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Prognosticating Common Neurological Disorders

Prognosticating Common Neurological Disorders. Vincent B. Macalintal, MD, FPNA. Types of Stroke. Ischemic 83% Hemorrhagic 17%. Stroke : risk factors. Well established hypertension TIA heart diseases smoking diabetes mellitus carotid disease. Stroke : risk factors.

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Prognosticating Common Neurological Disorders

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  1. Prognosticating Common Neurological Disorders Vincent B. Macalintal, MD, FPNA

  2. Types of Stroke Ischemic 83% Hemorrhagic 17%

  3. Stroke : risk factors • Well established hypertension TIA heart diseases smoking diabetes mellitus carotid disease

  4. Stroke : risk factors • Less well established hypercholesterolemia excessive alcohol and drug use physical inactivity dietary factors and obesity infection

  5. Well established risk factors I. Hypertension • Directly related to stroke risk (2-4X) • Higher BP – higher risk • Prevalence 22% • ischemic and hemorrhagic

  6. Well established risk factors I. Hypertension • Treatment reduces risk • 5 to 6 mmHg decrease reduces risk by 42% • Treatment of isolated systolic hypertension decreases risk 36% • Diuretics - 39% odds reduction • Beta blockers – 25%

  7. HypertensionRisk of 2nd Stroke in 2 years % months

  8. Well established risk factors II. TIA • Important predictor of future stroke • Risk of stroke after TIA 24 to 29% during next 5 years • 4 to 8% first month • 12 to 13% first year • 24 t0 29% five years

  9. Well established risk factors II. TIA • Hemispheric TIA w/ more than 70% carotid stenosis – poor prognosis • Stroke rate more than 40% in 2 years • Antiplatelets reduce stroke risk after TIA or minor stroke by 18 to 31% • Aspirin should be considered as the first choice

  10. Well established risk factors III. Valvular heart disease

  11. Well established risk factors III. Valvular heart disease • Coumadin given to increase INR to 2.5 to 3.5 • Significantly reduced the risk for stroke & Thromboembolism • With no significant increase in problems of bleeding • Important for protime monitoring and reporting of INR ratio

  12. Well established risk factors IV: Atrial fibrillation • Non valvular AF increases the risk 6x • Causes 36% of all strokes in patients 80 to 89 years • Coumadin reduced occurrence by 68% • Aspirin by 21% • Recommended to patients with age 65 & up with multiple risk factors

  13. Effect of Arrhythmia on Survival %

  14. Well established risk factorsV. Coronary Artery Dse & MI • CAD 3x risk of stroke • 4x w/ cardiac failure • Acute MI 5% risk in 2 weeks • More if MI is transmural and anterior wall • Incidence is 1 to 2% per year after MI

  15. Effect of MI on Survival %

  16. Well established risk factorsV. Coronary Artery Dse & MI • Risk is greatest in 1st month 31% • Oral anticoagulation after MI, INR values of 2.5 to 4.8 associated with 10x increase in hemorrhagic stroke • INR below 2.0 not effective, Ideal 2.5 • Statins decrease stroke & TIA after MI by 29 to 31%

  17. Well established risk factorsVI. Carotid Stenosis • Stroke risk increases with the degree of stenosis • Carotid endarterectomy in 60 to 99% stenosis decreased death and stroke 5.9% in 5 yrs compared to medical Tx.

  18. Well established risk factorsVII. Diabetes Mellitus • 1.5 to 3x more likely to have stroke • Tight control of serum glucose levels not conclusive in decreasing risk but reduced complications of DM • Retinopathy • Nephropathy • Neuropathy

  19. Well established risk factorsVIII. Cigarette Smoking • Relative risk 1.5% for stroke • Thromboembolic stroke 2.5% • Hemorrhagic stroke 2.8% • Return to non-smoker risk in 2-5 years

  20. Less established risk factorsI. Hyperlipidemia • Clear relationship not well established • meta-analysis of 10 studies showed 31% risk w/ hyperlipedemia • only 2 studies demonstrated a significant association with total cholesterol

  21. Less established risk factorsI. Hyperlipidemia • Recent studies show Statins beneficial in inducing carotid plaque regression • Statins reduced stroke by 30% among those with 1st MI • 30% reduction in LDL & 32% reduction in total cholesterol reduced risk by 29%

  22. Less established risk factorsII Alcohol • Direct dose dependent effect on risk of hemorrhagic stroke in daily or binges • 2 drinks protective • 5 drinks increased risk • Moderation 30cc or 28 grams of ethanol per day

  23. Less established risk factorsIII. Physical inactivity • Leisure time physical activity reduced risk in young and old, males and females by adjusted OR of 0.37 (95% CI 0.25-0.55) • Benefit is observed even for light to moderate physical activity • Exercise moderate level for 30 minutes 5-7x a week

  24. Less established risk factorsIV. Diet • Role of homocysteine also with deficiency of folate, vitamin B6 and B12 associated with increased risk of stroke • Eat antioxidants and decrease sodium intake

  25. Stroke Survivors

  26. 30 Day Survival

  27. 1 Year Survival

  28. Death Rates For Stroke in Specific Groups

  29. Seizures and Epilepsy • Abnormal brain activity • 7-10% population will have seizures • Begin usually before 20 y/o • Epilepsy recurrent seizure due to brain abnormality

  30. Seizures and Epilepsy • Found in all ethnic groups • Prevalence 1.5/1000 to 19.5/1000 most studies 4-10/1000 • Incidence is highest in the first year of life and after age 60 • Etiology not found in 79% of cases • Partial Seizure commonest type

  31. Seizures and Epilepsy • 65% handicapped medical conditions • 29% mental retardation • Prognosis better if onset is before 10 yrs age • Poor prognosis if present at birth • 10% sudden unexplained deaths (20-40 y/o) proposed causes : cardiac arrhythmias or respiratory failure

  32. Head and Spinal Injury • Leading cause of death 44 y/o and above in US • ½ are head injuries • 5-18% disabled 6 mos. and after • 1-5% vegetative • 20% require neurosurgical intervention

  33. Head and Spinal Injury • 1 family in 300 will have disables • Head injury deaths 1-2% of all deaths • Mortality rate is almost 60-62% • Mental retardation 3x if with head injury

  34. Head and Spinal Injury • 1 skull fracture in 4 will develop intracranial hematoma • Duration of coma, resolution of amnesia, recovery of cognition are predictors of outcome

  35. Head and Spinal Injury • Post-traumatic epilepsy early epilepsy after injury enhances occurance of seizures later • First seizure develops at 12 months or more • Higher in missile injuries (40%) than blunt injury (5%)

  36. Infection • Epidemics occur 10 yr. Cycles • Pneumococcal, H. Influenzae & Meningococcus have worldwide distribution • Usually affects very young and very old • 12,000 to 15,000 cases yearly

  37. Infection • 40% nosocomial infections • Untreated fatal in one week • Treated: H. influenzae & Meningococcal mortality rate of 5% Pneumococcal 15-30% Meningococcemia 90-95% • Neonates mortality 40-75% ½ who recover have serious neurological disability

  38. Infection • 9% behavioral problems • 30% neurological deficits (predicts seizure later) • 26% still abnormal over a year • Brain abscess : 40% from sinuses, mastoid 20% not known 30% endocarditis

  39. Infection • Brain Abscess • Antibiotics and surgery reduces mortality • Lapse into coma before Tx – 50% mortality • Tx began while awake – 5 to 10% mortality • TB Meningitis : 16% increase yearly because of AIDS

  40. Infection • With AIDS, TB is 500x incidence compared to normal • 2/3 present with active TB in the lungs • 20-30% manifest variety of sequelas mental retardation visual disturbance and seizures

  41. Neoplasm • Early morning headache 10-15% • Seizures 50% • Systemic cancer 20% metastasize to the brain • Malignant melanomas 50% have intracranial tumors • Common sources are: lung, breast, skin & kidney

  42. Neoplasm Prognosis • Astrocytoma Gr.1 –good • Anaplastic Astrocytoma – 2 to 5 years • Glioblastomas – 18 months

  43. Neoplasm • Secondary cause of death from intracranial disease ( stroke 1st) • Yearly incidence US All – 46/100000 primary – 15/100000 • Types 20% gliomas 15% meningiomas 10% astrocytomas

  44. Guillain Barre Syndrome • Ascending paralysis • Monophasic Nonseasonal, Nonepidemic • Incidence 0.4 to 1.7 per 100,000 / yr • Females, 8 mos to 81y • 1.7/100000 worldwide

  45. Guillain Barre Syndrome • 10% severe disability • 3-5% do not survive • Mortality • Early: cardiac arrest secondary to dysautonomia • ARDS • Later: pulmonary embolism and other complications of immobilization

  46. Prevalence 4-6% men 13-17% women 4 to 5 billion sick days 3 out of 4 had a headache occurrence in 1 year 80% begins adolescence before 30 15% perimenstrual attacks 40% predisposed to stroke Hemiplegic Retinal 5x AVM incidence Migraine

  47. Migraine • 50-80% will improve or disappear during pregnancy while 10–40% can worsen or remain unchanged with pregnancy • 64% of women w/ menstrual migraine had relief during pregnancy compared to 48% relief in those without menstrual migraine

  48. Migraine • Prevalence decreases with age • Characteristics may change with advancing age • May remit or evolve into chronic daily headache, w/ or w/o medication overuse

  49. Migraine • May transform into a periodic neurological deficit with little or no headache –”late life migraine accompaniment” • Normal angiograms and rarely develop permanent neurological deficit

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