Brain Injuries Caused By Stroke. Felix E. Chukwudelunzu, MD, FAHA 27th. Annual Conference; brain Injury Association of Minnesota March, 29 2012 ©2011 MFMER | slide-1

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

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

Epidemiology Cont.. Age adjusted incidence first stroke per 1000 person-years in US: Men/Women: 1950 -1977 = 7.6/6.2 1978 – 1989 = 6.2/5.8 1990 – 2004 = 5.3/5.1 ©2011 MFMER | slide-4

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

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

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

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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

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Pathophysiology of Stroke ©2011 MFMER | slide-11

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

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

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

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

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

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

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

Medical Complication Cont…. Complications Percent Falls 25 UTI 24 Chest Infection 22 Pressure Sores 21 Depression 16 Shoulder Pain 9 DVT & PE 2-1 Data: Langhorn P, et al. Stroke 2000;31:1223 ©2011 MFMER | slide-22

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

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

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

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

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

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

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

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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

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

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

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

Questions? ©2011 MFMER | slide-35