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Adding Insult to Injury: When Stroke and Other Brain Injury Occurs Together

Explore the long-term consequences of stroke and brain injury, the increased risk they pose to each other, and the impact of other illnesses on cumulative brain injuries.

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Adding Insult to Injury: When Stroke and Other Brain Injury Occurs Together

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  1. Adding Insult to Injury: When Stroke and Other Brain Injury Occurs Together Mandi Counters, MSN, FNP-BC, RN, CNRN, SCRN

  2. Disclosures • I have no disclosures

  3. Objectives • Identify long term consequences of brain injury vs stroke • Discuss the cumulative impact of stroke and brain injury • Discuss how other illness impact cumulative brain injuries

  4. Brain Injury defined • Baseball bat upside the head, head over heels down the stairs, bump head on car door or kitchen cabinet, helmet hit in sports… • Range from mild to severe • A leading cause of death/disability worldwide • 30% of injury deaths • Causes: falls, intentional self harm, MVA, assaults • Effects can last days to forever

  5. Stroke defined • 5th leading cause of death in US • Ischemic or hemorrhagic • Largely an “older person” disease, though creeping down • Risk factors: HTN, HLD, DM, overweight/obesity, tobacco • Effects can last days to forever

  6. Age-related differences • TBI most often in younger • More years of lost work • MVA most common in young adults, falls with kids and elderly • When happens in older, poorer outcomes (greater disability) • Stroke most often in older • Happening younger and younger due to risk factors

  7. Long term consequences

  8. Healing after single insult

  9. Healing after multiples • Part time job…

  10. Which came first, the chicken or the egg?

  11. Increased risk of each other • Not surprising, increased incidence of TBI after stroke, due to fall risk, polypharmacy, self-harm • More surprising, increased incidence of stroke after TBI, exact mechanism unknown

  12. TBI: Another stroke risk factor • Highest rate of stroke within 1st month • Still 8% increased risk at 5 years post • In study of Medicare patients, rate of hemorrhagic stroke 10x higher after TBI • In severe TBI, ICU admissions, >40% mortality rate with secondary stroke • In-hospital, non-ICU, >10% mortality rate with secondary stroke • Increased mortality post TBI with stroke history • In trauma population, TBI caused more strokes than HTN • Worse outcomes overall with AIS after TBI, even controlling for other variables

  13. How does TBI increase risk? • Alterations in coagulation cascade • Disturbance in blood supply causing obstructions • Vascular dissections • Increased intracranial pressure and HTN • Due to more sedentary lifestyle s/p TBI, may increase rate of conventional risk factors

  14. Case example • 39 y.o. male • Hx of multiple concussions playing football in early 2000s (stopped in 2008) • Onset of ocular migraines while playing football, MRI with multiple scattered lesions in his brain, “common” for football players • 2 years after stopping football, multiple territory strokes in 2010 (age 30) • Extensive workup, no cause found

  15. Case images, 2019 MRI

  16. What about acute interventions? • Serious head trauma listed as contraindication for Alteplase • But Alteplase is considered gold standard… • Stroke provider can modify the contraindication • AIS may have immediately preceded/precipitated the TBI

  17. Case example • 57 y.o. female • s/p MVA – went down a ravine and hit a tree • Airbag did not deploy, car windows not broken • EMS called within moments • Patient reported sudden left sided numbness/weakness prior to crash, lost control of car • Received IV tPA & thrombectomy for right M1 occlusion • Cognition impaired per OT

  18. Case imaging

  19. What if something else happens?

  20. Illness on top of brain injury

  21. References • Albrecht, JS, Liu, X, Smith, GS, Baumgarten, M, Rattinger, GB, Gambert, SR, Langenberg, P, Zuckerman, IH. Stroke Incidence Following Traumatic Brain Injury in Older Adults. Journal of Head Trauma Rehabilitation. 2015; 30(2): E62-67. • Belavic, M, Jancic, E, Miskovic, P, Brozovic-Krijan, A, Bakota, B, Zunic, J. Secondary stroke in patients with polytrauma and traumatic brain injury treated in an Intensive Care Unit, Karlovac General Hospital, Croatia. Injury. 2015; 46 Supplement 6: 531-535. • Burke, JF, Stulc, JL, Skolarus, LE, Sears, ED, Zahuranec, DB, Morgenstern, LB. Traumatic brain injury may be an independent risk factor for stroke. Neurology. 2013; 81(1): 33-39. • Centers for Disease Control and Prevention. Stroke Fact Sheet. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_stroke.htm. Accessed March 5, 2019. • Centers for Disease Control and Prevention. TBI: Get the Facts. https://www.cdc.gov/traumaticbraininjury/get_the_facts.html. Accessed March 5, 2019. • Chen, Y, Kang, J, Lin, J. Patients With Traumatic Brain Injury: Population-Based Study Suggests Increased Risk of Stroke. Stroke. 2011; 42(10): 2733-2739. • Chou, Y, Yeh, C, Ju, C, Meng, N, Chiu, W, Chou, W, Chen, T, Liao, C. Risk and Mortality of Traumatic Brain Injury in Stroke Patients: Two Nationwide Cohort Studies. Journal of Head Trauma Rehabilitation. 2014; 29(6): 514-521. • Cramer, SC, Riley, JD. Neuroplasticity and brain repair after stroke. Current Opinion in Neurology. 2008; 21(1): 76-82. • Kapral, MK, Fang, J, Alibhai, SMH, Cram, P, Cheung, AM, Casaubon, LK, Prager, M, Stamplecoski, M, Rashkovan, B, Austin, PC. Risk of fractures after stroke: Results from the Ontario Stroke Registry. Neurology. 2017; 88(1): 57-64. • Kowalski, RG, Haarbauer-Krupa, JK, Bell, JM, Corrigan, JD, Hammond, FM, Torbey, MT, Hofmann, MC, Kams-O’Connor, K, Miller, AC, Whiteneck, GG. Acute Ischemic Stroke After Moderate to Severe Traumatic Brain Injury: Incidence and Impact on Outcome. Stroke. 2017; 48(7): 1802-1809. • Meschia, JF. Traumatic Brain Injury and Stroke. Mayo Clinic Proceedings. 2014; 89(2): 142-143. • Teh, WH, Smith, CJ, Barlas, RS, Wood, AD, Bettencourt-Silva, JH, Clark, AB, Metcalf, AK, Bowles, KM, Potter, JF, Myint, PK. Impact of stroke-associated pneumonia on mortality, length of hospitalization, and functional outcome. ActaNeurologicaScandinavica. 2018; 138(4): 293-300.

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