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Clinical correlation of Vitamin D Deficiency and Stroke Subtypes: According to TOAST criteria

Clinical correlation of Vitamin D Deficiency and Stroke Subtypes: According to TOAST criteria. Varuna Nargunan, PGY 3 Mentors: Peterkin Lee-Kwen, MD Michael Merrill, MD. Objective. Prevalence of Vitamin D deficiency in patient diagnosed with stroke at South Buffalo Mercy Hospital

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Clinical correlation of Vitamin D Deficiency and Stroke Subtypes: According to TOAST criteria

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  1. Clinical correlation of Vitamin D Deficiency and Stroke Subtypes: According to TOAST criteria Varuna Nargunan, PGY 3 Mentors: Peterkin Lee-Kwen, MD Michael Merrill, MD

  2. Objective • Prevalence of Vitamin D deficiency in patient diagnosed with stroke at South Buffalo Mercy Hospital • Classification of ischemic strokes subtypes according to TOAST criteria • Clinical correlation of Vitamin D deficiency with • Ischemic stroke subtypes (TOAST criteria), • Stroke severity (NIHSS) • Disability due to Stroke (Modified Rankin Score)

  3. Vitamin D Physiology

  4. Vitamin D Physiology

  5. Incidence of Vitamin D Deficiency

  6. Clinical significance of Vitamin D • Mortality decrease by 7% with vitamin D replacement • Bone – Decrease incidence of osteoporosis, 43% decrease of hip fracture and 58% reduction of non vertebral fracture • Muscle - >30% decrease in grip strength is related to Vitamin D deficiency • More than >50% of multiple sclerosis associated with low vitamin D • CAD & CVD – increase Hypertension, Diabetes mellitus, dyslipidemia (accelerated rate of atherosclerosis)

  7. Vitamin D and Vascular disease • 34 out of 44 patients with acute stroke had low vitamin D within 30 days statistically significant. Stroke. 2006;37:243-45 • LURIC study – 3316 patients, 42 fatal(27 ischemic, 8 hemorrhagic, 7 of unknown) strokes. Low vitamin D are independently predictive for fatal strokes Stroke. 2008;39:2611-2613 • Deficiency and post stroke hemiplegia – Significant bone mass reduction in hemiplegic side related to Vitamin D deficency – statistically significant. Stroke a journal of cerebral circulation. 1996; Volume 27(12): 2183-2187

  8. Vitamin D and Vascular Disease • 120 patients with 1st cardiovascular event were found to have low vitamin D level after adjusting other risk factors Circulation. 2008; 117 • Case series: 4 out of 5 wheelchair bound patients had complete resolution of the muscle ache and pain, fully mobile: Arch intern Med. 2000;160:1199-1203 • Large prospective study yet to be done

  9. Clinical Significance of TOAST Criteria • Widely used to classify ischemic stroke subtypes • It is used to determine • the prognosis • long term survival • risk of recurrence • treatment options

  10. Toast Subtypes • Large Artery Atherosclerosis (LAA) • CardioEmbolism (CE) • Small Artery Occlusion (SAO) • Stroke of other determined causes (OC) • Stroke of undetermined cause (UND)

  11. Modified Rankin Score 0 No symptoms at all • No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance

  12. Modified Rankin Score • Moderate disability; requiring some help, but able to walk without assistance • Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance • Severe disability; bedridden, incontinent and requiring constant nursing care and attention 6 Dead

  13. Study Method • Retrospective chart review of patients with stroke presented to Mercy Hospital between Jan 2008 to Mar 2009 • 225 charts with stroke diagnosis were reviewed • 62 patients met study inclusion criteria

  14. Inclusion criteria Age >20 years Diagnosis of Ischemic stroke, confirmed by CT or MRI 25 hydroxy Vitamin D level measured within 30 days of stroke Exclusion criteria 25 hydroxy Vitamin D measured more than 30 days after stroke Study Method contd.

  15. Data Collected • Demographic information • History of • Hypertension • Diabetes mellitus • Dyslipidemia • Atrial fibrillation • CAD • CHF • Smoking • Osteoporosis • Family history of stroke • Vitamin D supplements

  16. Data Collected • 25 hydroxy Vitamin D • Fasting Lipid profile • 2D Echo/TEE • Carotid doppler/CTA/MRA • CT or MRI of the brain

  17. Results • Prevalence of Vitamin D deficiency (<30 nmol/l) = 45/62 (=70%) • Compared Vit D levels to TOAST sub types, MRS values and NIH Stroke Scale for Correlation and Regression analysis.

  18. Regression Analysis Vit D vs NIH Stroke Scale (NIHSS) Pearson Correlation = 0.07

  19. Regression Analysis Vit D Vs Modified Rankin Score (MRS) Pearson Correlation = 0.02

  20. Regression AnalysisVit D vs TOAST type Pearson Correlation = 0.17

  21. Prevalence of Vitamin D deficiency for TOAST Subtypes

  22. Prevalence of Vitamin D deficiency for MRS values

  23. Prevalence of Vit D deficiency for NIHSS values

  24. Conclusions • Vitamin D deficiency is unrecognized • High incidence in Western NY • Very high incidence in Stroke(70%) • No correlation with stroke subtype • Probably associated with increased association with LAA and CE • Easily treatable condition

  25. Thank you

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