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