Apoplexy – colloquially called stroke – (synonyms: apoplectic insult; apoplexia cerebri; apoplexy; cerebrovascular accident; cerebral insult; hemorrhagic infarction; cerebral infarction; insult; ischemic infarction; ischemic insult; stroke; cerebral angiospastic insult; cerebral insult; cerebral stroke; cerebrovascular insult; ICD-10-GM I64: Stroke, not referred to as hemorrhage or infarction* ) refers to the sudden disturbance of blood flow to the brain. As a result, ischemia (undersupply of oxygen) occurs with subsequent death of nerve cells in the affected area. * In the new international diagnosis code ICD-10-GM of the World Health Organization (WHO), apoplexy will appear in the group of neurological diseases. Apoplexy can be caused by:
- Ischemic infarction (ischemic insult, cerebral infarction; e.g., embolism resulting in sudden reduced blood flow to the brain) (80-85% of cases).
- Hemorrhagic infarction (intracerebral hemorrhage (ICB); cerebral hemorrhage); e.g., due tohypertensive mass hemorrhage, fibrinolytic or anticoagulant therapy) (15-20% of cases)
- Subarachnoid hemorrhage (SAB) (about 5% of cases).
- Sinus vein thrombosis (SVT) (<1% of cases).
In every fourth apoplexy the cause is unclear, one speaks of a cryptogenic apoplexy (“Embolic Stroke of Undetermined Source” (ESUS)). Studies show that in most cases the cause is an embolism. In 40-50% of patients with cryptogenic stroke, a persistent patent foramen ovale (PFO) is diagnosed. For the definition of ESUS, see Medical Device Diagnostics.In juvenile apoplexy, approximately 25-50% of cases are crytogenic. About 25% of all apoplectic strokes strike people while they are asleep. According to the time course, stroke is classified as follows:
- TIA – transient ischemic attack – symptoms last less than 24 hours.
- PRIND – prolonged reversible ischemic neurologic deficit – symptoms lasting longer than 24 hrs that resolve slowly but eventually completely
- Infarction in progression – steady increase in neurological symptoms.
- Completed infarction or complete apoplexy – partial or lack of regression of neurological deficits symptoms.
One speaks of a juvenile stroke when an apoplexy occurs in the age group 18-55 years. In Germany, about 30,000 people per year are affected. Gender ratio: The risk for men from the age of 55 to about 75 is more than 50% higher than that for women! Frequency peak: The disease occurs predominantly from middle age: After age 55, the risk of stroke doubles every 10 years! Women are on average 7.6 years older than men when they have a stroke or TIA (77.9 versus 70.3 years).Thirty-one percent of all apoplectic strokes occur in the 20- to 64-year-old group; one in 20 apoplectic strokes occurs in adolescents and children.The incidence of ischemic stroke more than doubled in the 35- to 39-year-old group from 1995 to 2014 (rate ratio [RR] 2.47). The lifetime prevalence (incidence of disease over a lifetime) is 15% (in Germany), and the global lifetime risk of adult stroke (over 25 years of age) is 24.9%. The incidence (frequency of new cases) in industrialized countries is distributed as follows:
- Age <25 years: <1 disease per 100,000 population per year.
- Age 25-34 years: 3.7 diseases per 100,000 inhabitants per year.
- Age 35-44 years: 19.1 diseases per 100,000 inhabitants per year.
- Age 55-64 years: 300 diseases per 100,000 inhabitants per year.
- Age 65-74 years: 800 diseases per 100,000 inhabitants per year.
The highest incidences are found in Germany and Eastern Bloc countries. The incidence in childhood is 1-8 diseases per 100,000 inhabitants per year (slight increase in preschool age; boys slightly more than girls). Strokes are the third most common cause of death in Germany. 15% of all deaths in Germany are caused by stroke.Course and prognosis: High age and the existence of heart disease influence the prognosis after apoplexy, with the consequence of increased morbidity (frequency of illness) and mortality (number of deaths in a given period, relative to the number of the population concerned). A simple drawing test (trail-making test, TMT), designed to connect dots with dashes as quickly as possible, assesses cognitive function and allows prognosis after apoplexy. The tests were administered years before the apoplexy. Participants with the worst scores (lower tertile) had a threefold higher mortality risk. CONCLUSION: Pre-damage to the brain (a common cause of impaired cognition in old age), leaves patients with fewer reserves available for regeneration after an ischemic infarction. A long-term study (619 patients, between 1980 and 2010, aged 18 to 50 years) demonstrated that ischemic stroke in young adulthood often has lifelong consequences: Women were affected twice as often as men. Mobility is also initially impaired in about two-thirds of apoplexy patients. Rehabilitation methods can help improve walking ability, walking distance, walking speed, and gait and stance stability. Note: Adequate oral anticoagulation (OAC) can prevent about two-thirds of ischemic strokes; resulting bleeding complications are significantly lower. The lethality (mortality relative to the total number of people with the disease) of apoplexy within the first three months is about 15%. The cumulative recurrence risk for apoplexy is 5-20% in the first year – thereafter the risk decreases.According to an analysis of data from the Erlangen Stroke Registry (ESPRO), nearly one in two patients dies within five years of the first apoplexy: one in five patients suffers a recurrent stroke during this period. The mortality risk is 49.6% in women and 41.8% in men.In juvenile apoplexy, the lethality in the first year is 4.5%; 1.5% suffer a recurrence (new apoplexy) during this period. Comorbidities (concomitant diseases):Apoplexy is increasingly associated with other disease such as coronary artery disease (CAD; coronary artery disease), hypertension (high blood pressure), diabetes mellitus, and atrial fibrillation (AF).
