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

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Presentation on theme: "Cerebrovascular Disease William R. Rooney, MD VP & Medical Director Generali USA Life Reassurance William R. Rooney, MD VP & Medical Director Generali."— Presentation transcript:

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

2 Welcome & Webinar Guidelines Thanks for attending!! Phones will be locked during the presentation Please submit questions by using the question “?” function in the lower right corner to type in your question Question & Answers will be discussed at the end (time permitting) Your comments are important; please complete the survey at the end of the webinar 2

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

4 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 4

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 90 th 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 5

6 Stroke Facts 1.795,000 Americans suffer strokes each year 2.134,000 deaths each year 3.6,400,000 stroke survivors 4.34% of people hospitalized for stroke in 2009 were under 65 years of age ,000 Americans suffer strokes each year 2.134,000 deaths each year 3.6,400,000 stroke survivors 4.34% of people hospitalized for stroke in 2009 were under 65 years of age. 6

7 Rosamond W et al. Circulation 2007;115:e69-e171 Copyright © American Heart Association Prevalence of stroke by age and sex 7

8 Stroke Facts 1.Women are twice as likely to die from stroke than breast cancer annually. 2.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. 3.A leading cause of death in the United States : –Annual stroke death rate fell 35%. –Actual number of deaths fell 19%. 1.Women are twice as likely to die from stroke than breast cancer annually. 2.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. 3.A leading cause of death in the United States : –Annual stroke death rate fell 35%. –Actual number of deaths fell 19%. 8

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

10 Similar downward trend noted in the European Union. Kunst A E et al. Stroke 2011;42: Copyright © American Heart Association Point #1 The stroke mortality rate in the Western countries is declining. Decreased incidence Decreased case-fatality rate Point #1 The stroke mortality rate in the Western countries is declining. Decreased incidence Decreased case-fatality rate Mortality rate from Stroke Point #2 The projected total number of US deaths from strokes is not expected to decline through 2030 however because of the aging population Point #2 The projected total number of US deaths from strokes is not expected to decline through 2030 however because of the aging population 10

11 Definitions 1.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 1.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 2.CVA An infarction of the central nervous system tissue 2.CVA An infarction of the central nervous system tissue 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. 2009:40:

12 Consequences of the definition change 1.Anticipate a drop in annual incidence of TIA’s by 33% 2.Increase in diagnosis of CVA’s by 7%. 1.Anticipate a drop in annual incidence of TIA’s by 33% 2.Increase in diagnosis of CVA’s by 7%. 3.There has been a change in the enrollment of members into studies Potential change in treatment guidelines in the future Mortality statistics impact 4.Comparison of old statistics to newer and future statistics won’t be apples to apples 5.Potential improvement in CVA morbidity and mortality results from earlier treatment. Decreased “wait and see” approach. 3.There has been a change in the enrollment of members into studies Potential change in treatment guidelines in the future Mortality statistics impact 4.Comparison of old statistics to newer and future statistics won’t be apples to apples 5.Potential improvement in CVA morbidity and mortality results from earlier treatment. Decreased “wait and see” approach. 12

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% 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 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 13

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

15 Anatomy of the cerebrovascular system15

16 16The vascular “tree” The size of the emboli impacts the size of the infarction 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. 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) 17 80% of strokes are secondary to ischemic cerebral infarction 20% of strokes due to hemorrhage 80% of strokes are secondary to ischemic cerebral infarction 20% of strokes due to hemorrhage

18 18

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 –Thrombus Same as large blood vessels but also includes Moya-Moya –Emboli –Dissection –Rupture of the Blood vessel and bleeding 19

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 20

21 TIA—Making the diagnosis21

22 TIA—Making the diagnosis22 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. 23 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 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 24

25 Diagnostic dilemma 25 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. What could it be? What is wrong with me????? You are not eating properly!!!! JOKE TIME!!

26 Making the diagnosis of a CVA 26

27 27 DWI T2 weighted FLAIR Cerebellum region Thalamocapsular region

28 Dissection 28 center/treatment/arterial-dissections

29 Primary treatment of an acute ischemic CVA or TIA 29 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. 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. 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 30 Subarachnoid hemorrhage –Aneurysmal (~80%) Surgical management usually needed Surgical clipping Endovascular therapy with coil system –Non-aneurysmal (~20%) AVM Surgical clipping Endovascular therapy Intracranial artery dissection Surgical clipping Endovascular therapy 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. Subarachnoid hemorrhage –Aneurysmal (~80%) Surgical management usually needed Surgical clipping Endovascular therapy with coil system –Non-aneurysmal (~20%) AVM Surgical clipping Endovascular therapy Intracranial artery dissection Surgical clipping Endovascular therapy 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) 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 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. 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. 31 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 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 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 32 Atrial Fibrillation (paroxysmal or permanent): Anticoagulation with a vitamin K antagonist preferred ASA alone for those who can’t tolerate a vitamin K antagonist Atrial Fibrillation (paroxysmal or permanent): Anticoagulation with a vitamin K antagonist preferred ASA alone for those who can’t tolerate a vitamin K antagonist Cardiomyopathy with EF <35%: Warfarin, ASA, Clopidogrel, or the combo of ASA and dipyridamole may be considered Cardiomyopathy with EF <35%: Warfarin, ASA, Clopidogrel, or the combo of ASA and dipyridamole may be considered Acute MI and left ventricular thrombus Oral anticoagulation recommended for at least 3 months Acute MI and left ventricular thrombus Oral anticoagulation recommended for at least 3 months 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 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 Non-cardioembolic ischemic strokes or TIA’s Antiplatelet therapy Non-cardioembolic ischemic strokes or TIA’s Antiplatelet therapy 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. 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. 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 (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 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 33 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 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 complication 1 24% of patients have at least one serious, life threatening complication 1 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 is 2 : First week: Cerebrovascular disease 2-4 weeks:PE 2-3 months:Pneumonia >3 monthsCardiac disease 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 complication 1 24% of patients have at least one serious, life threatening complication 1 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 is 2 : First week: Cerebrovascular disease 2-4 weeks:PE 2-3 months:Pneumonia >3 monthsCardiac disease 34 1 Randomized trial of Tirilizad Mesylate in Acute Stroke (RANTTAS) 2 Risk of myocardial infarction and vascular disease after transient ischemic stroke and ischemic stroke: a systematic review and meta-analysis. Touze E et al. Stroke. 2005:36 (12):2748 TIA TIA without images being positive90 day stroke risk <1% Transient event that is image positive90 day stroke risk 14% TIA TIA without images being positive90 day stroke risk <1% Transient event that is image positive90 day stroke risk 14%

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 35

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

37 4 QUESTIONS What percentage of stroke victims die within 1 month of their first stroke? 2.What percentage of stroke victims die within 5, 10 and 15 years? 3.Does age matter? 4.Does type of stroke matter? 1. What percentage of stroke victims die within 1 month of their first stroke? 2.What percentage of stroke victims die within 5, 10 and 15 years? 3.Does age matter? 4.Does type of stroke matter?

38 Proportion of patients dead 1 year after first stroke. Go A S et al. Circulation 2013;127:e6-e245 Copyright © American Heart Association y/o >64 y/o

39 Proportion of patients dead within 5 years after first stroke. Writing Group Members et al. Circulation 2012;125:e2-e220 Copyright © American Heart Association 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 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 y/o >64 y/o

40 Figure 1. Short-term survival probability for patients aged 65 years at first nonfatal stroke by subtype (Cox regression). Brønnum-Hansen H et al. Stroke 2001;32: Copyright © American Heart Association Estimated cumulative risk for death: 28 days28% 1 year41% 5 years60% Estimated cumulative risk for death: 28 days28% 1 year41% 5 years60% 40 SAHSubarachnoid Hemorrhage However, risk of death did vary based upon type of stroke CICerebral Infarct PICH1 o Intracerebral Bleed IDSIll Defined Stroke

41 Figure 2. Long-term survival probability for patients aged 65 years at first nonfatal stroke by subtype (Cox regression). Brønnum-Hansen H et al. Stroke 2001;32: Copyright © American Heart Association om/stroke/stats.htm 41 SAHSubarachnoid Hemorrhage CICerebral Infarct PICH1o Intracerebral Bleed IDSIll Defined Stroke SAHSubarachnoid Hemorrhage CICerebral Infarct PICH1o Intracerebral Bleed IDSIll Defined Stroke Estimated cumulative risk for death: 5 years60% 10 years76% 15 years86% Estimated cumulative risk for death: 5 years60% 10 years76% 15 years86% SAHSubarachnoid Hemorrhage

42 42

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 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 43

44 /S (05) /abstract CIMT measures the thickness of 2 layers (intima and media) of the carotid artery walls Thought by some to be an even earlier indicator of atherosclerosis than Coronary artery calcium measurements since thickening precedes a plaque 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. Carotid artery intima-media thickness (CIMT)

45 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 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 45 Abnormal (“high risk”) frequently defined as media thickness above the 75th percentile. Meta-analysis has shown that serial measurements are not useful for predicting progression.

46 US and MRA 46

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 47

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 48 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 49 Evaluated in the Rotterdam Scan study 2 Published in 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 Evaluated in the Rotterdam Scan study 2 Published in 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 A not so uncommon incidental finding Evaluated in the Cardiovascular Health Study 1 Published in 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 Cardiovascular Health Study 1 Published in 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 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): 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 Silent Strokes Not such good outcomes when found

50 Zhu Y et al. Stroke 2011;42: Copyright © American Heart Association More examples of silent CVA’s Axial T2-weighted Axial T1-weighted FLAIR Axial Proton Density 50

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 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 51

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 >75 th 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 52

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

54 Questions? or call me if you think of questions later (913) Copies of the presentation will be available: On the Website: or By contacting A recording of the webinar should be available in few days: On the Website: Webinars.aspx Questions? Please use the ? function on your screen to type in a question.

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


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