1. Cerebrovascular Disease
William R. Rooney, MD
VP & Medical Director
Generali USA Life Reassurance

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3. Introduction: William Rooney, M.D. FAAFP, EMBA
Joined Generali USA in April, 2012
20 year history of direct patient care.
Eight years of insurance industry experience.
Board certified in Family Medicine

4. Primary and secondary treatment Another look at Mortality numbers
Overview
Stroke Facts
Mortality numbers
Definitions
Anatomy review
Types of strokes
Diagnosis
Primary and secondary treatment
Another look at Mortality numbers
CIMT, Carotid US, and Silent strokes

5. CASE
2 cases arrive for underwriter review. Which has the worst mortality risk based upon the following limited information provided?
Case 1:
66 y/o female with hx. of a “TIA-like” event 4 years ago with no subsequent symptoms. Hx. of hypertension and hyperlipidemia. BMI 30
MRI of the brain WNL.
US of the carotids WNL.
ECG WNL.
CIMT abnormal at 90th percentile for age.
Case 2:
65 y/o female with no known neurological complaints—past or present
Hx. of hypertension and hyperlipidemia. BMI 30
MRI of the brain shows 2 small lacunar infarcts—age unknown
US of the carotids WNL
ECG WNL
CIMT normal

6. 795,000 Americans suffer strokes each year
Stroke Facts
795,000 Americans suffer strokes each year
134,000 deaths each year
6,400,000 stroke survivors
34% of people hospitalized for stroke in 2009 were under 65 years of age.
References:
American Heart Association. Heart Disease and Stroke Statistics 2010 Update At-a-Glance. At:

7. Prevalence of stroke by age and sex
Chart 4-1. Prevalence of stroke by age and sex (NHANES: 1999–2004). Source: NCHS and personal communication with NHLBI.
Rosamond W et al. Circulation 2007;115:e69-e171
Copyright © American Heart Association

8. Annual stroke death rate fell 35%. Actual number of deaths fell 19%.
Stroke Facts
Women are twice as likely to die from stroke than breast cancer annually.
African Americans have almost twice the risk of first ever stroke compared to whites. Hispanic Americans’ risk falls between those of whites and African Americans.
A leading cause of death in the United States :
Annual stroke death rate fell 35%.
Actual number of deaths fell 19%.
Stroke is a leading cause of death in the United States behind heart disease and all forms of cancer combined.
Approximately 795,000 Americans have a new or recurrent stroke each year.
Stroke kills approximately 134,000 Americans each year. From 1996 to 2006, the stroke death rate fell 33.5% and actual number of stroke deaths fell by 18.4%.
There are more than 6 million stroke survivors living in the United States. Men make up about 2,500,000 of survivors and women make up 3,900,000. About one-third have mild impairments, another third are moderately impaired and the remainder are severely impaired.
References:
American Heart Association. Heart Disease and Stroke Statistics 2010 Update At-a-Glance. At:

9. Temporal trends in age-adjusted death rates for the top 10 causes of death in the United States from 1931 to 2008.
2nd most common cause of death world wide
In 2008 CVA dropped from the 3rd most common cause of death in the US to the 4th.
Temporal trends in age-adjusted death rates for the top 10 causes of death in the United States from 1931 to 2008.
Towfighi A , and Saver J L Stroke 2011;42:
Copyright © American Heart Association

10. Mortality rate from Stroke
Similar downward trend noted in the European Union.
Point #1
The stroke mortality rate in the Western countries is declining.
Decreased incidence
Decreased case-fatality rate
Point #2
The projected total number of US deaths from strokes is not expected to decline through 2030 however because of the aging population
Trend between 1980 and 2005 stroke mortality rates (rates per 100,000 person-years, standardized using the European Union comprising 25 member states [EU25] population by 5 years as the standard population). Men and women in 7 European countries.
Kunst A E et al. Stroke 2011;42:
Copyright © American Heart Association

11. Definitions
TIA
Classic Definition: Rapidly developing clinical signs of focal or global disturbance of cerebral function lasting fewer than 24 hours, with no apparent non-vascular cause.
June 2009 AHA/ASA scientific statement definition: A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction
CVA
An infarction of the central nervous system tissue
References:
Definition and Evaluation of Transient Ischemic Attack. A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke Council; Easton, Donald J et al Stroke :40:
Definition and Evaluation of Transient Ischemic Attack. A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke Council; Easton, Donald J et al Stroke :40:

12. Consequences of the definition change
Anticipate a drop in annual incidence of TIA’s by 33%
Increase in diagnosis of CVA’s by 7%.
There has been a change in the enrollment of members into studies
Potential change in treatment guidelines in the future
Mortality statistics impact
Comparison of old statistics to newer and future statistics won’t be apples to apples
Potential improvement in CVA morbidity and mortality results from earlier treatment. Decreased “wait and see” approach.
References:
American Heart Association. Heart Disease and Stroke Statistics 2010 Update At-a-Glance. At:

13. Consequences of definition change---Consider 3 diagnosis outcomes
TIA
No longer is this the poor prognostic event that it was
90 day risk of stroke with residual symptoms is <1%
Image-positive transient event
90 day risk of stroke with residual symptoms is ~14%
~15 x the chance of having a stroke with residual symptoms in the next 7 days as compared to those with a stroke that already have residual neurological symptoms
Ischemic stroke with residual neurological symptoms

14. Brain cells have different functions in different locations
Frontal Lobe
Personality
Memory
Reasoning
Temporal Lobe
Speech
Hearing
Parietal Lobe
Language
Sensation
Telling right from left
Occipital Lobe
Vision
Cerebellum
Balance
Fine motor control
Coordination
Brain Stem
Breathing
Swallowing
Blood Pressure
Smell
Hearing
Speech
Fingers
Arm
Hip
Hand
Language
Vision
Balance
Coordination

15. Anatomy of the cerebrovascular system

16. The size of the emboli impacts the size of the infarction
The vascular “tree”
Strokes from atrial fibrillation are typically associated with more brain tissue
involved when compared to carotid artery disease-induced strokes.
Presumably due to larger emboli.

17. Two Major Types of Stroke
Ischemia
Thrombosis (local obstruction of an artery)
Embolism (Debris or blood clot traveling from elsewhere and lodging in an artery causing obstruction)
Systemic hypo-perfusion (general medical condition with lack of blood supply reaching the brain
Hemorrhage
Subarachnoid hemorrhage (bleeding into the CSF within the subarachnoid space around the brain)
Intra-cerebral hemorrhage (bleeding directly into the brain tissue)
80% of strokes are secondary to ischemic cerebral infarction
20% of strokes due to hemorrhage

19. CVA’s are caused by anything that can cause vascular compromise
Heart
Atrial fibrillation/rhythm disturbances
VSD/PFO/Endocarditis
Large Blood Vessels
Thrombus
Atherosclerosis
Takayasu arteritis
Giant cell arteritis
Fibromuscular dysplasia
Emboli
Dissection
Marfan’s syndrome and other similar conditions
Intracranial Blood Vessels
Same as large blood vessels but also includes Moya-Moya
Rupture of the Blood vessel and bleeding

20. Vascular Compromise Blood itself Bleeding Tendencies
Complication of anticoagulation medications
Hemophilia
Clotting Tendencies
Protein C or S deficiency
Prothrombin gene mutation
Factor V Leiden
Antithrombin III deficiency
Hyperhomocysteinemia
Antiphospholipid syndrome
Essential thrombocytosis
Sickle cell anemia
Polycythemia Vera

21. TIA—Making the diagnosis

22. TIA—Making the diagnosis
The important point here is that there are several potential etiologies for transient neurological events If vascular compromise is of concern there ideally will be results of a typical diagnostic work-up for underwriter review to assess mortality risk

23. CVA—Making the diagnosis
Brain imaging with CT or MRI is indicated in all patients with a suspected TIA or minor non-disabling stroke as soon as possible.
The 2013 AHA/ASA guidelines suggest:
Imaging techniques and quality of the exams has evolved
To some extent the type of imaging performed is based upon the availability of testing devices and expertise of staff
Many feel that the Diffusion Weighted Imaging (DWI) MRI is more sensitive than CT for the early detection of acute ischemia.
CT’s are frequently more accessible and are frequently used—especially first tests. CT’s are also especially good at detecting the presence of hemorrhage.
Imaging within 24 hours of symptom onset
MRI and specifically Diffusion-weighted Imaging MRI as the preferred modality
Noninvasive imaging (MRA, CTA) of the cervico-cephalic vessels to be part of the evaluation of suspected TIA’s or non-disabling strokes

24. CVA—Making the diagnosis
Cardiac evaluation is important when TIA or CVA is suspected. Testing frequently performed include:
ECG
Echocardiogram
Cardiac monitoring
Other tests are performed as needed
Blood cultures
Sed rate
CBC
PT/PTT

25. JOKE TIME!! Diagnostic dilemma What could it be?
What is wrong with me?????
So far I have removed a banana from your right ear and a carrot from your nose. Now I find part of an apple in your left ear.
You are not eating properly!!!!

26. Making the diagnosis of a CVA

27. Thalamocapsular region
DWI
T2 weighted
FLAIR
Cerebellum region
Thalamocapsular region

28. Dissection

29. Primary treatment of an acute ischemic CVA or TIA
Acute Ischemic strokes:
Thrombolytic therapy with intravenous alteplase (tPA—recombinant tissue-type plasminogen activator)
Early treatment important
Many exclusions
Unfortunately, in the US only about 8% of all ischemic stroke victims present to the ER within 3 hours and also meet the eligibility criteria for tPA.
Vertebral artery or Carotid artery dissecting aneurysms
Thrombolytic therapy is not contraindicated and the effectiveness and safety is comparable to ischemic strokes from other causes
Extension of the aortic dissection is a potential complication of the thrombolysis however.

30. Primary treatment of an acute bleed
Subarachnoid hemorrhage
Aneurysmal (~80%)
Surgical management usually needed
Surgical clipping
Endovascular therapy with coil system
Non-aneurysmal (~20%)
AVM
Endovascular therapy
Intracranial artery dissection
Perimesencephalic non-aneurysmal subarachnoid hemorrhage
Subtype identified in 1985
Findings of localized blood on CT, normal angiography, and a relatively benign course
Long term mortality is significantly better than aneurysmal SAH approaching normal controls.
Intra-cerebral bleeding
Reversal of anticoagulation
Monitoring of intracranial pressure
Seizure prophylaxis
Surgery for cerebellar decompression and possibly supratentorial ICH (controversial)

31. Secondary Treatment of the acute ischemic CVA or TIA
Smoking cessation
Heavy ETOH consumption should be avoided but light to moderate consumption (no more than 2 per day for men and 1 drink per day for women) is reasonable
Physical exercise—30 min of moderate-intensity for 30 min or more 1-3 times per week
Antithrombotic therapy initiation within 48 hours of stroke
BP management—Goal of therapy is BP of <120/80 mm Hg.
Lipid lowering therapy (Statins) for those with elevated LDL >100 mg/dl with goal LDL-C of <70 mg/dL.
Prophylaxis for DVT and PE important for those at risk
DM management (Diabetics have twice the typical risk for CVA). Unfortunately studies have not provided conclusive evidence that tight control decreases macro-vascular disease similar to the benefit in micro-vascular disease. The AHA/ASA still supports good control of blood sugars however.
Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack. A guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2011; 42:

32. Secondary Treatment of the acute ischemic CVA or TIA—Slide 2
Atrial Fibrillation (paroxysmal or permanent):
Anticoagulation with a vitamin K antagonist preferred
ASA alone for those who can’t tolerate a vitamin K antagonist
Prosthetic heart valves
Oral anticoagulation with an INR of
ASA is recommended to be added to the oral anticoagulation for those with an ischemic event while on anticoagulation
Cardiomyopathy with EF <35%:
Warfarin, ASA, Clopidogrel, or the combo of ASA and dipyridamole may be considered
Non-cardioembolic ischemic strokes or TIA’s
Antiplatelet therapy
Acute MI and left ventricular thrombus
Oral anticoagulation recommended for at least 3 months
PFO (Patent Foramen Ovale)
Antiplatelet therapy is reasonable
Insufficient data to make a recommendation for surgical closure in those with PFO who have had a stroke
PFO closure. RESPECT and PC trial results published in the NEJM early PC Trial involved 414 patients. RESPECT involved 980 patients. Both randomized patients to either medical therapy or PFO closure after suffering an ischemic stroke or TIA. No benefit of closure in the main, intention-to-treat- analysis. However in the RESPECT trial there was benefit to closure in a “as-treated_ analysis.
Arterial Dissection
Antithrombotic treatment for 3-6 months
Endovascular stenting should be considered for recurrent ischemic events despite medical treatment
Surgical treatment should be considered for those failing stenting.
Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack. A guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2011; 42:

33. Secondary Treatment of the acute ischemic CVA or TIA
Symptomatic extracranial carotid disease:
70-99% stenosis of ipsilateral side: Carotid endarterectomy recommended
When morbidity and mortality risk is <6%
50-69% stenosis: Carotid endarterectomy to be considered
When morbidity and mortality risk is <6% and
Dependent on pt specific factors (age, sex, comorbid conditions)
<50% stenosis
No indication for endarterectomy or stenting
Carotid angioplasty and stenting is an alternative in some settings
> 70% stenosis by noninvasive testing
Especially those difficult to assess surgically such as radiation induced stenosis or restenosis after endarterectomy
> 50% stenosis by angiography
Optimal medical therapy including antiplatelet therapy, statins, etc.
Extracranial vertebrobasilar disease:
Optimal medical therapy
Consider surgery when medical therapy has failed.
Intracranial atherosclerosis
50-99% stenosis:
ASA recommended (in preference to warfarin)
Angioplasty and/or stent placement usefulness is unknown and considered E/I
Bypass surgery is not recommended
Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack. A guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Furie, Karen et al. Stroke. 2011; 42:

34. Mortality implications of TIA’s and CVA’s
TIA without images being positive 90 day stroke risk <1%
Transient event that is image positive 90 day stroke risk 14%
CVA
CVA’s have a high peri-stroke period mortality rate
Complications clearly are determined by
Location of the stroke
How much brain tissue is involved
95% of patients have at least one medical complication1
24% of patients have at least one serious, life threatening complication1
Direct effects of the stroke cause death in the first few days. Medical complications account for the mortality thereafter
In the first year the most common cause of death is2:
First week: Cerebrovascular disease
2-4 weeks: PE
2-3 months: Pneumonia
>3 months Cardiac disease
1Randomized trial of Tirilizad Mesylate in Acute Stroke (RANTTAS)
2Risk of myocardial infarction and vascular disease after transient ischemic stroke and ischemic stroke: a systematic review and meta-analysis. Touze E et al Stroke :36 (12):2748

35. Cardiac complications of a stroke
Cardiac complications are not just the association of atherosclerosis
Stroke is a coronary artery disease risk equivalent
Those with a stroke with no known coronary disease have a similar risk of MI as those with established coronary disease
Takotsubo cardiomyopathy is one condition that can occur
Extreme catecholamine release is postulated to cause this
Causes an acute cardiomyopathy
Interestingly it typically involves the apical and mid sections of the heart
ECG abnormalities present in 92% of patients with an acute stroke
Classic large and upright T waves can occur
Prolonged QT intervals are common
Cardiac arrhythmias

36. Included those with hx. of heart disease
Did not include those with hx. of heart disease

37. What percentage of stroke victims die within 5, 10 and 15 years?
4 QUESTIONS
What percentage of stroke victims die within 1 month of their first stroke?
What percentage of stroke victims die within 5, 10 and 15 years?
Does age matter?
Does type of stroke matter?

38. Proportion of patients dead 1 year after first stroke.
>64 y/o
45-64 y/o
Proportion of patients dead 1 year after first stroke. Source: Pooled data from the Framingham Heart Study, Atherosclerosis Risk in Communities study, and Cardiovascular Health Study of the National Heart, Lung, and Blood Institute.
Go A S et al. Circulation 2013;127:e6-e245
Copyright © American Heart Association

39. Proportion of patients dead within 5 years after first stroke.
>64 y/o
45-64 y/o
Proportion of patients dead within 5 years after first stroke. Source: pooled data from the Framingham Heart Study, Atherosclerosis Risk in Communities study, and Cardiovascular Health Study of the National Heart, Lung, and Blood Institute.
Compared to the general population nonfatal stroke is associated with a:
5 fold increase for death between 1 month and 1 year.
2 fold increase for death at 5 years
Writing Group Members et al. Circulation 2012;125:e2-e220
Copyright © American Heart Association

40. Figure 1. Short-term survival probability for patients aged 65 years at first nonfatal stroke by subtype (Cox regression).
Estimated cumulative risk for death:
28 days 28%
1 year 41%
5 years 60%
However, risk of death did vary based upon type of stroke
IDS Ill Defined Stroke
CI Cerebral Infarct
SAH Subarachnoid Hemorrhage
PICH 1o Intracerebral Bleed
Part of the World Health Organizations (WHO) MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) Project. 4,162 patients with a first stroke eligible for analysis
Brønnum-Hansen H et al. Stroke 2001;32:
Copyright © American Heart Association

41. Figure 2. Long-term survival probability for patients aged 65 years at first nonfatal stroke by subtype (Cox regression).
Estimated cumulative risk for death:
5 years 60%
10 years 76%
15 years 86%
SAH Subarachnoid Hemorrhage
Figure 2. Long-term survival probability for patients aged 65 years at first nonfatal stroke by subtype (Cox regression). PICH, primary intracerebral hemorrhage; CI, cerebral infarct; and IDS, ill-defined stroke patients.
SAH Subarachnoid Hemorrhage
CI Cerebral Infarct
PICH 1o Intracerebral Bleed
IDS Ill Defined Stroke
Brønnum-Hansen H et al. Stroke 2001;32:
Copyright © American Heart Association

42. A well-designed prospective cohort study of 2447 participants from the Dutch TIA trial found that the risk for major vascular events and stroke was highest shortly after TIA or minor nondisabling stroke, declined to its lowest point at about three years, and then progressively increased over the remainder of the 10-year follow-up (figure 4) [19]. In contrast, the risk for mortality gradually rose throughout the study. By 10 years, 60 percent had died and 54 percent had experienced new vascular events (stroke and myocardial infarction). Event-free survival was 48 percent. Predictive factors for risk of vascular events and death included age over 65 years, diabetes, claudication, previous vascular surgery, and pathologic Q waves on baseline electrocardiogram.

43. Imaging results frequently encountered by the underwriting staff
3 tests, frequently seen, that I want to discuss in more depth are:
CIMT testing
Carotid Duplex Ultrasound testing
MRI or CT scan which shows the presence of a previous infarct—incidental finding

44. Carotid artery intima-media thickness (CIMT)
CIMT measures the thickness of 2 layers (intima and media) of the carotid artery walls
Carotid artery methods are being refined so it is important to know exactly where the artery is being measured (Carotid bulb, common carotid, or internal carotid), near or far walls or both.
/S (05) /abstract
Thought by some to be an even earlier indicator of atherosclerosis than Coronary artery calcium measurements since thickening precedes a plaque

45. Carotid artery intima-media thickness (CIMT)
Abnormal (“high risk”) frequently defined as media thickness above the 75th percentile.
Conflicting evidence whether this test has independent predictive power as compared to usual CV risk factors
American Heart Association Position Statement (dated 3/7/12) even suggested this test not be mandated by health insurers as the predictive power hasn’t been established. (Of note however is that they also did not support EBCT measurements whereas there is some evidence this test is helpful, at least in intermediate risk individuals, independently of other tests).
In the Multi-Ethnic Study of Atherosclerosis (MESA) which had 6698 subjects aged years CIMT was a modestly better predictor of stroke than EBCT but was not as good as EBCT for CV disease prediction
Meta-analysis has shown that serial measurements are not useful for predicting progression.

46. US and MRA

47. Evaluation of the Carotid arteries
Carotid duplex ultrasound frequently performed:
81-98% sensitive
82-89% specific
Less precise for stenosis of <50%
Less precise for stenosis of 100%
Frequently used with MRA or CTA for confirmation of stenosis of >50% or for 100% stenosis.
Complete Obstruction: No surgical treatment has been proven to be of benefit.
Combo of US and MRA very good at detecting this
CTA is also extremely good at detecting this
Gold standard is angiography

48. Asymptomatic extracranial carotid artery disease
The 2011 AHA/ASA Guidelines
Medical therapy and lifestyle changes should be instituted
Population screening for asymptomatic carotid artery stenosis is not recommended
Benefit in women is very controversial
Prophylactic CEA performed with <3% morbidity and mortality should be considered when:
Minimum of 60% occlusion by angiography or
>/= 70% occlusion on doppler
>80% occlusion on CTA or MRA for those with US showing 50% to 69% stenosis
The number to treat (NTT) to prevent 1 stroke over 3 years is 33
Carotid artery stenting can be considered but the advantage over medical therapy is not well established
Guidelines for the Prevention of Stroke in Patients With Stroke or Transient Ischemic Attack. A guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Furie, Karen et al. Stroke. 2011; 42:

49. Silent Strokes A not so uncommon incidental finding
Not such good outcomes when found
Evaluated in the Cardiovascular Health Study1
Published in 2002
5888 people >/= 65 y/o with normal MRI followed by repeat MRI in 5 years.
17.7% had 1 or more infarct
Only 11% had experienced a documented TIA or CVA .
Those with + MRI scans showed > decline in Mini-Mental exam test results
Evaluated in the Rotterdam Scan study2
Published in 2003
1077 elderly people followed for over 4 years.
Silent brain infarcts increased the chance of a subsequent major CVA by 5 times.
Those with >1 silent infarct were at the highest risk for a subsequent major CVA.
The presence of silent infarcts significantly increased the risk of dementia
Silent strokes typically involve small areas of the brain or areas that have tremendous amount of potential for redundancy....not areas like the pre-Rolandic motor cortex area containing the pars opercularis or its connections which would result in Broca’s aphasia.
1. Incidence, manifestations, and predictors of brain infarcts defined by serial cranial magnetic resonance imaging in the elderly: The Cardiovascular Health Study. Longstreth WT et al Stroke. 2002;33(10):2376.
2. Silent brain infarcts and white matter lesions increase stroke risk in the general population: the Rotterdam Scan Study.
Vermeer SE, et al, Rotterdam Scan Study Stroke. 2003;34(5):1126

50. More examples of silent CVA’s
Axial T2-weighted
Axial T1-weighted
FLAIR
Axial Proton Density
Main signal characteristics used for defining SBI on different MRI sequences. A–D, A silent brain infarct (SBI) corresponds to CSF signal on all MRI sequences (black arrows). A, Axial T2-weighted; (B) axial T1-weighted; (C) axial fluid-attenuated inversion-recovery (FLAIR); (D) axial proton density. E–H, A hyperintense lesion on T2-weighted images that is moderately hypointense on T1 in the left thalamus (white arrows) is not defined as SBI in studies defining only cavities containing CSF as infarcts, whereas it is diagnosed as an infarct in studies that simply defined hyperintense T2 and hypointense T1 foci as infarcts. E, Axial T2-weighted; (F) axial T1-weighted; (G) axial FLAIR; (H) axial proton density. CSF indicates cerebrospinal fluid.
Zhu Y et al. Stroke 2011;42:
Copyright © American Heart Association

51. Summary
CVA rates in the US are declining. However, based upon population demographics the total number/year is anticipated to continue to rise
Definition changes regarding TIA and CVA will impact mortality numbers
There are several types of strokes and multiple etiologies. Regardless of the type there are significant adverse long term mortality concerns
Diagnosis of TIA’s and CVA’s can be accomplished with several types of imaging. A diffusion weighted MRI probably is one of the best methods. Quick evaluation is important
Primary and secondary treatment depends on the etiology of the stroke but does impact mortality
CIMT testing might demonstrate future potential value in underwriting but as an independent cardiac or cerebrovascular disease indicator there are currently conflicting results
Carotid US results and the presence of CVA’s found incidentally do help with underwriting

52. CASE
2 cases arrive for underwriter review. Which has the worst mortality risk based upon the following limited information you are provided?
Case 1:
66 y/o female with hx. of a “TIA-like” event 4 years ago with no subsequent symptoms. Hx. of hypertension and hyperlipidemia. BMI 30
MRI of the brain WNL.
US of the carotids WNL.
ECG WNL.
CIMT abnormal at >75th percentile for age—no plaque.
Case 2:
65 y/o female with no known neurological complaints—past or present
Hx. of hypertension and hyperlipidemia. BMI 30
Recent MRI of the brain shows 2 small lacunar infarcts—age unknown
US of the carotids WNL
ECG WNL
CIMT normal

53. The patient has been depressed ever since she began seeing me in 1983.
JOKE TIME AGAIN!!
Medical Record Documentation---sometimes words just come out …well, wrong
The patient has been depressed ever since she began seeing me in 1983.
The patient was to have a bowel resection.
However he took a job as a stockbroker instead.
The patient has no past history of suicides.
The patient left the hospital feeling much better,
except for her original complaints.

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55. Thank You For Attending Housecalls: Webinar #8 Cerebrovascular Disease
Presented by:
William R. Rooney, M.D., VP & Medical Director
July 24, 2013