ISCHEMIC STROKE / ETIOPATHOGENESIS
Stroke and idiopathic inflammatory bowel diseases
Created 16/02/2023, last revision 18/02/2023
- idiopathic inflammatory bowel diseases (IBDs) are chronic, medically incurable inflammatory disorders of the gastrointestinal (GI) tract with unknown etiopathogenesis. In general, idiopathic IBDs includes two forms:
- ulcerative colitis (UC) – transmural segmental involvement
- Crohn’s disease (CD) – superficial inflammation without T-cell activation, humoral mechanisms predominate
- ulcerative colitis (UC) – transmural segmental involvement
- the incidence and prevalence of IBD are increasing around the world
- IBDs are associated with an increased risk of thromboembolic events (including stroke)
- meta‐analysis indicates that IBD was associated with an elevated risk of stroke (OR/RR = 1.21, 95% CI 1.08 to 1.34, I 2 = 83.6%, p < .001) (Chen, 2021)
- the study also showed that CD was more relevant to the risk of stroke than UC
- increased risk of stroke is probably related to inflammatory mechanisms (elevated CRP), as it is also associated with other systemic diseases such as psoriasis, systemic sclerosis, and systemic lupus erythematosus
- diagnosis is based on the following:
- clinical presentation
- endoscopic and radiologic findings
- histology
Etiopathogenesis of complications
- systemic inflammation with the production of cytokines and free oxygen radicals
- the exact etiology of IBD remains unclear; epidemiologic data suggest that multiple risk factors are associated with IBD, including diet, smoking, and genetic factors
- probable mechanisms increasing the risk of stroke and other CV diseases include:
- systemic inflammation (inflammation‐mediated premature atherosclerosis)
- intestinal microflora has also been implicated as a potential contributor to CVD
- abnormalities of the coagulation system (→ hypercoagulable state)
- protein C and S deficiency
- high fibrinogen concentrations
- hyperhomocysteinemia [Romagnuolo, 2001]
- antiphospholipid syndrome [Mevorach, 1996]
Clinical presentation
Extraintestinal non-thrombotic symptoms
- non-neurological
- arthritis
- sclerosing cholangitis
- gluten-sensitive enteropathy
- neurological
- peripheral neuropathies
- myelopathy
- myasthenia gravis
Extraintestinal thrombotic symptoms
- deep vein thrombosis and/or pulmonary embolism (VTE)
- venous thrombosis of atypical localization (mesenteric, etc.)
- stroke and cerebral venous sinus thrombosis (CVST)
- mostly due to hypercoagulable state
- vasculitis is rare
Management
Acute stroke management
- recanalization therapy in eligible patients
- intravenous thrombolysis (IVT) may be associated with an increased risk of bleeding
- mechanical recanalization or local thrombolysis may be preferred [Brosch, 2012]
- antiplatelet therapy if recanalization therapy is not indicated
Stroke prevention
- the mainstay of prevention is the compensation for the inflammatory disease + treatment of traditional vascular risk factors
- low-dose anticoagulation or antiplatelet therapy reduces the risk of thromboembolism but increases the risk of bleeding
- start vitamin supplementation in case of hyperhomocysteinemia → see here