Clinical correlation of Clinical correlation of Vitamin D Deficiency Vitamin D Deficiency and Stroke Subtypes: and Stroke Subtypes: According to TOAST According to TOAST

criteriacriteria

Varuna Nargunan, PGY 3Varuna Nargunan, PGY 3

Mentors: Peterkin Lee-Kwen, Mentors: Peterkin Lee-Kwen, MDMD

Michael Merrill, MDMichael Merrill, MD

ObjectiveObjective

Prevalence of Vitamin D deficiency in Prevalence of Vitamin D deficiency in patient diagnosed with stroke at South patient diagnosed with stroke at South Buffalo Mercy HospitalBuffalo Mercy Hospital

Classification of ischemic strokes subtypes Classification of ischemic strokes subtypes according to TOAST criteriaaccording to TOAST criteria

Clinical correlation of Vitamin D deficiency Clinical correlation of Vitamin D deficiency withwith– Ischemic stroke subtypes (TOAST criteria), Ischemic stroke subtypes (TOAST criteria), – Stroke severity (NIHSS)Stroke severity (NIHSS)– Disability due to Stroke (Modified Rankin Score) Disability due to Stroke (Modified Rankin Score)

Vitamin D Physiology Vitamin D Physiology

Vitamin D PhysiologyVitamin D Physiology

Incidence of Vitamin D Incidence of Vitamin D DeficiencyDeficiency

World wideWorld wide 1 billion1 billion

US prevalenceUS prevalence 40%40%

Harvard teaching hospitalHarvard teaching hospital 57%57%

Italian women with Italian women with OsteoporosisOsteoporosis

76%76%

Beijing women in winterBeijing women in winter 45%45%

Iranian women at childbirthIranian women at childbirth 80%80%

Postmenopausal womenPostmenopausal women 50%50%

Buffalo Psychiatry centerBuffalo Psychiatry center 50%50%

South Buffalo Mercy HospitalSouth Buffalo Mercy Hospital 20-30%20-30%

Clinical significance of Clinical significance of Vitamin DVitamin D

Mortality decrease by 7% with vitamin D replacement Mortality decrease by 7% with vitamin D replacement Bone – Decrease incidence of osteoporosis, 43% Bone – Decrease incidence of osteoporosis, 43%

decrease of hip fracture and 58% reduction of non decrease of hip fracture and 58% reduction of non vertebral fracturevertebral fracture

Muscle - >30% decrease in grip strength is related to Muscle - >30% decrease in grip strength is related to Vitamin D deficiency Vitamin D deficiency

More than >50% of multiple sclerosis associated with More than >50% of multiple sclerosis associated with low vitamin Dlow vitamin D

CAD & CVD – increase Hypertension, Diabetes CAD & CVD – increase Hypertension, Diabetes mellitus, dyslipidemia (accelerated rate of mellitus, dyslipidemia (accelerated rate of atherosclerosis)atherosclerosis)

Vitamin D and Vascular Vitamin D and Vascular diseasedisease

34 out of 44 patients with acute stroke 34 out of 44 patients with acute stroke had low vitamin D within 30 days had low vitamin D within 30 days statistically significant. statistically significant. Stroke. 2006;37:243-45Stroke. 2006;37:243-45

LURIC study – 3316 patients, 42 fatal(27 LURIC study – 3316 patients, 42 fatal(27 ischemic, 8 hemorrhagic, 7 of unknown) ischemic, 8 hemorrhagic, 7 of unknown) strokes. Low vitamin D are independently strokes. Low vitamin D are independently predictive for fatal strokes predictive for fatal strokes Stroke. 2008;39:2611-2613 Stroke. 2008;39:2611-2613

Deficiency and post stroke hemiplegia – Deficiency and post stroke hemiplegia – Significant bone mass reduction in hemiplegic Significant bone mass reduction in hemiplegic side related to Vitamin D deficency – statistically side related to Vitamin D deficency – statistically significant. significant. Stroke a journal of cerebral circulation. 1996; Volume 27(12): Stroke a journal of cerebral circulation. 1996; Volume 27(12): 2183-2187 2183-2187

Vitamin D and Vascular Vitamin D and Vascular DiseaseDisease

120 patients with 1120 patients with 1stst cardiovascular event cardiovascular event were found to have low vitamin D level after were found to have low vitamin D level after adjusting other risk factors adjusting other risk factors Circulation. 2008; 117Circulation. 2008; 117

Case series: 4 out of 5 wheelchair Case series: 4 out of 5 wheelchair bound patients had complete resolution bound patients had complete resolution of the muscle ache and pain, fully of the muscle ache and pain, fully mobile: mobile: Arch intern Med. 2000;160:1199-1203Arch intern Med. 2000;160:1199-1203

Large prospective study yet to be doneLarge prospective study yet to be done

Clinical Significance of TOAST Clinical Significance of TOAST CriteriaCriteria

Widely used to classify ischemic Widely used to classify ischemic stroke subtypesstroke subtypes

It is used to determineIt is used to determine– the prognosisthe prognosis– long term survival long term survival – risk of recurrencerisk of recurrence– treatment optionstreatment options

Toast SubtypesToast Subtypes

1.1. Large Artery Atherosclerosis (LAA)Large Artery Atherosclerosis (LAA)

2.2. CardioEmbolism (CE)CardioEmbolism (CE)

3.3. Small Artery Occlusion (SAO)Small Artery Occlusion (SAO)

4.4. Stroke of other determined causes (OC)Stroke of other determined causes (OC)

5.5. Stroke of undetermined cause (UND)Stroke of undetermined cause (UND)

Modified Rankin ScoreModified Rankin Score00 No symptoms at all No symptoms at all

11 No significant disability despite No significant disability despite symptoms; able to carry out all usual symptoms; able to carry out all usual duties and activitiesduties and activities

22 Slight disability; unable to carry out Slight disability; unable to carry out all previous activities, but able to all previous activities, but able to look after own affairs without look after own affairs without assistanceassistance

Modified Rankin ScoreModified Rankin Score

33 Moderate disability; requiring some help, Moderate disability; requiring some help, but able to walk without assistancebut able to walk without assistance

44 Moderately severe disability; unable to Moderately severe disability; unable to walk without assistance and unable to walk without assistance and unable to attend to own bodily needs without attend to own bodily needs without assistanceassistance

55 Severe disability; bedridden, incontinent Severe disability; bedridden, incontinent and requiring constant nursing care and and requiring constant nursing care and attentionattention

66 Dead Dead

Study MethodStudy Method

Retrospective chart review of patients Retrospective chart review of patients with stroke presented to Mercy Hospital with stroke presented to Mercy Hospital between Jan 2008 to Mar 2009between Jan 2008 to Mar 2009

225 charts with stroke diagnosis were 225 charts with stroke diagnosis were reviewedreviewed

62 patients met study inclusion criteria62 patients met study inclusion criteria

Study Method contd.Study Method contd.

Inclusion criteriaInclusion criteria– Age >20 yearsAge >20 years

– Diagnosis of Ischemic Diagnosis of Ischemic stroke, confirmed by stroke, confirmed by CT or MRICT or MRI

– 25 hydroxy Vitamin 25 hydroxy Vitamin D level measured D level measured within 30 days of within 30 days of stroke stroke

Exclusion criteriaExclusion criteria– 25 hydroxy Vitamin 25 hydroxy Vitamin

D measured more D measured more than 30 days after than 30 days after strokestroke

Data CollectedData Collected Demographic informationDemographic information History ofHistory of

– HypertensionHypertension– Diabetes mellitusDiabetes mellitus– DyslipidemiaDyslipidemia– Atrial fibrillationAtrial fibrillation– CADCAD– CHFCHF– SmokingSmoking– OsteoporosisOsteoporosis– Family history of strokeFamily history of stroke– Vitamin D supplementsVitamin D supplements

Data CollectedData Collected

– 25 hydroxy Vitamin D25 hydroxy Vitamin D– Fasting Lipid profileFasting Lipid profile– 2D Echo/TEE2D Echo/TEE– Carotid doppler/CTA/MRACarotid doppler/CTA/MRA– CT or MRI of the brainCT or MRI of the brain

ResultsResults

Prevalence of Vitamin D deficiency Prevalence of Vitamin D deficiency (<30 nmol/l) = 45/62 (=70%)(<30 nmol/l) = 45/62 (=70%)

Compared Vit D levels to TOAST sub Compared Vit D levels to TOAST sub types, MRS values and NIH Stroke types, MRS values and NIH Stroke Scale for Correlation and Regression Scale for Correlation and Regression analysis.analysis.

Regression Analysis Regression Analysis Vit D vs NIH Stroke Scale (NIHSS)Vit D vs NIH Stroke Scale (NIHSS)

Pearson Correlation = 0.07

Regression Analysis Regression Analysis Vit D Vs Modified Rankin Score Vit D Vs Modified Rankin Score

(MRS)(MRS)

Pearson Correlation = 0.02

Regression AnalysisRegression Analysis Vit D vs TOAST typeVit D vs TOAST type

Pearson Correlation = 0.17

Prevalence of Vitamin D Prevalence of Vitamin D deficiency for TOAST Subtypesdeficiency for TOAST Subtypes

13 / 1621 / 28

8 / 13

1 / 1

2 / 4

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

1 2 3 4 5

Toast type

Pe

rce

nta

ge

of

Vit

D d

efi

cie

nc

y

Prevalence of Vitamin D Prevalence of Vitamin D deficiency for MRS valuesdeficiency for MRS values

1 / 3

2 / 38 / 15

19 / 2414 / 16

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

1 2 3 4 5

MRS

Pe

rce

nta

ge

of

Vit

D d

efi

ce

nc

y

Prevalence of Vit D deficiency Prevalence of Vit D deficiency for NIHSS valuesfor NIHSS values

ConclusionsConclusions

Vitamin D deficiency is unrecognizedVitamin D deficiency is unrecognized High incidence in Western NYHigh incidence in Western NY Very high incidence in Stroke(70%)Very high incidence in Stroke(70%) No correlation with stroke subtypeNo correlation with stroke subtype Probably associated with increased Probably associated with increased

association with LAA and CEassociation with LAA and CE Easily treatable conditionEasily treatable condition

Thank youThank you