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stroke

Stroke

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Definition

A stroke, sometimes referred to as a cerebrovascular accident (CVA), cerebrovascular insult (CVI), or colloquially called a brain attack, is the loss of brain function due to a disturbance in the blood supply to the brain. This disturbance is due to either ischemia (lack of blood flow) or hemorrhage.

Epidemiology

Spontaneous intracerebral hemorrhage (ICH) is a global public health issue and accounts for 10–15% of all stroke cases 1).

Stroke is the fourth killer and number one cause of adult disability in the United States. The estimated direct and indirect costs of stroke care in this country are $68.9 billion for 2009. The prevalence of stroke and its cost will undoubtedly rise as the aging population increases. In addition, stroke incidence and mortality are increasing in less developed countries in which the lifestyles and population restructuring are rapidly changing. More population-based research to assess incidence, risk factors, and outcomes are needed in these countries. Epidemiologic studies can help identify groups of individuals or regions at higher risk for stroke. They can also help us better understand the natural history of certain conditions and therefore push the direction of therapeutic investigations. Furthermore, the study of trends across different time periods and different populations can help investigators evaluate the effects of stroke care programs and treatment options 2).


Although the prevalence of stroke and its risk factors has been widely reported in some Western countries, information on essential stroke parameters is lacking in China, the most populous nation. A community-based cross-sectional study with 8,018 Chinese adults aged ≥40 years was used to determine the prevalence of stroke and associated risk factors. Within the screened population, the prevalence of stroke was 2.21% for both sexes, 1.60% for females, and 3.18% for males. Prevalence increased with age in both sexes (P < 0.0001). In a multivariable model, factors significantly associated with stroke were increasing age (odds ratio [OR] = 1.87, 95% CI: 1.58-2.24), male gender (OR = 2.03, 95% CI: 1.42-2.90), family history of stroke (OR = 4.33, 95% CI: 2.89-6.49), history of hyperlipidemia (OR = 1.87, 95% CI 1.31-2.68), history of hypertension (OR = 1.47, 95% CI 1.02-2.12), and physical inactivity (OR = 1.74, 95% CI: 1.16-2.59). The findings indicate that stroke prevalence in middle-aged and older Chinese adults is higher in males than in females, and increases with age in both sexes. Population-based public health intervention programs and policies targeting hyperlipidemia and hypertension control and encouragement of physical activity should be highly prioritized for middle-aged and older adults in Shenzhen, China 3).

Classification

Ischemic stroke.

Hemorrhagic stroke

A rapid and reliable diagnostic test to distinguish ischemic from hemorrhagic stroke in patients presenting with stroke-like symptoms is essential to optimize management and triage for thrombolytic therapy.

The term major stroke is used to distinguish a full-blown stroke from a minor stroke, or transient ischemic attack (TIA).

Etiology

Extra cranial carotid artery dissection and vertebral artery dissection is an important cause of stroke, especially in young people.

Stroke etiology was classified as cardioembolism in 22 patients (59.4%), large-artery atherosclerosis in 8 (21.6%), and undetermined in 7 (18.9%). The clots from cardioembolism had a significantly higher proportion of red blood cells (37.8% versus 16.9%, P = .031) and a lower proportion of fibrin (32.3% versus 48.5%, P = .044) compared with those from large artery atherosclerosis. The proportion of red blood cells was significantly higher in clots with a susceptibility vessel sign than in those without it (48.0% versus 1.9%, P < .001), whereas the proportions of fibrin (26.4% versus 57.0%, P < .001) and platelets (22.6% versus 36.9%, P = .011) were significantly higher in clots without a susceptibility vessel sign than those with it.

The histologic composition of clots retrieved from cerebral arteries in patients with acute stroke differs between those with cardioembolism and large-artery atherosclerosis. In addition, a susceptibility vessel sign on gradient echo sequence is strongly associated with a high proportion of red blood cells and a low proportion of fibrin and platelets in retrieved clots 4).


There is conflicting evidence for whether or not the incidence of stroke is influenced by the daily temperature.

The daily temperature had measurable and different associations with the number of strokes and strokes subtypes in Seoul, Korea 5).

Pathophysiology

Pathophysiology and Neuroprotective Strategies in Hypoxic-Ischemic Brain Injury and Stroke 6).

Syndromes

Diagnosis

Stroke has been extensively studied in clinical practice and experimental research by means of MR images with ever-emerging new technologies, such as DWI, PWI, and ADC maps. More recently, different PWI-derived parameters, such as the rCBV), the relative cerebral blood flow (rCBF), the relative MTT, and the time to peak (TTP) have been applied to quantify the perfusion deficit and to evaluate the temporal infarct growth in acute stroke either in patients or in small animals with high field strength MR spectrometers 7).

Outcome

A bursting inflammation has been observed that compromises neurologic function in patients who experience stroke.

A common complication after stroke is development of cognitive impairment and dementia.

Stroke is deemed a worldwide leading cause of neurological disability and death.

Stroke causes life long disabilities where few therapeutic options are available. Using electrical and magnetic stimulation of the brain and physical rehabilitation, recovery of brain function can be enhanced even late after stroke.

Stroke recovery is the next frontier in stroke medicine. While growth in rehabilitation and recovery research is exponential, a number of barriers hamper our ability to rapidly progress the field. Standardized terminology is absent in both animal and human research, methods are poorly described, recovery biomarkers are not well defined, and we lack consistent timeframes or measures to examine outcomes. Agreed methods and conventions for developing, monitoring, evaluating and reporting interventions directed at improving recovery are lacking, and current approaches are often not underpinned by biology. We urgently need to better understand the biology of recovery and its time course in both animals and humans to translate evidence from basic science into clinical trials. A new international partnership of stroke recovery and rehabilitation experts has committed to advancing the research agenda. In May 2016, the first Stroke Recovery and Rehabilitation Roundtable will be held, with the aim of achieving an agreed approach to the development, conduct and reporting of research. A range of methods will be used to achieve consensus in four priority areas: pre-clinical recovery research; biomarkers of recovery; intervention development, monitoring and reporting; and measurement in clinical trials. We hope to foster a global network of researchers committed to advancing this exciting field. Recovery from stroke is challenging for many survivors. They deserve effective treatments underpinned by our evolving understanding of brain recovery and human behaviour. Working together, we can develop game-changing interventions to improve recovery and quality of life in those living with stroke 8).

Prevention

Effective strategies for reducing the risk of developing problems after stroke remain undefined. Potential strategies include intensive lowering of blood pressure (BP) and/or lipids.

Treatment

Time is of the essence when diagnosing, and treating a stroke (brain attack) and restoring normal blood flow to the affected areas. The success and effectiveness of interventional stroke therapy literally depends on how quickly a patient recognizes the symptoms of stroke and seeks emergency medical care. Interdisciplinary in nature.


TeleStroke considerably improves quality of stroke care (for instance, by increasing thrombolysis) and may be valuable for the management of intracranial hemorrhages in rural hospitals and hospitals lacking neurosurgical departments, given that surgical/interventional therapy is only recommended for a subgroup of patients.


For ischemic strokes caused by blood clots, the medical team will first give clot-busting drugs, such as tPA (tissue plasminogen activator) intravenously to patients who arrive at the hospital within three hours from the onset of stroke symptoms. If the tPA does not adequately dissolve the clot or cannot be administered within the ideal timeframe, Northwestern’s neuroendovascular experts can offer intra-arterial (through the artery) thrombolysis treatment. This therapy helps extend the required treatment time for tPA up to six hours by delivering the clot-busting drug directly to the blockage. This intra-arterial procedure involves inserting, under x-ray guidance, a catheter (a thin tube) into the femoral artery located in the patient’s leg, near the groin area, and guiding it to the site of the clot. From there, the interventional neuroradiology team can locally administer a clot-busting agent to dissolve the blockage. The patient undergoes the entire procedure under general anesthesia.

Clots can also be broken up or removed via mechanical means. Using the same type of catheter-based technique as other intra-arterial therapies, Northwestern’s interventional neuroradiologists have at their disposal advanced clot-retrieving systems for the treatment of ischemic stroke. Inserted through the catheter, a tiny corkscrew-shaped device, called the MERCI, allows the neuroendovascular specialists to capture the clot and pull it free and away from the site of the blockage. This procedure can be used up to eight hours after the onset of stroke symptoms.


For Guideline see American Heart Association.

Case series

611 ischemic and 805 hemorrhagic stroke patients who were admitted within 24 h after the symptom onset. Data were analyzed with independent t test and Chi square test, and then with multivariate logistic regression analysis.

In ischemic stroke, National Institutes of Health Stroke Scale (NIHSS) score (OR 1.08; 95 % CI 1.06-1.11; P < 0.01), white blood cell count (OR 1.11; 95 % CI 1.05-1.18; P < 0.01), systolic blood pressure (BP) (OR 0.49; 95 % CI 0.26-0.90; P = 0.02) and age (OR 1.03; 95 % CI 1.00-1.05; P = 0.03) were associated with in-hospital mortality. In hemorrhagic stroke, NIHSS score (OR 1.12; 95 % CI 1.09-1.14; P < 0.01), systolic BP (OR 0.25; 95 % CI 0.15-0.41; P < 0.01), heart disease (OR 1.94; 95 % CI 1.11-3.39; P = 0.02) and creatinine (OR 1.16; 95 % CI 1.01-1.34; P = 0.04) were related to in-hospital mortality. Nomograms using these significant predictors were constructed for easy and quick evaluation of in-hospital mortality.

Variables in acute stroke can predict in-hospital mortality and help decision-making in clinical practice using nomogram 9).

1)
Qureshi AI, Mendelow AD, Hanley DF. Intracerebral haemorrhage. Lancet. 2009 May 9;373(9675):1632-44. doi: 10.1016/S0140-6736(09)60371-8. Review. PubMed PMID: 19427958; PubMed Central PMCID: PMC3138486.
2)
Ovbiagele B, Nguyen-Huynh MN. Stroke epidemiology: advancing our understanding of disease mechanism and therapy. Neurotherapeutics. 2011 Jul;8(3):319-29. doi: 10.1007/s13311-011-0053-1. Review. PubMed PMID: 21691873; PubMed Central PMCID: PMC3250269.
3)
Gan Y, Wu J, Zhang S, Li L, Yin X, Gong Y, Herath C, Mkandawire N, Zhou Y, Song X, Zeng X, Li W, Liu Q, Shu C, Wang Z, Lu Z. Prevalence and risk factors associated with stroke in middle-aged and older Chinese: A community-based cross-sectional study. Sci Rep. 2017 Aug 25;7(1):9501. doi: 10.1038/s41598-017-09849-z. PubMed PMID: 28842623.
4)
Kim SK, Yoon W, Kim TS, Kim HS, Heo TW, Park MS. Histologic Analysis of Retrieved Clots in Acute Ischemic Stroke: Correlation with Stroke Etiology and Gradient-Echo MRI. AJNR Am J Neuroradiol. 2015 Jul 9. [Epub ahead of print] PubMed PMID: 26159515.
5)
Shin DW, Yoon JE, Hwang HW, Kim JS, Park SQ, Roh H, Ahn MY, Lee KB. Numbers of Stroke Patients and Stroke Subtypes According to Highest and Lowest Daily Temperatures in Seoul. J Clin Neurol. 2016 Oct;12(4):476-481. doi: 10.3988/jcn.2016.12.4.476. PubMed PMID: 27819418.
6)
Meloni BP. Pathophysiology and Neuroprotective Strategies in Hypoxic-Ischemic Brain Injury and Stroke. Brain Sci. 2017 Aug 22;7(8). pii: E110. doi: 10.3390/brainsci7080110. PubMed PMID: 28829350.
7)
Park JW, Kim HJ, Song GS, Han HS. Blood-brain barrier experiments with clinical magnetic resonance imaging and an immunohistochemical study. J Korean Neurosurg Soc. 2010 Mar;47(3):203-9. doi: 10.3340/jkns.2010.47.3.203. Epub 2010 Mar 31. PubMed PMID: 20379473; PubMed Central PMCID: PMC2851093.
8)
Bernhardt J, Borschmann K, Boyd L, Carmichael ST, Corbett D, Cramer SC, Hoffmann T, Kwakkel G, Savitz S, Saposnik G, Walker M, Ward N. Moving Rehabilitation Research Forward: Developing Consensus Statements for Rehabilitation and Recovery Research. Neurorehabil Neural Repair. 2017 Aug;31(8):694-698. doi: 10.1177/1545968317724290. PubMed PMID: 28803534.
9)
Ho WM, Lin JR, Wang HH, Liou CW, Chang KC, Lee JD, Peng TY, Yang JT, Chang YJ, Chang CH, Lee TH. Prediction of in-hospital stroke mortality in critical care unit. Springerplus. 2016 Jul 11;5(1):1051. doi: 10.1186/s40064-016-2687-2. eCollection 2016. PubMed PMID: 27462499.
stroke.txt · Last modified: 2017/09/27 17:25 by administrador