Hello, brucelool-ga!
I have found several studies assessing the relationship between
cardiovascular disease risk, high blood pressure and spinal cord
injury, as well as vertebral artery damage as a result of cervical
spine injuries. Since a cerebrovascular accident involves the
cardiovascular system, these studies can be considered relevant. Age,
sedentary lifestyle, obesity, alcohol and tobacco consumption, etc.
are also known risk factors for stroke, and they must also be
considered when speculating on the potential cause of a CVA. Another
condition associated with spinal cord injuries at several levels is
Autonomic Dysreflexia, which can also precipitate a stroke. This
condition may or may not pertain to the patient in question, but I
have provided some references for your review.
GENERAL OVERVIEW OF SPINAL CORD INJURY AND RISK FACTORS
========================================================
The following article highlights the correlation between spinal injury
and increased aging, including in the cardiovascular system:
From "Grey Anatomy," by CHRISTINE MORRIS. University of Miami Medicine Online
http://www.miami.edu/ummedicine-magazine/winter2002/gray.html
"At UM?s Miami Project to Cure Paralysis and the Veterans
Administration Medical Center, Marca L. Sipski, M.D., and colleagues
are exploring the added stress of aging on people who already are
disabled. "We all have cumulative trauma as we age, but it?s a lot
worse with spinal cord injury," says Dr. Sipski, who is project
director for the South Florida Spinal Cord Injury Model System. Last
summer the UM/VA affiliation also was designated a Center for
Excellence in Functional Recovery in Chronic Spinal Cord Injury, one
of 11 VA Rehabilitation Research and Development Centers of
Excellence."
"A wealth of projects is under way to develop treatment for the pain
and spasticity of spinal cord injury, to improve bowel and bladder
function, to build muscle mass, and to
** reduce the elevated risk of cardiac disease that comes with such an injury.
Those problems naturally have escalated as the life expectancy of
injured patients has increased.
"People with spinal cord injury age more quickly," Dr. Sipski says.
The problems that develop can be related to overuse or underuse: Arms,
for example, are not built to bear as much weight as they must for
patients with spinal cord injury. The result can be carpal tunnel
syndrome and other musculoskeletal complications.
** Research is targeting the changes in lipid profiles that develop
with spinal cord injury, raising the risk of heart disease."
"The incidence of diabetes is higher as well, and the skin problems
that go along with the injury become repetitive with aging. Some of
the problems are secondary effects of the treatment patients receive -
for instance, catheters can cause infections. And there is a higher
risk of bladder problems, including bladder cancer and renal failure.
Other researchers are studying cultural differences in the function of
patients with spinal cord injury.
====
Many of the factors associated with increased risk of stroke are also
symptomatic of spinal cord injuries, including physical inactivity,
obesity and high blood pressure, carotid artery disease, and diabetes
among other factors such as age, gender, and race.
See "Stroke." Neurosurgery Today. September, 2005
http://www.neurosurgerytoday.org/what/patient_e/stroke1.asp?ShowMenu=false&ShowPrint=false
==
General information about Spinal Cord injury can be found on the following pages:
"The Facts about Spinal Cord Injury." Healthlink. Medical College of Wisconsin.
http://healthlink.mcw.edu/article/1031002248.html
"Types of spinal cord injuries." Neurosurgey Today.
http://www.neurosurgerytoday.org/what/patient_e/spinal.asp
RELATIONSHIP BETWEEN CARDIOVASCULAR RISK OR DISEASE AND SPINAL CORD INJURY
===========================================================================
"The relationship between neurological level of injury and symptomatic
cardiovascular disease risk in the aging spinal injured." Groah SL,
Weitzenkamp D, Sett P, Soni B, Savic G. Spinal Cord. 2001
Jun;39(6):310-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11438852&dopt=Citation
STUDY OBJECTIVES: "To describe the distribution of clinically apparent
cardiovascular disease (CVD) in people with long-term spinal cord
injury (SCI) according to neurologic level and severity of injury.
DESIGN: Historical prospective study. SETTING: Two British Spinal
Injuries Centers. PARTICIPANTS: Five hundred and forty-five
individuals surviving at least 20 years with SCI were divided into
three neurologic categories by level of injury and Frankel/ASIA grade
as follows: Tetra ABC, Para ABC, and All D. MAIN OUTCOME MEASURES:
Cardiovascular disease outcomes defined by ICD/9 codes 390-448 and
obtained through medical record review. Cardiovascular disease
outcomes measured included All CVD, coronary heart disease (CHD),
hypertension, cerebrovascular disease, valvular disease, and
dysrhythmia. RESULTS: After age-adjustment, the rates of All CVD were
35.2, 29.9, and 21.2 per 1000 SCI person-years in the Tetra ABC, Para
ABC, and All D groups, respectively. Rates of All CVD increased with
increasing age in all neurologic groups. Tetraplegic level of SCI
conferred an excess 16% risk of All CVD (95% Confidence interval [CI],
0.93-1.46), a fivefold risk of cerebrovascular disease (relative risk
[RR] 5.06; 95% CI, 1.21-21.15), and 70% less CHD (RR 0.30; 95% CI,
0.13-0.70) when compared with paraplegics. More complete SCI was
associated with an excess 44% All CVD risk (95% CI, 1.16-1.77).
CONCLUSIONS: Risk of All CVD increased with increasing age, rostral
level of SCI, and severity of SCI. More rostral level of SCI was
associated with cerebrovascular disease, dysrhythmia, and valvular
disease. Conversely, there was an inverse relationship between level
of SCI and CHD."
==
"Risk factors for coronary heart disease in patients with spinal cord
injury in Turkey." Demirel S, Demirel G, Tukek T, Erk O, Yilmaz H.
Spinal Cord. 2001 Mar;39(3):134-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11326322&query_hl=30
OBJECTIVE: To compare the standard risk factors for coronary heart
disease (CHD), defined in National Cholesterol Education Program II
(NCEP II) of Turkish spinal cord injury (SCI) patients with healthy
controls, discuss the results according to the findings in Turkish
population, and SCI patients in the literature. DESIGN: We assessed 52
age and sex matched healthy control subjects, and 69 SCI patients (16
females, 53 males with the mean age of 33.9+/-11.37 years) with time
since injury of 12.8+/-13.45 months. The study consisted of 45
paraplegics, and 24 tetraplegics with 54% incomplete, and 46% complete
injury. RESULTS: Risk factors for CHD according to NCEP II were; age
and sex in 16%, positive family history in 0%, cigarette smoking in
54%, hypertension (HT) in 0%, high total cholesterol (TC) in 32%, high
low-density lipoprotein cholesterol (LDL) in 41%, low high-density
lipoprotein cholesterol (HDL) in 52%, and diabetes mellitus (DM) in 7%
of our SCI patients, respectively. Compared to controls DM, high TC,
LDL, and low HDL were statistically more frequent in SCI patients. We
found a negative correlation between serum HDL and time since injury.
TC (186+/-32 vs 205+/-36; P=0.025), TC/HDL (5.34+/-1.17 vs 6.26+/-1.5;
P=0.005), and LDL/HDL (3.57+/-0.9 vs 4.16+/-1.3; P=0.027) were
significantly increased in patients with time since injury of more
than 1 year, while HDL levels (35.8+/-6.36 vs 33.86+/-6.47; P=0.213)
decreased without reaching statistical significance. The lipid
profiles did not show any correlation with the neurological level, and
completeness of lesions."
CONCLUSIONS: "SCI confers additional CHD risk over that present
inherently in the parent population due to enforced sedentary
lifestyle and this increases with time since injury. The preliminary
study consisting of 26 patients was accepted for poster presentation
in Copenhagen, Denmark (18-20 June 1999) at the 38th Annual Scientific
Meeting of IMSOP in association with the Nordic Medical Society of
Paraplegia."
==
"Coronary heart disease risk indicators, aerobic power, and physical
activity in men with spinal cord injuries." Janssen TW, van Oers CA,
van Kamp GJ, TenVoorde BJ, van der Woude LH, Hollander AP. Arch Phys
Med Rehabil. 1997 Jul;78(7):697-705.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9228871&query_hl=1
OBJECTIVE: "To compare the lipid and (apo-)lipoprotein profile and
blood pressure of men with long-standing spinal cord injuries (SCI) to
those of an age-matched able-bodied (AB) population, and to assess the
most important determinants of this profile and blood pressure."
CONCLUSION: "Men with long-standing SCI do not appear to have an
essentially different coronary heart disease risk profile compared
with AB persons. Modifiable risk factors such as activity level,
smoking, alcohol consumption, body mass index, and adipose tissue were
more important than lesion level and aerobic power in the
determination of the lipid and lipoprotein profile, suggesting several
potential interventions."
==
"Risk factors for cardiovascular disease in chronic spinal cord injury
patients." Krum H, Howes LG, Brown DJ, Ungar G, Moore P, McNeil JJ,
Louis WJ. Paraplegia. 1992 Jun;30(6):381-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1635786&query_hl=32
"To establish whether the reported increased cardiovascular (CV)
morbidity in spinal cord injury (SCI) patients is due to increased
levels of established CV risk factors, we assessed overall CV risk in
102 consecutive patients aged 25-64 by calculation of a 'risk factor
score' (RFS) derived from the MRFIT study (age, diastolic blood
pressure (DBP), total cholesterol (TC) level, cigarettes/day, sex),
obtaining a percentile position amongst an age and sex matched peer
group from the 1983 Australian Risk Factor Prevalence Study. Chronic
SCI patients had a very low overall percentile position of risk of
26.03 + 15.06 (mean +/- S.D.) and those patients with SCI for greater
than 10 years had only a slightly higher risk position of 33.16 +/-
29.66. The low relative risk in SCI patients was due mainly to
significantly lower DBP levels (67 +/- 13 mm hg), as TC levels (5.38
+/- 1.60 mmol/L) and cigarette consumption (31% smokers, mode
11-20/day) were similar to the control population (83 +/- 12 mmHg,
5.68 +/- 1.2 mmol/L, 28% smokers, mode 11-20/day, respectively). As
other known risk factors such as lipoprotein cholesterol fractions
were not included in the RFS index, these were measured in 327
consecutive SCI patients. HDL cholesterol levels, which are negatively
correlated with CV risk, were significantly lower in SCI patients
(1.12 +/- 0.30 mmol/L) compared to controls (1.35 +/- 0.35 mmol/L) and
those patients more than 10 years post SCI had still lower levels
(1.02 +/- 0.40)."
"These data suggest that the reported increased incidence of CV
disease in SCI patients is unexplained by increases in BP, TC or
smoking. However, low HDL levels may contribute to CV risk and the
role of other risk factors such as increased vascular reactivity
remain to be established."
AUTONOMIC DYSREFLEXIA
=======================
From "OTHER COMPLICATIONS OF SPINAL CORD INJURY: AUTONOMIC DYSREFLEXIA
(HYPERREFLEXIA)." http://calder.med.miami.edu/pointis/automatic.html
"Autonomic dysreflexia, also known as hyperreflexia, is a state that
is unique to patients after spinal cord injury at a T-5 level and
above. Patients with spinal cord injuries at Thoracic 5 (T-5) level
and above are very susceptible. Patients with spinal cord injuries at
Thoracic 6 - Thoracic 10 (T6-T10) may be susceptible. Patients with
Thoracic 10 (T-10) and below are usually not susceptible. Also, the
older the injury the less likely the person will experience autonomic
dysreflexia."
Read further..
==
From "Complications of Spinal Cord Injury."
http://www.geocities.com/HotSprings/Spa/5325/sci/scicompl.html
"Autonomic dysreflexia (AD) is a condition that can occur in anyone
who has a spinal cord injury at or above the T6 level. It is related
to disconnections between the body below the injury and the control
mechanisms for blood pressure and heart function. It causes the blood
pressure to rise to potentially dangerous levels."
* Uncontrolled AD can cause a stroke if not treated.
"The primary risk of AD is stroke. It is a potentially
life-threatening condition. If AD is left untreated, the body's
attempt to control blood pressure will severely decrease the heart
rate. This, combined with uncontrolled high blood pressure, can be
fatal. For this reason, it is very important to treat this condition
as soon as possible. The most important thing patients can do to
prevent AD from occurring is to take good care of themselves. Patients
should monitor bladder output and should maintain a regular bowel
program which fully empties the bowels. They should also do regular
skin checks to prevent pressure sores from occurring."
==
"Autonomic dysreflexia: the forgotten medical emergency." Jacob C,
Thwaini A, Rao A, Arya N, Shergill IS, Patel HR. Hosp Med. 2005
May;66(5):294-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15920860&query_hl=18
"Autonomic dysreflexia (AD) is a potentially dangerous complication of
spinal cord injury (SCI). In AD, an individual's blood pressure may
rise to dangerous levels and, if not treated, can lead to stroke and
possibly death. All medical personnel, especially those interacting
with SCI patients, must have a good understanding of its aetiology,
complications and emergency management."
==
From "Animal Models to Humans: Strategies for Promoting CNS Axon
Regeneration and Recovery of Limb Function after Spinal Cord Injury."
Journal of Neurologic Physical Therapy, Jun 2005
http://www.findarticles.com/p/articles/mi_qa4108/is_200506/ai_n13642343
"People with SCI may suffer from autonomic dysreflexia and may be at
increased risk for stroke, decubitus ulcers, fractures, and
depression. There are no fully restorative clinical therapies for
SCI."
HIGH BLOOD PRESSURE AND INCREASED RISK OF STROKE IN SPINAL CORD PATIENTS
===========================================================================
From Spinal injuries Research Centre Projects. Prince of Wales Medical
Research Institute. http://www.powmri.edu.au/research/injury/spinal/sircresearch.htm
Dr James Brock - Recipient of a grant from the Christopher Reeve
Paralysis Foundation.
* "Spinally injured patients often have periods of excessively high
blood pressure that may cause stroke or death."
"We have discovered that changes in the way blood vessels are
activated by nerves contribute to this condition. Bladder distension
or minor unheeded injuries below the lesion in spinally injured people
often lead to episodes of high blood pressure that may cause stroke or
death. These events require emergency hospitalization and are
expensive as well as dangerous. After spinal injury, the control of
sympathetic nerves that supply arteries and regulate blood pressure is
lost. However, the nerves below the injury remain in place and the
spinal cord below the lesion contains connections that can activate
them. Signals from the bladder or skin enter the lower part of the
spinal cord and activate the sympathetic supply generating a rise in
blood pressure. We have shown that increased sensitivity of arteries
below the lesion to the chemicals released from the sympathetic nerves
leads to excessive vessel constriction (nearly 10 times normal),
contributing to the exaggerated increase in pressure. We are now
investigating how the muscle of the arteries changes to produce this
increased sensitivity."
DAMAGE TO VERTEBRAL ARTERY WITH CERVICAL SPINE INJURY
======================================================
These will not likely pertain to the patient fourteen years after the
trauma, but they are worth considering!
"Vertebral artery injury after acute cervical spine trauma: rate of
occurrence as detected by MR angiography and assessment of clinical
consequences." Friedman D, Flanders A, Thomas C, Millar W. AJR Am J
Roentgenol. 1995 Feb;164(2):443-7; discussion 448-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7839986&query_hl=13
OBJECTIVE. "The purposes of this study were to assess prospectively
the frequency of vertebral artery injuries after major acute cervical
spine trauma as determined by MR angiography and to assess the
clinical consequences of these injuries."
CONCLUSION. "In our experience, vertebral artery injuries due to major
cervical spine trauma as determined by MR angiography are common.
Although these vascular abnormalities usually remain clinically
occult, a small percentage of patients may suffer devastating
neurologic complications of posterior fossa infarction. Noninvasive
assessment of the vertebral arteries by means of MR imaging should be
an integral part of the evaluation of the acutely injured cervical
spine."
==
"Cerebellar stroke due to vertebral artery occlusion after cervical
spine trauma. Two case reports." Miyachi S, Okamura K, Watanabe M,
Inoue N, Nagatani T, Takagi T. Spine. 1994 Jan 1;19(1):83-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8153813&query_hl=6
"The authors report two cases of cerebellar infarction due to
vertebral artery (VA) occlusion resulting from cervical spine trauma.
In one patient with dens and C2 body fracture, the left VA was
occluded, resulting in a left cerebellar infarction. The second
patient, with a subluxation of C4 on C5, presented with cerebellar
swelling and infarction along with acute hydrocephalus secondary to
bilateral vertebral artery occlusion. Because vertebral artery
injuries with cervical trauma are rarely symptomatic, they can be
easily overlooked. Bilateral or dominant vertebral artery occlusion,
however, may cause rapid and fatal ischemic damage to the cerebellum
and brain stem. Rapid recognition and optimal treatment for this
injury depends on early vertebral artery angiography."
==
"Fatal basilar artery occlusion following cervical spine injury."
Woolsey RM, Chung HD. Paraplegia. 1979 Sep;17(3):280-3.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=503560&query_hl=6
"A patient rendered acutely quadriplegic in an automobile accident was
shown by angiography to have occlusion of the left vertebral artery.
One month later, he abruptly became unconscious, apneic and died.
Autopsy showed an organised thrombus in the left vertebral artery and
a fresh thrombus occluding the entire basilar artery. This case
differs from previously reported cases of traumatic vertebral artery
thrombosis wherein symptoms of brain stem infarction were more
immediately evident."
==
"Carotid and vertebral artery injury following severe head or cervical
spine trauma." Rommel O, Niedeggen A, Tegenthoff M, Kiwitt P, Botel U,
Malin J.
Cerebrovasc Dis. 1999 Jul-Aug;9(4):202-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10393406&query_hl=6
"In order to determine the frequency of neck vessel injuries, Doppler
investigations were performed in 60 patients following either severe
head injury (n = 29), cervical spine injury (n = 26), or combined head
and cervical spine injury (n = 5). The majority of patients were
referred to our hospital for early rehabilitation; before admission
Doppler investigations had been performed in only 2 patients.
Clinically, 3 patients sustained severe cerebral ischemia due to neck
vessel trauma: 1 patient with left-sided ICA dissection after head
trauma revealed Doppler abnormalities only in the early phase of the
disease; the second patient demonstrated persistent Doppler
abnormalities due to traumatic right-sided ICA and VA occlusion. The
third patient sustained a fatal vertebral and basilar artery
thrombosis following cervical spine injury. In 57 patients without
clinical signs suspicious of neck vessel trauma, sonography revealed
abnormalities in 3 patients (11%) with severe head injury and in 6
patients (20%) with cervical spine or combined head and spine injury,
in both groups mainly related to the vertebrobasilar system. Neck
vessel injury is probably an underdiagnosed complication of severe
head or cervical spine trauma. Although interpretation of Doppler
findings may be difficult, particularly in the vertebrobasilar system,
Doppler investigations can be recommended as a screening method to
exclude neck vessel injuries."
==
"The Incidence of Vertebral Artery Injury after Midcervical Spine
Fracture or Subluxation." Willis, Brian K. M.D.; Greiner, Frank M.D.;
Orrison, William W. M.D.; Benzel, Edward C. M.D. Neurosurgery.
34(3):435-442, March 1994.
http://www.neurosurgery-online.com/pt/re/neurosurg/abstract.00006123-199403000-00008.htm;jsessionid=Di0EZO57mPNNQolzwe8xDtT7QrEGAbujddTcflQbyBLw3N1Si0q8!-2035160892!-949856144!9001!-1
Abstract:
TWENTY-SIX PATIENTS WITH blunt trauma of the cervical spine, producing
a subluxation from a "locked" or "perched" facet, facet destruction
with evidence of instability, or a fracture involving the foramen
transversarium, underwent preoperative vertebral angiography to
determine the incidence of vertebral artery injury. The cervical spine
injury in all the patients was deemed unstable and in need of surgical
stabilization. Spinal cord injury was present in one-half of the
patients studied. Vertebral artery injury was identified
angiographically in 12 patients (46%). Occlusion of the vertebral
artery near its origin or at the level of the spinal injury was
identified in nine patients. An intimal flap, arterial dissection, and
a pseudoaneurysm were identified in the remaining three patients. The
injury involved the left vertebral artery in all but three patients.
In none of the patients did the vertebral artery injury clearly result
in neurological dysfunction or other sequelae. After cervical spine
fracture or dislocation, vertebral artery injury is more prevalent
than commonly believed. The possibility of vertebral artery injury
should be considered during the establishment of clinical management
schemes for blunt trauma of the cervical spine."
==
I hope these references have given you some research that is relevant
to your patient. Obviously, they cannot provide a definitive answer,
since I doubt an absolute answer can be found for the reason behind
the patient's stroke. However, they should give rise to some potential
reasoning and facts for speculation.
Sincerely,
umiat
Search Strategy
stroke AND spinal cord injury
risk factors associated with spinal cord injury
long term effects of spinal cord injury
spinal injury and cerebral accident
spinal injury patient prone to stroke
spinal cord research and stroke
Pub Med searches for stroke OR cerebrovascular accident and spinal cord injury |
