Stroke & Society : Dr Vijay Sardana

Stroke DefinitionStroke Definition

Clinical syndrome characterized by sudden Clinical syndrome characterized by sudden onset symptom and sign of focal (at time onset symptom and sign of focal (at time global) cerebral dysfunction of vascular global) cerebral dysfunction of vascular origin lasting more than 24 hrs or leading to origin lasting more than 24 hrs or leading to deathdeath

StrokeStroke

22ndnd commonest cause of death commonest cause of death Most common cause of disabilityMost common cause of disability

STROKESTROKEEpidemiologyEpidemiology

5 – 6 million die of stroke worldwide 5 – 6 million die of stroke worldwide annuallyannually

Reducing trend in western countries – Reducing trend in western countries – change in life stylechange in life style

87% of all strokes occur in 87% of all strokes occur in underdeveloped and developing countriesunderdeveloped and developing countries

Stroke is second common killerStroke is second common killer 2929thth October as world stroke day October as world stroke day

(WFN,WHO,WSO) theme for 2008, “ Little (WFN,WHO,WSO) theme for 2008, “ Little Strokes, Big Trouble” Strokes, Big Trouble”

Stroke : IndiaStroke : India

• Stroke incidence – 163/1,00,000Stroke incidence – 163/1,00,000 Population/yr.Population/yr.

• Stroke prevalence – 545/1.00.000Stroke prevalence – 545/1.00.000

• Ischemic stroke incidence- 14.43.539/yr (80% Ischemic stroke incidence- 14.43.539/yr (80% of all) - 2005of all) - 2005

Stroke IndiaAnnual incidence

145/1,00,000/per year (India) 29/1,00,000 Sri Lanka 370/1,00,000 China 523/1,000 Japan

Stroke Prevalence

India57 - 843/1,00,000 China 620 - 1,1,00/1,00,000 Japan 398 – 3540/1,00,000

WHO – Global Stroke Mortality WHO – Global Stroke Mortality Projections 2003 to 2030Projections 2003 to 2030

• 20052005 - - 16 million first ever Stroke16 million first ever Stroke -- 62 million Stroke Survivors62 million Stroke Survivors -- 51 million Disability 51 million Disability

Adjusted Life year (DALYs)Adjusted Life year (DALYs) -- 5.7 million Stroke Deaths5.7 million Stroke Deaths

• Same year India -Same year India - 53% of all deaths Including 53% of all deaths Including Stroke from ch. Stroke from ch.

DiseasesDiseases• By 2015By 2015 - - 18 millions First Ever Stroke18 millions First Ever Stroke

-- 6.5 ,, ,, Deaths 6.5 ,, ,, Deaths • By 2030By 2030 - - 23 million First Ever Stroke23 million First Ever Stroke

-- 7.8 million Deaths7.8 million Deaths

Stroke: IndiaStroke: India

73%- don’t realize that symptoms are due to 73%- don’t realize that symptoms are due to cerebral strokecerebral stroke

Low threat perception of stroke in comparison Low threat perception of stroke in comparison to ‘heart attack”to ‘heart attack”

Most of rural patients – not aware of Time Most of rural patients – not aware of Time windowwindow

Raised Stroke burden in IndiaRaised Stroke burden in India

SmokingSmoking Increased longitivityIncreased longitivity

41.2yrs (1951-61)41.2yrs (1951-61)

61.4yrs (1991-96)61.4yrs (1991-96)

Change in lifestyle accompanying urbanizationChange in lifestyle accompanying urbanization

Genetic syndromeGenetic syndrome

Centra obesityCentra obesity

High triglycerideHigh triglyceride

Low HDL +/- glucose intleranceLow HDL +/- glucose intlerance

Stroke & community

75% Stroke managed offside academic 75% Stroke managed offside academic medical centremedical centre

Need to optimize stroke care in the Need to optimize stroke care in the community settingcommunity setting

Stroke care in communityStroke care in community

Stroke awarenessStroke awareness

Emergency Medical Services transport V/S Emergency Medical Services transport V/S Personal transportPersonal transport

Stroke: IndiaStroke: India

7-24% present to hosp. within 3 hrs (Indian 7-24% present to hosp. within 3 hrs (Indian urban based study)urban based study)

Major factor for early advise – living within Major factor for early advise – living within 10 km radius (Pandian et al 2006)10 km radius (Pandian et al 2006)

Major factor for delay – non availability of Major factor for delay – non availability of transporttransport

STROKE MORTALITY IN INDIASTROKE MORTALITY IN INDIA

1990(WHO)-6,19,000/90,40,000 total deaths1990(WHO)-6,19,000/90,40,000 total deaths

73/1,00,000 population73/1,00,000 population

Stroke deathsStroke deaths equal to IHDequal to IHD 20 times more than malaria20 times more than malaria 1.5 times Tuberculosis1.5 times Tuberculosis

Stroke outcomeStroke outcome

One third independent in ADLOne third independent in ADL

More than one fifth- bed riddenMore than one fifth- bed ridden

Rest – in betweenRest – in between

Inevitable Stroke epidemicInevitable Stroke epidemic

STROKE SPECIFIC TO INDIASTROKE SPECIFIC TO INDIA

YOUNG STROKE-20-25%YOUNG STROKE-20-25%

CVTCVT

RHDRHD

ARTERITISARTERITIS

Stroke- what needs to be doneStroke- what needs to be done

Imparting physicians knowledge about Imparting physicians knowledge about stroke management, importance of window stroke management, importance of window period & thrombolytic therapyperiod & thrombolytic therapy

Educating publicEducating public

stroke warning symptomsstroke warning symptoms

risk factorsrisk factors

mortality & dependencemortality & dependence

importance of time windowimportance of time window Stroke unitsStroke units

Run For Stroke at KotaRun For Stroke at Kota

Stroke care in communityStroke care in community

FF -Face weakness-Face weakness

AA -Arm weakness-Arm weakness

SS -Speech disturbance-Speech disturbance

TT -Time-Time

Stroke care in Community issuesStroke care in Community issues

Hospital readinessHospital readiness

Ship & DripShip & Drip Drip & ShipDrip & Ship Role of TelemedicineRole of Telemedicine

Ischemic stIschemic strokeroke Time window in BrainTime window in Brain

ATP exhaustionATP exhaustion : 2 min : 2 min First neuronal damageFirst neuronal damage : 5 min : 5 min Infarction beginsInfarction begins : 1-2 : 1-2

hrshrs Infarction continues to enlarge : 6 -12 Infarction continues to enlarge : 6 -12

hrshrs

Re-establishment of circulation in less Re-establishment of circulation in less than one hour leads to restoration of than one hour leads to restoration of physiological and biochemical functionsphysiological and biochemical functions

Ischaemic StrokeIschaemic Stroke Brain OedemaBrain Oedema

OnsetOnset 1 – 3 hrs 1 – 3 hrs MaxMax 2 days 2 days ResolveResolve 2 weeks 2 weeks

Diagnostic evaluationDiagnostic evaluation

Stroke mimics

Hypoglycemia

Hyperglycemia

Hepatic encephalopathy

Seizures

Hemiplegic migraine

SDH

Brain abcess

Hypertensive encephalopathy

MS

Hysterical

Stroke chameleonsAcute confusional states

Seizures with acute strokes

Sensory symptoms

Movement disorders

• Uncommon manifestations of common clinical problems are more common than common manifestations of uncommon clinical problems

Ischaemic Stroke Ischaemic Stroke

Risk FactorsRisk Factors** Hypertension Hypertension * Atrial fibrillation * Atrial fibrillation** DiabetesDiabetes * * Myxomatous Deg. Mit. Myxomatous Deg. Mit.

ValveValve** SmokingSmoking * * Deficient ant thrombin iiiDeficient ant thrombin iii** Antiphoshpholipid Antiphoshpholipid * * Protin - SProtin - S

AntibodiesAntibodies * * Protin - CProtin - C** Lupus anticoagulant Lupus anticoagulant * * AgingAging• AnticardiolipinAnticardiolipin * Hyperhomocystenemia * Hyperhomocystenemia

Ischaemic StrokeIschaemic Stroke

Cerebral circulation – regulation – Cerebral circulation – regulation – pathophysiolgypathophysiolgy

Blood flow & glucose consumption 1/5 Blood flow & glucose consumption 1/5 resting cardiac outputresting cardiac output

Gray matter > whiteGray matter > white No metabolic reserveNo metabolic reserve Normal CBF 55ml/100gm/mt.Normal CBF 55ml/100gm/mt. Critical 23ml/100gm/mtCritical 23ml/100gm/mt Infarction 8-9ml/100gm/mtInfarction 8-9ml/100gm/mt Ischaemic Penumbra 8-23ml/100gm/mt Ischaemic Penumbra 8-23ml/100gm/mt


CompleteComplete : : Persistence neuro Persistence neuro deficit deficit

> 24 hrs> 24 hrs

TIATIA : : Transient neuro deficit Transient neuro deficit <24hrs <24hrs

Time of onset of isch strokeTime of onset of isch stroke

TimeTime % cases% cases

12 am - 4 am12 am - 4 am 1818

4 am – 8 am4 am – 8 am 2323

8 am – 12 noon8 am – 12 noon 2525

12 noon – 4 pm12 noon – 4 pm 1313

4 pm – 8 pm4 pm – 8 pm 1919

8 pm – 12 pm8 pm – 12 pm 1212

Ischaemic StrokeIschaemic Stroke Focal Cerebral AetiologyFocal Cerebral Aetiology

Vascular DisordersVascular Disorders- Atherosclerosis- Atherosclerosis- - Moyamoya synd Fibro muscular dysplasiaMoyamoya synd Fibro muscular dysplasia

- Lacunar infarction- Lacunar infarction- Vascular dissectionVascular dissection

- CVT- CVT

Cardiac DisordersCardiac Disorders- Mural thrombMural thromb - RHD, Prosth valve - RHD, Prosth valve - ArrhythmiasArrhythmias - Endocarditis- Endocarditis

Haematologic DisordersHaematologic Disorders Hypercoag state, ThrombocytosisHypercoag state, Thrombocytosis


Infarct size depends uponInfarct size depends upon CollateralsCollaterals Blood viscosityBlood viscosity Mean arterial B.P.Mean arterial B.P. CSF pressureCSF pressure


Ring Ring around infracted centre,around infracted centre,

PenumbraPenumbra CBF in this areaCBF in this area Partial Ischaemic statePartial Ischaemic state Functional activityFunctional activity Preserved structural integrity Preserved structural integrity

Stroke - DiagnosisStroke - Diagnosis

Is it a stroke ?Is it a stroke ? Which type of stroke ?Which type of stroke ?

- Ischaemic- Ischaemic- Hemorrhagic- Hemorrhagic

If ischaemic stroke :If ischaemic stroke :

- What is the event ?- What is the event ?- Which is the territory- Which is the territory- What is the aetiology- What is the aetiology

Cardioembolic StrokeCardioembolic StrokeCriteriaCriteria

ClinicalClinical- Young adult, onset deficit with no - Young adult, onset deficit with no antecedent TIAantecedent TIA- Involvement of multiple vascular - Involvement of multiple vascular territories territories - Cardiac source- Cardiac source

Diagnostic studiesDiagnostic studies- CT or MRI : ischaemic bland / - CT or MRI : ischaemic bland / haemorrhagic infarcts in multiple haemorrhagic infarcts in multiple vascular territoriesvascular territories- Echocardiography : cardiogenic emboli- Echocardiography : cardiogenic emboli- Angiography - Angiography : no significant : no significant stenosisstenosis

Stroke early CT Signs

Hyperdense MCA Sign – (sensitivity 27-34%) Loss of gray White diffrentiation in the

insular ribbon at the lat. margin of insula (loss of the insular ribbon sign)

Sylvian dot sign specificity 38-46%

Management of Ischaemic StrokeManagement of Ischaemic Stroke

PhasePhase II Acute ManagementAcute Management

PhasePhase IIII RehabilitationRehabilitation

PhasePhase IIIIII Prevention of rec.Prevention of rec.

Stroke Management - Variations

Availability of technology Affordability Type of Medical practice (Public v/s private) Difference in Philosophy of practice

(evidence based or not)

RAPID CLINICAL EVALUATION RAPID CLINICAL EVALUATION Reperfuse Ischemic brainReperfuse Ischemic brain

Act within a time limit of the penumbra Act within a time limit of the penumbra NIHSS evaluationNIHSS evaluation

– Non-Neurologists and Neurologists Non-Neurologists and Neurologists – Identifies Identifies

Candidates for thrombolysisCandidates for thrombolysis Patients with increase risk of Patients with increase risk of hemorrhagic complicationshemorrhagic complications

NIHSS <10: 60-70% Favorable outcome after 1 yr ;3% chance of ICH

NIHSS >20: 4-16% have favorable outcome; 17% chance of ICH

EMERGENCY ROOMEMERGENCY ROOM

Obtain vitalsObtain vitalsEnsure ABCEnsure ABCCannulate (0.9 N sal at 50ml /hr)Cannulate (0.9 N sal at 50ml /hr)Spot sugarSpot sugarBPBPEKGEKGSend BT, CT, Platelet CtSend BT, CT, Platelet CtOO22 at 2L/ min (nasal cannula) at 2L/ min (nasal cannula)Intubation Intubation (Poor ventilatory drive)(Poor ventilatory drive)Brain CT Non ContrastBrain CT Non ContrastIf potential thrombolysis-DO NOT If potential thrombolysis-DO NOT

GIVE ASP./ ANTICOAGULATIONGIVE ASP./ ANTICOAGULATION

• Treat as any other emergency(eg. Unstable Trauma, AMI)

NINDS – Recommended stroke NINDS – Recommended stroke evaluation target for Thrombolysisevaluation target for Thrombolysis

TaskTask Time target (min)Time target (min)

Door to DoctorDoor to Doctor 1010

Door to CT completionDoor to CT completion 2525

Door to CT readDoor to CT read 4545

Door to DepartmentDoor to Department 6060

Access to Neurological expertiseAccess to Neurological expertise 1515

Access to Neurosurgical expertise Access to Neurosurgical expertise 120120

Admit to Monitored bedAdmit to Monitored bed 180180


Medical Treatment : GeneralMedical Treatment : General Rapid Rapid BP. - Don’t treat - 10days BP. - Don’t treat - 10days

Unless V.high diasUnless V.high dias - 120 - 120 Nasogastric intubations if vomitingNasogastric intubations if vomiting Frequent turningFrequent turning Air waysAir ways DietDiet

Stroke – what needs to be doneStroke – what needs to be done

Imparting physicians knowledge about stroke Imparting physicians knowledge about stroke management, importance of window period management, importance of window period & thrombolytic therapy& thrombolytic therapy

Educating publicEducating public

stroke warning symptomsstroke warning symptoms

risk factorsrisk factors

mortality & dependencemortality & dependence

importance of time windowimportance of time window

Stroke unitsStroke units

Stroke unitsStroke units

20% reduction in mortality & dependency as 20% reduction in mortality & dependency as compared to gen wardcompared to gen ward

Stroke unit patients- at 1 yrStroke unit patients- at 1 yr

more likely to be alivemore likely to be alive

independentindependent

living at homeliving at home

Stroke unit : 100 Stroke unit : 100

3 additional would survive3 additional would survive 3 additional would avoid long term hosp. 3 additional would avoid long term hosp.

care care 6 additional would return home physically 6 additional would return home physically

independentindependent

Stroke : IndiaStroke : India

Dr. P.M. Dalal – specialized stroke Dr. P.M. Dalal – specialized stroke Management concept Management concept

mortality 33% - 12%mortality 33% - 12%

Late Sh. Nagi ReddiLate Sh. Nagi Reddi

Dr. T.J. Cherian – First Stroke unit in Dr. T.J. Cherian – First Stroke unit in private sector in 1985private sector in 1985

Stroke service in developing countriesStroke service in developing countries

Brazil Iran ChinaChina Pakistan India

Neurologist

5000 420 20,000 60 1500

Neurology deptt.

90 24 1500 15 40

Stroke units

35 20 150 5 100

StrokePrevalence /1,00,000

128 43 400 48 545

Stroke unit- AimsStroke unit- Aims

Giving patients rapid access to wide range of Giving patients rapid access to wide range of modern clinical & radiological facilitiesmodern clinical & radiological facilities

Providing facility for safe administration & Providing facility for safe administration & monitoring of hyper acute treatmentmonitoring of hyper acute treatment

Early rehabilitation & patient educationEarly rehabilitation & patient education

Stroke unitStroke unit

ICU bedsICU beds Cardiac monitorsCardiac monitors VentilatorsVentilators DefibrillatorsDefibrillators Rehab equipmentRehab equipment Central gas supplyCentral gas supply

Kota Med college Stroke unit : policiesKota Med college Stroke unit : policies

12 beds12 beds Admission – adults where stroke is major Admission – adults where stroke is major

clinical problemclinical problem SAH – NS – backSAH – NS – back

ExclusionExclusion Major medical co morbidityMajor medical co morbidity Requirement of other ongoing surgical & Requirement of other ongoing surgical &

other medical treatmentother medical treatment Major preexisting psychiatric disorderMajor preexisting psychiatric disorder TIATIA

Stroke Therapy - BreakthroughStroke Therapy - Breakthrough

1996 – thrombolytic Therapy1996 – thrombolytic Therapy

ThrombolysisThrombolysis

Less than 5% patientsLess than 5% patients Few hundred in IndiaFew hundred in India

Ischaemic StrokeIschaemic Stroke Thrombolytic Therapy Thrombolytic Therapy

Intravenous tPAIntravenous tPA

Intra-arterial tPA/ urokinaseIntra-arterial tPA/ urokinase

Ischaemic Stroke Ischaemic Stroke Thrombolytic agentsThrombolytic agents

IV recanalizationIV recanalization - 30-40%- 30-40% I.A. recanalizationI.A. recanalization - 60-70%- 60-70% V. good but potentially dangerous for V. good but potentially dangerous for

clot lysesclot lyses Must adopt strict guidelines Must adopt strict guidelines

exclusion / inclusion criteriaexclusion / inclusion criteria Emergency CT essentialEmergency CT essential Neurosurgery back up essential for ICHNeurosurgery back up essential for ICH

Eligibility Criteria for iv TPA Eligibility Criteria for iv TPA

Inclusion criteriaInclusion criteria

Onset of symptom to drug administration Onset of symptom to drug administration time is below 3 hourstime is below 3 hours

Patient has significant neurological deficit Patient has significant neurological deficit

No hemorrhage on CT scanNo hemorrhage on CT scan

Exclusion criteriaExclusion criteria

Stroke or server head trauma in last three monthStroke or server head trauma in last three month Major surgery in last 14 daysMajor surgery in last 14 days Systolic BP. Above 185 mm of Hg or diastolic BP above Systolic BP. Above 185 mm of Hg or diastolic BP above

110 of mm of Hg110 of mm of Hg If Patient is rapidly improving or has minor symptomsIf Patient is rapidly improving or has minor symptoms Symptoms suggest SAHSymptoms suggest SAH Hematuria, Malena, hemoptysis within last 21 daysHematuria, Malena, hemoptysis within last 21 days Seizure at the onset of strokeSeizure at the onset of stroke Prothrombin time>15secProthrombin time>15sec Platelet count 1,00,000/mm3Platelet count 1,00,000/mm3 Glucose<50 or >400 mg/DIGlucose<50 or >400 mg/DI

Thrombolysis - advantage with KotaThrombolysis - advantage with Kota

Nearby districts within window periodNearby districts within window period

Population densityPopulation density

Vigilant & relatively health conscious peopleVigilant & relatively health conscious people

Relative economic vibrancyRelative economic vibrancy

TPA cost in developing countryTPA cost in developing country

India- Rs. 55,000 (1217 USD)India- Rs. 55,000 (1217 USD) China – 9586 Yuan Remuinbi (1269 USD)China – 9586 Yuan Remuinbi (1269 USD) Argentina – 4810 Argentina Peso (1586 USD)Argentina – 4810 Argentina Peso (1586 USD) Mexico -24059 Mexico Peso (2306 USD)Mexico -24059 Mexico Peso (2306 USD) Turkey – 1919 Lira (1480 USD)Turkey – 1919 Lira (1480 USD)

Acute Ischaemic StrokeAcute Ischaemic Stroke Medical TherapyMedical Therapy

Antithrombotic TherapyAntithrombotic Therapy-- Antiplatelet drugs – Aspirin; Antiplatelet drugs – Aspirin; clopidogrelclopidogrel-- Anticoagulants – Heparin; WarfarinAnticoagulants – Heparin; Warfarin

Reperfusion TherapyReperfusion Therapy-- Thrombolytic Drugs – Streptokinase; Thrombolytic Drugs – Streptokinase; tPAtPA

Neuronal ProtectionNeuronal Protection-- Ca Channel Antigonissts – NimodipineCa Channel Antigonissts – Nimodipine

NicardipineNicardipine


Anti convulsantsAnti convulsants VasodilatorsVasodilators

-- Poor benefitPoor benefit

-- May produce intracerebral steal / May produce intracerebral steal / damage damage infracted areainfracted area

Volume expandersVolume expanders Low mol. Wt. DextranLow mol. Wt. Dextran -- mixed resultmixed result PentoxicyfylinePentoxicyfyline BarbituratesBarbiturates -- poor valuepoor value Ca Chh.inhib.Ca Chh.inhib. -- mixed mixed

resultresult


Antioedema agentsAntioedema agents CorticosteroidsCorticosteroids -- less effectiveless effective use only if patientuse only if patient -- ObtundationObtundation

-- ComaComa-- HerniationHerniation

DexamethasoneDexamethasone -- 10mg bolus 10mg bolus 4mg IV 4mg IV

4-6 hrly4-6 hrly Mannitol/glycerolMannitol/glycerol

Treatment of Acute Ischaemic StrokeTreatment of Acute Ischaemic Stroke

Acute TherapyAcute Therapy Maintanence TherapyMaintanence Therapy ThrombolyticsThrombolytics * Antiplatelets* Antiplatelets AntiplateletsAntiplatelets * Antithrombotics* Antithrombotics AntithromboticsAntithrombotics * Statins* Statins

* Ace Inhibitors* Ace Inhibitors* ARB-II Blockers* ARB-II Blockers* Folic Acid/ Vitamins* Folic Acid/ Vitamins

Risk Factors ModificationRisk Factors Modification

Ischaemic StrokeIschaemic StrokeAntiplatelet AgentsAntiplatelet Agents

AspirinAspirin – inhibit thromboxane A2 30-325 mg– inhibit thromboxane A2 30-325 mg

DipyrimadoleDipyrimadole (persantine) less effective (ESPS) (persantine) less effective (ESPS)

200mg slow release BD200mg slow release BD

Combined Aspirin + Dipyrimadole (ESPS 2)Combined Aspirin + Dipyrimadole (ESPS 2)

Clopidogrel 75mg OD (CAPRIE)Clopidogrel 75mg OD (CAPRIE)

Ischaemic Stroke Ischaemic Stroke - - ClopidogrelClopidogrel

Similar efficiency as AspirinSimilar efficiency as Aspirin ESP2ESP2

-- Aspirin – Risk reductionAspirin – Risk reduction18%18%

-- Aspirin and DipyarimadoleAspirin and Dipyarimadole

Risk reductionRisk reduction37%37%

Ischaemic StrokeIschaemic Stroke AnticoagulationAnticoagulation

IndicationsIndications-- Cardioembolic strokesCardioembolic strokes-- Strokes in evolutionStrokes in evolution-- Posterior circulation stroke Posterior circulation stroke (basilar artery thrombosis)(basilar artery thrombosis)-- Recurrent TIA with tight Recurrent TIA with tight stenosisstenosis-- Carotid / Vertebrobasilar Carotid / Vertebrobasilar dissectiondissection


AnticoagulantsAnticoagulants : : ControversialControversial

-- Large infarct AvoidLarge infarct Avoid

-- Non compliment patientNon compliment patient

-- Can not be followed upCan not be followed up

-- Bleeding diathesesBleeding diatheses

-- Peptic ulcerPeptic ulcer

-- Liver diseaseLiver disease

Management of Acute Management of Acute


Use ofUse of HeparinHeparin may still be used in certainmay still be used in certain subgroupssubgroups

Acute MIAcute MI AFAF Intracardiac thrombusIntracardiac thrombus Critical Stenosis of supplying Critical Stenosis of supplying

arteriesarteries Recent acute basilar occlusionRecent acute basilar occlusion

Ischaemic StrokeIschaemic StrokePrevention After first StrokePrevention After first Stroke

Statin TherapyStatin Therapy Reduce 10 year stroke recurrence, Reduce 10 year stroke recurrence,

improves survivalimproves survival 794 consecutive first ever acute 794 consecutive first ever acute

Ischaemic StrokeIschaemic Stroke 10 year Follow up10 year Follow up Recurrence with statin _ 7.5%Recurrence with statin _ 7.5% Recurrence without statin – 16.3%Recurrence without statin – 16.3%

Milionis et al – Neurology 2009 : 72 : 1816 - 1822Milionis et al – Neurology 2009 : 72 : 1816 - 1822

Ischaemic Stroke Prevention Ischaemic Stroke Prevention Atrial FibrillationAtrial Fibrillation

Average stroke risk 4.5% / yearAverage stroke risk 4.5% / year High risk if additional factors presentHigh risk if additional factors present

- Age > 75 years- Age > 75 years- Recent stroke or TIA- Recent stroke or TIA- Systolic HT- Systolic HT- Diabetes- Diabetes

Anticoagulation (Warfarin) reduces risk Anticoagulation (Warfarin) reduces risk by 70%by 70%

Aspirin may be used in patients under Aspirin may be used in patients under 65 year without risk factors65 year without risk factors

We have a dream

Population knows about sign & symptom of stroke

“Brain attack” is taken as seriously as “Heart attack”

Patient are brought to hospital early Stroke centers are established at every

distrct of the country

We have a dream

More patients receive Thrombolytic therapy

Technology should be used for Tele-consultation of stroke patient to compensate for shortage of stroke specialits

National programme on Stroke

Health & Medicine

Stroke & Society : Dr Vijay Sardana