Autonomic Dysfunction in Stroke Patients

Leonard S.W. Li
Head, Division of Neurology and Rehabilitation
University Department of Medicine
Tung Wah Hospital, The University of Hong Kong
National Scientific Meeting of Indonesian Neurologists
Stroke 2012
Component of the
Central Autonomic
Network
Central Autonomic Network
Insula Cortex
Insula
Taste bud
GI tract
Baroreceptor
Chemoreceptor
In Heart
contralateral
insula
parabrachial nucleus
amygadala
contralateral insula
thalamus
lateral hypothalamic
cingulated gyrus,
orbitofrontal area
Insular Lesion
! Left Insular lesion
shift towards sympathetic
predominance
decreased parasympathetic
tone
decreased heart rate
variability
increased risk (RR of 1.75)
for adverse cardiac events
! Right Insular lesion
reduced circadian blood
pressure variability
increased nocturnal blood
pressure
more profound decrease in
HRV (p<0.001)
communication between the 2 insula is required for balanced interhemispheric
cardiovascular control
Arrays of Disturbances
Korpeloinen jT, Sotoniemi KA, Mokikollio A, Huikuri HV, Myllylo
VV. Autonomic nervous system JisorJers in strokeBo. Clin Auto
Resp i Dec, (6). :-
Acute infarct
affecting central
autonomic
network
Cold limb/
decrease
sweating
Diurnal BP
disruption
Myocardial
Damage/ Cardiac
Dysfunction/
Arrhythmia
Glucose intolerance/
immuno- suppression
Orthostatic
Hypotension
Sympathetic drive !
Parasympathetic drive "
Serum Catecholamine level !
Hypothalamo-
pituitary-adrenal axis
!
Structural brain damage
affecting central
autonomic network
Pathological
sympathetic
activation
Increased cAMP production
resulted in opening of
calcium channels
Influx of Ca and
efflux of K ions
Continue beta adrenergic
activation Ca channel
failed to close
Cell death in
hypercontracted
state
Sequestration of Ca ion,
free radical release,
peroxidation of lipid
membranes
Histologically there is
subendocardial
haemorrhage with
contraction band necrosis
Myocardial
damage with
release of
troponin, lethal
arrhythmias, LV
dysfunction,
Heart Rate Variability in Stroke:
Outcomes
! One to 7 years mortality was shown to
positively correlated with reduced heart rate
variability
! Clinical functional outcomes were shown to be
adversely affected by lower values of SDNN
SDNN
(standard deviation of all normal to normal RR interval recorded on
24 hour Holter monitoring)
! Across studies, 18%
(0-34%) of acute stroke
patients have raised
Troponin T or I
! Most tests were drawn
within 24 to 72 hours
after stroke onset
Prevalence in Hong Kong
! Troponin was
sampled time at
mean of 2.4 days
! 11 out of 100
(11%) patients has
elevated troponin
level (defined as
#0.04ng/ml)
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5 patients died in 6
months
Not yet published
Raised Troponin: Prognosis (Hong Kong)
! Both stroke severity (NIHSS) and
elevated troponin level were
independent predictor of mortality at 6
months
! Adjusting for age, presence of arrhythmias,
insular cortex involvement and demographic
risk factors
! Together both factors explained about
52% of all cause mortality
! Troponin concentration however is NOT
a predictor for functional outcome at 6
months when adjusted for stroke
severity and age
Outcome Parameters at discharge.
Recommendation & Guidelines
Controversies
! Acute stroke guidelines from the National Institute of
Clinical Excellence and the Scottish Intercollegiate
Guidelines Network
! DO NOT recommend the routine checking of cardiac
enzymes
! American Stroke Association DOES recommend
routine checking of cardiac enzymes in acute stroke
Autonomic Assessment in Stroke Patients:
Skin Sympathetic Response SSR
! a somato-sympathetic
reflex with
a spinal,
A bulbar, and
a suprabulbar
component,
! the precise pathways
in humans being not
yet precisely defined.
Stroke. 1993;24:1389-1392.
Study on the autonomic dysfunction after stroke
Am. J. Phys. Med. Rehabil. ! Vol. 81, No. 10,
2002
SSR
R-R variation
Sympathetic Skin Response (SSR)
! Using a 6mm disk electrodes were used
! Stimulate the median nerve at the wrist contralateral to
the side of SSR recording
! Active electrode was placed on the palm
! Reference electrode on the dorsum of the hand
! A ground electrode on the forearm
! SSR was record on both the hemiplegic hand after
stimulation on contralateral median nerve and on the
uninvolved hand
! Auditory stimulation will be applied if initial response to
electrical stimulation is absent
! Both latency and amplitude of SSR are recorded
! principal markers still controversy
! the main clinical consideration remains
the presence/absence of the response.
Cohort Study on autonomic dysfunction after stroke
Hong Kong
! Inclusion Criteria:
Patients who are over 18
years old
First ever Ischaemic or
Haemorrhagic stroke patients
Evidence of acute
hemispheric Ischaemic or
Haemorrhagic lesion
consistent with clinical
manifestation on CT or MRI
brain
! Exclusion Criteria:
Presence of any concomitant nervous
system disease possibly affecting the
autonomic nervous system (ANS) and
heart rate variability (HRV)
Presence of history of Ischaemic Heart
Disease, Heart failure or Arrhythmias
including Atrial Fibrillation (AF), Atrial
flutter, and 1st, 2nd and complete heart
block
Presence of any pharmacological treatment
including beta-blockers, possibly affecting
the ANS and HRV
Presence of any major concurrent illness
including renal failure or malignancies
Presence of fever, hypoxia, severe
hypertension, alternations in consciousness
or any relevant haemodynamic
compromise on admission
Finometric Study of Autonomic Function
Autonomic Function Test
For patients who have impaired
cognition, limited version of test
will be performed:
! Supine Blood Pressure
! 60 head up tilt for 10 minutes
! Cold Pressor Response
! Standing Blood Pressure for 5
minutes (if possible)
For patients who have reasonable cognition to
follow instructions, full version of test will be
performed:
! Supine Blood Pressure
! 60 head up tilt for 10 minutes
! Isometric Exercise
! Respiratory sinus Arrhythmia
! Mental Arithmetic
! Valsalva Manoeuvre (BP profile and ratio is
assessed)
! Cold Pressor Response
! Hyperventilation
! Standing Blood Pressure for 5 minutes
! using Finometer for continuous blood pressure and heart
rate monitoring

Autonomic function assessment
! Vasomotor response was assessed by
Isometric exercise
Mental Arithmetic
Cold Pressor
Abnormal response is defined if the response is
absent (i.e. no systolic blood pressure (BP),
minimal (defined as systolic BP rise of less or equal
to 5) or
modest (systolic BP rise of 5-9mmgHg).
Vasomotor impairment is defined when all 3 tests
were abnormal
Autonomic function assessment
! Orthostatic Hypotension is defined when
there is a systolic BP drop of #20mmHg
or a diastolic BP drop of #10mmHg on at
least 3 minutes of 60 Tilt or active
standing
Parasympathetic function
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Poststroke autonomic evaluation
! A cohort, 1 year follow up
! Age 36-88 mean age 68.2611.21
! Total 97 patient has SSR done (3 died before SSR), 74
patients over 60 and 26 patients age $ 60
! Normal in 45 (46.4%) and Abnormal (unilateral or
bilateral absent SSR) in 52 (53.6%)
(Not yet published)
Autonomic dysfunction in Stroke
Test Abnormal (%)
SSR Bilateral absence 35
Unilateral 18.5
Total 53.5
Finometry Tilt (postural) 63.9
Sympathetic component 35.5
Parasympathetic component 33.3
Not published yet
Summary
! Cardiovascular autonomic dysfunction is shown to be not
uncommon after acute stroke patients.
! It is associated with increase mortality and probably
affecting the functional outcome.
! However, it has not been put enough emphasis in terms of
short and long term evaluation and management of this
complication after stroke.