Anemia and Stroke

1. A D E W I J A Y A , M D – A P R I L 2 0 1 8
Anemia & Stroke

2. Introduction
 Have a clear relationship with cerbrovascular events
 The fifth cardiovascular risk factors
 Related to stroke poor outcome; increase mortality
and morbidity
 Anemia: 15-29 % of acute stroke patients
Dubyk MD, Card RT, Whiting SJ, et al. Iron deficiency anemia prevalence at first stroke or transient ischemic attack. Can J Neurol Sci. 2012;39:189–195.
Kaiafa G, Kanellos I, Savopoulos C, Kakaletsis N, Giannakoulas G, Hatzitolios AI. Is anemia a new cardiovascular risk? Int J Cardiol. 2015;186:117–124.
Hao Z, Wu B, Wang D, Lin S, Tao W, Liu M. A cohort study of patients with anemia on admission and fatality after acute ischemic stroke. J Clin Neurosci. 2013;20:37–42.
Huang WY, Chen IC, Meng L, Weng WC, Peng TI. The influence of anemia on clinical presentation and outcome of patients with first-ever atherosclerosis-related
ischemic stroke. J Clin Neurosci. 2009;16:645–649.

3. Pathophysiology
 Anemia disturbs endothelial adhesiom molecule
genes that may lead to thrombus formation.
 Blod flow augmentation and turbulence  thrombus
migration  artery to artery embolism.
Kannel WB, Gordon T, Wolf PA, McNamara P. Hemoglobin and the risk of cerebral infarction: the Framingham Study. Stroke. 1972;3:409–420.

4. Pathophysiology in Iron Deficiency Anemia
 ↑ EPO levels  secondary reactive thrombocytosis.
 Altered erythrocyte deformability may impair oxygen
tissue delivery, either through changes in oxygen
capacity or through blood flow abnormalities.
 Inflammation, occurring in the setting of anemic
hypoxia, can lead to ischemic brain tissue damage.
 Diffuse ischemic damage in watershed brain regions
Yager JY, Hartfield DS. Neurologic manifestations of iron deficiency in childhood. Pediatr Neurol. 2002;27:85-92.
Dubyk MD, Card RT, Whiting SJ, et al. Iron deficiency anemia prevalence at first stroke or transient ischemic attack. Can J Neurol Sci. 2012;39:189–195.

5. Pathophysiology in Hemoglobinopathies
 Sludging occurs in small brain vessels,
 Anemia results in abnormal cerebrovascular
reactivity and perfusion
 Large vessel disease (vasculopathy)
Del Fabbro P, Luthi JC, Carrera E, Michel P, Burnier M, Burnand B. Anemia and chronic kidney disease are potential risk factors for mortality in stroke patients: a
historic cohort study. BMC Nephrol. 2010;16:11–27.

6. Pathophysiology in Other Anemias
 Hypercoagulability in thallasemia.
 Acute bleeding: Induce increased platelet
adhesiveness and decreased fibrinolytic activity 
increase thrombus formation in patients with
vascular risk factors.
 Increased homocysteine (Hcy) serum levels in
megaloblastic or pernicious anemia
Huang WY, Chen IC, Meng L, Weng WC, Peng TI. The influence of anemia on clinical presentation and outcome of patients with first-ever atherosclerosis-related
ischemic stroke. J Clin Neurosci. 2009;16:645–649.
Del Fabbro P, Luthi JC, Carrera E, Michel P, Burnier M, Burnand B. Anemia and chronic kidney disease are potential risk factors for mortality in stroke patients: a
historic cohort study. BMC Nephrol. 2010;16:11–27.
Choi SH, Choi-Kwon S, Kim MS, Kim JS. Poor nutrition and alcohol consumption are related to high serum homocysteine level at post-stroke. Nutr Res Pract. 2015;9:503–510.
Neogi SS, Thomas M, Sharma A, Kumar J, Khanduri U. Early markers of occult megaloblastosis for low-cost detection of hyperhomocysteinemia in patients with ischaemic
stroke: preventive approach for primary health care. Can J Physiol Pharmacol. 2014;92:713–716.

8. Treatment
 RBC transfusion
 EPO
 Chronic exchange transfusion, hydroxiurea and stem
cell transplantation in SCD or thallasemia
 Iron administration. Newer iv iron complexes (i.e.,
sucrosic and carboxymaltose iron low-molecular-
weight dextran) are more safe, without side effects
and can be easily administered at a relatively low
cost.  U-shaped (avoid too much iron)
Kaiafa, G., Savopoulos, C., Kanellos, I., Mylonas, K. S., Tsikalakis, G., Tegos, T., ... & Hatzitolios, A. I. (2017). Anemia and stroke: Where do we stand?. Acta Neurologica
Scandinavica, 135(6), 596-602.

9. SUMMARY
 Anemia may increase stroke risk
 Higher mortality and morbidity
 Treatment including PRBC transfusion, iron
administation, etc.

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