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
Objective
Prevalence of Vitamin D deficiency in patient
diagnosed with stroke at South Buffalo Mercy
Hospital
 Classification of ischemic strokes subtypes
according to TOAST criteria
 Clinical correlation of Vitamin D deficiency with

– Ischemic stroke subtypes (TOAST criteria),
– Stroke severity (NIHSS)
– Disability due to Stroke (Modified Rankin Score)
Vitamin D Physiology
Vitamin D Physiology
Incidence of Vitamin D Deficiency
World wide
1 billion
US prevalence
Harvard teaching hospital
Italian women with Osteoporosis
Beijing women in winter
40%
57%
76%
45%
Iranian women at childbirth
Postmenopausal women
Buffalo Psychiatry center
80%
50%
50%
South Buffalo Mercy Hospital
20-30%
Clinical significance of Vitamin D
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
 Muscle - >30% decrease in grip strength is related to
Vitamin D deficiency
 More than >50% of multiple sclerosis associated with
low vitamin D


CAD & CVD – increase Hypertension, Diabetes mellitus,
dyslipidemia (accelerated rate of atherosclerosis)
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

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
Vitamin D and Vascular Disease

120 patients with 1st 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

Large prospective study yet to be done
Clinical Significance of TOAST
Criteria
Widely used to classify ischemic stroke
subtypes
 It is used to determine

– the prognosis
– long term survival
– risk of recurrence
– treatment options
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)
Modified Rankin Score
0 No symptoms at all
1
No 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
Modified Rankin Score
3 Moderate disability; requiring some help, but
able to walk without assistance
4 Moderately severe disability; unable to walk
without assistance and unable to attend to own
bodily needs without assistance
5 Severe disability; bedridden, incontinent and
requiring constant nursing care and attention
6 Dead
Study Method

Retrospective chart review of patients with
stroke presented to Mercy Hospital
between Jan 2008 to Mar 2009

225 charts with stroke diagnosis were
reviewed

62 patients met study inclusion criteria
Study Method contd.

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
– 25 hydroxy Vitamin D
measured more than
30 days after stroke
Data Collected


Demographic information
History of
–
–
–
–
–
–
–
–
–
–
Hypertension
Diabetes mellitus
Dyslipidemia
Atrial fibrillation
CAD
CHF
Smoking
Osteoporosis
Family history of stroke
Vitamin D supplements
Data Collected
– 25 hydroxy Vitamin D
– Fasting Lipid profile
– 2D Echo/TEE
– Carotid doppler/CTA/MRA
– CT or MRI of the brain
Results
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.

Regression Analysis
Vit D vs NIH Stroke Scale (NIHSS)
Pearson Correlation = 0.07
Regression Analysis
Vit D Vs Modified Rankin Score (MRS)
Pearson Correlation = 0.02
Regression Analysis
Vit D vs TOAST type
Pearson Correlation = 0.17
Prevalence of Vitamin D deficiency
for TOAST Subtypes
Percentage of Vit D deficiency
100.00%
80.00%
60.00%
1/1
40.00%
13 / 16
21 / 28
8 / 13
2/4
20.00%
0.00%
1
2
3
Toast type
4
5
Prevalence of Vitamin D deficiency
for MRS values
Percentage of Vit D deficency
100.00%
80.00%
60.00%
14 / 16
40.00%
19 / 24
2/3
8 / 15
20.00%
1/3
0.00%
1
2
3
MRS
4
5
Prevalence of Vit D deficiency for
NIHSS values
Conclusions
Vitamin D deficiency is unrecognized
 High incidence in Western NY
 Very high incidence in Stroke(70%)
 No correlation with stroke subtype
 Probably associated with increased
association with LAA and CE
 Easily treatable condition

Thank you