Presentation on theme: "Cerebrovascular Disease"— Presentation transcript:
1Cerebrovascular Disease William R. Rooney, MDVP & Medical DirectorGenerali USA Life Reassurance
2Welcome & Webinar Guidelines Thanks for attending!!Phones will be locked during the presentationPlease submit questions by using the question “?” function in the lower right corner to type in your questionQuestion & Answers will be discussed at the end (time permitting)Your comments are important; please complete the survey at the end of the webinar
3Introduction: William Rooney, M.D. FAAFP, EMBA Joined Generali USA in April, 201220 year history of direct patient care.Eight years of insurance industry experience.Board certified in Family Medicine
4Primary and secondary treatment Another look at Mortality numbers OverviewStroke FactsMortality numbersDefinitionsAnatomy reviewTypes of strokesDiagnosisPrimary and secondary treatmentAnother look at Mortality numbersCIMT, Carotid US, and Silent strokes
5CASE2 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 30MRI 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 presentHx. of hypertension and hyperlipidemia. BMI 30MRI of the brain shows 2 small lacunar infarcts—age unknownUS of the carotids WNLECG WNLCIMT normal
6795,000 Americans suffer strokes each year Stroke Facts795,000 Americans suffer strokes each year134,000 deaths each year6,400,000 stroke survivors34% 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:
8Annual stroke death rate fell 35%. Actual number of deaths fell 19%. Stroke FactsWomen 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:
11DefinitionsTIAClassic 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 infarctionCVAAn infarction of the central nervous system tissueReferences: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:
12Consequences 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 studiesPotential change in treatment guidelines in the futureMortality statistics impactComparison of old statistics to newer and future statistics won’t be apples to applesPotential 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:
13Consequences of definition change---Consider 3 diagnosis outcomes TIANo longer is this the poor prognostic event that it was90 day risk of stroke with residual symptoms is <1%Image-positive transient event90 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 symptomsIschemic stroke with residual neurological symptoms
14Brain cells have different functions in different locations Frontal LobePersonalityMemoryReasoningTemporal LobeSpeechHearingParietal LobeLanguageSensationTelling right from leftOccipital LobeVisionCerebellumBalanceFine motor controlCoordinationBrain StemBreathingSwallowingBlood PressureSmellHearingSpeechFingersArmHipHandLanguageVisionBalanceCoordination
16The size of the emboli impacts the size of the infarction The vascular “tree”Strokes from atrial fibrillation are typically associated with more brain tissueinvolved when compared to carotid artery disease-induced strokes.Presumably due to larger emboli.
17Two Major Types of Stroke IschemiaThrombosis (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 brainHemorrhageSubarachnoid 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 infarction20% of strokes due to hemorrhage
19CVA’s are caused by anything that can cause vascular compromise HeartAtrial fibrillation/rhythm disturbancesVSD/PFO/EndocarditisLarge Blood VesselsThrombusAtherosclerosisTakayasu arteritisGiant cell arteritisFibromuscular dysplasiaEmboliDissectionMarfan’s syndrome and other similar conditionsIntracranial Blood VesselsSame as large blood vessels but also includes Moya-MoyaRupture of the Blood vessel and bleeding
20Vascular Compromise Blood itself Bleeding Tendencies Complication of anticoagulation medicationsHemophiliaClotting TendenciesProtein C or S deficiencyProthrombin gene mutationFactor V LeidenAntithrombin III deficiencyHyperhomocysteinemiaAntiphospholipid syndromeEssential thrombocytosisSickle cell anemiaPolycythemia Vera
22TIA—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
23CVA—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 evolvedTo some extent the type of imaging performed is based upon the availability of testing devices and expertise of staffMany 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 onsetMRI and specifically Diffusion-weighted Imaging MRI as the preferred modalityNoninvasive imaging (MRA, CTA) of the cervico-cephalic vessels to be part of the evaluation of suspected TIA’s or non-disabling strokes
24CVA—Making the diagnosis Cardiac evaluation is important when TIA or CVA is suspected. Testing frequently performed include:ECGEchocardiogramCardiac monitoringOther tests are performed as neededBlood culturesSed rateCBCPT/PTT
25JOKE 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!!!!
29Primary treatment of an acute ischemic CVA or TIA Acute Ischemic strokes:Thrombolytic therapy with intravenous alteplase (tPA—recombinant tissue-type plasminogen activator)Early treatment importantMany exclusionsUnfortunately, 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 aneurysmsThrombolytic therapy is not contraindicated and the effectiveness and safety is comparable to ischemic strokes from other causesExtension of the aortic dissection is a potential complication of the thrombolysis however.
30Primary treatment of an acute bleed Subarachnoid hemorrhageAneurysmal (~80%)Surgical management usually neededSurgical clippingEndovascular therapy with coil systemNon-aneurysmal (~20%)AVMEndovascular therapyIntracranial artery dissectionPerimesencephalic non-aneurysmal subarachnoid hemorrhageSubtype identified in 1985Findings of localized blood on CT, normal angiography, and a relatively benign courseLong term mortality is significantly better than aneurysmal SAH approaching normal controls.Intra-cerebral bleedingReversal of anticoagulationMonitoring of intracranial pressureSeizure prophylaxisSurgery for cerebellar decompression and possibly supratentorial ICH (controversial)
31Secondary Treatment of the acute ischemic CVA or TIA Smoking cessationHeavy 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 reasonablePhysical exercise—30 min of moderate-intensity for 30 min or more 1-3 times per weekAntithrombotic therapy initiation within 48 hours of strokeBP 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 riskDM 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:
32Secondary Treatment of the acute ischemic CVA or TIA—Slide 2 Atrial Fibrillation (paroxysmal or permanent):Anticoagulation with a vitamin K antagonist preferredASA alone for those who can’t tolerate a vitamin K antagonistProsthetic heart valvesOral anticoagulation with an INR ofASA is recommended to be added to the oral anticoagulation for those with an ischemic event while on anticoagulationCardiomyopathy with EF <35%:Warfarin, ASA, Clopidogrel, or the combo of ASA and dipyridamole may be consideredNon-cardioembolic ischemic strokes or TIA’sAntiplatelet therapyAcute MI and left ventricular thrombusOral anticoagulation recommended for at least 3 monthsPFO (Patent Foramen Ovale)Antiplatelet therapy is reasonableInsufficient data to make a recommendation for surgical closure in those with PFO who have had a strokePFO 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 DissectionAntithrombotic treatment for 3-6 monthsEndovascular stenting should be considered for recurrent ischemic events despite medical treatmentSurgical 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:
33Secondary Treatment of the acute ischemic CVA or TIA Symptomatic extracranial carotid disease:70-99% stenosis of ipsilateral side: Carotid endarterectomy recommendedWhen morbidity and mortality risk is <6%50-69% stenosis: Carotid endarterectomy to be consideredWhen morbidity and mortality risk is <6% andDependent on pt specific factors (age, sex, comorbid conditions)<50% stenosisNo indication for endarterectomy or stentingCarotid angioplasty and stenting is an alternative in some settings> 70% stenosis by noninvasive testingEspecially those difficult to assess surgically such as radiation induced stenosis or restenosis after endarterectomy> 50% stenosis by angiographyOptimal medical therapy including antiplatelet therapy, statins, etc.Extracranial vertebrobasilar disease:Optimal medical therapyConsider surgery when medical therapy has failed.Intracranial atherosclerosis50-99% stenosis:ASA recommended (in preference to warfarin)Angioplasty and/or stent placement usefulness is unknown and considered E/IBypass surgery is not recommendedGuidelines 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:
34Mortality 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%CVACVA’s have a high peri-stroke period mortality rateComplications clearly are determined byLocation of the strokeHow much brain tissue is involved95% of patients have at least one medical complication124% of patients have at least one serious, life threatening complication1Direct effects of the stroke cause death in the first few days. Medical complications account for the mortality thereafterIn the first year the most common cause of death is2:First week: Cerebrovascular disease2-4 weeks: PE2-3 months: Pneumonia>3 months Cardiac disease1Randomized 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
35Cardiac complications of a stroke Cardiac complications are not just the association of atherosclerosisStroke is a coronary artery disease risk equivalentThose with a stroke with no known coronary disease have a similar risk of MI as those with established coronary diseaseTakotsubo cardiomyopathy is one condition that can occurExtreme catecholamine release is postulated to cause thisCauses an acute cardiomyopathyInterestingly it typically involves the apical and mid sections of the heartECG abnormalities present in 92% of patients with an acute strokeClassic large and upright T waves can occurProlonged QT intervals are commonCardiac arrhythmias
36Included those with hx. of heart disease Did not include those with hx. of heart disease
37What percentage of stroke victims die within 5, 10 and 15 years? 4 QUESTIONSWhat 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?
42A 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) . 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.
43Imaging results frequently encountered by the underwriting staff 3 tests, frequently seen, that I want to discuss in more depth are:CIMT testingCarotid Duplex Ultrasound testingMRI or CT scan which shows the presence of a previous infarct—incidental finding
44Carotid artery intima-media thickness (CIMT) CIMT measures the thickness of 2 layers (intima and media) of the carotid artery wallsCarotid 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) /abstractThought by some to be an even earlier indicator of atherosclerosis than Coronary artery calcium measurements since thickening precedes a plaque
45Carotid 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 factorsAmerican 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 predictionMeta-analysis has shown that serial measurements are not useful for predicting progression.
47Evaluation of the Carotid arteries Carotid duplex ultrasound frequently performed:81-98% sensitive82-89% specificLess 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 thisCTA is also extremely good at detecting thisGold standard is angiography
48Asymptomatic extracranial carotid artery disease The 2011 AHA/ASA GuidelinesMedical therapy and lifestyle changes should be institutedPopulation screening for asymptomatic carotid artery stenosis is not recommendedBenefit in women is very controversialProphylactic 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% stenosisThe number to treat (NTT) to prevent 1 stroke over 3 years is 33Carotid artery stenting can be considered but the advantage over medical therapy is not well establishedGuidelines 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:
49Silent Strokes A not so uncommon incidental finding Not such good outcomes when foundEvaluated in the Cardiovascular Health Study1Published in 20025888 people >/= 65 y/o with normal MRI followed by repeat MRI in 5 years.17.7% had 1 or more infarctOnly 11% had experienced a documented TIA or CVA .Those with + MRI scans showed > decline in Mini-Mental exam test resultsEvaluated in the Rotterdam Scan study2Published in 20031077 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 dementiaSilent 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
51SummaryCVA rates in the US are declining. However, based upon population demographics the total number/year is anticipated to continue to riseDefinition changes regarding TIA and CVA will impact mortality numbersThere are several types of strokes and multiple etiologies. Regardless of the type there are significant adverse long term mortality concernsDiagnosis 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 importantPrimary and secondary treatment depends on the etiology of the stroke but does impact mortalityCIMT testing might demonstrate future potential value in underwriting but as an independent cardiac or cerebrovascular disease indicator there are currently conflicting resultsCarotid US results and the presence of CVA’s found incidentally do help with underwriting
52CASE2 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 30MRI 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 presentHx. of hypertension and hyperlipidemia. BMI 30Recent MRI of the brain shows 2 small lacunar infarcts—age unknownUS of the carotids WNLECG WNLCIMT normal
53The patient has been depressed ever since she began seeing me in 1983. JOKE TIME AGAIN!!Medical Record Documentation---sometimes words just come out …well, wrongThe 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.
54Please use the ? function on your screen to type in a question. Questions?Questions?Please use the ? function on your screen to type in a question.or call me if you think of questions later(913)Copies of the presentation will be available:On the Website:orBy contactingA recording of the webinar should be available in few days:On the Website:
55Thank You For Attending Housecalls: Webinar #8 Cerebrovascular Disease Presented by:William R. Rooney, M.D., VP & Medical DirectorJuly 24, 2013