1 / 33

La morte cerebrovascolare: può presentarsi come la morte improvvisa cardiaca?

Eleventh International Symposium Heart Failure & Co. Morte Improvvisa Reggia di Caserta 29-30 Aprile 2011. La morte cerebrovascolare: può presentarsi come la morte improvvisa cardiaca?. Giuseppe Micieli Dip Neurologia d’Urgenza IRCCS Istituto Neurologico Nazionale C Mondino Pavia.

salim
Download Presentation

La morte cerebrovascolare: può presentarsi come la morte improvvisa cardiaca?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Eleventh International Symposium Heart Failure & Co. Morte Improvvisa Reggia di Caserta 29-30 Aprile 2011 La morte cerebrovascolare: può presentarsi come la morte improvvisa cardiaca? Giuseppe Micieli Dip Neurologia d’Urgenza IRCCS Istituto Neurologico Nazionale C Mondino Pavia

  2. After a stroke/TIA, patients are at high risk of short-term non-fatal stroke and • of long-term fatal CHD • CHD is highly prevalent at autopsy in patients with stroke TIA • Recent studies confirm 10-year incidence of CHD in patients with stroke/TIA is • 20% • Secondary prevention should not only focus on the first 2-3 years • Long-term (4-5 years) secondary prevention trials (PROGRESS, SPARCL) show • reduction in CHD events

  3. Malattiacerebrovascolare: sottotipidi ictus Ictus emorragico (17%) Ictus ischemico (83%) Patologialacunaredeipiccolivasi (25%) Emorragiaintracranica (59%) Malattiaaterotrombotica (20%) Emorragiasubaracnoidea (41%) Cardioembolismo (20%) Criptogenetico e da cause rare(30%) Albers GW et al. Chest. 1998;114:683S-698S. Rosamond WD et al. Stroke. 1999;30:736-743.

  4. Complicanze • Mediche: • Cardiocircolatorie • Respiratorie • Infettive • Internistiche • Neurologiche: • Stroke in evoluzione • Infarcimento emorragico • Ipertensione endocranica • Crisi epilettiche

  5. Numbers and causesofdeath per week fromstrokeonset Prosser J et al, Stroke 2007;38:2295-2302

  6. TC cerebrale: ischemia cerebrale ed edema 16 hrs 4,5 hrs

  7. 30-day Case-Fatality Rate Stroke type No. CFR 95%CI Subarachnoid hemorrhage (n=118) 40 33.9% 25.4-42.4 Intracerebral hemorrhage (n=588) 284 48.3% 44.3-52.4 Cerebral ischemia (n=3594) 763 21.2% 19.9-22.5 Ill-defined events (n=53) 39 73.6% 61.7-85.5 Total (n=4353) 1126 25.9% 24.6-27.2 CFR: case-fatality rate, CI: confidence interval L’Aquila Stroke Registry, 2004

  8. Timeintervalqualifyingsuddendeath (fromsymptoms) • Up to 1 h Lie JT et al, 1975; Herzog CA et al, 2006 • Within 6 h Davies MJ et al, 1987; Corrado D et al, 1992 • Up to 24 h WHO , Sarkioja T et al, 1984; Siboni A et al, 1986 The day of the dead (1923-1924) Diego Rivera

  9. UnexpectednaturaldeathamongKoreanworkers (1994-1995) Park J et al. J OccupHealth 1999; 41:238-243

  10. Effects of cerebral lesions on the heart and blood pressure Modified from Norris, 1983

  11. 64-year-old woman collapsed in the lobby of her apartment building CT-scan: right subdural hematoma with intracerebral right temporal and insular hemorrhage within 72 hoursofadmission within 24 hoursofadmission Baranchuk A et al. Cardiol J 2009;16:105-112

  12. Brugada syndrome revealed by vertigo caused by cerebellar infarction (36-year-old man) Denier C et al. Eur J Neurol 2010;17:e35-e36

  13. Neurogenic T wave inversion in pure left stroke associated with hyperhomocysteinemia admission 7 daysafter the secondstroke Mandrioli J et al. JNNP 2003

  14. Sudden cardiac arrest in a successfully embolized case of giant VA aneurysm with hydrocephalus Mishra NK. Sur Neurol 2007;67:652-653

  15. QT variability in CADASIL Piccirillo G et al. Eur J Neurol 2008;15:1216-1221

  16. Elettrocardiographic changes during central nervous system lesions Baranchuk A et al. Cardiol J 2009;16:105-112

  17. Neuroanatomicbasisofstroke-relatedmyocardialinjury Zhu et al, Neurology 2006

  18. Stroke-induced sudden-autonomic death • Role of the insular cortex in the pathophysiology of sudden death Oppenheimer et al, 1991 • Significant modulating effects of ventromedial prefrontal cortex (VMPFC) on cardiovascular responses to emotional stimuli Hiltz MJ et al. 2006 • Hemispheric dominance of sympathetic (RH) or parasympathetic (LH) activity Zamrini EY et al, 1990; Hiltz MJ et al, 2001

  19. Stroke-induced sudden-autonomic death • Left-hemispheric inactivation increased sympathetic cardiovascular modulation; right-hemispheric inactivity furthered parasympathetic activity Hitz MJ et al, 2001 • Tailored resection of temporal lobe areas lowers sympathetic cardiovascular activation (shift towards cardiovagal predominance with possibile bradycardia or even asystole) Hiltz MJ et al 2006, Hiltz et al, 2001

  20. Predictors of cardiac death within 5 years after first ischemic stroke: multivariate analysis Rincon F et al. Stroke 2008;39:2425-2431

  21. Stroke-induced sudden-autonomic death • Infarction involving parietal lobe seem to be associated with an increased risk of cardiac events (HR 4.45 of cardiac death) Rincon et al, 2008 • Similar high risk of death after right parietal lobe infarction when infarct size is considered Rincon et al, 2008 • Probably, the parietal lobe has buffering effects on the insular region which are disinhibited after loss of parietal activity

  22. Cardiovascular Response after Insula Stimulation in Human Subjects * significant difference compared with right anterior insula, p < 0.005 ** significant difference compared with right posterior insula, p < 0.005 # significant difference compared with aggregate of right anterior and posterior insula, p < 0.005 § significant difference compared with left posterior insula, p < 0.005 ## significant difference compared with aggregate of left anterior and posterior insula, p < 0.005 Oppenheimeret al, 1992

  23. ECG abnormalities and insularinvolvement Christensen et al, JNNP 2005 mod.

  24. Two-year survival curves according to right-insular involvement Abboud H et al, Ann Neurol 2006;59:691-699

  25. ECG predictorsformortalityamongstrokecaseswithinsularinvolvement Abboud H et al, Ann Neurol 2006;59:691-699

  26. Plasma norepinephrineconcentration Meyer S et al. Neuroreport 2004;15:357-361

  27. Plasma epinephrineconcentration Meyer S et al. Neuroreport , 2004;15:357-361

  28. PathologicalFindings in the HeartofPatientswithBrainLesions • Focal myocytolysis • Myofibrillar degeneration • Lipofuscin pigment deposition in myofibrils • Hystocytic infiltration of the diffuse necrotic areas Greenhoot and Reichenbach, 1969

  29. The neurocardiaclesion: 30-year-old man diedduring an acute psychological stress Fresh endocardial hemorrhage Intense mineralizationwithinminutesof the onsetofcontraction band necrosis • Myocardialnecrosismainpatterns(Baroldi F, 1975): • Coagulationnecrosis • Colliquative myocytolysis • Coagulative myocytolysis(in reperfusionareasaround • regionsofcoagulationnecrosis in transplantedheart, in sudden • unexpected and accidentaldeath, in heartsexposedtotoxiclevels • ofcatecholamines) Contraction band necrosis (coagulative myocytolysis, myofibrillardegeneration) Samuels MA. Circulation 2007;116:77-84

  30. Cascadeofeventsthatleadtoneurocardiacdamage Samuels MA, Circulation 2007;116:7784

  31. PossibletherapeuticapproachesaimedtopreventneurocardiacdamagePossibletherapeuticapproachesaimedtopreventneurocardiacdamage Samuels MA, Circulation 2007;116:7784

More Related