StrokeStroke

Omar Khan, MD MHSOmar Khan, MD MHS

February 2006February 2006

Etymology before Etymology before epidemiologyepidemiology

• Why is a stroke called a stroke?Why is a stroke called a stroke?– Maybe since all sudden attacks were called Maybe since all sudden attacks were called

strokes, and the rest acquired specific terms e.g. strokes, and the rest acquired specific terms e.g. MIMI

– An abbreviation of the phrase 'stroke of apoplexy’An abbreviation of the phrase 'stroke of apoplexy’– Apoplexy (from the Greek meaning to strike off)Apoplexy (from the Greek meaning to strike off)– Divine origin as in, ‘being struck down’Divine origin as in, ‘being struck down’

What it isWhat it is

• A neurological event following an A neurological event following an interruption in blood flow due tointerruption in blood flow due to– Thrombus/embolusThrombus/embolus– HemorrhageHemorrhage– HypotensionHypotension

• 30 % of strokes are immediately fatal30 % of strokes are immediately fatal• 30 % result in long-term patient care30 % result in long-term patient care

Epidemiology of strokeEpidemiology of stroke

• Morbidity:Morbidity:– Every year: 500,000 have a first strokeEvery year: 500,000 have a first stroke– Every year: 200,000 have a subsequent strokeEvery year: 200,000 have a subsequent stroke– Frequency of stroke doubles every 10 years after 55 y.o.Frequency of stroke doubles every 10 years after 55 y.o.

• Mortality:Mortality:– 33rdrd leading cause of mortality in the US (i.e., more than leading cause of mortality in the US (i.e., more than

chronic lung disease, accidents, diabetes…)chronic lung disease, accidents, diabetes…)– Causes about 7% of all US deathsCauses about 7% of all US deaths

Diff’rent strokesDiff’rent strokes

• Strokes are more prevalent in the Strokes are more prevalent in the following (Relative Risk compared to following (Relative Risk compared to US white population):US white population):– Finns, Japanese: 1.6Finns, Japanese: 1.6– Black Americans: 2.2Black Americans: 2.2

Stroke mortalityStroke mortality

Stroke morbidityStroke morbidity

Primary prevention: risksPrimary prevention: risks

Primary prevention: Primary prevention: medical risksmedical risks

• HTN: RR of stroke in untreated HTN: RR of stroke in untreated hypertensive (>140/90) is 1.2 – 4.0hypertensive (>140/90) is 1.2 – 4.0

• MI: Risk of stroke increases MI: Risk of stroke increases 30%30% in the first in the first month post-MI, then 1-2% each year after month post-MI, then 1-2% each year after that.that.

• AF: strong independent risk for ischemic AF: strong independent risk for ischemic stroke (RR = 5). 70% are cardioembolic, stroke (RR = 5). 70% are cardioembolic, 30% are ‘other-embolic’. Stroke risk in 30% are ‘other-embolic’. Stroke risk in untreated AF is 6% per year.untreated AF is 6% per year.– A side note: if electively cardioverting for AF, A side note: if electively cardioverting for AF,

do warfarin for 3 wks prior and 4 wks postdo warfarin for 3 wks prior and 4 wks post

Primary prevention: Primary prevention: medical risksmedical risks

• DMDM– The bad news: increased RR of 1.4-1.7 The bad news: increased RR of 1.4-1.7 – The bad news: glycemic control may not helpThe bad news: glycemic control may not help

• Hypercholesterolemia: RCTs on those with Hypercholesterolemia: RCTs on those with TC>240, when treated, had decreased RR of 0.7TC>240, when treated, had decreased RR of 0.7

• Carotid artery stenosis: isolated as risk factor in Carotid artery stenosis: isolated as risk factor in 1914 by Ramsey Hunt (yes, 1914 by Ramsey Hunt (yes, thatthat Ramsey Hunt) Ramsey Hunt)– The bad news: only 33% of significant stenosis=bruitThe bad news: only 33% of significant stenosis=bruit– The bad news: only 60% of bruits=significant The bad news: only 60% of bruits=significant

stenosisstenosis– Risk of same-side stroke is 2% after CEA (find a good Risk of same-side stroke is 2% after CEA (find a good

surgeon)surgeon)

Coumadin and stroke Coumadin and stroke preventionprevention

Coumadin and stroke Coumadin and stroke preventionprevention

• In patients >75 y.o., more strokes In patients >75 y.o., more strokes (hemorrhagic and ischemic) in (hemorrhagic and ischemic) in those on warfarin vs those just on those on warfarin vs those just on aspirinaspirin

• The best balance of INR seems to The best balance of INR seems to be 2.0 – 3.0 for most patientsbe 2.0 – 3.0 for most patients

Coumadin and stroke Coumadin and stroke prevention: the final prevention: the final

word?word?

Coumadin and stroke Coumadin and stroke prevention prevention

Lifestyle Risk FactorsLifestyle Risk Factors

• SmokingSmoking– Risk of stroke doubles with each packRisk of stroke doubles with each pack– Risk of stroke returns to baseline 2 yrs Risk of stroke returns to baseline 2 yrs

after quittingafter quitting

• DrinkingDrinking– Regular intake of Regular intake of >> 4 drinks/wk=small 4 drinks/wk=small

increase in risk of stroke,moderate increase in risk of stroke,moderate increase on risk of death after strokeincrease on risk of death after stroke

Lifestyle Risk FactorsLifestyle Risk Factors

• DietDiet

Secondary prevention for Secondary prevention for special populationsspecial populations

• TIATIA– Focal neurologic deficit (e.g., Focal neurologic deficit (e.g.,

hemiparesis, slurred speech, hemiparesis, slurred speech, diplopia, ataxia) resolving in 24 diplopia, ataxia) resolving in 24 hours (60-70% within 1 hour)hours (60-70% within 1 hour)

– Usual cause: temporary ischemia Usual cause: temporary ischemia from emboli, vasospasm, from emboli, vasospasm, hypotensionhypotension

Secondary prevention for Secondary prevention for special populationsspecial populations

• TIATIA

Secondary prevention for Secondary prevention for special populationsspecial populations

• TIATIA

Secondary prevention for Secondary prevention for special populationsspecial populations

• WomenWomen– After 65 y.o., more women than men have strokeAfter 65 y.o., more women than men have stroke– Why? Undertreatment, increased risk of HTN, hypothesized reasons: being female itself does not seem to be a factorWhy? Undertreatment, increased risk of HTN, hypothesized reasons: being female itself does not seem to be a factor– Pregnancy: increased RR but very small increase in ARPregnancy: increased RR but very small increase in AR– Use of OCs esp. in conjunction with smoking and HTN is a risk factorUse of OCs esp. in conjunction with smoking and HTN is a risk factor– OCs+HTN = RR 10.7OCs+HTN = RR 10.7– OCs+smoke=7.2OCs+smoke=7.2– Newer OCs + <35y.o. + no HTN = no increased riskNewer OCs + <35y.o. + no HTN = no increased risk

Stroke and TPAStroke and TPA

• Hospital treatment of strokeHospital treatment of stroke– TPA within 3 hours minimizes stroke sizeTPA within 3 hours minimizes stroke size– TPA within 3 hours decreases disability at 3 monthsTPA within 3 hours decreases disability at 3 months– May cause bleeding (see contraindication chart)May cause bleeding (see contraindication chart)

Post-stroke carePost-stroke care

• Post-stroke concerns which are frequently managed by family physicians:Post-stroke concerns which are frequently managed by family physicians:– Secondary prevention including modification of risks Secondary prevention including modification of risks – Depression: Depression:

•major (studies cite 1-25%), minor (20-30%) major (studies cite 1-25%), minor (20-30%) •Identifiable risk factors for post-stroke depression (see chart). Manic symptoms less commonIdentifiable risk factors for post-stroke depression (see chart). Manic symptoms less common•Post-stroke depression associated with 3-year mortality increase of 350%Post-stroke depression associated with 3-year mortality increase of 350%•Treat with counseling and with antidepressant RxTreat with counseling and with antidepressant Rx

Post-stroke care: DepressionPost-stroke care: Depression

Post-stroke care: RehabPost-stroke care: Rehab

• Rehab should begin soon after the patient is stable (ideally, within 48hrs)Rehab should begin soon after the patient is stable (ideally, within 48hrs)

• Early rehab can prevent DVT, contractures, pneumonia, skin breakdown, and aids early return to Early rehab can prevent DVT, contractures, pneumonia, skin breakdown, and aids early return to ADLsADLs

Post-stroke care: RehabPost-stroke care: Rehab

Post-stroke care: RehabPost-stroke care: Rehab

Stroke Q & AStroke Q & A

1. B1. B

2. D2. D

3. C3. C

4. A4. A

5. B5. B

6. E6. E

7. A7. A

8. D8. D

9. B9. B

10. A10. A