‘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

1i

6in

1i

6in

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)

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