1. Post TIA, Post Stroke Prognosis D. Darwin A. Dasig, M.D., F.P.N.A. Makati Medical Center

2. Cerebrovascular Disease • any abnormality of the brain resulting from a pathologic process of the blood vessels

3. Cerebrovascular Disease • Atherosclerotic thrombosis • Transient ischemic attacks • Embolism • Hypertensive hemorrhage • Ruptured or unruptured saccular aneurysm or AVM • Arteritis • Meningovascular syphilis, arteritis secondary to pyogenic and tuberculous meningitis, rare infective types (typhus, schistosomiasis, malaria, trichinosis, mucormycosis, etc.)

4. Cerebrovascular Disease • Connective tissue diseases (polyarteritis nodosa, lupus erythematosus), necrotizing arteritis, Wegener arteritis, temporal arteritis, Takayasu disease, granulomatous or giant cell arteritis of the aorta, giant cell granulomatous angiitis of cerebral arteries • Cerebral thrombophlebitis: secondary to infection of ear, paranasal sinus, face, etc.; with meningitis and subdural empyema; debilitating states, postpartum, postoperative, cardiac failure, hematologic disease (polycythemia, sickle-cell disease), and of undetermined cause

5. Cerebrovascular Disease • Hematologic disorders: polycythemia, sickle-cell disease, thrombotic thrombocytopenic purpura, throbocytosis, etc. • Trauma to carotid artery • Dissecting aortic aneurysm • Systemic hypotension with arterial stenoses: “simple faint”, acute blood loss, myocardial infarction, Stokes-Adams syndrome, traumatic and surgical shock, sensitive carotid sinus, severe postural hypotension • Complications of arteriography • Neurologic migraine with persistent deficit

6. Cerebrovascular Disease • Tentorial, foramen magnum, subfalcial herniations • Miscellaneous types: fibromuscular dysplasia, radioactive or x-irradiation, lateral pressure of intracerebral hematoma, unexplained middle cerebral infarction in closed head injury, pressure of unruptured saccular aneurysm, local dissection of carotid or middle cerebral artery, complication of oral contraceptives • Undetermined cause as in children and young adults: Moyamoya; multiple, progressive intracranial arterial occlusions

7. vascular disorders of the nervous system • ischemia/infarction • hemorrhage

8. stroke • neurological deficit of sudden onset accompanied by focal dysfunction and symptoms lasting more than 24 hours that are presumed to be of non-traumatic vascular origin (WHO)

9. stroke • sudden onset of focal neurological deficit lasting more than 24 hours due to an underlying vascular pathology (Stroke Society of the Philippines, 1999) • acute clinically relevant brain lesion on imaging in patients with rapidly vanishing symptoms

10. stroke • sudden, focal, nonconvulsive neurologic deficit → brain attack ≠ apoplexy ≠ cerebrovascular accident (CVA)

11. STROKE FACTS • leading cause of adult disability • 3rd leading cause of death in the US • # 2 killer disease worldwide • most important cause of mortality in Asia • 75% of all strokes > 65 years of age

12. USA • prevalence: 1 in 59 (1.69%) → 4.6 million • incidence: 1 in 453 (0.22%) → 600,000 total (500,000 new cases & 100,000 recurrence) Worldwide • incidence: 15 million people survive minor stroke each year (WHO)

13. one year mortality: 25% - 40% • three year mortality: 32% - 60% • over 50% dead in 5 years • Framingham study ten-year survival: 35%

14. non-modifiable older age male gender non-white ethnicity family history modifiable elevated blood pressure diabetes mellitus atrial fibrillation hyperlipidemia cigarette smoking obesity high alcohol consumption risk factors & predictors of stroke Cerebrovascular Disease 2003; Advances in Neurology 2003; Stroke 2001

15. hypertension diabetes atrial fibrillation myocardial infarction rheumatic heart disease smoking snoring stress frequent Alcohol intake RIFASAF Study: independent risk factors for Stroke among Filipinos A. Roxas, Phil J. of Neurology, 2002

16. ischemic stroke a clot blocks flow to an area of the brain hemorrhagic stroke bleeding occurs inside or around brain tissue types of stroke

17. ischemic stroke • atherothrombotic • cardioembolic • lacunar

18. cardioembolism atherothrombotic (large-vessel) lacunar (small vessel) elderly (> 70 yr), low rate of early stroke recurrence middle age (45-70 yr), high rate of early stroke recurrence, highest male preponderance hypertension, diabetes, hypercholesterolemia, obesity major risk factors are unevenly distributed among stroke subtypes

19. atherothrombotic stroke (large vessel disease) • usually develops at night during sleep • symptoms felt in the morning • suspect history of atherosclerosis, hypercoagulable states, collagen vascular diseases

22. macroangiopathy: large vessel disease TOAST Criteria • presence of occlusion with 50% diameter reduction of a brain-supplying artery corresponding to clinical symptoms and with location and morphology typical of atherosclerosis on Doppler ultrasound or angiography

25. mechanism of atherosclerotic stroke in large cerebral arteries • artery to artery embolism • thrombotic occlusion • hemodynamic infarction: watershed infarction

26. extracranial atherosclerosis (ECAS) • most common source of embolism among Whites • asymptomatic cervical stenosis or bruits: risk of ipsilateral stroke with > 60% narrowing approximately 2% per year

27. transient ischemic attack (TIA) • transient episode of focal neurologic dysfunction secondary to ischemia in one of the vascular territories of the brain (Stroke Council, American Heart Association, 1994) • brief episode of neurological dysfunction caused by focal disturbance of brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour and without evidence of infarction

28. transient ischemic attack (TIA) • onset sudden & rapid, with complete resolution • lasts approximately 2 to 20 minutes • initially should involve all affected areas relatively simultaneously • should involve focal loss of neurologic function, with symptoms reflecting dysfunction of cerebrum, brainstem, or cerebellum

29. probably not TIA • ill-defined onset, waxes & wanes, or slowly worsens • leaves persistent neurologic deficits, however mild • neurologic dysfunction of few seconds duration • episode lasting for more than 1 hour • marching of symptoms from one body part to another • “positive phenomena”: involuntary movements, jerking, scintillating scotoma • “global” brain symptoms: giddiness, LOC, presyncope

30. TIA as predictor of future strokes • highest risk in 1st week 1st month = 4% - 8% 90 days = 10.5% 1st year = 12% - 13% 5 years = 24% - 29% 2 years = > 40%

31. intracranial atherosclerosis (ICAS) • more common in Asian and Blacks • Asia: 40% - 50% • West: 8% • no proven treatment for ICAS

32. atherothrombotic • early in course of cerebral thrombosis → difficult to give accurate prognosis • progression: increasing stenosis of involved artery by mural thrombus • mild paralysis → disastrous hemiplegia • worsen temporarily for 1- 2 days • often progressive: cautious attitude

35. cardioembolic stroke • occurs anytime • frequently during periods of vigorous activity • history of atrial fibrillation, valvular vegetations, thromboembolism from MI • seizures in 20% of cases

36. atrial fibrillation • 2% - 4% risk for stroke annually • persons < 60 years with no other cardiac disorder (lone AF): relatively low risk for stroke • AF: abetting factor leading to formation of intra-atrial thrombi in patient with another heart disease • at risk: chronic sustained & intermittent

37. atrial fibrillation with greatest risk for embolization: • prior stroke or TIA (most important) • age > 75 years, especially women • history of hypertension or systolic blood pressure > 160 mm Hg • diabetes mellitus • coronary artery disease • congestive heart failure • left ventricular dysfunction

38. cardioembolism acute myocardial infarction (with left ventricular thrombus) • 5% risk for stroke within 2 weeks • risk higher with anterior than inferior infarcts • may reach 20% risk in those with large anteroapical infarcts

39. cardioembolism cardiomyopathy • EF 29% - 35%: 0.8% stroke per year • EF < 28%: 1.7% stroke per year prosthetic heart valves • annual percentage of occurrence of systemic thromboembolism: 20%

40. valvular heart disease: annual incidence of thromboembolism

42. lacunar infarction • microangiopathy: <1.5 cm diameter • pure motor, pure sensory, sensorimotor, ataxic hemiparesis, dysarthria-clumsy hand syndrome

45. survival & recurrence after 1st cerebral infarction • Petty et al, Mayo clinic, 1998 • Neurology 50: 208-216 • population-based study • Rochester, Minnesota • 1975 – 1989: 1,111 residents with 1st cerebral infarction

46. survival & recurrence after 1st cerebral infarction risk of death: • 7% ± 0.7% at 7 days • 14% ± 1.0% at 30 days • 27% ± 1.3% at 1 year • 53% ± 1.5% at 5 years

47. survival & recurrence after 1st cerebral infarction independent risk factors for death after 1st cerebral infarction: • age • congestive heart failure • persistent atrial fibrillation • recurrent stroke • ischemic heart disease

48. survival & recurrence after 1st cerebral infarction risk of recurrent stroke after 1st cerebral infarction: • 2% ± 0.4% at 7 days • 4% ± 0.6% at 30 days • 12% ± 1.1% at 1 year • 29% ± 1.7% at 5 years

49. survival & recurrence after 1st cerebral infarction significant independent predictors of recurrent stroke: • age • diabetes mellitus