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
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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
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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)
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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
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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
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hypertension
diabetes
atrial fibrillation
myocardial infarction
rheumatic heart
disease
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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
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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: <1.5 cm diameter
• pure motor, pure sensory,
sensorimotor, ataxic hemiparesis,
dysarthria-clumsy hand syndrome
survival & recurrence after
1st cerebral infarction
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Petty et al, Mayo clinic, 1998
Neurology 50: 208-216
population-based study
Rochester, Minnesota
1975 – 1989: 1,111 residents with
1st cerebral infarction
survival & recurrence after
1st cerebral infarction
risk of death:
 7% ± 0.7% at 7 days
 14% ± 1.0% at 30 days
 27% ± 1.3% at 1 year
 53% ± 1.5% at 5 years
survival & recurrence after
1st cerebral infarction
independent risk factors for death
after 1st cerebral infarction:
 age
 congestive heart failure
 persistent atrial fibrillation
 recurrent stroke
 ischemic heart disease
survival & recurrence after
1st cerebral infarction
risk of recurrent stroke after 1st
cerebral infarction:
 2% ± 0.4% at 7 days
 4% ± 0.6% at 30 days
 12% ± 1.1% at 1 year
 29% ± 1.7% at 5 years
survival & recurrence after
1st cerebral infarction
significant independent predictors
of recurrent stroke:
 age
 diabetes mellitus
intracranial hemorrhage
• Framingham study: 5% - 10% of all
strokes
• Kunitz et al (NINCDS Stroke Data
Bank, 1984): 10.7% of all cases
• US: 12 – 15 per 100,000
• Caucasians: 11-31 per 100,000
intracranial hemorrhage
• overall incidence of ICH declined
since 1950s
• higher incidence among population
with higher frequency of hypertension
• Blacks: 1.4 X Caucasians
intracranial hemorrhage
• Asian countries with higher incidence
than other regions of the world
 Asia: 20% - 50%
 West: 10% - 15%
• may be due to environmental and/or
genetic factors
age
• increase ICH incidence > 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
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(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
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(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
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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