Prognosticating Common Neurological Disorders

Vincent B. Macalintal, MD, FPNA

Types of Stroke

32%

10%31%

20%

7%

embolicICHSAHThrom. LargeThrom. Small

Ischemic 83%Hemorrhagic 17%

Stroke : risk factors

Well established

hypertension

TIA

heart diseases

smoking

diabetes mellitus

carotid disease

Stroke : risk factors

Less well established

hypercholesterolemia

excessive alcohol and drug use

physical inactivity

dietary factors and obesity

infection

Well established risk factorsI. Hypertension

Directly related to stroke risk (2-4X)

Higher BP – higher risk

Prevalence 22% ischemic and

hemorrhagic

Well established risk factorsI. 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%

HypertensionRisk of 2nd Stroke in 2 years

0

5

10

15

20

25

30

35

40

6 12 18 24 30 36 42

None HPNmonths

%

Well established risk factorsII. 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

Well established risk factorsII. 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

Well established risk factorsIII. Valvular heart disease

w/o AF w/ AF

Prosthetic valve

20% higher

Rheumatic Mitral Stenosis

1.5 to 4% higher 7-18x

Rheumatic Mitral Regurg.

7.7% 22%

Mitral valve prolapse

low less 2% higher

Well established risk factorsIII. 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

Well established risk factorsIV: 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

Effect of Arrhythmia on Survival

0

10

20

30

40

50

60

70

80

90

100

6mo 12mo 18mo 24mo 30mo 36mo 42mo

NoneARR

%

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

Effect of MI on Survival

0

10

20

30

40

50

60

70

80

90

100

6mo 12mo 18mo 24mo 30mo 36mo 42mo

No MIMI

%

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%

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.

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

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

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

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%

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

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

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

Stroke Survivors

31

20

71

0

10

20

30

40

50

60

70

80

need care assist walk impairedwork

survivor

30 Day Survival

All Thromb.

Embolic

ICH SAH

Roch. 72 81 16 48

Farming.

72 81 36 36

Oxford. 81 90 50 54

1 Year Survival

All Thromb.

Embolic

ICH SAH

oxford 69 77 38 52

Death Rates For Stroke in Specific Groups

6946.9

0.5 0.6 4.3 3.7

33 26.2

369.2

423.4

0

50

100

150

200

250

300

350

400

450

All 15-24 25-44 45-64 65+

MalesFemales

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

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

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

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

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

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

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%)

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

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

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

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

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

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

Neoplasm

Prognosis Astrocytoma Gr.1 –

good Anaplastic

Astrocytoma – 2 to 5 years

Glioblastomas – 18 months

Neoplasm

Secondary cause of death from intracranial disease ( stroke 1st)

Yearly incidence US All – 46/100000primary – 15/100000

Types 20% gliomas15% meningiomas10% astrocytomas

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

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

Migraine

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

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

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

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