©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


Agenda

• Epidemiology

• Pathophysiology

• Medical Complications

• Neuropsychiatric Complications

Type the footnote/source in this space


Epidemiology of Stroke

• 795,000 new/recurrent per year

• Every 40 seconds, someone in US has a stroke

• Stroke incidence on the decline


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


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%)


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


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.


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%


Pathophysiology of Stroke


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.


Normal Cerebral blood Vessel

● Rate of CBF → Resistance & Diameter

●Dilation of BV = ↑Blood volume and ↑CBF

●Constriction = Blood volume and CBF


Cerebral Autoregulation (CAR)


CAR and STROKE

●CAR is impaired during stroke

●Initially CPP, cerebral vessels dilate = ↑CBF

●CPP beyond threshold = CBF


CBF Results in:

• Protein synthesis inhibition

Glucose utilization

• Onset of anaerobic glycolysis = tissue acidosis

• Neuronal electrical failure

• Membrane ion homeostasis failure

• Cerebral Infarction (stroke)


Why Do People Get Stroke


Medical Complications of Ischemic Stroke

• Very Common

• Poor Clinical Outcome

• Recognition important

• Appropriate prevention & treatment strategies


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


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


Risk of Cognitive Impairment after Stroke

• Age

• History of DM

• History of Afib

• Ethnicity

• Educational attainment

• Location of Stroke


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


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.


Sleep Related Breathing Disorders (SRBD).

Obstructive Sleep Apnea

• Increases the risk of stroke

• Correlation b/w severity and stroke

• Apnea-Hypopnea Index >19.1


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


Sleep Apnea And Stroke

• Coagulation (increase blood clot formation)

• Disruption of lining of blood vessels

• Inflammatory markers (CRP, IL6)

• Metabolic deregulation ( Insulin, leptin)


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)


SRBD And Stroke

●↑Male elderly patients

●Stroke with the following characteristics:

▪Presence of DM▪Presence of Microangiopathy▪Nocturnal Onset


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%


Post Stroke Fatigue

●Occurs in 68% of stroke patients

●Hightened awareness of physical/emotional strain

●Contributing Factors:▪Sleep disorder▪Imobility▪Deconditioning▪Psychologic


Questions?

©2011 mfmer | slide-1 brain injuries caused by stroke. felix e. chukwudelunzu, md, faha 27 th....

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