The role of the neurologist in the care and cure of patients

What neurologist may add to the care and cure of of stroke

patients, or…

Peter Sandercock

Perugia December

2007

What is the place of the neurologist in stroke medicine?

In America…to perform many expensive investigations?

In the UK…to diagnose a rare cause of stroke

by clinical examination?

Role of neurologist in acute phase of stroke

Acute care: the neurologist will often be involved at all points in the ‘path of acute care’

Acute brain attack

If neurologist finds NO clinical evidence of ‘stroke mimic’, e.g.: epileptic seizure, migraine, Hypo- orhyper-glycaemia, or other obvious non-stroke diagnosis -> do CT

CT/MR Scan Non-stroke pathologySubdural, tumour

Scan: Normal, Infarct, intracerebral bleed, SAH

NIHSS helps distinguish ‘stroke’ from ‘non-stroke mimic’

NIHSS and ‘stroke’ vs ‘not stroke’

• About one third of patients with NIHSS 1-4 do not have an acute stroke

• NIHSS > 4 is a useful indicator that the deficit is due to a stroke

If CT or MR excludes blood and ‘stroke mimic’ neurologist decides

Probably ELIGIBLE for thrombolysis’• Known time of onset • Unilateral neurological signs • Increasing NIH score (>4)• Abnormal vascular signs (AF, PVD)

Probably NOT ELIGIBLE• Deficit first noted on waking from sleep• Prior cognitive impairment• Loss of consciousness at/soon after onset• Seizure• Can walk now ( too mild)

Some clinical problems, where neurologist very helpful

? POCI

• Man 75 years, arrives at ER 3.5 hrs after, sudden onset ‘dizziness’ and unsteadiness

• Exam: Unsteady when standing

• No limb ataxia• NIHSS = 2• ? POCI

?Hyper-attenuating basilar artery?

What to do?

• MR and angiography not available

• ‘Outside 3 hour window’: iv thrombolysis not approved

• If this is a basilar thrombosis, could he deteriorate rapidly if not treated?

• Randomised in IST-3

Migraine or ischaemic stroke?

This 53-year-old female patient with acute headache and right-sided hemianopia. Not treated with thrombolysis, because significance of

abnormality not appreciated

Krings et al, Stroke. 2006;37:399-403.)

Initial CT (A to C) show a hyperattenuating posterior cerebral artery (arrow in B). On follow-up (D to F), a large PCA infarction is now visible.

Blood on CT can be

a) missed if not looked for carefully

b) Have disappeared if the patient presents a day or more after the haemorrhage

Subarachnoid haemorrhage with focal deficit

(eg hemiparesis) due to delayed cerebral ischaemia

Patient has clinical diagnosis of ‘acute stroke’ but CT is normal.

• The time of onset of stroke symptoms is known precisely

• You have an experienced stroke physician/stroke neurologist able to see the patient urgently in A&E or at CT scan room

• Urgent non-contrast CT scan is interpreted by someone with expertise in acute stroke CT

• -> MRI not essential; its place in routine acute stroke care yet to be determined

Can you diagnose ‘acute ischaemic stroke suitable for thrombolysis’ without

DWI MR? Yes, if:

‘Telephone neurology’ in acute stroketo patient / family: confirm diagnosis, seek

consent. Neurologist to general physician: advice, IST-3 helpline

Role in prevention

Neurologists and ‘dizzy turns’

• a 50 year old woman (depressed, just started on anti-depressant) has an episode where speech is ‘dizzy and confused’.

• At emergency department: BP 180/90. Normal examination.

• diagnosis ‘?reaction to anti-depressant;’

• Management ‘stop drug and go home’, but does refer neurologist

Neurologist asks about other symptoms: the day before she describes a brief episode of

loss of vision in the left eye (amaurosis fugax).

The correct diagnosis

• An ocular and a cerebral TIA in the distribution of the left internal carotid artery

• High early risk of stroke

• Immediate action required

High early risk of stroke after TIA

0

2

4

6

8

10

12

14

0 7 14 21 28

Days

Ris

k o

f st

roke

(%

)

OXVASC

OCSP

Lancet 2005; 366: 29-36

10% risk of stroke by 7 days

Management• Start dual antiplatelet therapy, statin

and anti-hypertensive immediately

• Immediate carotid ultrasound study - often performed by neurologist

Overall, 62% of patients referred with ‘TIA’ were found to have other

diagnoses

migrainesyncope/pre-syncope‘funny turn’ (= event it is not possible to categorise)vertigo or dizziness onlyepilepsytransient global amnesiacerebral tumour

Oxfordshire Community Stroke Project: of 542 patients referred with possible TIAs, in 317 (62%) the diagnosis was not a TIA

Neurologist organises management of TIA and minor stroke

• Urgent brain imaging if symptoms persist > 1-2 hours

• high ABCD2 score, ?admit to hospital for treatment & investigation

• Aspirin• Add dipyridamole in high-risk cases• Statin to lower cholesterol• Blood pressure lowering: diuretic and angiotensin

converting enzyme (ACE) inhibitor• Urgent non-invasive carotid imaging ->

endarterectomy < 2 weeks if severe stenosis

Role of neurologist in care of stroke patients?

The neurologist is often the leader of the multi-disciplinary team on the

stroke unit

Research led by neurologists identified effective stroke

treatments• Treatment acute ischaemic stroke

– Aspirin, – Thrombolysis

• Prevention– Anticoagulants in AF– Antiplatelet for secondary prevention after

TIA/stroke– Carotid surgery for symptomatic stenosis

• Diagnosis of in acute phase

• Management in the acute phase

• Lead multidisciplinary team on stroke unit

• Co-ordinate stroke services, including secondary prevention

• Lead research

The neurologist has many roles in cure and care of stroke