Stroke Omar Khan, MD MHS February 2006

Etymology before epidemiology Why is a stroke called a stroke?Why is a stroke called a stroke? –Maybe since all sudden attacks were called strokes, and the rest acquired specific terms e.g. MI –An abbreviation of the phrase 'stroke of apoplexy’ –Apoplexy (from the Greek meaning to strike off) –Divine origin as in, ‘being struck down’

What it is A neurological event following an interruption in blood flow due toA neurological event following an interruption in blood flow due to –Thrombus/embolus –Hemorrhage –Hypotension 30 % of strokes are immediately fatal30 % of strokes are immediately fatal 30 % result in long-term patient care30 % result in long-term patient care

Epidemiology of stroke Morbidity:Morbidity: –Every year: 500,000 have a first stroke –Every year: 200,000 have a subsequent stroke –Frequency of stroke doubles every 10 years after 55 y.o. Mortality:Mortality: –3 rd leading cause of mortality in the US (i.e., more than chronic lung disease, accidents, diabetes…) –Causes about 7% of all US deaths

Diff’rent strokes Strokes are more prevalent in the following (Relative Risk compared to US white population):Strokes are more prevalent in the following (Relative Risk compared to US white population): –Finns, Japanese: 1.6 –Black Americans: 2.2

Stroke mortality

Stroke morbidity

Primary prevention: risks

Primary prevention: medical risks HTN: RR of stroke in untreated hypertensive (>140/90) is 1.2 – 4.0HTN: RR of stroke in untreated hypertensive (>140/90) is 1.2 – 4.0 MI: Risk of stroke increases 30% in the first month post-MI, then 1-2% each year after that.MI: Risk of stroke increases 30% in the first month post-MI, then 1-2% each year after that. AF: strong independent risk for ischemic stroke (RR = 5). 70% are cardioembolic, 30% are ‘other- embolic’. Stroke risk in untreated AF is 6% per year.AF: strong independent risk for ischemic stroke (RR = 5). 70% are cardioembolic, 30% are ‘other- embolic’. Stroke risk in untreated AF is 6% per year. –A side note: if electively cardioverting for AF, do warfarin for 3 wks prior and 4 wks post

Primary prevention: medical risks DMDM –The bad news: increased RR of –The bad news: glycemic control may not help Hypercholesterolemia: RCTs on those with TC>240, when treated, had decreased RR of 0.7Hypercholesterolemia: RCTs on those with TC>240, when treated, had decreased RR of 0.7 Carotid artery stenosis: isolated as risk factor in 1914 by Ramsey Hunt (yes, that Ramsey Hunt)Carotid artery stenosis: isolated as risk factor in 1914 by Ramsey Hunt (yes, that Ramsey Hunt) –The bad news: only 33% of significant stenosis=bruit –The bad news: only 60% of bruits=significant stenosis –Risk of same-side stroke is 2% after CEA (find a good surgeon)

Coumadin and stroke prevention

In patients >75 y.o., more strokes (hemorrhagic and ischemic) in those on warfarin vs those just on aspirinIn patients >75 y.o., more strokes (hemorrhagic and ischemic) in those on warfarin vs those just on aspirin The best balance of INR seems to be 2.0 – 3.0 for most patientsThe best balance of INR seems to be 2.0 – 3.0 for most patients

Coumadin and stroke prevention: the final word?

Coumadin and stroke prevention

Lifestyle Risk Factors SmokingSmoking –Risk of stroke doubles with each pack –Risk of stroke returns to baseline 2 yrs after quitting DrinkingDrinking –Regular intake of > 4 drinks/wk=small increase in risk of stroke,moderate increase on risk of death after stroke

Lifestyle Risk Factors DietDiet

Secondary prevention for special populations TIATIA –Focal neurologic deficit (e.g., hemiparesis, slurred speech, diplopia, ataxia) resolving in 24 hours (60-70% within 1 hour) –Usual cause: temporary ischemia from emboli, vasospasm, hypotension

Secondary prevention for special populations TIATIA

Secondary prevention for special populations TIATIA

Secondary prevention for special populations WomenWomen –After 65 y.o., more women than men have stroke –Why? Undertreatment, increased risk of HTN, hypothesized reasons: being female itself does not seem to be a factor –Pregnancy: increased RR but very small increase in AR –Use of OCs esp. in conjunction with smoking and HTN is a risk factor –OCs+HTN = RR 10.7 –OCs+smoke=7.2 –Newer OCs + <35y.o. + no HTN = no increased risk

Stroke and TPA Hospital treatment of strokeHospital treatment of stroke –TPA within 3 hours minimizes stroke size –TPA within 3 hours decreases disability at 3 months –May cause bleeding (see contraindication chart)

Post-stroke care Post-stroke concerns which are frequently managed by family physicians:Post-stroke concerns which are frequently managed by family physicians: –Secondary prevention including modification of risks –Depression: major (studies cite 1-25%), minor (20-30%)major (studies cite 1-25%), minor (20-30%) Identifiable risk factors for post-stroke depression (see chart). Manic symptoms less commonIdentifiable risk factors for post-stroke depression (see chart). Manic symptoms less common Post-stroke depression associated with 3-year mortality increase of 350%Post-stroke depression associated with 3-year mortality increase of 350% Treat with counseling and with antidepressant RxTreat with counseling and with antidepressant Rx

Post-stroke care: Depression

Post-stroke care: Rehab Rehab should begin soon after the patient is stable (ideally, within 48hrs)Rehab should begin soon after the patient is stable (ideally, within 48hrs) Early rehab can prevent DVT, contractures, pneumonia, skin breakdown, and aids early return to ADLsEarly rehab can prevent DVT, contractures, pneumonia, skin breakdown, and aids early return to ADLs

Post-stroke care: Rehab

Stroke Q & A

1. B

2. D

3. C

4. A

5. B

6. E

7. A

8. D

9. B

10. A