©2011 MFMER | slide-1 Brain Injuries Caused By Stroke. Felix E. Chukwudelunzu, MD, FAHA 27 th....
-
Upload
alannah-harris -
Category
Documents
-
view
213 -
download
0
Transcript of ©2011 MFMER | slide-1 Brain Injuries Caused By Stroke. Felix E. Chukwudelunzu, MD, FAHA 27 th....
©2011 MFMER | slide-1
Brain Injuries Caused By Stroke.
Felix E. Chukwudelunzu, MD, FAHA27th. Annual Conference; brain Injury Association of Minnesota
March, 29 2012
©2011 MFMER | slide-2
Agenda
• Epidemiology
• Pathophysiology
• Medical Complications
• Neuropsychiatric Complications
Type the footnote/source in this space
©2011 MFMER | slide-3
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-4
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-5
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-6
For white/Black Females: No 2 Cause of Mortality:
44.0 41.523.4
60.740.0 32.8
110.0
140.9
0
50
100
150
200
Coronary HeartDisease
Stroke Lung Cancer Breast Cancer
Per
100
,000
Pop
ulat
ion
White Females Black Females
©2011 MFMER | slide-7
How Does Ischemic Stroke Happen
●Ischemic Stroke:
A condition in which blood flow to part or all of the brain is reduced, resulting in tissue damage.
©2011 MFMER | slide-8
©2011 MFMER | slide-9
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-10
©2011 MFMER | slide-11
Pathophysiology of Stroke
©2011 MFMER | slide-12
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-13
Normal Cerebral blood Vessel
● Rate of CBF → Resistance & Diameter
●Dilation of BV = ↑Blood volume and ↑CBF
●Constriction = Blood volume and CBF
©2011 MFMER | slide-14
Cerebral Autoregulation (CAR)
©2011 MFMER | slide-15
CAR and STROKE
●CAR is impaired during stroke
●Initially CPP, cerebral vessels dilate = ↑CBF
●CPP beyond threshold = CBF
©2011 MFMER | slide-16
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-17
©2011 MFMER | slide-18
Why Do People Get Stroke
©2011 MFMER | slide-19
©2011 MFMER | slide-20
©2011 MFMER | slide-21
Medical Complications of Ischemic Stroke
• Very Common
• Poor Clinical Outcome
• Recognition important
• Appropriate prevention & treatment strategies
©2011 MFMER | slide-22
Medical Complication Cont….Complications Percent
Falls 25
UTI 24
Chest Infection 22
Pressure Sores 21
Depression 16
Shoulder Pain 9
DVT & PE 2-1Data: Langhorn P, et al. Stroke 2000;31:1223
©2011 MFMER | slide-23
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-24
Risk of Cognitive Impairment after Stroke
• Age
• History of DM
• History of Afib
• Ethnicity
• Educational attainment
• Location of Stroke
©2011 MFMER | slide-25
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-26
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-27
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-28
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-29
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-30
©2011 MFMER | slide-31
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-32
SRBD And Stroke
●↑Male elderly patients
●Stroke with the following characteristics:
▪Presence of DM▪Presence of Microangiopathy▪Nocturnal Onset
©2011 MFMER | slide-33
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-34
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-35
Questions?