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 Neurology Cardiology

Migraine ALS Heart attack Arrhythmias

ParkinsonƎs Headache V
 Heart failure Valvular disease
Seizures Neuropathy
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 V
ectives

± Highlight some important differences and

similarities etween heart attack and
stroke
± Motivate you to prevent a stroke
 How is a stroke different from a
heart attack?
± A stroke is a sudden neurological deficit
caused y a lood vessel pro lem
± 2 types
± Ischemic strokes
± Hemorrhagic strokes
± The effects of a stroke are extremely
varied
 hy is heart attack easier to
recognize than stroke ?
± Painful ± Vften painless
± the stroke itself often
± Pu lic and health affects awareness of
care providers symptoms
commonly ± Poor recognition of
recognize symptoms and need
symptoms and for action
need for action
 ~espondents una le to name
1 warning sign or risk factor for stroke

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 hich of the following are
warning signs of stroke?
A. Sudden weakness or num ness of the face, arm or leg,
especially on one side of the ody
B. Sudden confusion, trou le speaking
or understanding
C. Sudden chest pain
D. Sudden trou le seeing in one or oth eyes
E. Sudden trou le walking, dizziness, loss of alance or
coordination
F. Sudden, severe headache with no known cause
A. Sudden weakness or num ness of the face, arm or leg,
especially on one side of the ody
B. Sudden confusion, trou le speaking
or understanding
C. Sudden chest pain
D. Sudden trou le seeing in one or oth eyes
E. Sudden trou le walking, dizziness, loss of alance or
coordination
F. Sudden, severe headache with no known cause
 Is heart attack easier to diagnose
than stroke?
± Diagnosis is ± Diagnosis is
relatively easy. difficult. Many
EKG and cardiac things can mimic
enzymes readily stroke. There is
no lood test for
availa le. stroke. M~I not
readily availa le.
M~I with diffusion weighted
imaging

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    !!
here is the stroke?
CT scan of arteries of
neck and head
Are the causes of heart attack and
stroke different?

± Cause is usually ± Atherosclerosis is

rupture of a plaque important, ut there
within a coronary are many other
artery causes
± So the diagnostic and ± Determining the
treatment strategy is cause in an individual
fairly straightforward is often a deductive
(find the lockage process
and open it up!)
There are many potential
causes of stroke
 Stroke is not
ust a rain disease
and often the rain is
ust an
innocent ystander
± Usually caused y diseases that are affect
the entire vascular system
(atherosclerosis)
± Material locking rain arteries usually
comes from outside the rain (atrial
fi rillation, carotid artery disease)
 How is a Cardiologist different
than a Neurologist

± Basically a plum er or ± Diagnostician

electrician ± Detective
± Daredevil
 Case

± Healthy 61 year-
year-old man developed
confused speech 1 day after falling out of
a tree.
± August 11th, topping a tree, fell and
sustained a left collar one fracture and
small puncture of the lung.
± Next night suddenly developed confused
speech.
± Trauma (fall out of a tree)
± Vascular pro lem (leg vein in
ury)
± Blood disorder (hypercoagula ility)
± Congenital heart anomaly (patent foramen
ovale)
 How are heart attack and stroke
SIMILA~?
± Time is critical
± The first priority is to save tissue at
risk
Kidwell 2004
ñou need to call 911 ASAP for oth
heart attack and stroke!
± There is a 3 hour time limit for the medication
t-PA, and the sooner itƎs given the etter!
± Future strokes may e prevented if we identify
the cause of stroke ASAP
± People rought y am ulance are treated faster
± Neurological deterioration and other
complications may e prevented if a patient is
hospitalized earlier
± wune 2006 7AM: A 75 year-
year-old
woman collapsed at home, rought
to her local emergency room. She
cannot move her right side or speak.
The doctors there are not
comforta le using t-
t-PA so transfer to
DHMC is requested.
± 1:02 PM: Arrival DHMC ED.
4:49 PM artery is opened
± The system needs to e very
coordinated
P~EPA~ED ~APID EVALUATIVN INDIVIDUALIZED
CA~E
Improving Stroke Care
at DHMC

P~VTVCVLS TV DEC~EASE E~~V~S

A TEAM APP~VACH
 ays everyone here
can prevent a stroke

± Identify and control risk factors

± If a warning sign of stroke occurs, get
attention
10y risk 88% !
10y risk 13% !
± Preventing a heart attack or stroke is
MUCH more effective (and safer) than
a procedure!
   
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18/111 (16%) received t-PA
Average cost for transportation $4,623
2004: 144 pts ~x t-PA
50% had t-PA started at 1
of 47 referring hospitals
>50% of these have <60
eds
MGH TeleStroke
 Effectiveness of Stroke Prevention
A solute risk reduction in a year:
Strategy A~~ (%)

± arfarin for atrial fi rillation 8

± Carotid endarterctomy for symptomatic dz 4
± Smoking cessation 2
± Antihypertensive therapy if BP elevated 2
± Cholesterol lowering medications 2
± Aspirin 1-2
" #
$%&' !!!
anticoag
V

 
  
 

 Stroke arning Signs

± Sudden weakness or num ness of the face, arm
or leg, especially on one side of the ody
± Sudden confusion, trou le speaking
or understanding
± Sudden trou le seeing in one or oth eyes
± Sudden trou le walking, dizziness, loss of
alance or coordination
± Sudden, severe headache with no known cause
 hat is a TIA ?
± Transient Ischemic Attack=Stroke
symptoms that resolve with a short time.
± Can e a warning sign of impending
stroke.
± The highest risk period of stroke following
a TIA is the first 2 weeks.
± The risk of stroke soon after a TIA can
now e estimated.
 ABCD2 Tool
~isk of stroke following TIA
A Age> or = 60 1
B Blood pressure >140/90 1
C Clinical features
unilateral weakness 2
speech impairment 1
D2 Duration
> 60 min 2
10-59 min 1
Dia etes 1
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hich action would you take if you
thought someone was having a
heart or stroke?
A. take the person a hospital
B. advise the person to call a doctor
C. call 911
D. call a spouse or family mem er
E. do something else
hich action would you take if you
thought someone was having a
heart or stroke?
A. Take the person a hospital
B. Advise the person to call a doctor
C. Call 911
D. Call a spouse or family mem er
E. Do something else
± Bleeding into the ± Brain
heart doesnƎt hemorrhage is
occur common
CT scan: ischemic stroke
Intracere ral hemorrhage
at 1 hour and 6 hours
Intra--arterial throm olysis
Intra
Time window=6 hours
High resolution M~I to identify the
u
 plaque
± ñou need to open the artery
 Like with heart disease, the
treatment and prevention of stroke
needs to e individualized!
± A 65 yo man attends a vascular disease
prevention fair and an ultrasound shows a
lockage of his left carotid artery. He is
told to speak to his doctor ASAP and he
ecomes worried that there is a Ɛtime
om  ticking in his neck.