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3 1 %! 5/, &%( <.62 /</ <2.6</ 3 '1, =>3 <=/3 =/3 >=>3 >=23 3 =3 =3 <=.3 <=3 >=23 3 1, =3 =3 </3 <=>3 3 Coded diagnoses and co-morbidities are accurate when recorded and are well recorded when relevant to the admission PRISM Study Gattellari et al

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5 A 1 '5 ' ' *' *' * * 1 ' B A 1 ' 2= + ' '5 >6<= ' 1 1 ' ''5 1 1 '' &(*1 ' &(= '*'' ' *' *' * *Worth looking at NINDS-AIREN criteria if only to highlight the problems!

6 A 1 '5 ================ :'1 '9*' '5 0$ % : '+ &%:+(1 5 : ' ** #' = * 7' #'1 9' ** '9'1 * ** ' ' 1 '1 Do not believe anything you read about cerebral blood flow!

7 * *' "' %' " % ' "1 '5, ========= People who cannot do stuff and have abnormal blood vessels..and may also have Alzheimer s disease Worthington 2010 It s a duck

8 )* '5 Clinical cases with large vessel strokes motor signs, step wise cognitive deterioration correlated with stroke events fit most easily into the NINDS- AIREN criteria for vascular dementia

9 ' ' '5 ) = ' &?( It is no surprise that someone with this CT appearance would have cognitive issues although it can be surprising how well some appear

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11 0 * 0 ' DDDDDEE Carotid atheroma Aortic atheroma Atrial fibrillation Very high stroke risk Patient needs aggressive antihypertensive and statin therapy, warfarin and a carotid endarterectomy

12 1 1 #' 5 C ' * ' Strokes in just the right spot can have function effects disproportionate to their size and motor features and these may be hard to identify

13 VBI can effect the lightly shaded area 1 ''63 ' # *'

14 F 5 8&"( " ' = + ' ' 1 *'= : 8 ' =! 7' 9 5 G**1 5 * Posterior circulation strokes are often associated with early post stroke confusion and agitation

15 C,'' ' #'=: C' *' * '' ' = 0 ' C *1 ' 0 *'1 1 ** :*' 1' * 1 1 C Apraxias are an example of a very particular deficit from a strategic stroke, involving response to commands. Other strategic strokes can effect spatial perception, calculation, navigation and a wide variety of higher functions which may only be evident on return to a complex environment (home)

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20 51,?' ' '5 $ & 8 ''( On neuropsychological tests and clinical judgement the diagnosis of cortical Vs subcortical dementia is variable and most fall along a spectrum between the two. This probably reflects mixed underlying pathology and the varying manifestations often seen with a single pathological process.

21 ' B =) *1 '*'* 1 1 H ',7''8 5 * 1 =)1 = Frontal means the gait has been described with frontal lobe lesions or frontal lobe diseases. However diseases involving damaging connections of the frontal lobes can cause the changes too

22 )' &)"( Small sometimes silent infarctions )' )' 1& '.( 1 =09 ' ' * &543(=0 =0' '* = -, ' '*11'

23 )' &)"( )' ' 1'5 ' 1?' '7'*/. '&' "*'+ '( %1 '*8'5 *' &(1' &' 1 ( * ''1 '' ' 1 *' 0:H7' We can slow progression of lacunar white matter with stroke prevention. Can we slow the progression of other small vessel white matter disease?

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29 ! 50 0' G:7' 11 1 :% ' : ' 01 ' C 1 * 1 1&- C( '5 1 =& $5( 0 ' 1 '= '''1! *'& ( "0 A patient with a diagnosis of vascular dementia A 50 year old working father of young children with hypertension

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31 @05 Normal PET scan A vascular dementia case Pallor in left cerebellum 18 F-FDG PET images of vascular dementia. Hypometabolism (pallor) of cortical, subcortical, and cerebellar areas is often seen in vascular dementia. Importantly, hypometabolism of the left cerebellum caused by reduced afferent input (connection) from the cerebral cortex (on the other side. When you using less common advanced tests to try and resolve difficult diagnoses the lowered pre-test probability is often associated with greater false positives and negatives and no resolution of ambiguity

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33 "*'' '5 % &1 '( ' ' * 9C : * 'C Modelling suggests that targeted multifactorial risk factor reduction will reduce stroke risk by 80-90%

34 ?"- A risk calculator for all cardiovascular events Any threshold for use of aspirin in primary prevention should relate to a specific calculator

35 "*'' '5 '86482&<8> ( )8918 '1482 +'' B? ;! 1:%G 54 =.&?0(=G'/<3? N<1)8"F )?0* / *Anxious patients will often be medication averse with vague symptoms and no observable side-effects

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37 ! %-? G' G 0 G &3 ( 26% relative risk reduction all-cause mortality 54% 60% 78% 33% 70% 68% 64% G*GG'

38 G* ' ' 5'45<3 " *' /3 1'' *1 ;865482= 5' &1 (1 %-?B1.<3 * ' &?0( 1.5/3& (BB *Rhythm control/cardioversion in NVAF is not helpful in reducing stroke risk *Stroke 2004;35: **Lancet Jul 6;360(9326):7-22.

39 Age( years) :"+ %! The graphs show that the median age of ICH has been increasing rapidly Year of Separation Rate per 100, Average annual relative % Age (years) RR (95% CI) a ( ) ( ) * ( ) ( ) *** * p<0.05; ** p<0.01; *** p<0.001 a) Sex-adjusted Poisson regression Aitken, Worthington, Gattellari, Jalaludin < Year of Separation

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42 ' 1 H "H 'G? H ', )' % P1, H@F, G "" 5% H :+, ''A + &$ F( ) 1 &":(H 1 &" &$ F(?' ' % + G"?$%! " = % % <& ' ( PRISM DESPATCH STOP STROKE