epidemiology, mechanisms & clinical description of...
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Epidemiology, Mechanisms & Clinical Description of Stroke
Michael R. Jaff, DO, FACP, FACCDirector, Vascular Medicine
Massachusetts General HospitalBoston, Massachusetts
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Michael R. Jaff, DOConflicts of InterestMichael R. Jaff, DOConflicts of Interest
ConsultantCordis Endovascular (Modest)Boston Scientific (Modest)Medtronic Vascular (Modest)Pathway Medical (Modest)Paragon IP (Modest)X-Tent, Inc (Modest)Harvard Clinical Research Institute (Modest)Bacchus Vascular, Inc (Modest)Baxter, Incorporated (Modest)ActivBiotics (Modest)
EquityAccess Closure, Inc (Modest)Square One, Inc (Modest)Vascular Therapies, Inc (Modest)Icon Interventional, Inc (Modest)Setagon (Modest)I.C.Sciences, Incorporated (Modest)
Speaker’s BureauBristol-Myers/Sanofi-Aventis Pharmaceuticals Partnership (Modest)
Research SupportPfizer, Inc.Abbott VascularGenzyme
June, 2007
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Rate of Deaths Due to Atherosclerosis is Increasing in U.S.
JAMA 2005;294:1255.
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The Worldwide Stroke Pandemic
695,000
348,000
685,000316,000
468,000604,000
554,000
1,647,000
887,000
700,000
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Burden of Stroke in the U.S.
1 stroke every 45 seconds (700,000 per year)2.4 million non-institutionalized stroke survivorsStroke causes 1 in 15 deathsApproximately 30 % aged 70-80 have silent brain infarction Stroke cost= 58.8 billion/year
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Prevalence of Survivors of Various Disabling Neurologic Conditions
0 0.5 1 1.5 2 2.5 3 3.5
Stroke
Epilepsy
Alzheimer's
Parkinson's
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What is a Stroke?
Reduction in arterial blood flow to the brain, resulting in ischemia to the brain itselfThe brain has geographic territories responsible for our higher functions
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Transient Ischemic Attack (TIA)
15% of all strokes are heralded by a TIA. 1/3 of TIAs would be infarction based on diffusion weighted MRI findings. Males and blacks have higher rates of TIA.Half fail to report TIA to their healthcare providers. 90-day risk of stroke is 3-17% after TIA, highest within the first 30 days.Carotid-associated TIA: 20% 90-day stroke risk
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Carotid Artery Disease: TIA
Duration <24 h, usually <15 minSymptoms:
motor and sensory dysfunction of contralateral limbspure sensory dysfunctionisolated dysphasiatransient monocular blindness
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TIAs Cause Early Stroke and Cardiovascular Events
Follow up of 1707 subjects diagnosed with TIA in ED
Risk Factors for Events:OR
Age > 60 y 1.8Diabetes 2.0>10 Min TIA 2.3Weakness 1.9Speech 1.5
JAMA. 2000;284:2901-2906
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Territories of the Middle Cerebral Artery
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The Vascular Supply to the Brain is Rich, But Vulnerable!
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Intracranial Anatomy
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Vascular Territories and Stroke Syndromes
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What Are the Common Causes of Stroke?
Ischemic (80%)ThrombosisEmbolism
Hemorrhagic (20%)IntracerebralSubarachnoid
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Stroke Subtype Frequency
Furie KL, Kistler JP, NEJM 2000
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Frequency of Stroke Types
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Artery to Artery Embolism
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Does Risk of Stroke Increase with Greater Degrees of ICA Stenosis?
696 Patients evaluated with Carotid Duplex Ultrasonography369 Male/327 Female
Mean Age 64 yearsMean Follow-Up 41 monthsDuplex Ultrasonography Categories
Mild <50% StenosisModerate 50-75% StenosisSevere >75% Stenosis
Stroke 1991;22:1485
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Vascular Risk of Asymptomatic Carotid Stenosis
Category N TIA CVA CardiacEvent
VascularDeath
<50% 303 1 1.3 2.7 1.8
50-75% 216 3 1.3 6.6 3.3
>75% 177 7.2 3.3 8.3 6.5
75% of Events were Ipsilateral to the StenosisStroke 1991;22:1485
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What Can the Physical Exam Tell You About the Etiology of Stroke?
Atrial Fib/Flutter, Bradycardia Likely Cardiogenic EmbolusNo pulse below knee Recurrent systemic embolusCarotid Bruit Severe Extracranial Carotid
StenosisHead/Orbital Bruit AV MalformationFever and Acute CVA Endocarditis and Cardiogenic
EmbolusStroke and Altered MS Check Glucose, EtOH,
Narcotics, O/D, other Toxins
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Cervical Bruit
Marker of systemic atherosclerosisNot indicative of severity of internal carotid artery stenosis
NASCET: Sensitivity 63%/Specificity 61%Frequency of Cervical Bruits
~1-3% in adults aged 45-54 years~8% in adults >75 years
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Bruit and Carotid Artery Disease
Presence of Bruit Increases Likelihood of Carotid Disease
020406080
100
StrokewithBruit
TIA withBruit
Bruit Control
35-75% Stenosis >75% Stenosis
Zhu, CZ. Stroke 1990;21:1131-1134
Carotid ultrasound evaluation in 261 pts with ischemic CVA, 813 pts with carotid TIAs, 500 pts with asymptomatic neck bruits, and 500 controls.
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Causes of Cervical Bruit (Systolic, Diastolic, or Both)
Carotid atherosclerosisThyrotoxicosisTransmitted cardiac murmur
Aortic Stenosis (systolic)Aortic Insufficiency (diastolic)
Arteriovenous Fistula (systolic/diastolic)Venous Hum (systolic or systolic/diastolic)
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Once in an ED, You Must Get an Imaging Test IMMEDIATELY!
Classic Wedge-Shaped Acute Right MCA Stroke
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Important Characteristics of the CT Scan
Within 3 hours of onset of ischemia, the CT without contrast is virtually normalAfter 6-12 hours, there is evidence of hypodensity with brain edemaHemorrhage
Appearance will describe type– Subdural Hematoma: Crescent shape below dura– Subarachnoid Hemorrhage: Diffuse blood pattern along
surface of brain in subarachnoid space5% of SAH have NORMAL CT!!! MUST perform Lumbar PunctureDiscern between SAH and traumatic LPRBC Count in 4 tubes all similarXanthochromic Supernatant---old RBCs consistent with SAH
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MRI Demonstrating Acute Right MCA CVA
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National Institutes of Health Stroke Scale (NIHSS)
Systematic clinical assessment tool Designed in 1983 to standardize and document a reliable, valid neuro assessmentMeasures neurologic deficits
Does not assess function5-8 minutes to completeScores range from 0-42 11 items tested
http://www.ninds.nih.gov/doctors/stroke_scale_training.htm
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What if Patient Has Altered Mental Status?
Glasgow Coma Scale
Eye OpeningSpontaneous…4In response to speech…3In response to pain…2None…1
Best Verbal ResponseOriented…5Confused…4Inappropriate Words…3Incomprehensible…2None…1
Best Motor ResponseObeys…6Localizes…5Withdraws…4Abnormal Flexion…3Abnormal Extension…2None…1
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Glascow Coma Scale
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Stroke Prevention Strategies
Reduction in Blood PressureCessation of Tobacco UseReduction in Serum CholesterolAggressive Glycemic ControlAntiplatelet TherapyRevascularization of Carotid Stenosis