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‘I was having a great day at work and nothing seemed unusual.
Suddenly the lights went out.
Seven hours later I woke up inhospital. I couldn’t move my right side, andmy speech had gone.’
It is heart diseaseIt is not curableIt is not preventableEtiology (reason ) not known
Common believe
Etiology (reason ) not known
Reality of stroke
It is brain attack Prevention is better than cureThere is some curative treatmentOutcome goodOutcome goodPathogenesis is known (reason)
1in
6in
1i
6in
People world widewill have a
stroke
1in stroke
in their life timeIt could be you.6
in
People world widewill have a
stroke1in
Butstrokecan be prevented6
in
People world widewill have a
stroke1in
Ensure quality care and support after stroke6
in
Every 2 seconds, someone in the world suffers a stroke
Every 6 seconds, someone dies
1in Every 6 seconds,
someone’s quality of life will forever be changed –they will permanently be physically disabled6
in
1in
Every 6 seconds,regardless of age or gender –
6in Someone somewhere will die from
stroke
Every 6 seconds,stroke kills some one
Every other secondstroke attacks a person
15 millions people experience a stroke each year6 million of them do not survive
Preventable
and
TreatableCatastrophe
About 30 million peoplehave had a strokemost have residual disabilities
Behind these numbers arereal life
Second cause of death above 60
5th – people 15- 59
Also attack children
More death each yearthan AIDS TB malaria put together
Is indiscriminate & does not respect borders
FAST
FAST
FAST
FAST
FAST
FAST
Sudden confusion, trouble speaking or understanding
Sudden trouble seeing
Sudden trouble walking, dizziness, l f b l di tiloss of balance or coordination
Sudden, severe headache with no known cause
Whereas; stroke is a global epidemic that threatens lives, health and quality of life
Whereas; much can be done to prevent andtreat stroke, and rehabilitate those who sufferfrom one
Whereas; professional and public awareness is the first step to action.
Stroke - a non-communicable diseaseAttacks 15 million people worldwide every yearClaims a life every six seconds –
Can be beaten - effectively
Regardless of age, stroke can strike anyone at any time
Stroke can be prevented
Stroke survivors can regain their quality of lifetheir quality of life with appropriate care and long-term support
Reduce the number of people who
are affected by stroke
Reduce the number who die
Increased the number who recover
Increase the QOL of those who became disable
The lifetime risk of
stroke is
The Lancet Neurology 6(12), 1106-14
1 in 5 for women,
1 in 6 for men
Increase understanding of the solutions that exist
KnowledgeHealthy environment /Healthy environment /
Healthy behavior
Raise awareness
Translate knowledge into action
Transdisciplinary teamEvidence > Practice
Establish simple but comprehensive stroke units
Generate a movement
that stimulates collective responsibility and actionand action
1. Whereas; stroke is a global epidemic that threatens lives, health and quality of life.
2. Whereas; much can be done to prevent andtreat stroke, and rehabilitate those who sufferfrom one.
3. Whereas; professional and public awareness is the first step to action.
Growing epidemic >Preventable
Joint forces to prevent stroke
The growing epidemic
pThe same few risk factors accounts for the health problems
Ensure what we know becomes what is done
Recognized the uniqueness of stroke
Tx & prevent VCI
The growing epidemic
Build Transdisciplinary team
Stroke is PREVENTABLE
But rising
The growing epidemic
Globally
Aging, unhealthy diets, tobacco use, and physical inactivity fuel a growing epidemic >>
1i
6in
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6in
1i
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of >>
The growing epidemic
High BP
High Cholesterol
of >> Obesity
Diabetes
stroke
Heart disease
VCI
A treatable and preventable catastrophe
oHere are 6 steps anyone can taketo reduce the risk and the danger of stroke
1g
1. Know your personal risk factors
- BP - Diabetes- Cholesterol
oHere are 6 steps anyone can taketo reduce the risk and the danger of stroke
1g
2. Be physically active and exercise regularly3. Avoid obesity by keeping to a healthy diet4. Limit alcohol consumption
oHere are 6 steps anyone can taketo reduce the risk and the danger of stroke
1g
5. Avoid cigarette smoke, if you smoke, seek help to stop now
6. Learn to recognized the warning signs of stroke
oTime lost is Brain functionlost
2
Time window of opportunity to treat stroke short once symptoms appearsany one having a stroke
immediately
oTime lost is Brain functionlost
2
Call local Emergency phone no.Go to nearest hospital
Even symptoms disappearIt may the last opportunity to prevent a potentially forthcoming major stroke
oDisability in adult worldwide
3
PhysiotherapyOccupational therapyRehab
Transient ischaemic attacks (TIAs) offer a great opportunity to initiatetreatments that prevent strokes
HemiparesisHemisensory lossD th i
Typical symptoms
DysarthriaDiplopiaMonocular blindnessAtaxia
Altered consciousness or syncopeDizziness, wooziness, or giddinessI i d i i (“ t”) ith lt ti f
Following are NOT Typical symptoms
Impaired vision (“grey out”) with alteration ofconsciousnessAmnesia or confusion aloneTonic and/or clonic motor activityPurely sensory symptoms,
Sensory marchFocal positive neurological symptoms B l bl dd i ti
Following are NOT Typical symptoms
Bowel or bladder incontinenceVertigo, diplopia, dysphagia, or dysarthria
Stroke and TIA are both serious conditionsboth are markers of current or impendingdisability and a risk of death
PX are not benign
10 to 20% of patients have a stroke in the next 90 days,
In 50% stroke within the first 24 to 48 hours
Between 30% and 50% of TIA patients who undergo brain MRI with diffusion- weighted imaging
PX are not benign
Non-Focal symptomsD/DX
Loss of consciousnessFaintnessGeneralised weaknessVertigo onlyDrop attacksEpisodes of ‘confusion’
ABCD2Risk score
Age ≥ 60 years (1 point)BP≥ 140/90 mmHg (1 point)g ( p )Unilateral weakness (2 points)Speech impairment (1 point)Duration ≥ 60 minutes (2 points) or 10–59 minutes (1 point)Diabetes mellitus (1 point)
ABCD2Risk score
Low risk (0–3 points)Moderate risk (4–5 points)( p )High risk (6–7 points
B k t th llBack – to - the - wall
e m e r g e n c y
Australia
MI v Stroke
Extreme pain, fear of death
Pt screams for help
No pain, Sx are played down
Pt does not ask for HelppRapid alarm for EMS
Good Mx structure & logistic
Pt does not ask for Help
Bypass of EMS, primarycare Physician
Structure in development
Imaging guideline
Suspected TIA or stroke, urgent cranial CT (Class I), or
alternatively MRI (Class II), Level A)
If MRI - DWI and T2*-weighted (Class II, Level A)
TIA, minor stroke, or early spontaneous recovery,Ultrasound, CTA, or MRA (Class 1I, Level A)
ESO | AHA/ASAguidelines do not separate the management of TIA from
ischaemic stroke.
Loading dose of aspirin (160-325 mg) within 48hours of ischaemic stroke (ESO Class I, Level A).
No other antiplatelets or combinations (Class III, Level C)
Aspirin 50-325 mg/d, aspirin andextended-release dipyridamole, and clopidogrel monotherapy(AHA/ESO Class I, Level A).
ESO | AHA/ASAguidelines do not separate the management of TIA fromischaemic stroke.
The combination of aspirin and extended-release dipyridamole over aspirin alone (Class I, Level B)
Cl id l i d d i i lClopidogrel is recommended over aspirin alone (Class IIb, Level B),
For patients allergic to aspirin(Class IIa, Level B)
IV rt-PA within 4.5 hours (Class I, Level A)
BP of 185/110 mmHg or higher
IA rTPA acute MCA occlusion within a 6-hour
IV streptokinase - not recommended
Acute Stroke | General
IV - rTPA 3-4.5HIA - <6 HAnticoagulation
Antiplatelets
Aspirin should not be considered a substitute for other acute interventions
In acute settingSecondary preventionDrug Tx
Acute setting 140 – 180mgSecondary prevention HbA1C < 7
Anti lipidStatin / Niacin
X
BMI 18.5 – 25.4Waist : <35 F and < 40 M
physical activity, at least 30 minutes
Interventional approach
Stroke > 6 month with 70-90% stenosis> CEA
Recent stroke with 50-69% stenosis> CEA
<50% Med Tx
Interventional approach
ICAS with symptoms Stent / angioplasty unceretain
CardioEmbolic
AF – Anticoagulation
MI with mural thrombus Anticoagulation ( 9-12 months)ASA for MI
Cardiomyopathy > anticoagulation / ASA
Valvular heart disease with or without AF> Anticoagulation without ASA
CardioEmbolic
MAC with regurgiation with or without AF> Antiplatelet or Anticoagulation
Prosthetic valves> anticoagulation
NonCardioEmbolic
> Antiplatelet
Arterial dissectionAnticoagulation – 3-6 m or AntiplateletBeyond 6 m > Antiplatelet
PFOAntiplatelet
NonCardioEmbolic
> CVT with or without HgAnticoagulation for 3-6 months followed by
Antiplatelet only
NonCardioEmbolic
> HyperhomocysteinemiaB6 B12 & Folate
Hypercoagulable stateInherited ThrombophiliasCVT > AntiplateletRecurrent > Anticoagulation
NonCardioEmbolic
> APL Ab > Antiplatelet> APL syndrome > Anticoagulation
lower-risk > UFH / LMWH 1st trimester > ASA low dose
High risk PG UFH throughout
After ICH SAH Sub Hg > All anticoagulant – stopped for 1-2 wkResume 3-4 wk
Hemorrhagic transformation of Infarct Anticoagulation may be >>
No current recommendation of
CAMneuroprotectivesubstances (Class I, Level A)
Q&A
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