Stroke A Clinical Sciences PDF

Clinical Sciences: Medical and Neurological conditions Cerebral Vascular Accident (CVA) / Stroke A Tony Wong Assistant Professor of Practice, PolyU Learning Outcome After this lecture, you will be able to Have idea on the epidemiology of CVA in HK Dist...

Clinical Sciences: Medical and Neurological conditions Cerebral Vascular Accident (CVA) / Stroke A Tony Wong Assistant Professor of Practice, PolyU Learning Outcome After this lecture, you will be able to Have idea on the epidemiology of CVA in HK Distinguish the types of CVA Identifying the clinical feature and pathology of CVA Know about general medical management for CVA Outline of lecture Clinical Sciences of CVA in terms of Epidemiology Definition of CVA Types and Pathology Sign and Symptoms Classifications Clinical Features Medical Managements What is STROKE? S = Speech, or problems with language T = Tingling, or numbness in your body R = Remember, or problems with thinking O = off-balance, or problems with coordination K = Killer headache E = Eyes, or problems with vision Taylor, JB (2008) Stroke: It’s NOT an “Accident” CVA (cerebrovascular accident) is a poor term: Stroke is preventable and treatable Prevention is better than cure Mark decrease the medical cost  The Perceptions of Stroke www.stroke.org Myths Reality Stroke is not preventable Up to 80% of strokes are preventable Stroke cannot be treated Stroke requires emergency treatment Anyone can have a stroke Stroke only strikes the elderly Stroke is a “Brain Attack” Stroke happens in the heart Stroke recovery can last for lifetime Stroke recovery ends after 6 months Risk factors of Stroke Family history of stroke Aged over 55: the older the age, the higher the chance High blood pressure / High cholesterol: higher chance of atherosclerosis (an accumulation of cholesterol and other deposits (plaques) on the walls of your arteries. Plaques can reduce blood flow through your arteries) and narrowing of cerebral vessels Cigarette smoking Diabetes mellitus: increasing the chance of stroke by 4 times Obesity CardioVascular Disease Vascular Malformation or Aneurysm Alcohol: increasing the chance of stroke occurrence  * Epidemiology Source: WSO_Global_Stroke_Fact_Sheet https://www.world-stroke.org/assets/downloads/WSO_Global_Stroke_Fact_Sheet.pdf World Health Organization (WHO) Stroke carries a high risk of death. Survivors can experience loss of vision and/or speech, paralysis and confusion. Annually, 15 million people worldwide suffer a stroke. Of these, 5 million die and another 5 million are left permanently disabled, placing a burden on family and community. Stroke is uncommon in people under 40 years; when it does occur, the main cause is high blood pressure. High blood pressure and tobacco use are the most significant modifiable risks. Atrial fibrillation, heart failure and heart attack are other important risk factors. The incidence of stroke is declining in many developed countries, largely as a result of better control of high blood pressure and reduced levels of smoking. However, the absolute number of strokes continues to increase because of the ageing population. Epidemiology WHO 2016 Epidemiology cont’ Epidemiology cont’ Epidemiology cont’ Epidemiology cont’ Updates @2023 (Sources:2023 Heart Disease and Stroke Statistics Update Fact Sheet, AHA) In 2020, stroke accounted for approximately 1 of every 21 deaths in the United States. On average in 2020, someone died of stroke every 3 mins 17 secs in the United States. When considered separately from other CVD, stroke ranks No. 5 among all causes of death in the United States, causing 160,264 deaths in 2020. In 2020, the age-adjusted US stroke death rate as an underlying cause of death was 38.8 per 100,000, a decrease of 0.8% from 2010, whereas the actual number of stroke deaths increased 23.8% during the same time period. In 2020, there were 7.08 million deaths attributable to cerebrovascular disease worldwide (3.48 million deaths from ischemic stroke, 3.25 million deaths from intracerebral hemorrhage (ICH), and 0.35 million from subarachnoid hemorrhage). Central, Southeast and East Asia, Oceania, and sub-Saharan Africa have the highest rates of overall stroke mortality. Eastern Europe and Central Asia have the highest mortality rates attributable to ischemic stroke. ICH mortality is highest in Oceania, followed by western, central, and eastern sub-Saharan Africa and Southeast Asia. Mortality attributable to subarachnoid hemorrhage is highest in Oceania, Andean Latin America, and Central Asia. Epidemiology in Hong Kong In Hong Kong, stroke was the fourth commonest cause of death in Hong Kong with 3,164 registered deaths in 2020. https://www.info.gov.hk/gia/general/202310/29/P2023102700164.htm https://www21.ha.org.hk/smartpatient/SPW/en-us/Disease-Information/Disease/?guid=29ac1219-3d68- 4378-a2bd-09e111da3650 How stroke survivors suffer ? 2/3 got some forms of neurological impairment and disability 15% were institutionalized at five years 20% recurrent stroke 22.5% had dementia (Feigin, et al, 2010) Definition of Cerebral Vascular Accident CVA “rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin” (WHO, 1988) Sudden brain dysfunction due to blood vessel problem TIA is defined to last less than 24 hours, and patients with stroke symptoms caused by subdural hemorrhage, tumors, poisoning, or trauma are excluded 5.2% of people developed stroke within 7 days of TIA, 40% of people experience TIA will have actual stroke (Gile & Rothwell, 2007; Centre of Health Protection, 2013) Classification of CVA Ischemic Stroke (Infarction): ~80% Hemorrhage (Hemorrhagic stroke)~20% Transient ischemic attack Pathology Ischemic stroke (Infarction): diminished blood supply to focal area of brain / Mostly thromboembolism Pathology Sub-type of infarction Thromboembolism / – a blood clot forms in the vascular system Thrombotic infarction The clot can develop in the brain artery itself Embolic infarction The clot travel with the blood flow from another site like heart or another site large blood vessel Ischemic Stroke risk factors (non-modifiable) Advanced age Male gender Race (Asian, Black races) Family history of Myocardial Infarction (MI) or early stroke Ischemic Stroke risk factors (modifiable) Hypertension / (systolic and diastolic) Diabetes mellitus / Hypercholesterolemia Cigarette smoking Prior stroke/TIA Carotid disease, heart disease Hypercoagulable / states : pathologic state of exaggerated coagulation or coagulation in the absence of bleeding Cocaine, excessive alcohol use Pathology – Ischemic Stroke  Pathology Hemorrhagic stroke (Intracerebral hemorrhage ICH) Blood vessel rupture within skull but NOT due to TRAUMA Due to CHRONIC arteriolar hypertensive disease (HT) Blood vessels rupture and preventing blood flow to brain International incidence 8-13% Higher incidence in Asian patients (15-30%) Higher mortality than ischemic stroke Pathology Pathology Subarachnoid hemorrhage (SAH) mainly due to the rupture of aneurysms at the bifurcations of large arteries at the inferior surface of the brain Vessel malformation and tumor Non-traumatic subarachnoid haemorrhage Most common in the 40-60 year age group. Female: male = 2:1 Smoking increases your risk 3-10 fold. 50% of patients die or are permanently disabled from the initial event Pathology Brain arteriovenous malformation (AVM) is a tangle of abnormal blood vessels connecting arteries and veins in the brain AVM can be found throughout the body Usually congenital in origin and onset on age 20s-30s Once diagnosed, a brain AVM can often be treated successfully to prevent complications, such as brain damage or stroke I MoyaMoya disease : carotid artery in the skull becomes blocked or narrowed Pathology – Hemorrhagic Stroke Fatal outcome of ICH Intraventricular extension Pressure effect Increased ICP Mid-line shift Brain herniation Evidence for surgical intervention  Conflicting and non-conclusive  Usefulness of surgery of most patients is uncertain  Trend of improved outcome compared with medical therapy for patients with superficial clots ( 94% SpO2 – Blood sugar treat if able Low blood sugars – Pupils Stroke Prevention Guidelines Aware your blood pressure (AHA) Stroke Prevention Guidelines Find out if you have Atrial Fibrillation (AF), a type of irregular heartbeat. Stop smoking No excess alcohol intake Aware your cholesterol If you are diabetic, carefully to control the diabetes Exercise Low sodium (salt) and low fat diet Aware to your circulation, consult doctor if having problem If you experience any stroke symptoms, call 911 immediately (999 in HK) Stroke Team Stroke Physician Neurologist Nurses Physiotherapist Occupational therapist Speech therapist Pharmacist Dietitian Social worker Clinical psychologist  Useful Web sources Local I. HKU Stroke 中風研究組 https://www.stroke.med.hku.hk/ II. Hong Kong Brain Foundation 香港腦科基金會 https://www.brain.org.hk/ III. Hong Kong Stroke Fund 中風基金 http://www.strokefund.org/eng/home.php IV. Hospital Authority 醫院管理局 – Smart Patient 智友站 – Stroke Information https://www21.ha.org.hk/smartpatient/SPW/en-US/Disease-Information/Disease/?guid=29ac1219-3d68- 4378-a2bd-09e111da3650 V. The Hong Kong Neurological Society 香港腦科學會 https://www.hkns.org/ VI. The Hong Kong Stroke Association 新建社 http://www.hk-stroke-a.org.hk/ International I. American Stroke Association https://www.stroke.org/ II. Asia Pacific Stroke Organization https://www.theapso.com/ III. European Stroke Organization https://eso-stroke.org/ IV. World Stroke Organization https://www.world-stroke.org/