Your SlideShare is downloading. ×
Stroke Update Serum Markers for Acute Neurologic Conditions,  Jordan Barnett MD
Upcoming SlideShare
Loading in...5

Thanks for flagging this SlideShare!

Oops! An error has occurred.


Introducing the official SlideShare app

Stunning, full-screen experience for iPhone and Android

Text the download link to your phone

Standard text messaging rates apply

Stroke Update Serum Markers for Acute Neurologic Conditions, Jordan Barnett MD


Published on

2007 Lecture for residents regarding serum markers for CVA/Stroke. Jordan Barnett MD

2007 Lecture for residents regarding serum markers for CVA/Stroke. Jordan Barnett MD

Published in: Health & Medicine

  • Be the first to comment

  • Be the first to like this

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide


  • 1. Stroke Update Serum Markers for Acute Neurologic Conditions
  • 2. Introduction
    • Same diagnostic challenges that exist for stroke exist for myocardial infarction
    • Technology used in MI now being applied to stroke
  • 3. Overview
    • >700,000 strokes annually
    • 10% of strokes involve intracerebral hemorrhage
    • Large proportion of patients die or do badly
    • 35-52% of patients die with hemorrhage within 30 days
    • Half of deaths occur within 48 hrs
  • 4. Risk factors for hemorrhagic Stroke
    • Increase with age
    • Race (Blacks at least twofold over whites)
    • Prior stroke
    • Hypertension
    • Use of anticoagulant or thrombolytic agents
    • Alcohol and/or Cocaine
  • 5. Location of intracerebral Hemorrhages
    • Lobar
    • Putaminal
    • Cerebellar
    • Intraventricular
    • Posterior fossa (require surgery)
  • 6. Clinical Features Of hemorrhage
    • Headache
    • Vomiting
    • Seizures
    • 82% mental status change
    • >75% have hemiplegia or hemiparesis
    • 63% have headache
    • 22% vomit
  • 7. Providing Prognostic data
    • Volume of hemorrhage: estimated by using simplified formula ABC/2
    • A determined by measuring CT slice with largest diameter of hemorrhage in millimeters
    • B determined by measuring largest diameter of hemorrhage 90* to A on Same slice
    • C determined by adding number of slices on which hemorrhage seen multiplied by slice thickness
    • GCS
  • 8. Prognosis
    • 91% of patients with bleeding >60 ml and GCS of <=8 die in 30 days
    • All patients will bleeding >90 ml die
    • 19% of patients with bleeding <= 30 ml and GCS >= 9 die in 30 days
  • 9. Hemorrhage growth
    • Ongoing process rather than single episode
    • 38% of patients will have one-third increase in hemorrhage size in first 24 hrs
    • Presentation not subtle in most cases
    • Intraventricular extension significantly increases morbidity and mortality
    • 30% of hemorrhages in regions around basal ganglion expand
    • Hemorrhages in thalmus expand significantly
    • Lobar most amenable to therapy
  • 10. Lobar Hemorrhage
    • Open skull and evacuate blood
    • Endoscopic evacuation
    • Stereostactics
    • No good science, yet sterotactic and endoscopic techniques make most sens in lobar hemorrhage
  • 11. Neuronal Markers
    • Released from dying and ischemic neurons into cerebrospinal fluid and can be used to diagnose various neurologic emergencies
    • May be able to discriminate between patients with reversible vs irreversible events
    • Greatest Potential in prehospital setting
    • Maybe used to identify patients at higher risk for complications if treated by thrombolytics
  • 12. Cardiac Vs Neuronal Markers
    • Heart simple homogeneous muscle
    • Brain has complex populations of cells (neurons have various functions and distributions and variety of support cells)
    • Ideal marker must be able to pass blood-brain barrier
  • 13. Markers Under Investigation
    • Neuron-specific Enolase
    • Structural proteins
    • Direct Neuronal Markers
    • Myelin Basic protein
    • S-100 
    • Thrombomodulin
    • D-dimer
  • 14. Neuron-specific Enolase
    • Cytoplasmic enzyme
    • Any small stress allows NSE to egress across cell membrane
    • Cell does not need to die to release NSE – It just has to be leaky. Sensitive yet not specific
  • 15. Structural Proteins
    • Significant injury to cell and enzymatic degradation required before structural proteins found in CSF. More specific yet harder to see in early phases
  • 16. Direct Neuronal Markers
    • NSE and tau proteins most important
    • Complement each other because NSE from cytoplasm and tau from structural molecule
  • 17. Myelin basic protein
    • Used extensively in multiple sclerosis and other demyelinating disorders as a way to diagnose and predict outcome
  • 18. S-100 
    • Most studied neurolgic marker
  • 19. Thrombomodulin
    • Most promising for assessing integrity of vascular wall
  • 20. D-Dimer
    • Not specific but indicates abnormality
    • May be used to confirm that activation/coagulation pathway involved, and patients headache not migraine
  • 21. C-Reactive Protein
    • Used to measure inflammation
  • 22. Ideal Marker
    • Small molecular size
    • Must be sensitive for early ischemia (within 3 hrs)
    • Predictable and rapid and accurate
  • 23. NSE and tau protein
    • Specific for neurons
    • NSE also found in red blood cells
    • Levels can be falsely elevated if extensive hemolysis present
  • 24. Similarities to heart technology
    • Since no perfect marker available, variety of markers used as panel of tests to increase sensitivity an specificity
  • 25. Statistics
    • Stroke leading cause of adult disability
    • Patients fear stroke more than heart attack because stroke leaves victims cognitively impaired
    • 800,000 new strokes annually
    • 85% of strokes ischemic
  • 26. Why serum markers for stroke?
    • Stroke remains diagnosis of exclusion
    • MRI helpfully, but usually cannot be obtained in timely fashion
    • CT can be sensitive but not always
    • 70% who present weak and dizzy have clinically silent event
  • 27. Hemorrhage
    • Can be detected on CT
    • Diagnostic utility of markers may not be high in this setting, but may help determine which patients at risk for complications and which will extend infarct
    • MBP found in deep white matter where hemorrhages usually occur.
  • 28. Traumatic brain injury
    • Currently have poor tools to determine which patients have had cognitive deficit secondary to concussion and which are at risk for second impact syndrome
    • Markers have potential for diagnosing minor head injury
    • Markers shown to detect edema in animal modem
    • Markers very predictive of outcome in patients with negative head CTS
  • 29. Limitations
    • Time delay in serum
    • Some markers do not cross blood-brain barrier
    • No single marker sufficient
  • 30. Future
    • Goal to have marker by 2010 that will take 5 min and one drop of blood to make diagnosis
  • 31. Conclusion
    • No markers currently approved by FDA for routine use, although approved for scientific research purposes
    • Expect markers in 2-3 years