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