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Diseases and conditions Associated with Stroke • Pamela Nye RN MSN CNS • Patty Sheehan RN MN CNS

• Abdominal obesity (excessive fat tissue in and around the abdomen)

• Atherogenic dyslipidemia (blood fat disorders — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque buildups in artery walls)

• Elevated blood pressure • Insulin resistance or glucose intolerance (the body can’t

properly use insulin or blood sugar) • Prothrombotic state (e.g., high fibrinogen or

plasminogen activator inhibitor–1 in the blood) • Proinflammatory state (e.g., elevated C-reactive protein

in the blood)

American Heart Association Metabolic Syndrome

• A constellation of symptoms all noticed in one person • Increased risk of MI, CVA, and diabetes. • Incidence in U.S.A.? 50 million people. • Dominant underlying risk:

•Abdominal fat •Men: ≥40 inches Women: ≥35 inches

• Insulin resistance •Fasting Blood Sugar ≥100 mg/Dl.

Metabolic Syndrome

Apples and Pears

New Thinking: Risk Constellations

BIRTH CONTROL PILLS

SMOKING

HI BMI

HYPERTENSION

DIABETES

SLEEP APNEA

TOOTH DECAY

TOOTH LOSS

SMOKING: CIGARETTES / METHAMPHETAMINE

CHRONIC INFLAMMATION/INFECTION

• Chronic inflammatory states = cytokines • C-Reactive Proteins (stroke marker)

Risk Constellations (American Heart Association, 2004)

• TIAs • Atrial fibrillation/Flutter • Cardiopulmonary bypass • s/p MI • Vascular diseases • PFO • Hematologic disorders • Aortic dissection • Infections, Migraines

Conditions that can predispose to a Stroke

TIAs • Brief “episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction” (Albers et al. 2002).1

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• Stroke Symptoms which resolve within one hour • (not 24 hours) • Dizziness and vertigo • “4 million ED visits annually in the U.S. • 160,000- 240,000 have cerebrovascular causes”

• D. Newman- Toker et al 2013

Transient Ischemic Attack: Definition

• Risk of completed stroke within 90 days of untreated stroke is approximately 15% with highest risk within 1 week of the TIA.

• Risk factors are the same as ischemic stroke. • Goal of treatment: identification of mechanism

• Embolic □ Dissection • Dissection □ Small vessel disease • Cardiac □ Hypercoagulable states

• Furie et al, 2010

Facts About TIA

• Inflammation of blood vessels • Veins, arteries and capillaries • Faulty immune system • Vessel walls swell, harden, thicken • Narrows lumen of the vessels • Can occur anywhere in the body

Vasculitis

• Moya- Moya Disease • Fabry’s Disease rare X linked genetic disease lipid deposits

along inner lining of the blood vessels of the brain, heart, skin, kidneys

• Vasospasms after subarachnoid hemorrhage • Fibromuscular Dysplasia – abnormal cell development in

arterial wall.

Non Inflammatory Vascular Disorders

“Puff of Smoke” 1960: originally identified Now found in US, Africa, Japan, Europe & Australia Presentation: TIA and ischemic stroke Familial: probably genetic Outcomes: -Many die in childhood -Those with multiple events are cognitively impaired. -If live to adulthood, ICH is common due to mal- formed vessels. NINDS, 2014

Moya Moya

• Isolated angitis of the CNS • Cerebral vasculitis related to: infection, toxins,

neoplasms • Meningitis, varicella zoster, HIV, Hepatitis

C,tuberculosis • Amphetamines, cocaine,heroin, LSD, glue sniffing

Inflammatory Vascular Diseases

• Endocarditis • Lupus • Athrogenesis

•↑C Reactive proteins •↑Cytokines

• Smoking •New research shows smoking causes endothelial inflammation leading to platelets coating the endothelial lining of arteries

• New research on inflammation as the cause of stroke in children Sultan et al, 2013

Inflammatory Conditions

• Prothrombotic disorders • oral contraceptive • malignancies • myloproliferative disorders • Sickle Cell Disease • Thrombophilia

Hematological Disorders

• Risk factor for ischemic stroke • Cardiac ischemic disease • TIAs • Cardiac ischemic disease • 1.5 fold increase in hemorrhagic stroke • Stiffness, less compliance, altered flow dilation • Vascular changes in other vessels of the body • (Sacco, 2014)

Migraines with Aura

Progression of Atherosclerosis

• Fatty streak • Fibrous plaque • Complicated lesions • Angina > 70% obstruction

Myocardial Infarction

Causes

Progression of infarction

ST elevation

• Bacterial or fungal infection of the heart tissue • Vegetations that embolize • Causes: central lines, surgical repairs, intracardiac

shunts, IVDU, prosthetic cardiac devices, long term TPN, rheumatic fever, Kawasaki’s disease, Antiphospholipid AB syndrome

Endocarditis

• Anterior leaflet of mitral valve • Aortic valve • ASD • VSD • Aortic dissection

Left sided lesions

• Severe dehydration • ETOH • IVDU • s/p CPR

More conditions

• Non pulsatile flow • Length of time on bypass • Preexisting carotid narrowing or thickening • Low blood pressure • Preexisting emboli or air emboli

Cardiopulmonary Bypass

• Due to ischemia,structural changes,heart failure • Afib, Aflutter, heart blocks • Anticoagulant therapy:Lovenox, Heparin • Coumadin

Most common rhythms

A Fib

• Most common rhythm disorder world wide • Affects 1% of the general population • Prevalence increases with age • Estimated 16 million people in U.S. will be affected by

2050 • 5% of all acute medical admissions • Independent risk factor • 25% of all strokes caused by Afib • Ahmad,Y. & Lip, Y., 2012

Atrial Fibrillation

• Anti-coagulation • Incidence = 1-1.5% of general population

• Increases with age (i.e. age >70yrs = 7.3-13%

• Strong stroke risk factor (5 fold risk) • Silent symptoms, episodic, paroxsymal • CHADS score (risk factor for stroke evaluation)

• CHF 1pt -HTN 1pt -Age >75 1pt • Diabetes 1pt -Hx stroke/TIA 2pt Total poss=6

• Kathleen Hickey, Heart and

Lung, 2011

Atrial Fibrillation

• Afib increases risk of stroke five fold • Increases likelihood of stroke occurrence • Patients more likely to die • Spend longer in the hospital • Greater level of disability • Discharge to SNF

Risk Factors

• Goals: restore to NSR, antiarrhythmic therapy • Control the rate- Metoprolol, Diltiazem, Amiodarone

• Anticoagulation (warfarin, lst choice) • Dabigatran (Pradaxa) first new alternative to warfarin • INR goal: 2.0-3.0 (2.5-4.5 if valve replacement) • High rates of patient non-compliance

• Catheter ablation • Risks of treatment

• Cardioversion, risk of cardioembolic thrombi • ICH

Afib Treatment/Management

CHA2DS2-VASc Score for Risk of Stroke in non valvular AF

• Catheter ablation laser the source of Afib. (usually near the rt. Pulmonary vein)

• Risks: Incidence of thromboembolic events 48 hrs. after ablation

• new study demonstrated ablation without warfarin discontinuation, therapeutic INR, reduces the occurrence of periprocedural stroke/TIA

• (Di Biase et al. 2014)

Ablation

Aflutter

• Incidence 15-25% in general population • Amplatzer® device,Occlutech Figulla®

• Anticoagulation • PFO closure (cath lab procedure)

Patent Foramen Ovale

• Fetal structure that lies between the rt. And left atrium

• Normally closes within 72 hours after birth • Can be a source for cryptogenic stroke, the development of a TIA

• Shunting of blood from right – left • Air emboli or thrombus that travels into the cerebral circulation

Patent Foramen Ovale

Aortic Dissections

Vessels arising from Aorta

Aortic Dissection Repair

• Carotid stenosis • Plaque forms in carotid artery • Risk of TIA or CVA • > 50% occlusion carotid endarterectomy • Stroke 3rd leading cause of death in U.S.

Carotid Atherosclerosis

Carotid dissection

• Arteries: Carotid and Vertebral

• Often related to trauma

• Often heal over time

• Strokes as a result is un-known, though stroke-like symptoms result.

• Treatment

• Anticoagulation (small)

• Angioplasty (poss stent)

• Alteration in activity

• Furie et al, 2011

Dissection

• Carotid Endarterectomy • EC/IC Bypass Grafting • Angioplasty with Stenting

•Less invasive, less risk of surgery

• IR procedure: challenges include prior neck surgery

• Statins do NOT reverse the process, only slow progression

Athero Treatments

• Hypercoagulable : Sickle Cell Disease, Factor V Leiden

• Thrombophilia • Fabry’s Disease – lipids accumulate in the vasculature

•effecting:cardiac, renal • Hyperhomocystinemia- amino acid causing vascular dysfunction,↑ risk of thrombosis, Alzheimer’s, bone density

Hematological Diseases and Stroke

Sickle Cell

• Multisystem disease • Major source of morbidity and mortality CVAs • Historically before transcranial doppler and chronic transfusion therapy

• 11% of patients will suffer a stroke before the age of 20

• Silent cerebral infarct SCD > risk of stroke later in life

• Hydroxyurea known to reduce TCD velocities • (Madden.N. et al. 2014)

Sickle Cell Disease

• Affects 70,000 – 100,000 people in U.S. • Homozygous variant • Leads to transit problems in the microvascular system

• Hypoxia, hypothermia, acidosis, diminished blood flow.

Sickle Cell Disease

• MRIs • SWiTCH Stroke with transfusions changing to

Hydroxyurea • Randomized trial • Evaluated Hydroxyurea with phlebotomy as alternative

to ongoing transfusion therapy • Management of iron overload • Study closed higher number of stroke occurrence in this

group • (N. Madden, et al. 2014)

Sickle Cell Disease

• Inactivation of activated Factor X • Inhibits prothrombin conversion to thrombin • Prevents fibrin formation • Dosing IV or sub q • Frequent monitoring of PT/PTT INR

Heparin

• Slow onset • Narrow therapeutic window • Long half life • Other drugs and foods can interfere with absorption • Frequent lab monitoring • INR 2.0 -3.0

Warfarin

• Inactivation of anti factor Xa and antithrombin • Inactivates anti Factor IIa • Monitor CBC, plt ct. occasionally • Sub q • Dosing 1 mg/kg specific to condition daily or BID

Fondaparinux / Lovenox

• Direct inhibitor of thrombin • Quick onset • Superior to warfarin • BID dosing • Dyspepsia • PTT Does not require routine anticoagulation monitoring

Dabigatran

• Direct factor Xa inhibitor • Fast onset • Excreted both renally and via liver

Rivaroxaban / Xarelto

• Reversible direct factor Xa inhibitor • Found to be superior to Warfarin • 55% reduction in stroke or systemic embolism • BID dosing • No routine monitoring required

Apixaban / Eliquis

• New anticoagulants impact prevention of stroke in pts. With Afib

• Stroke or systemic embolism • Major bleed • Intracranial hemorrhage • GI hemorrhage • Acute MI • Life threatening hemorrhage • mortality

RE-LY trial

Diagnostic Tools • ABCD2- risk assessment tool designed to improve prediction of short term stroke risk after TIA

• ‘HINTS to INFARCT’- 2 minute 3 item bedside eye movement screen

ABCD² Rule

• Low risk <1% likely to have a stroke w/in 7 days.

• Mod risk 4.1% risk of stroke w/in 2 days.

• High risk 8% risk of stroke w/in 2 day.

• 21% of ED patients fall into the high risk category.

Emergency Physicians Monthly, Jan 18 2009

• 3 step eye movement examination • More sensitive for acute vestibular syndrome • Head impulse – right and leftward • Nystagmus type – gaze testing • Test of skew- alternate cover test • Impulse normal bilaterally normal • Fast phase alternating (direction changing) • Refixation on cover test (skew deviation) • (Newman-Toker et al. 2013)

HINTS

• HINTS PLUS assessment of new hearing loss • Generally unilateral & on the side of the abnormal head impulse test

• Stroke findings:I.N.F.A.R.C.T. any of the results listed on previous slides

HINTS plus

• Formation of blood clot in the venous system of the leg

• Venous stasis • Altered coagulability

VTE Venous Thromboembolism

• 1 million patients in the U.S. • Cost of $1.5 billion • COPD,CHF, ACS,Cancer • Each new case costs $22,000 • (Prendergraft, T et al. 2013)

High Risk Patients

• Genetic • Immobility • Surgery • Air travel • Pregnancy • Cancer • Central lines • Obesity

Risk Factors

• D-dimer levels • CRP C-reactive protein • Homocysteine • Duplex ultra sound • Contrast venography • Spiral CT • VQ scan

Diagnostic Studies

McDermott, M.et al, 2008

• Avoid immobility, adequate hydration • Mechanical compression stockings • Antithrombolysis- tPA,urokinase • Anticoagulants- Heparin,CoumadinFondaparinux,

• IVC filter • Venous thrombectomy • (Buller,H. et al. 2004)

Management

Question 1 Having Afib increases a patient’s risk of stroke: • A. 2 times • B. 5 times • C 6 times • D. 10 times

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Question 2 A patient who has had an MI is at highest risk for having a stroke: • Within 24 hrs • Within 1 week • Within 2 weeks • Within 6 weeks

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Question 3 Cardiopulmonary bypass is a risk factor for stroke due to: • A nonpulsatile flow • B lowering the blood pressure • C. carotid stenosis • D. A & B • E. B

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Question 4 What percent of strokes are caused by Afib? • 10 % • 20 % • 40% • 25%

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References • Ahmad, Y., Lip, G. Y. (2012). Stroke prevention in atrial fibrillation: concepts and controversies.

Current cardiology reviews, 8(4), 290-301.

• Attia, F M, Maaty, A, & Kalil, F A. (2011). Circulating endothelial cells as a marker of vascular

dysfunction in patients with systemic lupus erythematosus by real-time polymerase chain

reaction. Archives of pathology & laboratory medicine, 135(11), 1482-5.

• Baddour, L. M., Wilson, W. R., Bayer, A. S., Fowler, V. G., Tleyjeh, I. M., Rybak, M. J., Taubert,

K. A. (2015). Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and

Management of Complications: A Scientific Statement for Healthcare Professionals From the

American Heart

• Di Biase, L Burkhardt, D. et al. (2014). Periprocedural stroke and bleeding complications in

patients undergoing catheter ablation of atrial fibrillation with different anticoagulation

management. Results for the role of Coumadin in preventing thromboembolism in Atrial

Fibrillation patients undergoing catheter ablation (COMPARE) Randomized Trial. Circulation

.2014;129:2638-2644.

References • Di Biase, L Burkhardt, D. et al. (2014). Periprocedural stroke and bleeding complications in patients undergoing

catheter ablation of atrial fibrillation with different anticoagulation management. Results for the role of Coumadin

in preventing thromboembolism in Atrial Fibrillation patients undergoing catheter ablation (COMPARE)

Randomized Trial. Circulation .2014;129:2638-2644.

• Dublin, S, Anderson, M L, Haneuse, S J, et al. (2011). Atrial fibrillation and risk of dementia: a prospective cohort

study. Journal of the American Geriatrics Society, 59(8), 1369-75.

• Edwards, N. J., Grill, M. F., Choi, H. A., & Ko, N. U. (2016). Frequency and Risk Factors for Cerebral Arterial

Disease in a HIV/AIDS Neuroimaging Cohort. Cerebrovascular diseases, 41(3-4), 170-176.

• Hirai, T, Cotseones, G, Makki, N, et al. (2014). Usefulness of left ventricular diastolic function to predict

recurrence of atrial fibrillation in patients with preserved left ventricular systolic function. The American journal of

cardiology, 114(1), 65-9.

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• Kul, S, Uyarel, H, Gul, M, et al. (2014). Metabolic syndrome and long-term cardiovascular

outcomes in NSTEMI with unstable angina. NMCD. Nutrition Metabolism and

Cardiovascular Diseases, 24(2), 176-82.

• Laird, E A, & Coates, V. (2013). Systematic review of randomized controlled trials to

regulate glycaemia after stroke. Journal of advanced nursing, 69(2), 263-77.

• Liu, J, Plötz, B, Rohr, A, et al. (2009). Association of right-to-left shunt with frontal white

matter lesions in T2-weighted MR imaging of stroke patients. Neuroradiology, 51(5), 299-

304.

• Madden, N A, Jones, G L, Kalpatthi, R, et al. (2014). Practice patterns of stroke screening

and hydroxyurea use in children with sickle cell disease: a survey of health care

providers. Journal of pediatric hematology/oncology, 36(6), e382-6.

References

• Mahanes, D. (2013). Neurologic assessment after fibrinolytic therapy for myocardial infarction.

Critical care nurse, 33(2), 78-80.

• Mahanes, D. (2013). Neurologic assessment after fibrinolytic therapy for myocardial infarction.

Critical care nurse, 33(2), 78-80.

• Mayer, F, Stahrenberg, R, Gröschel, K, et al. (2013). Cost-effectiveness of 7-day-Holter

monitoring alone or in combination with transthoracic echocardiography in patients with cerebral

ischemia. Clinical research in cardiology, 102(12), 875-84.

• Newman Toker, D E, Kerber, K A, Hsieh, Y, et al. (2013). HINTS outperforms ABCD2 to screen

for stroke in acute continuous vertigo and dizziness. Academic emergency medicine, 20(10),

986-96.

References

• Niesten, J M, van der Schaaf, I C, Biessels, G J, et al. (2013). Relationship between thrombus attenuation and different stroke subtypes. Neuroradiology, 55(9), 1071-9.

• Oto, A, Aytemir, K, Ozkutlu, S, et al. (2011). Transthoracic echocardiography guidance during percutaneous closure of patent foramen ovale. Echocardiography, 28(10), 1074-80.

• Sacco, S., Kurth, T. (2014). Migraine and the risk for stroke and cardiovascular disease. Current Cardiology Reports, 16(9), 524-.

• Sanders, D B, Smith, B P, Sowell, S R, et al. (2014). Sickle cell disease and complex congenital cardiac surgery: a case report and review of the pathophysiology and perioperative management. Perfusion, 29(2), 153-8.

References

Santa Monica UCLA Medical Center & Orthopaedic Hospital

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