neurological deterioration and other Neurological deterioration and other complications may be prevented if a patient complications may be prevented if a patient is hospitalized earlieris hospitalized earlier

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

1:02 PM: Arrival DHMC ED.1:02 PM: Arrival DHMC ED.

4:49 PM artery is opened4:49 PM artery is opened

The system needs to be very The system needs to be very coordinatedcoordinated

Improving Stroke Improving Stroke Care at DHMCCare at DHMC

PREPARED INDIVIDUALIZED CARE

PROTOCOLS TO DECREASE ERRORSA TEAM APPROACH

RAPID EVALUATION

Ways everyone here Ways everyone here can prevent a strokecan prevent a stroke

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

attentionattention

10y risk 88% !

10y risk 13% !

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

Copyright restrictions may apply.

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

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)

Copyright ©2005 American Heart Association

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

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

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 Effectiveness of Stroke Prevention Absolute risk Prevention Absolute risk

reduction in a year:reduction in a year:Strategy ARR (%)Strategy ARR (%)

Warfarin for atrial fibrillationWarfarin for atrial fibrillation 88 Carotid endarterctomy for symptomatic dzCarotid endarterctomy for symptomatic dz 44 Smoking cessationSmoking cessation 22 Antihypertensive therapy if BP elevatedAntihypertensive therapy if BP elevated 22 Cholesterol lowering medicationsCholesterol lowering medications 22 AspirinAspirin 1-21-2

Schaebitz W-R, 2000

anticoaganticoag

Stroke Diagnosis 40 years ago

Stroke Warning SignsStroke Warning Signs Sudden weakness or numbness of the Sudden weakness or numbness of the

face, arm or leg, especially on one side of face, arm or leg, especially on one side of the bodythe body

Sudden confusion, trouble speaking Sudden confusion, trouble speaking or understandingor understanding

Sudden trouble seeing in one or both eyesSudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of Sudden trouble walking, dizziness, loss of balance or coordinationbalance or coordination

Sudden, severe headache with no known Sudden, severe headache with no known causecause

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

Sudden confusion, trouble speaking Sudden confusion, trouble speaking or understandingor understanding

Sudden trouble seeing in one or both eyesSudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of Sudden trouble walking, dizziness, loss of balance or coordinationbalance or coordination

Sudden, severe headache with no known Sudden, severe headache with no known causecause

What is a TIA ?What is a TIA ?

Transient Ischemic Attack=Stroke Transient Ischemic Attack=Stroke symptoms that resolve with a short symptoms that resolve with a short time.time.

Can be a warning sign of impending Can be a warning sign of impending stroke. stroke.

The highest risk period of stroke The highest risk period of stroke following a TIA is the first 2 weeks. following a TIA is the first 2 weeks.

The risk of stroke soon after a TIA can The risk of stroke soon after a TIA can now be estimated. now be estimated.

ABCDABCD22 Tool Tool Risk of stroke following TIARisk of stroke following TIA

A Age> or = 60 1

B Blood pressure >140/901

C Clinical features

unilateral weakness2

speech impairment 1

D2 Duration

> 60 min 2

10-59 min 1

Diabetes 1

AA BB CC DD EE FFSystolic BP*Systolic BP* 95-10595-105 130-148130-148 130-148130-148 130-148130-148 130-148130-148 130-148130-148DiabetesDiabetes NoNo NoNo YesYes YesYes YesYes YesYesCigarettesCigarettes NoNo NoNo NoNo YesYes YesYes YesYesPrior Atrial Fib.Prior Atrial Fib. NoNo NoNo NoNo NoNo Yes Yes YesYesPrior CVDPrior CVD NoNo NoNo NoNo NoNo NoNo YesYes

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

*BP in millimeters BP in millimeters of mercurymercury (mmHg(mmHg))

Which action would you take if Which action would you take if you thought someone was you thought someone was having a heart or stroke?having a heart or stroke?

A.A. take the person a hospitaltake the person a hospital

B.B. advise the person to call a doctoradvise the person to call a doctor

C.C. call 911call 911

D.D. call a spouse or family membercall a spouse or family member

E.E. do something elsedo something else

Which action would you take if Which action would you take if you thought someone was you thought someone was having a heart or stroke?having a heart or stroke?

A.A. Take the person a hospitalTake the person a hospital

B.B. Advise the person to call a doctorAdvise the person to call a doctor

C.C. Call 911Call 911

D.D. Call a spouse or family memberCall a spouse or family member

E.E. Do something elseDo something else

Bleeding into Bleeding into the heart the heart doesn’t occurdoesn’t occur

Brain Brain hemorrhage is hemorrhage is commoncommon

CT scan: ischemic stroke

Intracerebral hemorrhageIntracerebral hemorrhage at 1 hour and 6 hours at 1 hour and 6 hours

Intra-arterial thrombolysisIntra-arterial thrombolysis

Time window=6 hoursTime window=6 hours

You need to open the arteryYou need to open the artery

Like with heart disease, the Like with heart disease, the treatment and prevention of treatment and prevention of

stroke needs to be stroke needs to be individualized!individualized!

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