Stroke is a Medical Emergency

Face Arm Speech Test

Helps public recognise symptoms of stroke;

• Can they smile? Does one side droop? • Can they lift both arms? Does one drop? • Is their speech slurred or muddled? • Test all three symptoms

Of course, there can be other focal neurological symptomstoo (and not all of the above symptoms are due to a stroke)

Acute Management (1)

• Ischaemic stroke– Aspirin (within 48 hours of onset) – Clot busting drugs (only within 4.5 hours of symptom

onset)– Decompressive craniectomy (lifting a flap of the skull

to relieve pressure) in a tiny proportion of patients

• Haemorrhagic stroke– Neurosurgery (only occasionally) to remove blood– Reverse blood clotting defects

Acute management (2)

• General supportive– Intravenous fluids (for patients who can’t swallow)– Nutrition (nasogastric tube, modified diet, normal diet)– Oxygen (if oxygen levels low)– Bowel and bladder care – Prevention of pressure sores (? Pressure relieving

mattress, regular turns)

• Best outcomes if patient is admitted to a stroke unit

What is a stroke unit?

• Organised stroke unit care is provided by multidisciplinary teams that exclusively manage stroke patients in; – a dedicated ward (stroke, acute, rehabilitation,

comprehensive)– with a mobile stroke team or – within a generic disability service (mixed rehabilitation

ward).

Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke Cochrane Database of Systematic Reviews. 2007.

Stroke Unit, Royal Infirmary, Edinburgh 2000

Cochrane Systematic Review of Stroke Units

• 31 trials, 6936 patients, compared stroke unit care with an alternative service

• 26 trials (5592 participants) compared stroke unit care with general wards

• Stroke unit care reduced the odds of death, institutionalised care and dependency

• Outcomes independent of patient age, sex or stroke severity

• Better when stroke units based in a discrete ward

Why do stroke units improve outcomes? • Care co-ordinated by a multidisciplinary team

• Team meets to discuss patients at least weekly

• Nurses have expertise in rehabilitation

• Team consists of professionals interested or specialising in stroke

• Regular in-service training for staff and involvement of carers in patient care

• ? Early mobilisation, rapid treatment of complications of stroke

Langhorne1995.

Rehabilitation Aims to Minimise Functional Effects

of Stroke

• Core team– Physician– Nurses– Physiotherapist– Occupational therapist– Speech and language

therapist– Social worker– Dietician

• Others who may be consulted– Psychologist– Psychiatrist– Vascular surgeon– Radiologist– Rheumatologist– Optometrist – Orthotist

Scottish Stroke Care Audit

• National Audit allows each health board to evaluate care against published standards– Brain imaging– Aspirin– Stroke Unit access– Swallowing

assessments– Neurovascular clinic

access

http://www.strokeaudit.scot.nhs.uk/

Complications from stroke during hospital admission

0

10

20

30

40

50

60

recurrentstroke

seizures urine infections chest infections other infections falls pain anxiety depression emotionalism confusion

frequency %

Patterns of recovery are variable

time

function

A 58 year old man• A shop keeper, drives a car

• Sudden onset of left arm and leg weakness, and slurred speech

• Presented at 6 hours, given aspirin

• Admitted to a stroke unit

• 2 days later weakness was improving

• 3 weeks later: slightly weak finger grip and reduced power left leg, ready for hospital discharge

• Long-term issues….driving, returning to work, secondary stroke prevention

• • He would like to know whether he will make a full recovery

A 70 year old lady

• Sudden onset of severe right sided weakness and dysphasia, drowsy; found lying on floor by husband

• Unable to swallow, so required nasogastric feeding

• Over the next few weeks, developed pneumonia, requiring antibiotics and oxygen

• Recovered from pneumonia but still had severe dysphasia and no movement in her right side

• No real neurological recovery at 2 months, required PEG tube feeding

• Decision made in consultation with family that nursing home care required

Patterns of Recovery

• Rate of recovery generally most rapid in the first few weeks

• If a patient deteriorates, consider medical complications, recurrent stroke

• 95% have completed functional recovery by 3 months

• But some patients continue to recover for several years

• Recovery related to – Restoration of blood flow (and so neurones not

irreversibly damaged may recovery) – Neuroplasticity– Functional adaptations

Summary• Stroke is a medical emergency: Act FAST!

• Acute treatments can improve outcome

• Stroke Unit care improves outcomes

• Medical complications are common after stroke

• Pattern and rate of recovery is highly variable