22511 - Stroke Omar Khan MD MHS February 2006 Etymology before epidemiology Etymology before epidemiology • Why is a stroke called a stroke –

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Unformatted text preview: Stroke Omar Khan, MD MHS February 2006 Etymology before epidemiology 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’ What it is 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 long­term patient care Epidemiology of stroke 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 Diff’rent strokes 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 Stroke mortality Stroke mortality Stroke morbidity Stroke morbidity Primary prevention: risks Primary prevention: risks Primary prevention: medical Primary prevention: medical risks • HTN: RR of stroke in untreated hypertensive (>140/90) is 1.2 – 4.0 • MI: Risk of stroke increases 30% in the first month post­MI, then 1­2% each year after that. • AF: strong independent risk for ischemic stroke (RR = 5). 70% are cardioembolic, 30% are ‘other­embolic’. 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 Primary prevention: medical risks • DM – The bad news: increased RR of 1.4­1.7 – 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 Coumadin and stroke prevention Coumadin and stroke prevention Coumadin and stroke prevention Coumadin and stroke prevention • 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 Coumadin and stroke prevention: the final word? Coumadin and stroke prevention Coumadin and stroke prevention Lifestyle Risk Factors Lifestyle Risk Factors • 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 Lifestyle Risk Factors • Diet Secondary prevention for special Secondary prevention for special populations • TIA – Focal neurologic deficit (e.g., hemiparesis, slurred speech, diplopia, ataxia) resolving in 24 hours (60­70% within 1 hour) – Usual cause: temporary ischemia from emboli, vasospasm, hypotension Secondary prevention for special Secondary prevention for special populations • TIA Secondary prevention for special Secondary prevention for special populations • TIA Secondary prevention for special Secondary prevention for special populations • 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 Stroke and TPA Stroke and TPA • 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) Post­stroke care Post­stroke care • Post­stroke concerns which are frequently managed by family physicians: – Secondary prevention including modification of risks – Depression: • major (studies cite 1­25%), minor (20­30%) • Identifiable risk factors for post­stroke depression (see chart). Manic symptoms less common • Post­stroke depression associated with 3­year mortality increase of 350% • Treat with counseling and with antidepressant Rx Post­stroke care: Depression Post­stroke care: Depression Post­stroke care: Rehab Post­stroke care: Rehab • 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 Post­stroke care: Rehab Post­stroke care: Rehab Post­stroke care: Rehab Post­stroke care: Rehab Stroke Q & A Stroke Q & A 1. B 1. B 2. D 2. D 3. C 3. C 4. A 4. A 5. B 5. B 6. E 6. E 7. A 7. A 8. D 8. D 9. B 9. B 10. A 10. A ...
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This note was uploaded on 02/26/2012 for the course PHARM 210 taught by Professor Staff during the Fall '10 term at Rutgers.

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