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Acute stroke in primary care
Executive Editor, InnovAiT
Email: chantal.simon{at}oxfordjournals.org
Hippocrates (460–370 BC) provided the first recorded description of the phenomenon of sudden paralysis. He termed the condition ‘apoplexy’ from the Greek meaning ‘struck down with violence’. The modern-day term ‘stroke’ is derived from a literal translation of this. Stroke is the most common cause of adult onset disability in the UK and is a devastating condition.
Management of acute stroke straddles three curriculum statements within the GP Curriculum:
Acute stroke is a primary care emergency. With the advent of thrombolysis, speed of admission is paramount. Curriculum Statement 7 requires GPs in training to be able to recognise and evaluate acutely ill patients, describe the differential diagnosis for presenting symptoms, decide whether urgent action is necessary and appreciate the response time required in order to optimise the outcome. It requires GPs in training to be able to use telephone triage systems and to be able to decide to use an ambulance where speed of referral to secondary care is paramount. GP Curriculum Statement 15.1 recognises stroke and transient ischaemic attacks (TIAs) as important conditions that GPs in training should be able to recognise and have a thorough knowledge of. Trainee GPs must know when to intervene urgently when patients present with a cardiovascular emergency such as stroke. Statement 15.7 also requires GPs in training to understand the indications for emergency referral of people with stroke and intracranial haemorrhage. Finally, Statement 15.1 requires GPs in training to be able to describe the key research findings that influence management of cardiovascular problems such as acute stroke management.
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The GP curriculum and...
Definitions |
Definitions |
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Stroke is a syndrome typified by rapidly developing signs of focal or global disturbance of cerebral functions, lasting for 24 hours or more, or leading to death, with no apparent causes other than of vascular origin (WHO, 1976). A stroke is classified as a transient ischaemic attack (TIA) or ‘mini-stroke’ if neurological symptoms resolve within 24 hours.
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Epidemiology |
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Every 5 minutes someone in England will have a stroke (approximately 110 000 strokes and a further 20 000 TIAs occur in England each year), and around one in four people can expect to have a stroke if they live to 85 years of age. Although the incidence of stroke doubles for every decade over the age of 45 years, a quarter of strokes occur in people under the age of 65 years. People of African or Caribbean ethnicity are at twice the risk of stroke, especially of having a stroke at a young age.
Mortality
Stroke accounts for 11% of deaths in England and Wales each year. This makes it one of the top three causes of death. The mortality rate for stroke has declined in the past 10 years by around 30%, due to a reduction in incidence due to improved primary and secondary prevention measures. The chance of dying from a stroke has remained constant at around 24% over that time.
Disability
There are more than 900 000 people who have had a stroke living in England. Around half of stroke survivors are left dependent on others for everyday activities.
Cost of stroke
Stroke care costs the NHS about £2.8 billion a year in direct care costs (Table 1) and costs the wider economy some £1.8 billion more in lost productivity and disability. Stroke will become increasingly expensive as the number of people living with stroke increases. The percentage of people over the age of 65 years in England is projected to rise from 16 to 23% by 2031, and the total costs of stroke care are predicted to rise in real terms by 30% over the same time period.
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Causes and classification |
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The majority of strokes (around 85%) are caused by infarction (Fig. 1). This in turn may be caused by atherosclerotic occlusion or embolism. Common sources of embolism are the left atrium (usually secondary to atrial fibrillation) or left ventricle (commonly due to myocardial infarction or heart failure). Rare causes of infarction include sudden drop in blood pressure (watershed infarct), sickle cell crisis, vasculitis, venous-sinus thrombosis and carotid artery dissection. Ischaemia causes direct neuronal injury due to lack of blood supply. Risk factors for cerebrovascular infarction are listed in Box 1.
Box 1. Risk factors for cerebrovascular infarction Age
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Intracerebral or subarachnoid haemorrhage (SAH) accounts for around 15% of all strokes (Fig. 1). Haemorrhage causes direct neuronal injury and pressure exerted by the blood results in adjacent ischaemia.
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Presentation and differential diagnosis of stroke |
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Stroke typically presents with sudden onset of central nervous system symptoms or stepwise progression of symptoms over a period of days. The precise symptoms depend on the area of the brain affected (Fig. 2). On examination, conscious level may be normal or decreased, and there are neurological signs. Check blood pressure, pulse rate and rhythm and listen for heart murmurs and carotid bruits as this may give a clue about the cause of the stroke. Examine for signs of infection or neoplasm as these are part of the differential diagnosis for stroke.
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Triage of symptoms
Sometimes stroke can be difficult to diagnose, particularly if the signs are subtle. Several quick screening tools have been developed that can be used over the telephone to assess whether a patient has had a stroke. The Face Arm Speech Test (FAST) has been developed as a stroke identification instrument. The test assesses three neurological signs of stroke:
- Facial weakness—Can the person smile? Has their mouth or eye drooped?
- Arm weakness—Can the person raise both arms?
- Speech disturbance—Can the person speak clearly and understand what you say?
If the patient has any facial weakness, arm weakness or speech disturbance, then the patient should be advised to go directly to hospital, without waiting for a GP visit or coming to the surgery before doing so.
Differential diagnosis
Patients who have suffered a previous stroke may incorrectly appear to have another if they decompensate after recovery, for example due to infection or a metabolic disorder. The other common differential diagnoses of stroke are as follows:
- Space-occupying lesion—primary or secondary neoplasm, cerebral abscess
- Trauma—subdural haematoma, traumatic brain injury
- Epileptic seizure and/or post-ictal state
- Migraine and
- Multiple sclerosis
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Acute management of stroke |
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Current guidance is that all patients who have suffered an acute stroke should be admitted to hospital. Speed is imperative, so advise patients or carers contacting primary care with symptoms suggestive of stroke to call for an emergency ambulance for transport to hospital immediately. Thrombolytic therapy, administered up to 6 hours after ischaemic stroke, significantly reduces the proportion of patients who die overall, or suffer long-term dependency (odds ratio 0.84). This is at the cost of an increase in death rate within the first 10 days (odds ratio 1.81), mainly due to fatal intracranial haemorrhage. Do not give aspirin prior to admission. Patients cared for in a defined stroke unit with organised stroke services are more likely to survive, have fewer complications, return home and regain independence than patients who stay on a general medical ward or remain in primary care.
In reality, not all patients suffering a stroke will be admitted to hospital. For example, it might not be appropriate to admit very elderly patients already in nursing home care, and some patients, especially those with milder strokes, may present to a GP several days or weeks after a stroke, or refuse admission. If appropriate, in these cases start aspirin and investigate and refer in the same way that you would for a TIA.
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Prognosis following stroke |
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Of patients who suffer a stroke and survive the initial phase, 10% have no residual deficit but the rest have some degree of lasting disability. The vast majority of recovery has been achieved within the first 3 months after the stroke, although functional recovery and recovery of speech may continue for some time after that.
Loss of consciousness at the time of the stroke, severe motor deficit, cognitive deficit, lack of early improvement and poor swallowing ability 3 weeks after stroke are poor prognostic signs. Outcome tends to be worse in those with diabetes, heart disease, previous stroke or other disability, incontinence, visual or other sensory loss or an abnormal ECG. By the end of the first year 75–85% of stroke patients are walking; 48–58% are independent in activities of daily living and 10–29% require residential care.
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Care after stroke |
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Stroke is a devastating illness for the patient. Provide information and support (Box 2). Monitor and reassess frequently after discharge from hospital. Continue follow-up even when specialist services have finished as stroke is a long-term problem. Monitor secondary prevention measures. Remember aids and appliances can help and refer as needed. Check patients are claiming all the benefits that they are entitled to. Refer for specialist rehabilitation if there is any deterioration in function.
Box 2. Information and support for patients and carers
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Remember to address psychosocial issues as well as physical disability. Depression is common, affecting up to half of all those who have suffered a stroke. Use the NICE depression screening questions to detect depression (Box 3). A positive response to either of these questions should prompt further assessment. If the patient cries (or laughs) with minimal provocation, consider emotionalism—impairment in the control of crying. This is common after stroke and does not imply depression.
Box 3. NICE depression screening questions
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Concordance with medication
After stroke most patients will be prescribed at least one drug to reduce their risk of further stroke, but some have memory loss or problems opening containers. All patients should receive verbal and written information about their medicines and receive help with packaging, for example drugs in bottles with non-childproof tops.
Carers
Stroke is a family illness. Involve the family in the care plan and include family members as part of the care team. Provide information and support (Box 2). Informal carers of stroke patients are usually spouses or close relatives. Depression among carers is common. One study showed that 40% are significantly depressed within 6 weeks of the stroke patient returning home and this depression persists for more than a year after discharge. Consider using the NICE depression screening questions (Box 2) to detect depression and enable additional support to be provided.
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Transient ischaemic attack |
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History of TIA is as for stroke but recovery takes place within 24 hours of initial symptoms. Patients often present to primary care after symptoms have resolved. Patients with a history of TIA have a 20% risk of stroke in the following month with highest risk in the first 72 hours. Risk can be predicted using the ABCD2 scoring system (Table 2).
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Management of TIA
Admit if a patient suffers more than one TIA within a week. Consider admission or same day outpatient assessment if the patient falls into a high-risk group on the ABCD2 score.
If not admitting the patient, once all symptoms have stopped, start aspirin 75–300 mg o.d. Check blood for full blood count, ESR, renal function, lipids and glucose. Consider a clotting screen and thrombophilia screening if there is a family history of thrombosis. Check an ECG and chest X-ray. Start treatment for risk factors, for example advise the patients to stop smoking or start antihypertensives if the patient has high blood pressure.
Refer all patients for assessment and further investigation to a specialist service, such as a specialist TIA clinic, or neurovascular clinic. The National Stroke Guidelines state that all patients with a history of TIA should be seen in a specialist clinic within a week of the event. Specialist investigations include CT or MRI scan to confirm diagnosis, carotid dopplers if there were carotid artery territory symptoms and echocardiogram if there is a history of recent myocardial infarction, evidence of congestive cardiac failure or left ventricular failure or a murmur.
Amaurosis fugax
Amaurosis fugax is a form of TIA due to emboli passing through the retina. It causes brief loss of vision for a matter of minutes ‘like a curtain’. Management is as for TIA (above).
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Subarachnoid haemorrhage |
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An Subarachnoid haemorrhage (SAH) is a spontaneous bleed into the subarachnoid space. SAH affects 6–12 per 100 000 of the population per year and constitutes about 6% of first strokes. It affects women more commonly than men. The peak age of SAH is 35–65 years and half of those who suffer a SAH are under 55 years of age. It is frequently fatal and 10–15% die before reaching hospital.
Causes
No cause is found for about 15% of cases of SAH. Rupture of a congenital berry aneurysm accounts for around 70% of cases and other vascular abnormalities including arterio-venous malformations account for most of the rest. Rare causes include bleeding disorders and mycotic aneurysm due to endocarditis. Hypertension, smoking and excessive alcohol intake are risk factors and each roughly doubles the risk of SAH. Berry aneurysms may run in families and are associated with polycystic kidneys, coarctation of the aorta and Ehlers-Danlos syndrome. Patients with a positive family history tend to have their first SAH at a younger age and have larger and multiple aneurysms.
Presentation
SAH typically presents as a sudden devastating headache—‘thunderclap headache’—that is often occipital. Rarely (6%) this headache may be preceded by a ‘sentinel headache’ representing a small leak ahead of a larger bleed.
Vomiting and collapse with loss of consciousness, sometimes accompanied by fitting and/or focal neurology follow. On examination there may be nothing to find initially. Neck stiffness takes around 6 hours to develop. In the later stages patients may have a reduced level of consciousness, signs of raised intracranial pressure such as papilloedema, focal neurology and/or retinal or other intraocular haemorrhages.
Management
If SAH is suspected, admit the patient immediately as a medical emergency. Only one in four patients admitted with suspected SAH turn out to have one. In most no cause for the headache is found.
Specialist management is aimed at establishing a diagnosis, preventing further bleeding and reducing the rate of secondary complications such as cerebral ischaemia or hydrocephalus. Once diagnosis is established, treatment is with calcium antagonists to help to reduce cerebral blood vessel spasm and cerebral ischaemia. Nimodipine is the drug of choice. Definitive treatment with endovascular or surgical obliteration can then be undertaken.
Key points
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References |
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