1. Post TIA, Post Stroke Prognosis D. Darwin A. Dasig, M.D., F.P.N.A. Makati Medical Center

2. Cerebrovascular Disease any abnormality of the brain resulting from a pathologic process of the blood vessels

3. Cerebrovascular Disease Atherosclerotic thrombosis Transient ischemic attacks Embolism Hypertensive hemorrhage Ruptured or unruptured saccular aneurysm or AVM Arteritis  Meningovascular syphilis, arteritis secondary to pyogenic and tuberculous meningitis, rare infective types (typhus, schistosomiasis, malaria, trichinosis, mucormycosis, etc.)

4. Cerebrovascular Disease  Connective tissue diseases (polyarteritis nodosa, lupus erythematosus), necrotizing arteritis, Wegener arteritis, temporal arteritis, Takayasu disease, granulomatous or giant cell arteritis of the aorta, giant cell granulomatous angiitis of cerebral arteries Cerebral thrombophlebitis: secondary to infection of ear, paranasal sinus, face, etc.; with meningitis and subdural empyema; debilitating states, postpartum, postoperative, cardiac failure, hematologic disease (polycythemia, sickle-cell disease), and of undetermined cause

5. Cerebrovascular Disease Hematologic disorders: polycythemia, sickle-cell disease, thrombotic thrombocytopenic purpura, throbocytosis, etc. Trauma to carotid artery Dissecting aortic aneurysm Systemic hypotension with arterial stenoses: “simple faint”, acute blood loss, myocardial infarction, Stokes- Adams syndrome, traumatic and surgical shock, sensitive carotid sinus, severe postural hypotension Complications of arteriography Neurologic migraine with persistent deficit

6. Cerebrovascular Disease Tentorial, foramen magnum, subfalcial herniations Miscellaneous types: fibromuscular dysplasia, radioactive or x-irradiation, lateral pressure of intracerebral hematoma, unexplained middle cerebral infarction in closed head injury, pressure of unruptured saccular aneurysm, local dissection of carotid or middle cerebral artery, complication of oral contraceptives Undetermined cause as in children and young adults: Moyamoya; multiple, progressive intracranial arterial occlusions

7. vascular disorders of the nervous system ischemia/infarction hemorrhage

8. stroke neurological deficit of sudden onset accompanied by focal dysfunction and symptoms lasting more than 24 hours that are presumed to be of non- traumatic vascular origin (WHO)

9. stroke sudden onset of focal neurological deficit lasting more than 24 hours due to an underlying vascular pathology (Stroke Society of the Philippines, 1999) acute clinically relevant brain lesion on imaging in patients with rapidly vanishing symptoms

10. stroke sudden, focal, nonconvulsive neurologic deficit → brain attack ≠ apoplexy ≠ cerebrovascular accident (CVA)

11. STROKE FACTS leading cause of adult disability 3 rd leading cause of death in the US # 2 killer disease worldwide most important cause of mortality in Asia 75% of all strokes > 65 years of age

12. USA prevalence: 1 in 59 (1.69%) → 4.6 million incidence: 1 in 453 (0.22%) → 600,000 total (500,000 new cases & 100,000 recurrence) Worldwide incidence: 15 million people survive minor stroke each year (WHO)

13. one year mortality: 25% - 40% three year mortality: 32% - 60% over 50% dead in 5 years Framingham study ten-year survival: 35%

14. risk factors & predictors of stroke non-modifiable older age male gender non-white ethnicity family history modifiable elevated blood pressure diabetes mellitus atrial fibrillation hyperlipidemia cigarette smoking obesity high alcohol consumption Cerebrovascular Disease 2003; Advances in Neurology 2003; Stroke 2001

15. RIFASAF Study: independent risk factors for Stroke among Filipinos hypertension diabetes atrial fibrillation myocardial infarction rheumatic heart disease smoking snoring stress frequent Alcohol intake A. Roxas, Phil J. of Neurology, 2002

16. types of stroke ischemic stroke a clot blocks flow to an area of the brain hemorrhagic stroke bleeding occurs inside or around brain tissue

17. ischemic stroke atherothrombotic cardioembolic lacunar

18. major risk factors are unevenly distributed among stroke subtypes cardioembolism atherothrombotic (large-vessel) lacunar (small vessel) elderly (> 70 yr), low rate of early stroke recurrence middle age (45-70 yr), high rate of early stroke recurrence, highest male preponderance hypertension, diabetes, hypercholesterolemia, obesity

19. atherothrombotic stroke (large vessel disease) usually develops at night during sleep symptoms felt in the morning suspect history of atherosclerosis, hypercoagulable states, collagen vascular diseases

22. macroangiopathy: large vessel disease TOAST Criteria presence of occlusion with 50% diameter reduction of a brain-supplying artery corresponding to clinical symptoms and with location and morphology typical of atherosclerosis on Doppler ultrasound or angiography

25. mechanism of atherosclerotic stroke in large cerebral arteries artery to artery embolism thrombotic occlusion hemodynamic infarction: watershed infarction

26. extracranial atherosclerosis (ECAS) most common source of embolism among Whites asymptomatic cervical stenosis or bruits: risk of ipsilateral stroke with > 60% narrowing approximately 2% per year

27. transient ischemic attack (TIA) transient episode of focal neurologic dysfunction secondary to ischemia in one of the vascular territories of the brain (Stroke Council, American Heart Association, 1994) brief episode of neurological dysfunction caused by focal disturbance of brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour and without evidence of infarction

28. transient ischemic attack (TIA) onset sudden & rapid, with complete resolution lasts approximately 2 to 20 minutes initially should involve all affected areas relatively simultaneously should involve focal loss of neurologic function, with symptoms reflecting dysfunction of cerebrum, brainstem, or cerebellum

29. probably not TIA ill-defined onset, waxes & wanes, or slowly worsens leaves persistent neurologic deficits, however mild neurologic dysfunction of few seconds duration episode lasting for more than 1 hour marching of symptoms from one body part to another “positive phenomena”: involuntary movements, jerking, scintillating scotoma “global” brain symptoms: giddiness, LOC, presyncope

30. TIA as predictor of future strokes highest risk in 1 st week 1 st month = 4% - 8% 90 days = 10.5% 1 st year = 12% - 13% 5 years = 24% - 29% 2 years = > 40%

31. intracranial atherosclerosis (ICAS) more common in Asian and Blacks  Asia: 40% - 50%  West: 8% no proven treatment for ICAS

32. atherothrombotic early in course of cerebral thrombosis → difficult to give accurate prognosis progression: increasing stenosis of involved artery by mural thrombus  mild paralysis → disastrous hemiplegia  worsen temporarily for 1- 2 days often progressive: cautious attitude

35. cardioembolic stroke occurs anytime frequently during periods of vigorous activity history of atrial fibrillation, valvular vegetations, thromboembolism from MI seizures in 20% of cases

36. atrial fibrillation 2% - 4% risk for stroke annually persons < 60 years with no other cardiac disorder (lone AF): relatively low risk for stroke AF: abetting factor leading to formation of intra-atrial thrombi in patient with another heart disease at risk: chronic sustained & intermittent

37. atrial fibrillation with greatest risk for embolization: prior stroke or TIA (most important) age > 75 years, especially women history of hypertension or systolic blood pressure > 160 mm Hg diabetes mellitus coronary artery disease congestive heart failure left ventricular dysfunction

38. cardioembolism acute myocardial infarction (with left ventricular thrombus) 5% risk for stroke within 2 weeks risk higher with anterior than inferior infarcts may reach 20% risk in those with large anteroapical infarcts

39. cardioembolism cardiomyopathy  EF 29% - 35%: 0.8% stroke per year  EF < 28%: 1.7% stroke per year prosthetic heart valves  annual percentage of occurrence of systemic thromboembolism: 20%

40. valvular heart disease: annual incidence of thromboembolism no AFwith AF prosthetic valve20%increased rheumatic mitral regurgitation 7.7%22% rheumatic mitral stenosis1.5% - 4%increased by 7 – 8 X mitral valve prolapse< 2%increased

42. lacunar infarction microangiopathy: <1.5 cm diameter pure motor, pure sensory, sensorimotor, ataxic hemiparesis, dysarthria-clumsy hand syndrome

45. survival & recurrence after 1 st cerebral infarction Petty et al, Mayo clinic, 1998 Neurology 50: 208-216 population-based study Rochester, Minnesota 1975 – 1989: 1,111 residents with 1 st cerebral infarction

46. survival & recurrence after 1 st cerebral infarction risk of death:  7% ± 0.7% at 7 days  14% ± 1.0% at 30 days  27% ± 1.3% at 1 year  53% ± 1.5% at 5 years

47. survival & recurrence after 1 st cerebral infarction independent risk factors for death after 1 st cerebral infarction:  age  congestive heart failure  persistent atrial fibrillation  recurrent stroke  ischemic heart disease

48. survival & recurrence after 1 st cerebral infarction risk of recurrent stroke after 1 st cerebral infarction:  2% ± 0.4% at 7 days  4% ± 0.6% at 30 days  12% ± 1.1% at 1 year  29% ± 1.7% at 5 years

49. survival & recurrence after 1 st cerebral infarction significant independent predictors of recurrent stroke:  age  diabetes mellitus

55. intracranial hemorrhage Framingham study: 5% - 10% of all strokes Kunitz et al (NINCDS Stroke Data Bank, 1984): 10.7% of all cases US: 12 – 15 per 100,000 Caucasians: 11-31 per 100,000

56. intracranial hemorrhage overall incidence of ICH declined since 1950s higher incidence among population with higher frequency of hypertension Blacks: 1.4 X Caucasians

57. intracranial hemorrhage Asian countries with higher incidence than other regions of the world  Asia: 20% - 50%  West: 10% - 15% may be due to environmental and/or genetic factors

58. age increase ICH incidence > 55 years doubles with each decade until 80 years relative risk in patient older than 70 years: >7

59. intracranial hemorrhage worse functional outcome than any other stroke subtype higher mortality: 30% - 40% 30 day mortality rate: 44% USA: 20,000 die annually pontine & other brainstem ICH: 75% mortality rate at 24 hours

60. Mitra et al, 1995  34% patients died  36% dependent on outside help for daily living  30% capable of independent existence

61. adverse impact on outcome (Mitra et al, 1995) age > 60 years GCS < 6 on admission ICH volume > 30 ml midline shift in CT Scan of > 3 mm intraventricular hemorrhage hydrocephalus

62. relatively favorable outcome (Mitra et al, 1995) young age GCS > 8 on admission ICH volume < 20 ml lobar hemorrhage absence of intraventricular hemorrhage or hydrocephalus

63. recurrence Hill et al, American Heart Association, Stroke 2000 423 patients with primary ICH (PICH) Toronto Hospital 1986 – 1996 27.4% died in first 30 days after admission recurrence rate for ICH: 2.4% per year recurrence rate for ischemic cerebrovascular: 3% per year (marker)

64. recurrence Hill et al 2000 only significant predictor for readmission for ICH: lobar location of index hemorrhage hazard ratio of 3.8 → PICH at risk for TIA, ischemic stroke, recurrent hemorrhage

65. recurrence Veimeer et al, Neurology 2002 243 patients with primary ICH 5.5 years mean follow-up  recurrence rate for ICH: 2.1%  vascular events: 5.9 %  vascular death: 3.2%

66. recurrence Veimeer et al, Neurology 2002 age > 65 years only predictor for: recurrence (hazard ratio 2.8) vascular death (hazard ratio 3.7)

71. subarachnoid hemorrhage ½ of all spontaneous intracranial hemorrhage (ICH is 20% of all strokes)  ruptured saccular aneurysm: 80% - 90%  AVM or tumor: 5%  idiopathic: 5% - 15%

72. SAH: ruptured aneurysm 15% die before reaching the hospital 25% die within 1 day 40% die by the end of 1 week 50% die within first 6 months 40% survivor with major neurological deficits > 50% survivor with some permanent disability rebleeding 40.9 % mortality 31.7%

73. aneurysm risk of rupture unknown ~ 1% - 2% per year Juvela (2000): 1%

74. aneurysm Wiebers (2003) small (< 7 mm) & anterior location: 0.05% (retrospective) & 0% (prospective) > 10 mm, other locations, prior aneurysmal bleed: 0.5% per year

76. arteriovenous malformation 5% - 10% of cases of SAH intraparenchymal hemorrhage small AVMs (< 2.5 mm) higher frequency of rupture than large Tasic et al (57 patients): 4/100 per year

77. Stroke Society of the Philipines, 1999 Stroke is a “brain attack”…needing emergency management, including specific treatments and secondary and tertiary prevention. is an emergency…where virtually no allowances for worsening are tolerated. is treatable…optimally, through proven, affordable, culturally-acceptable and ethical means. is preventable…in implementable ways across all levels of society.