Download Post TIA, Post Stroke Prognosis

Post TIA, Post Stroke Prognosis D. Darwin A. Dasig, M.D., F.P.N.A. Makati Medical Center

Cerebrovascular Disease • any abnormality of the brain resulting from a pathologic process of the blood vessels

Cerebrovascular Disease • • • • • •

Atherosclerotic thrombosis Transient ischemic attacks Embolism Hypertensive hemorrhage Ruptured or unruptured saccular aneurysm or AVM Arteritis  Meningovascular syphilis, arteritis secondary to pyogenic and tuberculous meningitis, rare infective types (typhus, schistosomiasis, malaria, trichinosis, mucormycosis, etc.)

Cerebrovascular Disease  Connective tissue diseases (polyarteritis nodosa, lupus erythematosus), necrotizing arteritis, Wegener arteritis, temporal arteritis, Takayasu disease, granulomatous or giant cell arteritis of the aorta, giant cell granulomatous angiitis of cerebral arteries

• Cerebral thrombophlebitis: secondary to infection of ear, paranasal sinus, face, etc.; with meningitis and subdural empyema; debilitating states, postpartum, postoperative, cardiac failure, hematologic disease (polycythemia, sickle-cell disease), and of undetermined cause

Cerebrovascular Disease • Hematologic disorders: polycythemia, sickle-cell disease, thrombotic thrombocytopenic purpura, throbocytosis, etc. • Trauma to carotid artery • Dissecting aortic aneurysm • Systemic hypotension with arterial stenoses: “simple faint”, acute blood loss, myocardial infarction, StokesAdams syndrome, traumatic and surgical shock, sensitive carotid sinus, severe postural hypotension • Complications of arteriography • Neurologic migraine with persistent deficit

Cerebrovascular Disease • Tentorial, foramen magnum, subfalcial herniations • Miscellaneous types: fibromuscular dysplasia, radioactive or x-irradiation, lateral pressure of intracerebral hematoma, unexplained middle cerebral infarction in closed head injury, pressure of unruptured saccular aneurysm, local dissection of carotid or middle cerebral artery, complication of oral contraceptives • Undetermined cause as in children and young adults: Moyamoya; multiple, progressive intracranial arterial occlusions

vascular disorders of the nervous system • ischemia/infarction • hemorrhage

stroke • neurological deficit of sudden onset accompanied by focal dysfunction and symptoms lasting more than 24 hours that are presumed to be of nontraumatic vascular origin (WHO)

stroke • sudden onset of focal neurological deficit lasting more than 24 hours due to an underlying vascular pathology (Stroke Society of the Philippines, 1999) • acute clinically relevant brain lesion on imaging in patients with rapidly vanishing symptoms

stroke • sudden, focal, nonconvulsive neurologic deficit → brain attack ≠ apoplexy ≠ cerebrovascular accident (CVA)

STROKE FACTS • • • • •

leading cause of adult disability 3rd leading cause of death in the US # 2 killer disease worldwide most important cause of mortality in Asia 75% of all strokes > 65 years of age

USA • prevalence: 1 in 59 (1.69%) → 4.6 million • incidence: 1 in 453 (0.22%) → 600,000 total (500,000 new cases & 100,000 recurrence) Worldwide • incidence: 15 million people survive minor stroke each year (WHO)

• • • •

one year mortality: 25% - 40% three year mortality: 32% - 60% over 50% dead in 5 years Framingham study ten-year survival: 35%

risk factors & predictors of stroke non-modifiable

modifiable

• • • •

• • • • • • •

older age male gender non-white ethnicity family history

elevated blood pressure diabetes mellitus atrial fibrillation hyperlipidemia cigarette smoking obesity high alcohol consumption

Cerebrovascular Disease 2003; Advances in Neurology 2003; Stroke 2001

RIFASAF Study: independent risk factors for Stroke among Filipinos • • • • •

hypertension diabetes atrial fibrillation myocardial infarction rheumatic heart disease

• • • •

smoking snoring stress frequent Alcohol intake

A. Roxas, Phil J. of Neurology, 2002

types of stroke ischemic stroke

hemorrhagic stroke

• a clot blocks flow to an area of the brain

• bleeding occurs inside or around brain tissue

ischemic stroke • atherothrombotic • cardioembolic • lacunar

major risk factors are unevenly distributed among stroke subtypes • elderly (> 70 yr), low rate of early stroke recurrence • middle age (45-70 yr), high • atherothrombotic rate of early stroke (large-vessel) recurrence, highest male preponderance • hypertension, diabetes, • lacunar hypercholesterolemia, (small vessel) obesity

• cardioembolism

atherothrombotic stroke (large vessel disease) • usually develops at night during sleep • symptoms felt in the morning • suspect history of atherosclerosis, hypercoagulable states, collagen vascular diseases

macroangiopathy: large vessel disease TOAST Criteria • presence of occlusion with 50% diameter reduction of a brain-supplying artery corresponding to clinical symptoms and with location and morphology typical of atherosclerosis on Doppler ultrasound or angiography

mechanism of atherosclerotic stroke in large cerebral arteries • artery to artery embolism • thrombotic occlusion • hemodynamic infarction: watershed infarction

extracranial atherosclerosis (ECAS) • most common source of embolism among Whites • asymptomatic cervical stenosis or bruits: risk of ipsilateral stroke with > 60% narrowing approximately 2% per year

transient ischemic attack (TIA) • transient episode of focal neurologic dysfunction secondary to ischemia in one of the vascular territories of the brain (Stroke Council, American Heart Association, 1994) • brief episode of neurological dysfunction caused by focal disturbance of brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour and without evidence of infarction

transient ischemic attack (TIA) • onset sudden & rapid, with complete resolution • lasts approximately 2 to 20 minutes • initially should involve all affected areas relatively simultaneously • should involve focal loss of neurologic function, with symptoms reflecting dysfunction of cerebrum, brainstem, or cerebellum

probably not TIA • • • • •

ill-defined onset, waxes & wanes, or slowly worsens leaves persistent neurologic deficits, however mild neurologic dysfunction of few seconds duration episode lasting for more than 1 hour marching of symptoms from one body part to another • “positive phenomena”: involuntary movements, jerking, scintillating scotoma • “global” brain symptoms: giddiness, LOC, presyncope

TIA as predictor of future strokes • highest risk in 1st week 1st month = 4% - 8% 90 days = 10.5% 1st year = 12% - 13% 5 years = 24% - 29% 2 years = > 40%

intracranial atherosclerosis (ICAS) • more common in Asian and Blacks  Asia: 40% - 50%  West: 8%

• no proven treatment for ICAS

atherothrombotic • early in course of cerebral thrombosis → difficult to give accurate prognosis • progression: increasing stenosis of involved artery by mural thrombus  mild paralysis → disastrous hemiplegia  worsen temporarily for 1- 2 days

• often progressive: cautious attitude

cardioembolic stroke • occurs anytime • frequently during periods of vigorous activity • history of atrial fibrillation, valvular vegetations, thromboembolism from MI • seizures in 20% of cases

atrial fibrillation • 2% - 4% risk for stroke annually • persons < 60 years with no other cardiac disorder (lone AF): relatively low risk for stroke • AF: abetting factor leading to formation of intra-atrial thrombi in patient with another heart disease • at risk: chronic sustained & intermittent

atrial fibrillation with greatest risk for embolization: • prior stroke or TIA (most important) • age > 75 years, especially women • history of hypertension or systolic blood pressure > 160 mm Hg • diabetes mellitus • coronary artery disease • congestive heart failure • left ventricular dysfunction

cardioembolism acute myocardial infarction (with left ventricular thrombus) • 5% risk for stroke within 2 weeks • risk higher with anterior than inferior infarcts • may reach 20% risk in those with large anteroapical infarcts

cardioembolism cardiomyopathy  EF

29% - 35%: 0.8% stroke per year  EF < 28%: 1.7% stroke per year

prosthetic heart valves annual percentage of occurrence of systemic thromboembolism: 20%

valvular heart disease: annual incidence of thromboembolism no AF

with AF

prosthetic valve

20%

increased

rheumatic mitral regurgitation

7.7%

22%

1.5% - 4%

increased by 7 – 8 X

< 2%

increased

rheumatic mitral stenosis mitral valve prolapse

lacunar infarction • microangiopathy: 55 years • doubles with each decade until 80 years • relative risk in patient older than 70 years: >7

intracranial hemorrhage • worse functional outcome than any other stroke subtype • higher mortality: 30% - 40% • 30 day mortality rate: 44% • USA: 20,000 die annually • pontine & other brainstem ICH: 75% mortality rate at 24 hours

Mitra et al, 1995  34% patients died  36% dependent on outside help for daily living  30% capable of independent existence

adverse impact on outcome • • • • • •

(Mitra et al, 1995) age > 60 years GCS < 6 on admission ICH volume > 30 ml midline shift in CT Scan of > 3 mm intraventricular hemorrhage hydrocephalus

relatively favorable outcome • • • • •

(Mitra et al, 1995) young age GCS > 8 on admission ICH volume < 20 ml lobar hemorrhage absence of intraventricular hemorrhage or hydrocephalus

recurrence Hill et al, American Heart Association, Stroke 2000 • 423 patients with primary ICH (PICH) • Toronto Hospital 1986 – 1996 • 27.4% died in first 30 days after admission • recurrence rate for ICH: 2.4% per year • recurrence rate for ischemic cerebrovascular: 3% per year (marker)

recurrence Hill et al 2000 • only significant predictor for readmission for ICH: lobar location of index hemorrhage • hazard ratio of 3.8

→ PICH at risk for TIA, ischemic stroke, recurrent hemorrhage

recurrence Veimeer et al, Neurology 2002 • 243 patients with primary ICH • 5.5 years mean follow-up recurrence rate for ICH: 2.1% vascular events: 5.9 % vascular death: 3.2%

recurrence Veimeer et al, Neurology 2002 age > 65 years only predictor for: • recurrence (hazard ratio 2.8) • vascular death (hazard ratio 3.7)

subarachnoid hemorrhage • ½ of all spontaneous intracranial hemorrhage (ICH is 20% of all strokes)  ruptured saccular aneurysm: 80% - 90%  AVM or tumor: 5%  idiopathic: 5% - 15%

SAH: ruptured aneurysm • • • • • • • •

15% die before reaching the hospital 25% die within 1 day 40% die by the end of 1 week 50% die within first 6 months 40% survivor with major neurological deficits > 50% survivor with some permanent disability rebleeding 40.9 % mortality 31.7%

aneurysm • risk of rupture unknown ~ 1% - 2% per year • Juvela (2000): 1%

aneurysm Wiebers (2003) • small (< 7 mm) & anterior location: 0.05% (retrospective) & 0% (prospective) • > 10 mm, other locations, prior aneurysmal bleed: 0.5% per year

arteriovenous malformation • 5% - 10% of cases of SAH • intraparenchymal hemorrhage • small AVMs (< 2.5 mm) higher frequency of rupture than large • Tasic et al (57 patients): 4/100 per year

Stroke • is a “brain attack”…needing emergency management, including specific treatments and secondary and tertiary prevention. • is an emergency…where virtually no allowances for worsening are tolerated. • is treatable…optimally, through proven, affordable, culturally-acceptable and ethical means. • is preventable…in implementable ways across all levels of society. Stroke Society of the Philipines, 1999