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
  • 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
Crohn disease

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)

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


Acute stroke management

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
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Stroke and idiopathic inflammatory bowel diseases (IBDs)