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Neurogenic Pain and DepressionNeurogenic Pain and Depression
Prof. A.V. SRINIVASAN,MD, DM, Ph.D, F.A.A.N, F.I.A.N.D.Sc
Emeritus Professor
The Tamilnadu Dr. M.G.R. Medical University
Former Head
Institute of Neurology, Madras Medical College
Prof. A.V. SRINIVASAN,MD, DM, Ph.D, F.A.A.N, F.I.A.N.D.Sc
Emeritus Professor
The Tamilnadu Dr. M.G.R. Medical University
Former Head
Institute of Neurology, Madras Medical College
20-1-11
Cerebrovascular Cerebrovascular EmergenciesEmergencies
Is survival a mere stroke of Luck?
“My Opinions are founded on knowledge but modified by experience”
Every minute matters: ‘time is brain’Every minute matters: ‘time is brain’
Expert is one who think to his chosen mode of ignorance
INTRODUCTIONINTRODUCTION
Perceptual Sense (Observation) Word Sense (Recording) Common Sense (Thinking)
– Will lead you to get - Clinical Sense
“ He who cannot forgive others destroys the bridge over which he himself must pass” - Annoy
Cerebrovascular disease – Cerebrovascular disease – Mind boggling factsMind boggling facts
CVD is the most disabling of all neurologic diseases. 50% of survivors have a residual neurologic deficit.
Greater than 25% require chronic care.
World wide incidence: 2/1000 population/annum1
Incidence in people aged 45 – 84 years: about 4/10001
Incidence in India: was 36/100,000 for the year 1998-19993 in a study in Calcutta
Incidence of mortality due to stroke (India: WHO study): 73/100,000 per year2
1.A practical approach to management of stroke patients; 1996; 360-3842. Epidemology of cerebrovascular disorders in India; 1999; 4-19
3. Neuroepidemiology 2001;20:201-207
If you think you can or you can’t You are always right
• CVD 6.7 %
• MI 2.5 %
• Death 7.2 %
• CVD, MI, Vascular death 8.6 %
• CVD, MI, Death 10.3 %
Annual risk CVD, MI, vascular Annual risk CVD, MI, vascular death following TIA, minor CVDdeath following TIA, minor CVDAnnual risk CVD, MI, vascular Annual risk CVD, MI, vascular
death following TIA, minor CVDdeath following TIA, minor CVD
Experience can be defined as yesterday’s answer to today’s problems
Indian scenario
1880 death / daydue to stroke in India
Equal to 6 Boeings 737 crashes every dayEqual to 6 Boeings 737 crashes every day
22 times that due to malaria 4 times that due to RHD 1.4 times that due to TB Almost equal to deaths due to IHD
Indian scenarioIndian scenarioNumber of deaths due to strokeNumber of deaths due to stroke
Indian immigrants to England have higher risk or dying due to stroke than local population
ComparisonComparisonIndia vs. established market economiesIndia vs. established market economies
(Age adjusted stroke mortality)(Age adjusted stroke mortality)
2 to 3 times stroke 2 to 3 times stroke mortality higher in Indiamortality higher in India
– Increase life expectancy (aging population)– Urbanization
ComparisonComparison USA – stroke mortality decline since 1940’sUSA – stroke mortality decline since 1940’s
India likely to increaseIndia likely to increase
Stroke units Aspirin Thrombolysis Heparin
Acute stroke interventions – Acute stroke interventions – reasonable evidencereasonable evidence
Neurologists
StrokeStroke
Vascular event due to atherosclerosisVascular event due to atherosclerosis
CardiologistsCardiologists PhysiciansPhysicians
Relevant to all of usRelevant to all of us
Limb weakness – 77% Urinary disturbance – 48% Dysphagia – 45% Cognitive deficit – 44%
Stroke disability worldwideStroke disability worldwide
35% functionally dependent at 1 year35% functionally dependent at 1 year
Stroke care units vs general wards– 9% relative risk reduction– 56 deaths or dependency avoided / 1000 acute
strokes treated / year Aspirin
– 3% relative risk reduction– 12 deaths or dependency avoided / 1000 active
strokes treated / year
Acute stroke interventions – Acute stroke interventions – evidence based medicineevidence based medicine
Thrombolysis – (even in USA only 1% of strokes are thrombolysed)– 10% relative risk reduction– 63 deaths or dependency avoided
(91 early deaths due to haemorrhage) Heparin
– No benefit
Acute stroke interventions – Acute stroke interventions – evidence based medicineevidence based medicine
People who survive stroke – 90% are left with deficit – minimal / mild / moderate / severe
None of the presently available therapy has any major impact hence prevention is critical
ConclusionConclusion
New role of doctorsNew role of doctors
““Managers of Change”Managers of Change”
““Preventors of Change”Preventors of Change”(Health ill health)(Health ill health)
GlobalGlobal
15 million deaths globally 15 million deaths globally every year due to vascular disease every year due to vascular disease
(30% of all deaths) (30% of all deaths)
GlobalGlobal
By 2020 – stroke and myocardial By 2020 – stroke and myocardial infarction will constitute leading cause infarction will constitute leading cause
of death / disabilityof death / disability
Lowering blood pressure Primary prevention – 17 randomised trials –
reduction of 5 to 6 mmHg diastolic and 10.12 mmHg systolic BP – 38% reduction of stroke
Secondary prevention – have we made PROGRESS
Common Stroke MimicsCommon Stroke Mimics Hypoglycemia Post ictal state Drug overdose Concussion with neck injury Migrainous accompaniment Encephalopathies with focal signs Hyponatremia Subdural hematoma, Empyema Focal Encephalitis: Herpes
Being ignorant is not so much a shame as being unwilling to learn
Level of Evidence
Level A: Based on RCT or Meta analysis of
RCT
Level B: Based on Robust Experiment or Observation Studies
Level C: Based on Expert opinion.
“The True Art of Memory is The Art of Attention” - S.Johnson
Guidelines for 24 hrs – MandatoryGuidelines for 24 hrs – Mandatory
1. History And Examination
a. Stroke clerking Performa (1994) R.C.P.1. Improved patient Assessment2. Improved Management - not clear3. Improved outcome - not clear
b. Examination1. Secure Diag of Stroke2. Specify Impairment3. Identify sub type of Ischemic stroke4. Rule out stroke mimics
“ We Sometimes think we have forgotten something when in fact we never really learned it in the first place”
Imp.Your Memory Skills
Guideline: 3 (B) - CPR– CPR is rarely successful in the setting of stroke – Sneeder
1993.
Guideline: 4(B) Investigations:(Sagar 1995)-435 PTS)– Chest x-ray 16% ABN – Only 4% change clinical management– Order x-ray chest if weight loss or chest symptoms
present
Through Action You Create your Own Education - D.B. ELLIS
Guideline 5: (B) ECG:– Cardiac cause of Death (30 days) Ebrahim 1990.– All conscious patients to have ECG
Guideline 6: (C) CT:– Routine CT Head is a must– King’s fund forum(1988) gives useful framework– Weir 1994 Clinical scoring cannot distinguish – CT done if: a) Uncertainty of Stroke
b) If Anticoagulation or Anti Platelet treatment contemplated
c) IV rtPA
Thought is the labour of the intellectReverie is its pleasure
Guideline 7:(B) M.R.I.
– Mohr 1995, - Unclear for Implications for clinical practice
– 2004 – PWI > DWI – IV rtPA very useful
Whatever the Mind can conceive and Believe, the mind can Achieve -Napoleon Hill
Imagination is more Important than KnowledgeImagination is more Important than Knowledge
Guideline 8: (B) ECHO no Routine
– Echo in Acute Stroke – Cardiac cause/Thrombus LV– TEE is superior to TTE– Amer Heart Asson (1997) - same conclusion– Yield is very low. (Leung 1993; Chambors 1997)– Only when abnormal ECGS - change clinical management
Guideline 9: (A) – Doppler scan for selected patients – > 80% stenosis benefits from Endarterectomy– Subst Storke -Good recovery - do doppler– Useful in posterior circulation
A open foe may prove a curse ; but a pretended friend is worse
Guideline 10: (B) Management:
– Fever (Worst Prog.) Reith 1996 – Hypoxia (Moroney 1996) - Exac. by seizures
Pneumonia and Arrythmias - Worst outcome
– Hyperbaric O2 ineffective (Nighoghossaln 1995)
– Haemodilut. Plasm Expanders; venesection – No evidence for efficacy (As plund - 1997)
Check ABG only if Hypoxia suspected.
It is a great misfortune not to possess sufficient wit to speak well nor sufficient judgment to keep silent - La Broyers character
Guideline 11: (A) Steroids and Hyperosmolar agents Unproven treatment –
– Tumor oedma responds but not cytotoxic stroke oedma qialbash 1997 - No effect on survival or improv. In funct. Outcome
– Mannitol - (Boysen 1997) - short term effective statistically in conclusive
You are what you think and not what you think you areYou are what you think and not what you think you are
We learn by thinking and the quality of the learning outcome is We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughtsdetermined by the quality of our thoughts
R.B. SchmeckR.B. Schmeck
Guideline 12: (B) - Blood Pressure
– Defer - acute reduction of BP - 10 days unless HT Encephalopathy or aortic dissection present
– Moris 1997 - Increase BP - falls in 10 days– UK - 5mm in D.B.P. 1/3 storke - Low BP prompt correct of
hypovoll. and withdrawal of hypotonic drugs– Collins 1994 - HT - Prim. stroke prevent– Neal 1996 (Current RCT) - HTs in stroke survivors -study
needed– Acute reduction of BP only if thrombolysis considered
Guideline 13: (A/B) – AF
– AF / ISCH Stroke/ Mild disability - Warfarin after 48 Hrs (Longer for larger)
– Aspirin for others EAFT 1995 Less than 2 PT - No effect SPAF 1996 > 5 - Bleeding
Discipline Weighs ounces; Regret weighs Tons
A great many people think they are thinking when they are A great many people think they are thinking when they are merely re arranging their prejudicesmerely re arranging their prejudices
W. JamesW. James
Guideline 14:(B/C) - Blood sugar
– Weir (1997) > 8 mm d/Lit - Poor outcome– Acute MI + 11 mm d/Lit - Intensive Insulin - improved
(Malmberg 1997)
Many Ideas grow better when transplanted into another mind than Many Ideas grow better when transplanted into another mind than in the one where they sprang UPin the one where they sprang UP
O.W. HolmosO.W. Holmos
Guideline 15: (A) Cholesterol
– Prosp. Study collob.: 1993 - Epidem study do not support
– Blaun 1997: Metranauetic - Chollest & statin 30% decrease - stroke in CAHD patients.
– Sacks 1996 - Tot chol: decrease to 4.8 mmol/Lit benefits
Guideline 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 but its value not
evaluated - (Wells 1994)– Use with caution - if periph artery insuf. is present hence do
not use heparin on stockings.
A woman’s desire for revenge outlasts all her other emotions
Every discovery contains an irrational element or Every discovery contains an irrational element or 4 creative intuition4 creative intuition
Guideline 17: (A/B) Pressure sure
– Event health care (1995) specialised low pressure mattress systems to be used than stand Hospital - mattress
I have never let my Medical schooling interfere with my education I have never let my Medical schooling interfere with my education Mark TwainMark Twain
Management of infarction– Guideline 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 possible with Clopidogrel
Ticlopidine etc.
Anti CoagulationAnti Coagulation Warfarin - AF
– In sinus rhythm - uncertain – Spirit 1997 low dose ABP + Warfarin in TIA &
Minor stroke - Stopped of HE– Heparin (IST 1997) – Significant reduction in
early death (12 fewer in 1000) not better than aspirin
– So avoid Heparin (A)
“ He who cannot forgive others destroys the bridge over which he
himself must pass” - Annoy
When they tell you to grow up, they mean stop growing When they tell you to grow up, they mean stop growing PiccasoPiccaso
Thrombolysis (A)
Warlow 1997 - Uncertain clinical benefit 2004 – NINDS – Thrombolysis
conclusively proved its efficacy – first 3 hrs
A (Neurologist’s) life is like a piece of paper on which everyone who A (Neurologist’s) life is like a piece of paper on which everyone who passes by leaves an impressionpasses by leaves an impression
- Chines proverb- Chines proverb
Guideline 20: (I) Hemorrhage
– Hankey and hon 1997: Supra tentorial evacuation for ICH is controversial - Avoid
– Infra tentorial - Yes– Main Indication - Deteriorating or depressed
consciousness
A medical school should not be a preparation for life. A medical school should not be a preparation for life. A school should be lifeA school should be life
3 D ied
3 4 R ed tag
7 D ied
2 1 d isch ton ver h om e
3 D ied
8 D isc fo rp a llim a
1 D iscH om e
6 4 D isch ar 6 7 D ied
1 3 1In tu b a tion
9 3N ot In tu b
2 2 4 P ts
Guideline 21 : Ventilation -Decreased level of consciousness - increased mortality and poor final outcome - Absent pupillary light responses - poor prognosis
PITFALLSPITFALLS Basing treatment of stoke on brain imaging
along without a vascular work-up Missing early infarct signs on CT Underestimating the time of symptom onset
for patients who wake up with a stoke Overtreatment of hypertension in acute
stoke
Three can be seen in the divisions of a human in mind, body and spirit
PITFALLSPITFALLS Overuse of carotid endarterectomy in
asymptomatic patients Not investigating both extracranial and
intracranial circulations Failure to distinguish severe cartid stenosis
from total occlusion Not obtaining spinal fluid for patients with
suspected subarachnoid hemorrhage
“Social Isolation is in itself a pathogenicFactor for disease production”
PITFALLSPITFALLS Not treating patients with large artery
ischmic stroke indefinitely with antiplatelet terapy
Failure to recognize lacunar stoke Inadequate use and dosing ofHMG Co-A
reductase inhibitors (statins) inpatients with cerebrovascular disease
Through Action You Create your Own Education - D.B. ELLIS
PROGNOSTIC PEARLSPROGNOSTIC PEARLS Flaccid Paralysis for more than 96 hrs When tendon reflexes recover without return of voluntary
movement – prognosis poor Recovery of sensory less in usual to a degree. Postion sense
recovers but not pain and temperature Recovery from Dysphasia is never complete Dysarthria usual improves and Dysphagia never improves Diplopia due to brain stem is usually permanent Conjugate gaze – recovers Vertigo improves but hearing loss is permanent Pseudobulbar palsy permanent
“By Nature All Men/ Women are alike butby Education widely different”
STOKE MYTHOLOGYSTOKE MYTHOLOGY
GENERAL MYTHS DIAGNOSTIC MYTHS THERAPEUTIC MYTHS
Serious, sincere, systematic study surely secures supreme success
GENERAL MYTHSGENERAL MYTHS
PHYSICIAN + MRI = NEUROLOGIST MINISTROKE CVA
CHAOTIC
COMMUNICATION
Discipline Weighs ounces Regret weighs Tons
DIAGNOSTIC MYTHSDIAGNOSTIC MYTHS
Self evident cause Ischaemic stroke + AF Lacunes, Lacunar infarcts and small vessel
disease Cryptogenic stroke PFO and Cardiogenic stroke
Experience can be defined as
yesterday’s answer to today’s problems
Ultrasound DiagnosisUltrasound Diagnosis
In skilled hands, ultrasound may show:• Carotid occlusion or stenosis• MCA occlusion or stenosis• Vertebrobasilar occlusion• Extracranial dissection
The secret of walking on water is Knowing where the stones are
UCLA Stroke CT ProtocolsUCLA Stroke CT ProtocolsSequence Time CT
WWOCT
Stroke
CT Stroke WWO Diamo
x
CT Stroke reduced Dye
CT Stroke
reduced Dye
WWO Diamox
SCOUT 0’15” ++ ++ ++ ++ ++
CT 0’30” ++ ++ ++ ++ ++
CTA-COW
16’
-- ++ ++ ++ ++
CTA-Neck
-- ++ ++ ++ ++
CTP 20’ -- ++ ++ ++ ++
CTP W diamox
30’ -- -- ++ -- ++
Post-contrast
0’30” ++ -- -- -- --
Magnetic Resonance Imaging (MRI)Magnetic Resonance Imaging (MRI)11
High level of anatomic detail for precisely locating the stroke and determining the extent of damage.
Especially useful for small blood vessels due to high sensitivity
Advances in the early detection of stroke involve using diffusion and perfusion weighted imaging.
1. Curr Opin Neurol. 2004 Aug;17(4):447-51
Memory, the daughter of attention, is the teeming mother of knowledge - Martin Tupper
UCLA Stroke MRI ProtocolsUCLA Stroke MRI ProtocolsSequence Time Brain
WWOTIA Stroke Thromb
olysis 1Thrombolysis 2
SCOUT 0’25” ++ ++ ++ ++ ++
MRA-Neck 6’44” -- ++ ++ - ++
DWI 0’40” -- ++ ++ ++ ++
T2 3’42” ++ ++ ++ ++ ++
MRA-COW 6’12” -- ++ ++ ++ --
FLAIR 2’41” ++ - ++ ++ --
GRE 2’35” - - ++ ++ ++
PWI 2’ - - - ++ ++
T1 3’ ++ - - - -
T1 post Gad
3’ ++ - - - -
Other Diagnostic Tools-1Other Diagnostic Tools-1
Magnetic Resonance Angiography1
(MRA) Carotid Duplex Scanning2: Transcranial Doppler (TCD)3
Xenon CT Scanning4
1.Neurol Res. 2004 Jun;26(4):429-342. J Vasc Surg. 2003 Sep;38(3):422-30. 3. .Neurology. 2004 May 11;62(9):1468-81,4. Keio J Med. 2000 Feb;49 Suppl
1:A25-8
Science is below the mind; Spirituality is beyond the mind
Other Diagnostic Tools -2Other Diagnostic Tools -2
Radionuclide SPECT Scanning1
PET Scanning2
Transesophageal Echocardiography3
1. AJNR Am J Neuroradiol. 2001 May;22(5):928-36
2.Neuroimaging Clin N Am. 2003 Nov;13(4):741-583. Heart Dis. 2003 Sep-Oct;5(5):320-2
Success is a prize to be won. Action is the road to it. Chance is what may lurk in the shadows at the road side.
THERAPEUTIC MYTHSTHERAPEUTIC MYTHS
Evidence based medicine = Randomized Clinical Trials– Best Research Evidence– Clinical Expertise– Patient Values
Systematic Escalation of anti thrombotic therapy Brain Hemorrhage Demands Neuro surgical
Consultation
Dead/dependent follow-upDead/dependent follow-up
Deaths by day 14Deaths by day 14
Deaths during follow-upDeaths during follow-up
Deaths ordered by antithromboticDeaths ordered by antithrombotic
Deaths ordered by thrombolyticDeaths ordered by thrombolytic
Deaths ordered by stroke severityDeaths ordered by stroke severity
Symptomatic ICH by 14 dysSymptomatic ICH by 14 dys
Fatal ICH by 14 dysFatal ICH by 14 dys
Dead/dependent follow-up < 3 hr.Dead/dependent follow-up < 3 hr.
Dead follow-up < 3 hr.Dead follow-up < 3 hr.
62% vs 69% s.62% vs 69% s.
22% vs 12% s.22% vs 12% s.
22% vs 19% s. 22% vs 19% s.
40% 30% 17% 10% 40% 30% 17% 10%
3% 20% ns.3% 20% ns.
11% 29% ns.11% 29% ns.
9.3% vs 2.5% s.9.3% vs 2.5% s.
6% vs 1% s.6% vs 1% s.
55% vs 71% s.! 55% vs 71% s.!
20% vs 25% ns.20% vs 25% ns.
Thrombolysis in acute strokeThrombolysis in acute strokeThrombolysis in acute strokeThrombolysis in acute stroke
NATURE, TIME AND PATIENCE are the 3 great physicians
NINDS ConsensusNINDS Consensus
Door to MD evaluation 10 min
Door to CT completion 25 min
Door to CT read 45 min
Door to treatment 60 min
Access to neurological expertise 15 min
Access to neurosurgical expertise 2 hrs
Admit to monitored bed 3 hrs
Memory, Pity and Beauty are short lived in life; But tinged with emotion persist in life
CONCLUSION CONCLUSION
• MYTHS
• PITFALLS
• PROGNOSTIC PEARLS
It is the disease of not listening, the malady of not marking,
that I am troubled withal - Shakespeare
CVD – Prevention or Cure?CVD – Prevention or Cure?
While number of curative methods are available, preventive therapy is undoubtedly the main strategy
in the management of CVD
Lijec Vjesn. 2003 Nov-Dec;125(11-12):322-8
The sign wasn’t placed there
By the Big Printer in the sky
Where are we ……?Where are we ……?
6-8 HO
UR
S
Call Call emergencemergency servicesy services
ER stroke teamER stroke team
ActivatedActivated(15 minutes)(15 minutes)
NeuroprotectivNeuroprotective drug infused e drug infused during during transporttransport
Brain scanBrain scan
Drugs Drugs administered administered
‘stroke-‘stroke-treatment’ treatment’
cocktailcocktail
Full Full recoveryrecovery
Stroke onsetStroke onsetSecondarySecondarypreventionprevention
The art of medicine is caring for the heart of the patient
Dedicated to my family for Dedicated to my family for making everything worthwhile making everything worthwhile
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