1. Clinical correlation of Vitamin D Deficiency and Stroke Subtypes: According to TOAST criteria Varuna Nargunan, PGY 3 Mentors: Peterkin Lee-Kwen, MD Michael Merrill, MD

2. Objective Prevalence of Vitamin D deficiency in patient diagnosed with stroke at South Buffalo Mercy Hospital Prevalence of Vitamin D deficiency in patient diagnosed with stroke at South Buffalo Mercy Hospital Classification of ischemic strokes subtypes according to TOAST criteria Classification of ischemic strokes subtypes according to TOAST criteria Clinical correlation of Vitamin D deficiency with Clinical correlation of Vitamin D deficiency with –Ischemic stroke subtypes (TOAST criteria), –Stroke severity (NIHSS) –Disability due to Stroke (Modified Rankin Score)

3. Vitamin D Physiology

5. Incidence of Vitamin D Deficiency World wide 1 billion US prevalence 40% Harvard teaching hospital 57% Italian women with Osteoporosis 76% Beijing women in winter 45% Iranian women at childbirth 80% Postmenopausal women 50% Buffalo Psychiatry center 50% South Buffalo Mercy Hospital 20-30%

6. Clinical significance of Vitamin D Mortality decrease by 7% with vitamin D replacement Mortality decrease by 7% with vitamin D replacement Bone – Decrease incidence of osteoporosis, 43% decrease of hip fracture and 58% reduction of non vertebral fracture Bone – Decrease incidence of osteoporosis, 43% decrease of hip fracture and 58% reduction of non vertebral fracture Muscle - >30% decrease in grip strength is related to Vitamin D deficiency Muscle - >30% decrease in grip strength is related to Vitamin D deficiency More than >50% of multiple sclerosis associated with low vitamin D More than >50% of multiple sclerosis associated with low vitamin D CAD & CVD – increase Hypertension, Diabetes mellitus, dyslipidemia (accelerated rate of atherosclerosis) CAD & CVD – increase Hypertension, Diabetes mellitus, dyslipidemia (accelerated rate of atherosclerosis)

7. Vitamin D and Vascular disease 34 out of 44 patients with acute stroke had low vitamin D within 30 days statistically significant. Stroke. 2006;37:243-45 34 out of 44 patients with acute stroke had low vitamin D within 30 days statistically significant. Stroke. 2006;37:243-45 LURIC study – 3316 patients, 42 fatal(27 ischemic, 8 hemorrhagic, 7 of unknown) strokes. Low vitamin D are independently predictive for fatal strokes Stroke. 2008;39:2611-2613 LURIC study – 3316 patients, 42 fatal(27 ischemic, 8 hemorrhagic, 7 of unknown) strokes. Low vitamin D are independently predictive for fatal strokes Stroke. 2008;39:2611-2613 Deficiency and post stroke hemiplegia – Significant bone mass reduction in hemiplegic side related to Vitamin D deficency – statistically significant. Stroke a journal of cerebral circulation. 1996; Volume 27(12): 2183-2187 Deficiency and post stroke hemiplegia – Significant bone mass reduction in hemiplegic side related to Vitamin D deficency – statistically significant. Stroke a journal of cerebral circulation. 1996; Volume 27(12): 2183-2187

8. Vitamin D and Vascular Disease 120 patients with 1 st cardiovascular event were found to have low vitamin D level after adjusting other risk factors Circulation. 2008; 117 120 patients with 1 st cardiovascular event were found to have low vitamin D level after adjusting other risk factors Circulation. 2008; 117 Case series: 4 out of 5 wheelchair bound patients had complete resolution of the muscle ache and pain, fully mobile: Arch intern Med. 2000;160:1199-1203 Case series: 4 out of 5 wheelchair bound patients had complete resolution of the muscle ache and pain, fully mobile: Arch intern Med. 2000;160:1199-1203 Large prospective study yet to be done Large prospective study yet to be done

9. Clinical Significance of TOAST Criteria Widely used to classify ischemic stroke subtypes Widely used to classify ischemic stroke subtypes It is used to determine It is used to determine –the prognosis –long term survival –risk of recurrence –treatment options

10. Toast Subtypes 1. Large Artery Atherosclerosis (LAA) 2. CardioEmbolism (CE) 3. Small Artery Occlusion (SAO) 4. Stroke of other determined causes (OC) 5. Stroke of undetermined cause (UND)

11. Modified Rankin Score 0 No symptoms at all 1No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance

12. Modified Rankin Score 3Moderate disability; requiring some help, but able to walk without assistance 4Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5Severe disability; bedridden, incontinent and requiring constant nursing care and attention 6 Dead

13. Study Method Retrospective chart review of patients with stroke presented to Mercy Hospital between Jan 2008 to Mar 2009 Retrospective chart review of patients with stroke presented to Mercy Hospital between Jan 2008 to Mar 2009 225 charts with stroke diagnosis were reviewed 225 charts with stroke diagnosis were reviewed 62 patients met study inclusion criteria 62 patients met study inclusion criteria

14. Study Method contd. Inclusion criteria Inclusion criteria –Age >20 years –Diagnosis of Ischemic stroke, confirmed by CT or MRI –25 hydroxy Vitamin D level measured within 30 days of stroke Exclusion criteria Exclusion criteria –25 hydroxy Vitamin D measured more than 30 days after stroke

15. Data Collected Demographic information Demographic information History of History of –Hypertension –Diabetes mellitus –Dyslipidemia –Atrial fibrillation –CAD –CHF –Smoking –Osteoporosis –Family history of stroke –Vitamin D supplements

16. Data Collected –25 hydroxy Vitamin D –Fasting Lipid profile –2D Echo/TEE –Carotid doppler/CTA/MRA –CT or MRI of the brain

17. Results Prevalence of Vitamin D deficiency (<30 nmol/l) = 45/62 (=70%) Prevalence of Vitamin D deficiency (<30 nmol/l) = 45/62 (=70%) Compared Vit D levels to TOAST sub types, MRS values and NIH Stroke Scale for Correlation and Regression analysis. Compared Vit D levels to TOAST sub types, MRS values and NIH Stroke Scale for Correlation and Regression analysis.

18. Regression Analysis Vit D vs NIH Stroke Scale (NIHSS) Pearson Correlation = 0.07

19. Regression Analysis Vit D Vs Modified Rankin Score (MRS) Pearson Correlation = 0.02

20. Regression Analysis Vit D vs TOAST type Pearson Correlation = 0.17

21. Prevalence of Vitamin D deficiency for TOAST Subtypes

22. Prevalence of Vitamin D deficiency for MRS values

23. Prevalence of Vit D deficiency for NIHSS values

24. Conclusions Vitamin D deficiency is unrecognized Vitamin D deficiency is unrecognized High incidence in Western NY High incidence in Western NY Very high incidence in Stroke(70%) Very high incidence in Stroke(70%) No correlation with stroke subtype No correlation with stroke subtype Probably associated with increased association with LAA and CE Probably associated with increased association with LAA and CE Easily treatable condition Easily treatable condition

25. Thank you