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Stroke

Stroke. Omar Khan, MD MHS February 2006. Etymology before epidemiology. Why is a stroke called a stroke? Maybe since all sudden attacks were called strokes, and the rest acquired specific terms e.g. MI An abbreviation of the phrase 'stroke of apoplexy’

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Stroke

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  1. Stroke Omar Khan, MD MHS February 2006

  2. Etymology before epidemiology • Why is a stroke called a stroke? • Maybe since all sudden attacks were called strokes, and the rest acquired specific terms e.g. MI • An abbreviation of the phrase 'stroke of apoplexy’ • Apoplexy (from the Greek meaning to strike off) • Divine origin as in, ‘being struck down’

  3. What it is • A neurological event following an interruption in blood flow due to • Thrombus/embolus • Hemorrhage • Hypotension • 30 % of strokes are immediately fatal • 30 % result in long-term patient care

  4. Epidemiology of stroke • Morbidity: • Every year: 500,000 have a first stroke • Every year: 200,000 have a subsequent stroke • Frequency of stroke doubles every 10 years after 55 y.o. • Mortality: • 3rd leading cause of mortality in the US (i.e., more than chronic lung disease, accidents, diabetes…) • Causes about 7% of all US deaths

  5. Diff’rent strokes • Strokes are more prevalent in the following (Relative Risk compared to US white population): • Finns, Japanese: 1.6 • Black Americans: 2.2

  6. Stroke mortality

  7. Stroke morbidity

  8. Primary prevention: risks

  9. HTN: RR of stroke in untreated hypertensive (>140/90) is 1.2 – 4.0 MI: Risk of stroke increases 30% in the first month post-MI, then 1-2% each year after that. AF: strong independent risk for ischemic stroke (RR = 5). 70% are cardioembolic, 30% are ‘other-embolic’. Stroke risk in untreated AF is 6% per year. A side note: if electively cardioverting for AF, do warfarin for 3 wks prior and 4 wks post Primary prevention: medical risks

  10. DM The bad news: increased RR of 1.4-1.7 The bad news: glycemic control may not help Hypercholesterolemia: RCTs on those with TC>240, when treated, had decreased RR of 0.7 Carotid artery stenosis: isolated as risk factor in 1914 by Ramsey Hunt (yes, that Ramsey Hunt) The bad news: only 33% of significant stenosis=bruit The bad news: only 60% of bruits=significant stenosis Risk of same-side stroke is 2% after CEA (find a good surgeon) Primary prevention: medical risks

  11. Coumadin and stroke prevention

  12. In patients >75 y.o., more strokes (hemorrhagic and ischemic) in those on warfarin vs those just on aspirin The best balance of INR seems to be 2.0 – 3.0 for most patients Coumadin and stroke prevention

  13. Coumadin and stroke prevention: the final word?

  14. Coumadin and stroke prevention

  15. Smoking Risk of stroke doubles with each pack Risk of stroke returns to baseline 2 yrs after quitting Drinking Regular intake of > 4 drinks/wk=small increase in risk of stroke,moderate increase on risk of death after stroke Lifestyle Risk Factors

  16. Diet Lifestyle Risk Factors

  17. TIA Focal neurologic deficit (e.g., hemiparesis, slurred speech, diplopia, ataxia) resolving in 24 hours (60-70% within 1 hour) Usual cause: temporary ischemia from emboli, vasospasm, hypotension Secondary prevention for special populations

  18. TIA Secondary prevention for special populations

  19. TIA Secondary prevention for special populations

  20. Women After 65 y.o., more women than men have stroke Why? Undertreatment, increased risk of HTN, hypothesized reasons: being female itself does not seem to be a factor Pregnancy: increased RR but very small increase in AR Use of OCs esp. in conjunction with smoking and HTN is a risk factor OCs+HTN = RR 10.7 OCs+smoke=7.2 Newer OCs + <35y.o. + no HTN = no increased risk Secondary prevention for special populations

  21. Hospital treatment of stroke TPA within 3 hours minimizes stroke size TPA within 3 hours decreases disability at 3 months May cause bleeding (see contraindication chart) Stroke and TPA

  22. Post-stroke concerns which are frequently managed by family physicians: Secondary prevention including modification of risks Depression: major (studies cite 1-25%), minor (20-30%) Identifiable risk factors for post-stroke depression (see chart). Manic symptoms less common Post-stroke depression associated with 3-year mortality increase of 350% Treat with counseling and with antidepressant Rx Post-stroke care

  23. Post-stroke care: Depression

  24. Rehab should begin soon after the patient is stable (ideally, within 48hrs) Early rehab can prevent DVT, contractures, pneumonia, skin breakdown, and aids early return to ADLs Post-stroke care: Rehab

  25. Post-stroke care: Rehab

  26. Post-stroke care: Rehab

  27. Stroke Q & A

  28. 1. B

  29. 2. D

  30. 3. C

  31. 4. A

  32. 5. B

  33. 6. E

  34. 7. A

  35. 8. D

  36. 9. B

  37. 10. A

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