cerebrovascular disease: a discussion of strokes and tia’s accompanied by an explanation of...

Cerebrovascular Disease:A Discussion of Strokes and TIA’s

Accompanied by an explanation of current use of IMT and Carotid Ultrasound

Reviewed by Bill Rooney MDVP/Medical DirectorSCOR Global Life USA Reinsurance Company

Nebraska Home Office Life Underwriters Association Meeting

1

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

2

“You only live once, but if you do it right, once is enough”Mae West

I have inserted some

life-related quotes at the

bottom of some of the

slides These are intended to

be interesting as well as thought

provoking

And oh, by the way, all of the

authors suffered strokes at some

point in their lifetime

Nebraska Home Office Life Underwriters Meeting Presentation 9/2014

Cases to Consider

2 cases arrive for underwriter review. Which has the worst mortality risk based upon the limited information provided?

3

Case #265 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 is WNL• ECG is WNL• CIMT is WNL

Case #166 y/o female with a 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 is WNL• ECG is WNL• CIMT at 90th percentile for age

Cases described above are not actual cases but instead have been created to illustrate points made during this presentation.


ECG Puzzler 4

795,000 Americans

suffer s

trokes each

year

.

6,400,000 stroke

survivors

134,000 deaths each year

1 out of every 19 deaths

4th leading cause of death for Americans

Strokes are

frequently

recurrent.

In fact nearly one of

four CVA’s occur in

people who have

had a previous

stroke

34% of people

hospitalized for stroke

in 2009 were under 65

years of age.

STROKES____

Facts to know Nebraska Home Office Life Underwriters Meeting Presentation 9/2014

Rosamond W et al. Circulation 2007;115:e69-e171Copyright © American Heart Association

Prevalence of stroke by age and sex 5


Stroke Facts

1. 1998-2008:

Annual stroke death rate fell 35%. Actual number of deaths fell 19%.

6Nebraska Home Office Life Underwriters

Meeting Presentation 9/2014

Temporal trends in age-adjusted death rates for the top 10 causes of death in the United States from 1931 to 2008.

Towfighi A , and Saver J L Stroke 2011;42:2351-2355

2nd most common cause of death world wide

In 2008 CVA dropped from the 3rd most common cause of death in the US to the 4th.

7

In just this time frame here (1998-2008): – Annual stroke death rate fell 35%. – Actual number of deaths fell 19%.


Similar downward trend noted in the European Union.

Kunst A E et al. Stroke 2011;42:2126-2130Copyright © American Heart Association

Point #1The stroke mortality rate in the Western countries is declining.

• Decreased incidence• Decreased case-fatality

rate

Mortality rate from Stroke

Point #2The projected total number of US deaths from strokes is not expected to decline through 2030 however because of the aging population

8


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

9

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. 2009:40:2276-2293

"You have enemies? Good. That means you’ve stood up for something, sometime in your life.“

Winston Churchill


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%.

10

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.


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%

11

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


Annual risk for future stroke after an initial TIA or ischemic stroke

Annual risk is estimated at ~3-4%1

12

Great progress has occurred in preventing recurrent stroke2.1960’s 8.71%1970’s 6.1%1980’s 5.41%1990’s 4.04%

1. Kernan, Walter et al. Guidelines for the prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals From the AHA/AS. Stroke. 2014; Accessed 5/5/20142 Hong KS, Yegiaian S, Lee M, Lee J, Saver JL. Declining stroke and vascularevent recurrence rates in secondary prevention trials over the past 50 yearsand consequences for current trial design. Circulation. 2011;123:2111–2119.

Prevention aided by: Antiplatelet therapy/anticoagulation Atrial fibrillation treatments Hypertensive and hyperlipidemia treatments Arterial obstruction treatments


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

13


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

14

“Today was tomorrow yesterday so don`t inhale.”Mel Blanc


What type of vascular problem is occurring is important

Inflammation Atherosclerosis LipohyalinosisAneurysmal

dilationArterial

dissection

Thrombosis Embolus

Rupture of a vessel in the subarachnoid

space or intracerebral tissue


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)

16

“Death solves all problems, No man, no problem”

Joseph StalinNebraska Home Office Life Underwriters


What type of vascular problem is occurring is important

17

Inflammation Atherosclerosis LipohyalinosisAneurysmal

dilationArterial

dissection

Thrombosis Embolus

Rupture of a vessel in the subarachnoid

space or intracerebral tissue

80% of strokes are ischemic

20% of strokes are

hemorrhagic


18

Smell

Hearing

Speech

Fingers

Arm

Hip

Hand

Language

Vision

Balance

Coordination

Brain cells have different functions in different locations

Frontal LobePersonality

Memory

Reasoning

Temporal LobeSpeech

Memory

Hearing

Parietal LobeLanguage

Sensation

Telling right from left

Occipital LobeVision

CerebellumBalance

Fine motor control

Coordination

Brain StemBreathing

Swallowing

Blood Pressure

Where the vascular compromise occurs is important


Anatomy of the cerebrovascular system 19


20The 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.

21

http://www.stroke.org/site/PageServer?pagename=brochures

Subarachnoid Hermorrhage

Blood vessel ruptures and blood leaks in between the brain and the skull

Intracerebral Hermorrhage

Blood vessel ruptures and bleeds directly into the brain tissue


http://www.stroke.org/site/PageServer?pagename=brochures

TIA—Making the diagnosis 22

Neurological Symptoms---A helpful chart


TIA—Making the diagnosis 23

Not all neurological symptoms are vascular in etiology

Several important points here:

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


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.

24

http://stroke.ahajournals.org/

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


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

25

“My formula for living is quite simple. I get up in the morning and I go to bed at night. In between, I occupy

myself as best I can”Cary Grant


Making the diagnosis of a CVA 26

http://www.medscape.com/viewarticle/452843


27DWI T2 weighted FLAIR

Cerebellum region

Thalamocapsular region

Dissection 28

http://uvahealth.com/services/vascular-center/treatment/arterial-dissections http://www.ajnr.org/content/24/10/2052/F1.expansion.html


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.

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.


Primary treatment of an acute bleed 30

Subarachnoid hemorrhage– Aneurysmal (~80%)

• Surgical management usually neededSurgical clippingEndovascular therapy with coil system

– Non-aneurysmal (~20%)• AVM

Surgical clippingEndovascular therapy

• Intracranial artery dissectionSurgical clippingEndovascular therapy

• Perimesencephalic non-aneurysmal subarachnoid hemorrhageSubtype identified in 1985Findings of localized blood on CT, normal angiography, and a relatively benign courseLong 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)


31

BREAKING NEWS!!!!May 2014 Development

Secondary Treatment of the acute ischemic CVA or TIA

Antiplatelet therapy initiation within 24 hours of stroke and continued for 90 days

BP management—Goal of therapy is BP of <140/90 mm Hg.

Lipid lowering therapy (Statins) for those with elevated LDL >100 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.

32

• 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; 42:227-276


Secondary Treatment of the acute ischemic CVA or TIA—Slide 2 33

Atrial Fibrillation (paroxysmal or permanent):• Anticoagulation with a vitamin K antagonist,

apixaban, dabigatran, or rivaroxaban are indicated

• 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. It is unclear which is more advantageous.

Acute MI and left ventricular thrombus• Oral anticoagulation recommended for at least 3

months

Prosthetic heart valves• Oral anticoagulation recommended• 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

Arterial Dissection• Antithrombotic treatment with either antiplatelet or anticoagulant

therapy 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 recommended for those not

obtaining anticoagulation.• Data doesn’t support closure for those with PFO and

TIA/cryptogenic ischemic stroke if no evidence of DVT

• Consider surgical closure with a trans-catheter device for those with PFO and DVT.

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; 42:227-276

Secondary Treatment of the acute ischemic CVA or TIA

Symptomatic recent (within last 6 months) 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 for those 70-99% stenotic. It is not

recommended for those <70% stenotic. Bypass surgery is not recommended

34

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; 42:227-276

“There is nothing so strong or safe in an emergency of life as the simple truth”

Charles Dickens


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 strokeHow much brain tissue is involved

95% of patients have at least one medical complication1

24% of patients have at least one serious, life threatening complication1

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 is2:First week: Cerebrovascular disease2-4 weeks: PE2-3 months: Pneumonia>3 months Cardiac disease

35

1Randomized trial of Tirilizad Mesylate in Acute Stroke (RANTTAS)2Risk 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 positive 90 day stroke risk <1%• Transient event that is image positive 90 day stroke risk 14%

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

36


Included those with hx. of heart disease

Did not include those with hx. of heart disease

37


4 QUESTIONS 38

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?


Proportion of patients dead 1 year after first stroke.

Go A S et al. Circulation 2013;127:e6-e245

Copyright © American Heart Association

39

45-64 y/o

>64 y/o


Proportion of patients dead within 5 years after first stroke.

Writing Group Members et al. Circulation 2012;125:e2-e220


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

40

45-64 y/o

>64 y/o


Figure 1. Short-term survival probability for patients aged 65 years at first nonfatal stroke by subtype (Cox regression).


Estimated cumulative risk for death:28 days 28%1 year 41%5 years 60%

41

SAH Subarachnoid Hemorrhage

However, risk of death did vary based upon type of stroke

CI Cerebral Infarct

PICH 1o Intracerebral Bleed

IDS Ill Defined Stroke

Brønnum-Hansen H et al. Stroke 2001;32:2131-2136


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;32:2131-2136


http://www.theuniversityhospital.com/stroke/stats.htm

42

SAH Subarachnoid HemorrhageCI Cerebral InfarctPICH 1o Intracerebral BleedIDS Ill Defined Stroke

Estimated cumulative risk for death:5 years 60%10 years 76%15 years 86%

SAH Subarachnoid Hemorrhage




43

Vascular event (with 95% CI)

Mortality

Stroke


Individual PrognosisAge

Infarct Location

Interventions done after the CVA

Complications

Comorbid conditions

The Mortality Risk Evaluation Needs to be Individualized

Adherence to therapeutic plan

Stroke Severity

Stroke Mechanism

Clinical Findings

44Nebraska Home Office Life Underwriters


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

45

“If you want to stay young-looking, pick your parents very carefully”Dick Clark


Carotid artery intima-media thickness (CIMT) 46

http://www.sonosite.com/apps-n-softwares/sonocalc-imt

http://www.prweb.com/releases/2011/5/prweb8502142.htm

http://www.preventionhealthscreenings.com/services_imt.html

http://www.diabetesresearchclinicalpractice.com/article /S0168-8227(05)00410-9/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)

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 45-89 years CIMT was a modestly better predictor of stroke than EBCT but was not as good as EBCT for CV disease prediction

47

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.


US and MRA 48


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

49


Asymptomatic extracranial carotid artery diseaseThe 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

50

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; 42:227-276

Bonus Quote: “I like to drive with my knees. Otherwise, how can I put on my lipstick and

talk on the phone”Sharon Stone

“If you act like you know what you are doing, you can do anything you want – except neurosurgery”

Sharon Stone

51

http://www.health.harvard.edu/newsletters/Harvard_Womens_Health_Watch/2012/June/could-a-silent-stroke-erode-your-memory

Evaluated in the Rotterdam Scan study2

• Published in 2003 • 1077 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 Study1

• Published in 2002 • 5888 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):2376.

2. 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 StrokesNot such good outcomes when found


http://www.health.harvard.edu/newsletters/Harvard_Womens_Health_Watch/2012/June/could-a-silent-stroke-erode-your-memory

Zhu Y et al. Stroke 2011;42:1140-1145


More examples of silent CVA’s

Axial T2-weighted Axial T1-weighted FLAIR Axial Proton Density

52


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

53


Cases to Consider

2 cases arrive for underwriter review. Which has the worst mortality risk based upon the limited information provided?

54

Case #265 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 is WNL• ECG is WNL• CIMT is WNL

Case #166 y/o female with a 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 is WNL• ECG is WNL• CIMT at 90th percentile for age


Questions? 55


56

Lifelong Risk for Rupture of Intracranial AneurysmsTake-HOME MESSAGE•Of 118 people, 34 (29%) had subarachnoid hemorrhage (SAH) during lifelong follow-up after diagnosis of unruptured intracranial aneurysm (UIA). The median age at SAH was 51.3 years. The annual rupture rate per patient was 1.6%. Risk factors for a lifetime SAH included female sex, current smoking, and aneurysm size of ≥7 mm in diameter. Depending on the risk factor burden, the annual rupture rate was from 0% to 6.5%, and the lifetime risk of an aneurysmal SAH varied from 0% to 100%. Of 96 patients with small (<7 mm) UIAs, 24 (25%) had an aneurysmal SAH during the follow-up. Although risk was associated with the risk factor burden, close to 30% of the aneurysms in working-age people ruptured over the course of lifelong follow-up.•The results suggest that maybe risk factor status should drive treatment decisions for individuals with UIAs given that even the small ones in this study ruptured.ABSTRACTBackground and PurposeOur aim was to define for the first time the lifelong natural course of unruptured intracranial aneurysms (UIAs) and identify high-risk and low-risk patients for the rupture.MethodsOne hundred and eighteen patients (61 women) with UIAs were diagnosed between 1956 and 1978 and followed up until death or subarachnoid hemorrhage (SAH). The median age at the diagnosis was 43.5 years (range, 22.6–60.7 years). The median size of the UIA at the diagnosis was 4 mm (range, 2–25 mm). Analyzed risk factors for a rupture included sex, age, cigarette smoking, systolic blood pressure values, diagnosed hypertension, UIA size, and number of UIAs.ResultsThirty four (29%) out of 118 people had SAH during the lifelong follow-up. The median age at SAH was 51.3 years (range, 30.1–71.8 years). The annual rupture rate per patient was 1.6%. Female sex, current smoking, and aneurysm size of ≥7 mm in diameter were risk factors for a lifetime SAH. Depending on the risk factor burden, the lifetime risk of an aneurysmal SAH varied from 0% to 100%, and the annual rupture rate from 0% to 6.5%. Of the 96 patients with small (<7 mm) UIAs, 24 (25%) had an aneurysmal SAH during the follow-up.ConclusionsAlmost 30% of all UIAs in people of working age ruptured during a lifelong follow-up. The risk varied substantially on the basis of risk factor burden. Because even small UIAs ruptured, treatment decisions of UIAs should perhaps be based on the risk factor status.

Stroke; A Journal of Cerebral CirculationLifelong Rupture Risk of Intracranial Aneurysms Depends on Risk Factors: A Prospective Finnish Cohort StudyStroke 2014 May 22;[EPub Ahead of Print], M Korja, H Lehto, S Juvela


57

Stroke; A Journal of Cerebral CirculationLong-Term Mortality After First-Ever and Recurrent Stroke in Young AdultsStroke 2014 Jul 24;[EPub Ahead of Print], K Aarnio, Elena Haapaniemi, S Melkas, M Kaste, T Tatlisumak, J PutaalaBackground and PurposeMortality after first-ever stroke, and particularly after recurrent stroke, and predictors of long-term mortality among young and middle-aged stroke patients are not well-known. We assessed 17-year risk of mortality with focus on the effect of recurrence on the risk of death of young and middle-aged patients with stroke.MethodsMortality and recurrent stroke rate of 970 consecutive 30-day survivors of first-ever ischemic stroke aged 15 to 49 years (1994–2007) were studied. Prospective follow-up data came from the Finnish Care Register for Health Care and Statistics Finland. Mean follow-up was 10.2±4.3 years. We compared survival between clinical subgroups and identified factors associated with mortality. Standardized mortality ratio was calculated for demographic and pathogenetic subgroups using mortality data of the general population matched with age, sex, calendar year, and geographical area.ResultsAt the end of follow-up, 152 (15.7%) patients had died (cumulative risk, 23.0%; 95% confidence interval, 19.1%–26.9%) and 132 (13.6%) had experienced a recurrent stroke. After adjusting for baseline characteristics, recurrent stroke was statistically the most important risk factor for mortality after first-ever ischemic stroke (hazard ratio, 16.68; 95% confidence interval, 2.33–119.56; P=0.005). Observed mortality was 7-fold higher than the expected mortality (standardized mortality ratio, 6.94; 95% confidence interval, 5.84–8.04) and particularly high among patients who experienced a recurrent stroke (standardized mortality ratio, 14.43; 95% confidence interval, 10.11–18.74).ConclusionsThe high mortality rates and the striking impact of recurrent stroke on the risk of death should lead to development of more robust primary and secondary prevention strategies for young patients with stroke.


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