1. Brain Injuries Caused By Stroke.
Felix E. Chukwudelunzu, MD, FAHA
27th. Annual Conference; brain Injury Association of Minnesota March,
©2011 MFMER | slide-1

2. Agenda Epidemiology Pathophysiology Medical Complications
Neuropsychiatric Complications
Type the footnote/source in this space
©2011 MFMER | slide-2

3. Epidemiology of Stroke
795,000 new/recurrent per year
Every 40 seconds, someone in US has a stroke
Stroke incidence on the decline
©2011 MFMER | slide-3

4. Epidemiology Cont..
Age adjusted incidence first stroke per 1000 person-years in US: Men/Women:
= 7.6/6.2
1978 – 1989 = 6.2/5.8
1990 – 2004 = 5.3/5.1
©2011 MFMER | slide-4

5. Epidemiology Cont.. Age adjusted severity of stroke = No Change
Overall No.3 cause of mortality (CHD & Cancer)
30-day mortality:
23% to 14% in men
No change in women (21% to 20%)
©2011 MFMER | slide-5

6. For white/Black Females: No 2 Cause of Mortality:
©2011 MFMER | slide-6

7. How Does Ischemic Stroke Happen
A condition in which blood flow to part or all of the brain is reduced, resulting in tissue damage.
©2011 MFMER | slide-7

8. ©2011 MFMER | slide-8

9. Ischemic Stroke Cont… ●Reduced or Complete blockage of blood Flow:
▪Thrombosis: Clot formed at the site
▪Embolization: Clot from remote site
▪Arteriosclerosis: (Lacunar Stroke)
●Ischemic Stroke = 87%
●Intracranial hemorrhage = 10%
●Subarachnoid Hemorrhage = 3%
©2011 MFMER | slide-9

10. ©2011 MFMER | slide-10

11. Pathophysiology of Stroke
©2011 MFMER | slide-11

12. Cerebral Autoregulation
●Phenomenon by which CBF is maintained at a relatively constant level despite moderate variations in perfusion pressure (PP).
●How? Not completely understood, but:
▪Smooth muscle response to changes in PP
▪Effect of vasoactive substances on the BV
▪Endothelial Nitric Oxide.
©2011 MFMER | slide-12

13. Normal Cerebral blood Vessel
● Rate of CBF → Resistance & Diameter
●Dilation of BV = ↑Blood volume and ↑CBF
●Constriction = Blood volume and CBF
©2011 MFMER | slide-13

14. Cerebral Autoregulation (CAR)
©2011 MFMER | slide-14

15. CAR and STROKE ●CAR is impaired during stroke
●Initially CPP, cerebral vessels dilate = ↑CBF
●CPP beyond threshold = CBF
©2011 MFMER | slide-15

16. CBF Results in: Protein synthesis inhibition Glucose utilization
Onset of anaerobic glycolysis = tissue acidosis
Neuronal electrical failure
Membrane ion homeostasis failure
Cerebral Infarction (stroke)
©2011 MFMER | slide-16

17. ©2011 MFMER | slide-17

18. Why Do People Get Stroke
©2011 MFMER | slide-18

19. ©2011 MFMER | slide-19

20. ©2011 MFMER | slide-20

21. Medical Complications of Ischemic Stroke
Very Common
Poor Clinical Outcome
Recognition important
Appropriate prevention & treatment strategies
©2011 MFMER | slide-21

22. Medical Complication Cont….
Complications Percent
Falls
UTI
Chest Infection 22
Pressure Sores 21
Depression
Shoulder Pain 9
DVT & PE
Data: Langhorn P, et al. Stroke 2000;31:1223
©2011 MFMER | slide-22

23. Neuropsychiatric Complications of Stroke
●Cognitive Syndrome/Post-Stroke Dementia
●30% of all Stroke Patients
●Slow progression
●Executive Functional Loss/deficite
▪Frontal Lobe dementia
▪Subcortical dementia
©2011 MFMER | slide-23

24. Risk of Cognitive Impairment after Stroke
Age
History of DM
History of Afib
Ethnicity
Educational attainment
Location of Stroke
©2011 MFMER | slide-24

25. Psychiatric Syndromes
Overt Sadness = 72% in acute phase
Depression = 60% (L insular cortex)
Acute psychosis – Rare (L PCA Stroke)
Anxiety = 25%
PTSD-like syndrome
Mania (R hemispheric Stroke)
Delusional disorder/Psychosis… Rare
©2011 MFMER | slide-25

26. Post Stroke Depression Associated With:
Poor social outcomes
Reduced quality of life
Reduced rehabilitation treatment efficiency
Increased cognitive impairment
Increased mortality Morris, et al., 1993
Poor functional recovery – may delay recovery by 2 years.
©2011 MFMER | slide-26

27. Sleep Related Breathing Disorders (SRBD).
Obstructive Sleep Apnea
Increases the risk of stroke
Correlation b/w severity and stroke
Apnea-Hypopnea Index >19.1
©2011 MFMER | slide-27

28. How does sleep apnea lead to stroke
●Decrease cerebral blood flow during apnea
●Hypoxemia (low oxygenation)
●Sympathetic activation (increase BP/HR)
●Abnormal heart rhythm and rate
©2011 MFMER | slide-28

29. Sleep Apnea And Stroke Coagulation (increase blood clot formation)
Disruption of lining of blood vessels
Inflammatory markers (CRP, IL6)
Metabolic deregulation ( Insulin, leptin)
©2011 MFMER | slide-29

30. ©2011 MFMER | slide-30

31. OSA After Stroke
●Systematic review of 29 studies that included 2,342 patients who had a stroke or TIA:
●AHI:
>5 = 70%
>10 = 60%
>20 = 40%
●Other SRBD:
▪Central Sleep Apnea (CSA)
▪Cheyne-Stokes Breathing Disorder (CSB)
©2011 MFMER | slide-31

32. SRBD And Stroke ●↑Male elderly patients
●Stroke with the following characteristics:
▪Presence of DM
▪Presence of Microangiopathy
▪Nocturnal Onset
©2011 MFMER | slide-32

33. Post Stroke Pain
Lesion: Spinothalamic pathways and its cortical projections.(Thalamic stroke—most common)
Incidence 8%
Constant or intermittent
Associated with sensory abnormality
Begin within the first month after stroke = 63%
©2011 MFMER | slide-33

34. Post Stroke Fatigue ●Occurs in 68% of stroke patients
●Hightened awareness of physical/emotional strain
●Contributing Factors:
▪Sleep disorder
▪Imobility
▪Deconditioning
▪Psychologic
©2011 MFMER | slide-34

35. Questions?
©2011 MFMER | slide-35