2. Primordial, primary, secondary, and tertiary prevention stages for global vascular risk. R. Sacco: Stroke, Volume 38(6).June 2007.1980-1987

3. Neurovascular Disease  Epidemiology  50% Ischemic stroke, 30% ICH, 20% SAH  Causes/ Pathophysiology  Ethnic Issues  Biology  Sociology

5. Epidemiology Worldwide Incidence per 100,000 persons/yr; age < 50 yrs  Israel 10.4  Northern Italy 13.6  Spain 13.9  South Africa 33.0  UK women 3.6 Bradley S. Jacobs et al. Stroke 33: 2789-2793, 2002

9. Risk Factors and Predictors of Stroke Older age Male gender Non-white genetic background Family history Prior stroke or TIA Non-modifiable risk factorsModifiable risk factors Previous TIA or stroke is the most important risk factor for stroke. Hypertension is the most prevalent. Hankey GJ. Cerebrovasc Dis 2003; 16 (Suppl 1): 14–19. Wolf PA. Adv Neurol 2003; 92: 165–172. Sacco et al. Stroke 1997; 28 (7): 1507–1517. Hypertension Diabetes mellitus Atrial fibrillation Carotid artery disease Dyslipidemia Cardiac disease Cigarette smoking Obesity Obstructive Sleep Apnea

10. Problem! Hispanics have higher prevalence of: Obesity Diabetes Mellitus Hypertension Hyperlipidemia

11. Prevalence of Identified Risk Factors on Admission to UMC

12. African-American45-594.063.22 60-742.572.31 75+1.261.10 Hispanic American45-591.731.30 60-741.091.07 75+0.770.63 AgeMenWomen STROKE IN MINORITIES Survey of Stroke Mortality in Texas Rate-Ratio in Comparison to Non-Hispanic Whites Morgenstern et al Stroke, 1997, 28:5-18

13. Stroke Subtypes in the NOMASS Study F. Rincon et al Cerebrovascular Diseases 2009; 28:65-71.

14. NOMASS Study F. Rincon et al Cerebrovascular Diseases 2009; 28:65-71.

15. NOMASS Study

16. Secondary Stroke Prevention

18. Problem! Individuals living in the Hispanic Community: Do not know stroke warning symptoms/ signs Do not come to the ED quickly Have less “technical” evaluations

22. Hypertension

23.  The most prevalent and modifiable risk factor for stroke  BP reduction lowers stroke recurrence ~28%  Stroke 1997;28:2557  Treatment of elevated SBP in elderly reduces stroke risk by 36%  Decrease in DBP of 5-6 mmHg reduces stroke risk by 42%  Treatment of stage-I hypertension prevents 1 death in 11 patients over 10 years; 1 in 9 if end- organ damage is present

24. Adjusted Relative Risk of Cardiovascular Mortality According to BP in Men Screened for MRFIT MRFIT, Multiple Risk Factor Intervention Trial Arch Intern Med. 1993;153:186.

26. “new” Risk Factors for stroke  Abdominal Obesity  Lack of Exercise  Poor Diet  Too Little Alcohol  Too Much Alcohol  Psychosocial Stress  Impoverishment  Genetic  Inflammation  Infectious  PFO  Insulin Resistance  Homocysteinemia  Thrombophilias

27. Cavernous Malformation

28.  Prevalence 0.1 to 0.5%  CCM1 – 7q21-q22  CCM2 – 7p13-p15  CCM3 – 3q25.2-q27  CCM1 - krit1: krev interaction trapped 1 protein  CCM2-CCM2 (malcavernin)  CCM3-PDCD10

29. Re-Search: To Look Again Santiago Ramon y Cajal

30. Primordial, primary, secondary, and tertiary prevention stages for global vascular risk. R. Sacco: Stroke, Volume 38(6).June 2007.1980-1987

31. Diet and Exercise

37. Lipid Levels in Patients Hospitalized with Coronary Artery Disease n = 136,905 Amit Sachdeva et. al. Am Heart J 2009;157:111-7.e2

39. JUPITER: Cumulative Incidence of Cardiovascular Events NEJM 2008;359:2195- 2207

40. JUPITER: Effects of Rosuvastatin on Primary End Point by baseline NEJM 2008;359:2195-2207 Primary Endpoints: MI Stroke CVD Unstable Angina Revascularization

51. Carotid Atherosclerosis

52. Hansson et al. Nature Reviews Immunology 6, 508-519 (July 2006) | doi:10.1038/nri1882 Atherothrombosis