1.QUALITY OF LIFE IN POST-STROKE PATIENTS - ROLE OF NOOTORPIL Prof. A.V. SRINIVASAN29th June 2003Madras Medical College, Chennai-3

2. STROKE Third cause of death after heart disease andcancer Prevalence rates are around 500- 800 /100,000 Enormous economic consequences A bad teacher complains;A good teacher explains; The best teacher inspires; 3. STROKE IN INDIA A huge base of population A prevalence rate of 900/ 100,000 can lead to anepidemic of stroke 2% of all hospital admission, 4-5% of medical and20% of neurological admission have CVD Incidence of stroke in younger persons ( more benefits from Endarterectomy Minor stroke -No disability Subst Storke -Good recovery do doppler Medically fitSerious, sincere, systematic studies, surely secure supreme success 37. Guide 10: (B) Management: Fever (Worst Prog.) Reith 1996 Hypoxia ( Moroney 1996) - Exac. by seizuresPneumonia and Arrythmias - Worst outcome Hyperbaric O2 ineffective (Nighoghossaln1995) Haemodilut. Plasm Expanders; venesection No evidence for efficacy (As plund - 1997)Check ABG only if Hypoxia suspected. Why is thought, being the secretion of the brain,more wonderful than gravity, a property of matter? 38. Guide 11: (A) Steroids and Hyperosmolaragents Unproven treatment - should not beused Tumor oedma responds but not cytotoxicstroke oedma qialbash 1997 - No effect onsurvival or improv. In funct. Outcome Manntol - (Boysen 1997) - short term effectivestatistically in conclusiveGod is a comedian performing before an audience that is afraid to laugh 39. Guide 12: (B) - Blood Pressure Defer - acute reduction of BP - 10 days unlessHT Encephalopathy or adrtic dissection present Moris 1997 - Increase BP - falls in 10 days UK - 5mm in D.B.P. 1/3 storke - Low BPprompt correct of hypovoll. and withdrawal ofhypotonic drugs Collins 1994 - HT - Prim. stroke prevent Neal 1996 (Current RCT) - HTs in strokesurvivors -study neededMan is made by his beliefs; as he beliefs, so he is 40. Guide 13: (A/B) - AF AF / ISCH Stroke/ Mild disability - warfarinafter 48 Hrs (Longer for larger) Aspirin for others EAFT 1995 Less than 2 PT - No effect SPAF 1996 > 5 - BleedingThe word shall perish not for lack of wonders but lack of wonder 41. Guide 14:(B/C) - Blood sugar Weir (1997) > 8 mm d/Lit - Poor outcome Acute MI + 11 mm d/Lit - Intensive Insulin -improved (Malmberg 1997) Guide 15: (A) Cholesterol Prosp. Study collob.: 1993 - Epidem study donot support Blaun 1997: Metranauetic - Chollest & statin30% decrease - stroke in CAHD patients. Sacks 1996 - Tot chol: decrease to 4.8mmol/Lit benefits 42. Guide 16: (A/C) Deep vein thrombosis Kalra 1995 - 10 days - stroke Pts - 50% Sandercock 1993 - Pul embol 6-16% only Ist 1997 - 5000 IV or 12500 twice daily -Hemorrage greater Gradual stocking value - useful in Surg - pts butits value not evaluated - (Wells 1994) Use with caution - if periph artery insuf. ispresent hence do not use heparin on stockings. In any field, find the strangest thing and explore it 43. Indications for Carotid EndarterectomyDegree of Carotid Stenosis Recommendationby NASCET criteriaSymptomatic disease70% to 99% CEA50% to 69% CEA if in high risk group (men and patients with hemispherical TIAs or strokes)60% Consider CEA 44. Guide 17: (A/B) Pressure sure Event health care (1995) specialised low pressure mattress systems to be used than stand Hospital - mattress Manag of infarction Guide 18: (A) Aspirin 75 - 150 /Day 3 yrs 40% reduces of vascular events in 1000 pts (APTC - 1994) Stroke sub type value ? (TACI, PACI, LACI, POCI) Dienners - 1996, synergy possibel with clopidogrel ticlopidine etc. 45. Anti Coagulation Warfarin - AF In sinus rhythm - uncertain Spirit 1997 low dose ABP + Warfarin in TIA &Minorstorke - Stopped of HE Heparin (IST 1997) - Signif. reduction in earlydeath (12 fewor in 1000) not better than aspirin So avoid Heparin (A)There are sixty trillion cells in the human body 46. Thrombolysis (A) Warlow 1997 - Uncertain clinical benefit atthe expense of greater hazard avoid -thrombolysisMen of Genius Adm ired: Men of W ealth enviedwom of power feared but only enwom of character are trusted en A- Friedman 47. Common Sites and their incidencePutaminal Haemorrhage -35%.Lobar Haemorrhage- 25%Thalamic Haemorrhage - 10-15%Caudate Haemorrhage -5%Pontine Haemorrhage- 5%Cerebellar Haemorrhage - 5-10%Baby hears 30,000 cycles / sec, teenage boy hears 20,000 and old hears 4,000 cycles / sec 48. Guide 20: (I) Hemorrhage Hankey and hon 1997: Supra tentorialevacuation for ICH is controversial - Avoid Infra tentorial - Yes Main Indication - Deteriorating or depressedconsciousnessMotivation is the Spark that lightsthe Fire of Knowledge and fuels the engine of Accomplishment 49. Causes of deterioration in stroke Neurological Non-NeurologicalProgression/completion of strokeInfectionsExtension/Early recurrenceMetabolic derangementHaemorrhagic transformation of an DrugsinfarctDeveloping cerebral edema HypoxiaObstructive hydrocephalus HypercapniaEpileptic seizuresIncorrect diagnosis 50. 2 2 4 P ts Guide 21 : Ventilation131 I n t u b a tio n93 N o t In tu b -Decreased level of consciousness - increased 6 4 D is c h a r 6 7 D ie d mortality and poor final 3 4 R e d ta g 2 1 d is c h t on ver h om e 8 D is c fo rp a llim a 1 D is c H om e outcome - Absent pupillary light 3 D ie d7 D ie d3 D ie d responses - poor prognosisIt is a great misfortune not to possess sufficient wit to speak wellnor sufficient judgment to keep silentLa Broyers character 51. Two diverging/converging pataways associated with VaDRisk factor CVD Ischemic Brain injuryMRI lesion Clinical syndromeHTNArteriosclerosis 1. occlusion complete infarct lacune lacunnar stateArteriosclerosis 2. Hypoperfusion incomplete infarct WHSM Bingswanger syndrome He who cannot forgive others destroy the bridgesover which he him m pass - Annoy self ust 52. Pathogenesis of dementia due to VaD1. Lacunar hypothesis2. Binswangers subtype of VaD3. VaD with coexisting Alzheimers diseaseIn all of us, even in good men, there is a wild - beast nature which peers out in sleep 53. Clinical syndromes1. Lacunar state --- 85%2. Strategic infarct dementia(e.g. thalamic dementia) --- unknown %3. Binswangers syndrome --- 10 15% The True Art of Memory isThe Art of Attention - S.Johnson 54. Features suggestive ofvascular dementiaFrom the historyOnset associated with a strokeImprovement following acute eventAbrupt onsetFrom the examFindings typical of stroke e.g., hemiparesis,hemianopiaFrom imagingInfarct(s) above the tentorium 55. Patterns of blood supply to thecerebral hemispheresVascularArterial supply Collateral supplydistributionCortex shorterCorpus callosumShorterSub cortical U fibers IntermediateInter digitatingExternal / extremeIntermediatecapsulesBasal Ganglia LongCentrum semiovale /PVWMLong 56. Categories of vascular DementiaCategoryClinical presentationLacunar infarctionsProgressive dementia, focal deficits, or apathetic, frontal-lobe-like syndrome, may have no stroke historySingle strategic infarctions Sudden onset aphasia, agnosia, anterograde amnesia, frontal lobe syndromeMultiple infarctions Step-wise appearance of cognitive & motor deficitsMixed AD VaD Progressive dementia with remote or concurrent history of strokeWhite matter infarctions Dementia, apathy, agitation, bilateral cortico-(Binswangers disease) spinal/bulbar signs 57. DiagnosisVascularMechanism of Pathological distribution Brain injuryphenotypeInfarctSingle artery Acute ischemia Multiple lacunarSmall arterioleinfarctsSingle artery Acute ischemia Single strategically placed lacunar infarctBorder zone ChronicWhite matterSmall arteriole hypo perfusion demyelination and axonal loss 58. Diagnostic criteria1. Hachinskis ischemic score2. DSM IV criteria3. ADDTC criteria4. NINDS AIREN criteria5. Binswangers criteria Starving Emotion- Humor Less; Rigid; Stereotype Repressing Emotion -Literal; Holier than thou Encouraging Emotion - Performs in Life Discourage Emotion -Poison Life Juseph Colins. 1868 59. Short comings1. Not interchangeable hence four fold rise in frequency2. DSM IV R most liberal3. NINDS- AIREN criteria conservative4. Gold standard for VaD (pathological definition difficult)5. Most of the criteria failed to distinguish between small and large vessel subtypesTake time to think; it is the source of powerTake time to read; it is the foundation of wisdomTake time to work; it is the price of success 60. Diagnosis of Dementia after stroke4 sets of criteria are usedSensSpec1.Hachinski ischemic score89%89%< 4 AD / 18, > 7 MID / 182. DSM IV43%95%3. NINDS AIREN 50%98%4. ADDTC criteria50%90% A (Neurologists) life is like a piece of paper on which everyonewho passes by leaves an impression- Chinese proverb 61. Clinical characteristics of Neuro behavioral syndrome of VaD Mental changes of dementia with singlebrain lesion Sub cortical infarcts Multi Infarct Dementia: - Sub cortical arterioscleroticleukoencephalopathy We Sometimes think we have forgotten something whenin fact we never really learned it in the first placeImp.Your Memory Skills 62. AD Vs VaDAD VaDNeuro transmitter defect Hemodynamic defectFemale predominanceMale predominanceGradual onsetAbrupt onsetSteady deterioration Stepwise deterioration, fluctuating courseBP normalHypertensionNo history of stroke History of strokeGlobal decline in cognitive function Focal neurological symptoms and signsUnlikely to respond to treatment May respond to a drug which modifies microcirculation and enhance cerebral tissue perfusion 63. Prognosis1. Risk factorsAdvanced ageEducationDevelops dementiaLacunar subtypefollowing ischemicLt. Hemisphere CVA strokeNon white Whatever the Mind can conceive and Believe,the mind can AchieveNapoleon Hill 64. Prognosiscontd.2. In Lacunar stroke - Leukoariosis is a poor prognosis3. Recurrence of strokeHence Atrophy cognitive impairment WMSH are inter related in VaD Many Ideas grow better when transplanted into anothermind than in the one where they sprang UP O.W. Holmos 65. Prognosis contd..,Neuro imaging phenotype CT lucency (lacunes and leukoariosis) MRI hyper intensity (lacunes and WMSH)At twenty the will rules At thirty the intellectAt forty the Judgment 66. Prevention and Treatment ofvascular dementiaI. Brain at risk stage The aged Hypertensive Smokers Diabetics Atrial fibrillators Cardiac patients When they tell you to grow up, they mean stop growingP. Diccaso 67. II. Pre-dementia stagePatients with TIAPatients with strokePatients with subtle cognitiveinfarctionsPatients with silent cerebral infarctions Expert is one who think to his chosen mode of ignorance 68. III. Dementia stage Cardiac embolism Atherosclerotic cerebrovascular disease Hypertensive cerebrovascular diseaseMaintaining the right attitude is easier thanregaining the right mental attitude 69. Potential therapies of vascular dementia1. Brain at risk stageSmoking cessationExercise (prevention and management of diabetes)Diet (control of diabetes, hyperlipidemias, obesity)Antihypertensives (ACE inhibitors and ca++ channel-blockers maybe particularly suitable)Lipid lowering agentsAnticoagulants (for atrial fibrillation)Aspirin (for selected patients at high risk) 70. 2. Pre-dementia stageCarotid endarterectomy (symptomatic patients with-carotid stenosis of 70-99%)AnticoagulantsAspirinTiclopidineAgents that interfere with amyloid deposition vesselsCa++ channel blockers (pre treatment to attenuate-effect of infarcts) NATURE, TIME AND PATIENCEare the 3 great physicians 71. 3. Dementia stageAntidepressentsAntihypertensives 6 mm of Hg reduction in systolic or diastolicBP -reduces the risk of stroke by 40%Cholinergics - Tacrine, Galantamine, rivastigmine, donepezilNMDA antagonist MemantineAspirinTiclopidineA womans desire for revenge outlasts all her other emotions 72. Prevention & TreatmentAnti dementia drug trials (not based on subtype of VaD)Alkaloid derivatives(hydergine or nicergoline)PentoxyfyllinePiracetam Modest benefitMemantineDonepezilGingko bilobaGive us the GRACE to acce pt with se re nity the thing s that canno t bechang e d the COURAGE to chang e the thing s that sho uld be chang e d and the WISDOM to kno w the diffe re nce 73. Strategies to prevent STROKE-TO-DEMENTIA TEN-STEP APPROACH1. Treat hypertension optimally2. Treat diabetes3. Control hyperlipidaemia, use dietary control for diabetes, obesity and hyperlipidaemia4. Persuade patients to cease smoking and decrease alcohol intake5. Prescribe anticoagulants for atrial fibrillation6. Provide antiplatelet therapy for high risk patientsThought is the labour of the intellectReverie is its pleasure 74. Strategies to prevent STROKE-TO-DEMENTIA contd7. Perform carotid endarterectomy for severe (>70%) carotid stenosis8. Recommend lifestyle changes (e.g., weight loss, exercise, reduce stress, decrease salt intake)9. N-methyl-D-aspartate receptor antagonists, antioxidants)10. Intervene early for stroke and transient ischemic attacks with neuroprotective agents (e.g., propentofylline, calcium channel antagosists, - ? Rivastigmine 75. READ not to contradict or confute Nor to Believe and Take for Granted but TO WEIGH AND CONSIDERTHANK YOUMy Opinions are founded on knowledge but modified by experience