Authors:Mr.Sc.Dr.Halil Ajvazi &Doc.Dr.Valbona Govori-Diabetes and Cerebrovascular Disease/UNIVERSITY OF PRISHTINA/UNIVERSITETI I PRISHTINËS/UNIVERSITAS PRISHTINIENSIS

FACULTY OF MEDICINE UNIVERSITY IN PRISHTINAFACULTY OF MEDICINE UNIVERSITY IN PRISHTINAUNIVERSITETI I UNIVERSITETI I PRISHTINËS FAKULTETIPRISHTINËS FAKULTETI I I MJEKËSISËMJEKËSISË

DIABETES AND CEREBROVASCULAR DIABETES AND CEREBROVASCULAR DISEASEDISEASE

Authors:Authors:

1. 1. HALIL Z. AJVAZIHALIL Z. AJVAZI,, MD, MMD, Mr. r. ScSc.,., 2. 2. VALBONA GOVORI, MD, PHD.,VALBONA GOVORI, MD, PHD.,

PRISHTINAPRISHTINA

12/06.200912/06.2009

Acute stroke is the leading cause of Acute stroke is the leading cause of disability in the modern society.disability in the modern society.

In developed countries it is the In developed countries it is the second cause of death, and in second cause of death, and in KosovaKosova the leading cause of death. the leading cause of death.

RISK FACTORS FOR RISK FACTORS FOR STROKESTROKE

NonmodifiableNonmodifiable

ModifiableModifiable

NonmodifibleNonmodifible

AgeAge SexSex Race-ethnicityRace-ethnicity HeredityHeredity

ModifiableModifiable

HypertensionHypertension Cardiac disease (particularly atrial Cardiac disease (particularly atrial

fibrillation)fibrillation) DiabetesDiabetes HypercholesterolemiaHypercholesterolemia Cigarette smokingCigarette smoking Excessive use of alcoholExcessive use of alcohol Physical inactivityPhysical inactivity

Classiffication of Classiffication of Cerebrovascular disease Cerebrovascular disease

regarding the duration of regarding the duration of symtpomssymtpoms

--Transient Transient insufficiency of cerebral insufficiency of cerebral circulationcirculation

TIA TIA RINDRIND- - PersistentPersistent insufficiency insufficiency cerebral infarctioncerebral infarction cerebral haemorrhagiacerebral haemorrhagia

TIATIA (Transient ischemic (Transient ischemic brain attack)brain attack)

- neurological symptoms clear - neurological symptoms clear completely in less than 24 hourscompletely in less than 24 hours

(mean duration of 14 minutes in (mean duration of 14 minutes in carotid-distribution and 8 min in carotid-distribution and 8 min in vertebrobasilar ischemia)vertebrobasilar ischemia)

- reversible ischemia without brain - reversible ischemia without brain lesion (13% of patients had silent lesion (13% of patients had silent brain infarction)brain infarction)

Causes of TIACauses of TIA

atherosclerosis of atherosclerosis of cerebrovascular arteriescerebrovascular arteries

cardioembolic cardioembolic hypercoagulable stateshypercoagulable states arterial dissectionarterial dissection arteritisarteritis aneurysmaneurysm arteriovenous malformationarteriovenous malformation

Risk of stroke for patients with TIA Risk of stroke for patients with TIA is 24% to 29% in the first 5 years is 24% to 29% in the first 5 years after event.after event.

Risk is higher in the first month and Risk is higher in the first month and highest in patients with hemispheric highest in patients with hemispheric TIA and carotid stenosis over 70% TIA and carotid stenosis over 70% (40% rate of stroke in 2 years).(40% rate of stroke in 2 years).

RINDRIND (Reversible ischemic (Reversible ischemic neurologic deficite)neurologic deficite)

Ischemic cerebral dysffunction in Ischemic cerebral dysffunction in which the symptoms clear which the symptoms clear completely in the period of 2 weeks completely in the period of 2 weeks (“small stroke” ?)(“small stroke” ?)

Classiffication of stroke Classiffication of stroke regarding the causeregarding the cause

IschemicIschemic cerebrovascular infarction cerebrovascular infarction

80%80%

Haemorrhagic Haemorrhagic intracerebral haemorrhagia intracerebral haemorrhagia

15%15% subarachnoidal haemorrhagia 5%subarachnoidal haemorrhagia 5%

STROKE WARNING STROKE WARNING SIGNSSIGNS

sudden numbness or weakness of the face, sudden numbness or weakness of the face, arm of leg, especially on one side of the bodyarm of leg, especially on one side of the body

sudden confusion, trouble speaking or sudden confusion, trouble speaking or understandingunderstanding

sudden trouble of seeing in one or both eyessudden trouble of seeing in one or both eyes sudden trouble of walking, dizziness, loss of sudden trouble of walking, dizziness, loss of

balance or coordinationbalance or coordination sudden, severe headache with no known sudden, severe headache with no known

causecause

Diagnosis of TIADiagnosis of TIA

Course of disease, determination of risk Course of disease, determination of risk factorsfactors

Neurological examinationNeurological examination Laboratory exams (glucose, blood count, Laboratory exams (glucose, blood count,

electrolytes, acidobasic status, coagulation)electrolytes, acidobasic status, coagulation) Neuroradiological examinationsNeuroradiological examinations - imaging of the brain- imaging of the brain - imaging of the vessels- imaging of the vessels ECG and cardiological examination ECG and cardiological examination

(ultrasound of the heart)(ultrasound of the heart)

Neuroradiological Neuroradiological examinationexamination

Imaging of the brainImaging of the brain- identifying the lesionidentifying the lesion- determining the type determining the type

of lesionof lesion- localizing the lesionlocalizing the lesion- quantifying the lesionquantifying the lesion- determining the age determining the age

of lesionof lesion

Imaging of the vesselsImaging of the vessels- identifying occlusive identifying occlusive

arterial diseasearterial disease- localizing the occlusion localizing the occlusion

in extracranial or in extracranial or intracranial vesselsintracranial vessels

- quantifying the degree quantifying the degree of occlusionof occlusion

- determining the determining the patologypatology

- identifying other identifying other vascular lesionsvascular lesions

Imaging of the brainImaging of the brain

CT (computed tomography)CT (computed tomography) MRI (magnetic resonance imaging)MRI (magnetic resonance imaging) SPECT (single-photon emission SPECT (single-photon emission

computed tomography)computed tomography)

CT scanCT scan- gold standard- gold standard

initial diagnostic evaluation to exclude initial diagnostic evaluation to exclude a rare lesion (subdural hematoma or a rare lesion (subdural hematoma or brain tumor)brain tumor)

limited role in evaluation of patients limited role in evaluation of patients with vertebrobasilar TIAswith vertebrobasilar TIAs

limited role in identifying lessions such limited role in identifying lessions such as subdural hematoma that are as subdural hematoma that are isodense with surrounding parenchymaisodense with surrounding parenchyma

MRIMRI- more expensive, time-- more expensive, time-

consuming, less availableconsuming, less available

no indication for rutine MRI of no indication for rutine MRI of patients with TIApatients with TIA

detects acute and small infarctsdetects acute and small infarcts detects small infarcts in brain stem detects small infarcts in brain stem

and cerebellar regionsand cerebellar regions

SPECTSPECT

- to differentiate ischemia from - to differentiate ischemia from epilepsy as the cause of transient epilepsy as the cause of transient neurological deficit (“cold” vrs. neurological deficit (“cold” vrs. “hot” areas)“hot” areas)

Imaging of the vesselsImaging of the vessels

NONINNONINVVASIVEASIVE – a contrast agent is – a contrast agent is not necessarynot necessary

RELATIVELY NONINVASIVERELATIVELY NONINVASIVE – a – a contrast agent is administred contrast agent is administred intravenouslyintravenously

INVASIVEINVASIVE – a contrast agent is – a contrast agent is injected intra-arteriallyinjected intra-arterially

Noninvasive imaging – Noninvasive imaging – initial diagnostic testinitial diagnostic test

Carotid duplex or DopplerCarotid duplex or Doppler ultrasonography – ultrasonography – gold standard in inital diagnosticgold standard in inital diagnostic

MRA (magnetic resonance arteriography)MRA (magnetic resonance arteriography) - imaging of the extracranial carotid, - imaging of the extracranial carotid,

vertebrobasilar and major intracranial vessels, vertebrobasilar and major intracranial vessels, but but leads to overestimationleads to overestimation of degree of stenosis of degree of stenosis

- not reliably for atheromatous ulcerations, - not reliably for atheromatous ulcerations, fibromuscular dysplasia and dissectionfibromuscular dysplasia and dissection

- - insufficient specificityinsufficient specificity to establish an indication to establish an indication for carotid endarterectomyfor carotid endarterectomy

Relatively noninvasive Relatively noninvasive imagingimaging

CT angiography – screening method CT angiography – screening method in patients with presumed in patients with presumed atherosclerosis of the carotid atherosclerosis of the carotid bifurcationbifurcation

Invasive imagingInvasive imaging Conventional radiographic angiographyConventional radiographic angiography – – reference standard of the diagnostic effort reference standard of the diagnostic effort

to identify surgically accessible and to identify surgically accessible and remediable carotid lesionsremediable carotid lesions

- recommended for a symptomatic patient - recommended for a symptomatic patient when noninvasive tests indicate more than when noninvasive tests indicate more than 70% occlusion70% occlusion

- for a diagnosis of dissection, vasculitis, - for a diagnosis of dissection, vasculitis, aneurysm or embolismaneurysm or embolism

- fails to demonstrate some vascular mural - fails to demonstrate some vascular mural changes (intraplaque hemorrage and trombus changes (intraplaque hemorrage and trombus attached to the arterial wall)attached to the arterial wall)

Therapy for TIA-sTherapy for TIA-s

RISK FACTOR MANAGEMENTRISK FACTOR MANAGEMENT

MEDICAL THERAPYMEDICAL THERAPY

SURGICAL MANAGEMENTSURGICAL MANAGEMENT

Risk factor managementRisk factor management

Treatment of hypertension (BP lower than Treatment of hypertension (BP lower than 140/90 mmHg, for diabetics lower than 140/90 mmHg, for diabetics lower than 130/85 mmHg)130/85 mmHg)

Cigarette smoking should be discontinuedCigarette smoking should be discontinued Coronary artery disease, cardiac arrhythmias, Coronary artery disease, cardiac arrhythmias,

congestive heart failure and valvular heart congestive heart failure and valvular heart disease should be treated appropriatelydisease should be treated appropriately

Excessive use of alcohol should be eliminated Excessive use of alcohol should be eliminated (1-2 drinks per day are associated with (1-2 drinks per day are associated with reduction in stroke rates)reduction in stroke rates)

Risk factor menagemet – Risk factor menagemet – cont.cont.

Treatment of hyperlipidemia (diet, Treatment of hyperlipidemia (diet, maintenance of ideal body weight, maintenance of ideal body weight, regular physical activity, lipid-regular physical activity, lipid-lowering agents if neccessary)lowering agents if neccessary)

Fasting glood glucose less than 6,25 Fasting glood glucose less than 6,25 mmol/l – 126 mg/dcl (diet, oral mmol/l – 126 mg/dcl (diet, oral hypoglycemics or insulin as needed)hypoglycemics or insulin as needed)

Physical activity (30-60 minutes of Physical activity (30-60 minutes of exercise 3 to 4 times per week)exercise 3 to 4 times per week)

Medical therapy of TIA-sMedical therapy of TIA-s

Antiplatelet agentsAntiplatelet agents

AnticoagulantsAnticoagulants

Antiplatelet agentsAntiplatelet agents

Aspirin (50 to 325 mg daily)Aspirin (50 to 325 mg daily) Clopidogrel (75 mg daily)Clopidogrel (75 mg daily) Ticlopidin (250 mg twice daily)Ticlopidin (250 mg twice daily) Aspirin and extended-release Aspirin and extended-release

dipyridamole (25 mg+200 mg twice dipyridamole (25 mg+200 mg twice daily)daily)

All acceptable options for initial therapy. All acceptable options for initial therapy.

AnticoagulantsAnticoagulants therapy of choice for stroke prevention therapy of choice for stroke prevention

in patients with atrial fibrilation who in patients with atrial fibrilation who have had TIA or are high-risk patients have had TIA or are high-risk patients (history of hypertension, poor left (history of hypertension, poor left vetricular function, rheumatic mitral vetricular function, rheumatic mitral valve disease, prosthetic heart valves, valve disease, prosthetic heart valves, systemic embolism, age over 75 years)systemic embolism, age over 75 years)

recommendation: target INR recommendation: target INR (International Normalized Ratio) of 2.0 (International Normalized Ratio) of 2.0 to 3.0to 3.0

Surgical managementSurgical management

Carotid endarterectomyCarotid endarterectomy

- stenosis of 70% to 99% - absolute indication- stenosis of 70% to 99% - absolute indication

- stenosis of 50% to 69% - optional treatment - stenosis of 50% to 69% - optional treatment depending sex, age and comorbiditydepending sex, age and comorbidity

Transluminal angioplasty with intravascular Transluminal angioplasty with intravascular placement of stentsplacement of stents

Extracranial-Intracranial Bypass (superficial Extracranial-Intracranial Bypass (superficial temporal to middle cerebral artery bypass)temporal to middle cerebral artery bypass)

Surgery for vertebrobasilar diseaseSurgery for vertebrobasilar disease

FACULTY OF MEDICINE UNIVERSITY IN FACULTY OF MEDICINE UNIVERSITY IN PRISHTINAPRISHTINA

UNIVERSITETI I UNIVERSITETI I PRISHTINËS FAKULTETIPRISHTINËS FAKULTETI I I MJEKËSISËMJEKËSISË

Tema: Tema: DIABETES DIABETES

AND CEREBROVASCULAR DISEASEAND CEREBROVASCULAR DISEASE

Authors:Authors:1. 1. HALIL AJVAZIHALIL AJVAZI, MD, M, MD, Mr. r. ScSc.,.,2.2. VALBONA GOVORI, MD, PHD.,VALBONA GOVORI, MD, PHD.,

PRISHTINAPRISHTINA

12/06.200912/06.2009