1,721,528 research outputs found
Antithrombotic therapy in carotid artery stenosis: an update
No full textCarotid stenosis is generally associated with high risks of stroke and vascular events. In asymptomatic and symptomatic patients, with or without revascularization, optimal managements of carotid artery stenosis require the use of medications or lifestyle modifications (stopping smoking and monitoring hypertension, hyperlipidemia, and diabetes) to control the processes associated with atheroma to reduce the risk of embolic events. Moreover, antiplatelet therapy should be considered. There is little evidence that antiplatelet therapy is beneficial in preventing stroke or the progression of stenosis in asymptomatic patients, whereas, evidence of a benefit from antiplatelet therapy for secondary prevention of recurrent stroke in symptomatic patients with carotid atherosclerosis is more robust. Also, in patients undergoing carotid endarterectomy, perioperative antithrombotic therapy should include aspirin, while the addition of clopidogrel should be decided case-by-case. Furthermore, perioperative antithrombotic therapy in patients undergoing carotid stenting should consist a combination of aspirin plus clopidogrel.Carotid stenosis is generally associated with high risks of stroke and vascular events. In asymptomatic and symptomatic patients, with or without revascularization, optimal managements of carotid artery stenosis require the use of medications or lifestyle modifications (stopping smoking and monitoring hypertension, hyperlipidemia, and diabetes) to control the processes associated with atheroma to reduce the risk of embolic events. Moreover, antiplatelet therapy should be considered. There is little evidence that antiplatelet therapy is beneficial in preventing stroke or the progression of stenosis in asymptomatic patients, whereas, evidence of a benefit from antiplatelet therapy for secondary prevention of recurrent stroke in symptomatic patients with carotid atherosclerosis is more robust. Also, in patients undergoing carotid endarterectomy, perioperative antithrombotic therapy should include aspirin, while the addition of clopidogrel should be decided case-by-case. Furthermore, perio..
Pure sensory syndromes in thalamic stroke
No full textWe studied 25 patients with an acute thalamic stroke (infarct or hemorrhage) on CT or MRI scan and sensory dysfunction, among the 3,628 patients with first-time stroke included in the Lausanne Stroke Registry. Twelve patients had a right-sided infarct, 11 a left-sided infarct, and 2 a left-sided thalamic hemorrhage. Sensory symptoms or signs were the only clinical abnormality. The presumed causes of stroke were small artery disease in 21 patients including both cases of hemorrhage, emboligenic heart disease in 2, while the etiology of ischemic stroke was undetermined in 2 patients. Nine patients had a loss of all modalities of sensation with faciobrachiocrural distribution, 5 patients suffered dissociated sensory loss with faciobrachiocrural distribution and 11 patients showed a dissociated involvement of sensation with a partial distribution pattern. The inferolateral region (thalamogeniculate arteries) was involved in all patients. Six patients complained of pain and/or dysesthesias during the stroke; 5 of them had involvement of the nucleus ventrocaudalis (in 3 with damage to the nucleus ventro-oralis intermedius, and in one to the pulvinar) and 1 patient had involvement of the nucleus ventro-oralis intermedius. Eighteen patients complained of paresthesias in the contralateral part of the body; 16 of them had involvement of the nucleus ventrocaudalis (in 4 with damage to the nucleus ventro-oralis intermedius, in 1 with damage to the nucleus ventro-oralis intermedius, and nucleus ventro-oralis externus, and in one with damage to the nucleus parvocellularis and pulvinar). Four patients developed delayed pain and/or dysesthesias; all of them had involvement of the nucleus ventrocaudalis (in 1 with damage to the nucleus parvocellularis and pulvinar). Time lag from stroke onset to developing pain ranged from 2 to 15 days (mean 10.5 days). One patient with dissociated involvement of sensation with a partial distribution pattern had paresthesias and dissociated hemisensory loss involving position sense without pain and temperature sensations. This patient had involvement of the posterolateral part of the nucleus ventrocaudalis. In conclusion, sensory dysfunction and delayed pain are more often found in thalamic lesions that involve the nucleus ventrocaudalis, and nucleus ventro-oralis intermedius. Restricted sensory abnormalities correlate with very small lesions located in critical areas within these nuclei.We studied 25 patients with an acute thalamic stroke (infarct or hemorrhage) on CT or MRI scan and sensory dysfunction, among the 3628 patients with first-time stroke included in the Lausanne Stroke Registry. Twelve patients had a right-sided infarct, 11 a left-sided infarct, and 2 a left-sided thalamic hemorrhage. Sensory symptoms or signs were the only clinical abnormality. The presumed causes of stroke were small artery disease in 21 patients including both cases of hemorrhage, emboligenic heart disease in 2, while the etiology of ischemic stroke was undetermined in 2 patients. Nine patients had a loss of all modalities of sensation with faciobrachiocrural distribution, 5 patients suffered dissociated sensory loss with faciobrachiocrural distribution and 11 patients showed a dissociated involvement of sensation with a partial distribution pattern. The inferolateral region (thalamogeniculate arteries) was involved in all patients. Six patients complained of pain and/or dysesthesias d..
Cerebrovascular complications of neck manipulation
No full textThe safety of spinal manipulation is an issue that demands regular and rigorous assessment, as manipulation of the upper spine has been associated with serious adverse events such as cerebrovascular accidents due to cervical artery dissection. A correlation between stroke and cervical manipulation has been reported with increasing frequency, and each new report seems to reignite debate between neurologists and manual therapists. Specific risk factors for cerebrovascular complications related to spinal manipulation have not been identified yet; for this reason, any patient may be at risk, particularly those below 45 years of age. Patients undergoing spinal manipulative therapy need to consent to the possible risk of stroke or vascular injury from the procedure.The safety of spinal manipulation is an issue that demands regular and rigorous assessment, as manipulation of the upper spine has been associated with serious adverse events such as cerebrovascular accidents due to cervical artery dissection. A correlation between stroke and cervical manipulation has been reported with increasing frequency, and each new report seems to reignite debate between neurologists and manual therapists. Specific risk factors for cerebrovascular complications related to spinal manipulation have not been identified yet; for this reason, any patient may be at risk, particularly those below 45 years of age. Patients undergoing spinal manipulative therapy need to consent to the possible risk of stroke or vascular injury from the procedure. Copyright © 2008 S. Karger AG
Primary and secondary prevention of ischemic stroke
No full textPrevention of stroke and transient ischemic attack includes both conventional approaches to vascular risk factor management (blood pressure lowering, cholesterol reduction with statins, smoking cessation and antiplatelet therapy) and more specific interventions, such as carotid revascularization or anticoagulation for atrial fibrillation. The objective of this review is to discuss effective interventions for optimal primary and secondary stroke prevention.Prevention of stroke and transient ischemic attack includes both conventional approaches to vascular risk factor management (blood pressure lowering, cholesterol reduction with statins, smoking cessation and antiplatelet therapy) and more specific interventions, such as carotid revascularization or anticoagulation for atrial fibrillation. The objective of this review is to discuss effective interventions for optimal primary and secondary stroke prevention. Copyright © 2010 S. Karger AG, Basel
Clopidogrel for cerebrovascular prevention
No full textIschemic stroke, myocardial infarction and peripheral arterial disease are different clinical manifestations commonly due to the same underlying disease, i.e. atherosclerosis with subsequent thrombosis/embolism (atherothrombosis). Many clinical trials of secondary prevention after stroke or TIA have evaluated the benefit of long-term use of antiplatelet drugs in reducing the risk of subsequent vascular events. Aspirin and triclopidine have been shown to be effective in placebo-controlled studies for the composite outcome of stroke, myocardial infarction, or vascular death. Contrasting with these benefits, there were potentially serious, though rare, adverse effects. These considerations certainly justify the development of new antiplatelet agents. Clopidogrel is a new ADP-receptor antagonist, with a greater activity in animal models of thrombosis. CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events) was a randomized, blinded, international trial designed to assess the relative efficacy of clopidogrel and aspirin in reducing the risk of the outcome cluster of ischemic stroke, myocardial infarction, or vascular death, as well as to assess their relative safety. 19,185 patients were recruited. The intention-to-treat analysis showed that the relative risk reduction was 8.7% (95% CI 0.3-16.5, p = 0.043) in favor of clopidogrel from an overall annual event rate of ischemic stroke, myocardial infarction, or vascular death, ranging from 5.83% in the aspirin group to 5.33% in the clopidogrel group. The percentage of adverse events reported was higher in the aspirin group for all categories except rash, diarrhea, and abnormal liver function. It seems likely that clopidogrel will replace ticlopidine for stroke prevention, because of its better safety profile, and comparable efficacy. Clopidogrel probably will not replace aspirin as the first line therapy for many clinicians because of its higher cost and lack of widespread experience. However, other clinicians have already decided that they will use clopidogrel as first choice, because of the significant advantage over aspirin demonstrated in the CAPRIE study.Ischemic stroke, myocardial infarction and peripheral arterial disease are different clinical manifestations commonly due to the same underlying disease, i.e. atherosclerosis with subsequent thrombosis/embolism (atherothrombosis). Many clinical trials of secondary prevention after stroke or TIA have evaluated the benefit of long-term use of antiplatelet drugs in reducing the risk of subsequent vascular events. Aspirin and triclopidine have been shown to be effective in placebo-controlled studies for the composite outcome of stroke, myocardial infarction, or vascular death. Contrasting with these benefits, there were potentially serious, though rare, adverse effects. These considerations certainly justify the development of new antiplatelet agents. Clopidogrel is a new ADP-receptor antagonist, with a greater activity in animal models of thrombosis. CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events) was a randomized, blinded, international trial designed to assess..
How did stroke become of interest to neurologists?: a slow 19th century saga
No full textIt was not until the first half of the 19th century that the vascular nature of strokes was readily recognized and accepted. Brain "softenings" were distinguished from hemorrhagic "apoplexy," but stroke etiology remained unstudied. The terms artherosclerosis, thrombosis, embolism, and lacune were introduced to indicate etiology, but carotid occlusive disease was recognized later, in the second half of the 19th century. The development of knowledge of stroke was slow, likely corresponding to limited interest by the great early neurologists: stroke never was a field of critical interest in the Salpêtrière and Pitié Schools at the time of the local leading figures, Vulpian and Charcot. By contrast, scarce studies were due to isolated physicians, who did not contribute much to other fields, including Rochoux, Rostan, Durand-Fardel, or Dechambre; critical advances came from pathologists such as Rokitansky and Virchow. The interest in stroke among neurologists generally was clearly triggered by the development of clinical-topographic correlation studies, promoted by Déjerine and Marie, and followed by Foix, the father of modern clinical stroke research.It was not until the first half of the 19th century that the vascular nature of strokes was readily recognized and accepted. Brain 'softenings' were distinguished from hemorrhagic 'apoplexy,' but stroke etiology remained unstudied. The terms artherosclerosis, thrombosis, embolism, and lacune were introduced to indicate etiology, but carotid occlusive disease was recognized later, in the second half of the 19th century. The development of knowledge of stroke was slow, likely corresponding to limited interest by the great early neurologists: stroke never was a field of critical interest in the Salpêtrière and Pitié Schools at the time of the local leading figures, Vulpian and Charcot. By contrast, scarce studies were due to isolated physicians, who did not contribute much to other fields, including Rochoux, Rostan, Durand-Fardel, or Dechambre; critical advances came from pathologists such as Rokitansky and Virchow. The interest in stroke among neurologists generally was clearly triggered..
The history of stroke and cerebrovascular disease
No full textThe first recorded reference to the nervous system
dates back to ancient Egyptian records. The Edwin
Smith Surgical Papyrus, composed circa 3500 BC, contains
the first use of the word ‘brain’ along with a
description of its coverings and the fluid beneath them
(Garrison, 1969).
The history of stroke and cerebrovascular disease
spans many centuries, although the observations that
have influenced current practice have been described
over the past 50 years
Statins and stroke prevention
No full textOver the past decade, statins have been proved to significantly decrease coronary events in the primary and secondary prevention of coronary artery disease. Recent clinical trials have indicated that statins significantly reduce stroke risk in patients with vascular disease. A meta-analysis of randomized trials of statins in combination with other preventive strategies, involving 165,792 individuals, showed that each 1-mmol/l (39 mg/dl) decrease in LDL-cholesterol equates to a reduction in relative risk for stroke of 21.1 (95% CI: 6.3-33.5; p = 0.009). It is not known whether these findings might be due to the cholesterol-reduction effect of statins or to the pleiotropic effects of statins, such as improved endothelial function, decreased platelet aggregability and reduced vascular inflammation. In the secondary prevention of stroke, The Stroke Prevention by Aggressive Reduction of Cholesterol Levels study found that treatment with atorvastatin reduced the risk of recurrent cerebrovascular events in patients with recent stroke or transient ischemic attack but no history of heart disease.Over the past decade, statins have been proved to significantly decrease coronary events in the primary and secondary prevention of coronary artery disease. Recent clinical trials have indicated that statins significantly reduce stroke risk in patients with vascular disease. A meta-ana lysis of randomized trials of statins in combination with other preventive strategies, involving 165,792 individuals, showed that each 1-mmol/l (39 mg/dl) decrease in LDL-cholesterol equates to a reduction in relative risk for stroke of 21.1 (95% CI: 6.3-33.5; p = 0.009). It is not known whether these findings might be due to the cholesterol-reduction effect of statins or to the pleiotropic effects of statins, such as improved endothelial function, decreased platelet aggregability and reduced vascular inflammation. In the secondary prevention of stroke, The Stroke Prevention by Aggressive Reduction of Cholesterol Levels study found that treatment with atorva statin reduced the risk of recurrent cerebrova..
The Borderland with Neurasthenia (Functional Syndromes')
No full textAt the end of the 19th century, neurasthenia and hysteria
were considered distinct diseases. Specifically, neurasthenia
was regarded as a disease of the body, whereas
hysteria was regarded as a disease of the psyche. However,
immediately before World War I, due to their common
characteristics, both hysteria and neurasthenia
were thought to be ‘functional diseases’. Moreover, it
was suggested that heredity and the presence in both of
the predisposing condition called ‘nervous weakness’
were other shared factors. Nervous weakness was considered
essential for the definition of neurasthenia, but
it was also considered a precondition for the development
of hysteria. Because of this, it is still difficult to demarcate
a line between neurasthenia and hysteria;
therefore, the two diseases should be considered as
sharing a common borderland with each other.At the end of the 19th century, neurasthenia and hysteria were considered distinct diseases. Specifically, neurasthenia was regarded as a disease of the body, whereas hysteria was regarded as a disease of the psyche. However, immediately before World War I, due to their common characteristics, both hysteria and neurasthenia were thought to be 'functional diseases'. Moreover, it was suggested that heredity and the presence in both of the predisposing condition called 'nervous weakness' were other shared factors. Nervous weakness was considered essential for the definition of neurasthenia, but it was also considered a precondition for the development of hysteria. Because of this, it is still difficult to demarcate a line between neurasthenia and hysteria; therefore, the two diseases should be considered as sharing a common borderland with each other. © 2014 S. Karger AG, Basel
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