Seminars in neurology
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Seminars in neurology · Nov 2010
ReviewAcute stroke management: endovascular options for treatment.
The management of acute ischemic stroke has advanced greatly over the past 2 decades. New interventions, including intravenous and endovascular treatment strategies, have evolved to recanalize arteries and salvage the ischemic brain. ⋯ The major techniques that have defined the current field of interventional acute stroke management and the relevant past and current data, and ongoing clinical trials on interventional stroke therapy will be reviewed. New issues, such as futile recanalization, and time to microcatheter, will also be discussed.
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Seminars in neurology · Nov 2010
ReviewAneurysmal subarachnoid hemorrhage: an overview for the practicing neurologist.
Subarachnoid hemorrhage (SAH) accounts for ~5% of strokes, but causes high rates of morbidity and mortality and occurs at a relatively young age. The rupture of an intracranial aneurysm is the leading cause of nontraumatic SAH and will be the subject of this review. Rebleeding remains the most imminent danger until the aneurysm is secured (i.e., excluded from the cerebral circulation). ⋯ Hemodynamic augmentation therapy remains the mainstay of medical treatment, but various agents are being tested as means to prevent or ameliorate vasospasm, including magnesium sulfate, statins, and an endothelin antagonist. Medically refractory vasospasm demands angioplasty of the affected vessel or intraarterial infusion of vasodilators. In this review, the authors provide an overview of the diagnosis and management of aneurysmal SAH with an emphasis on these main topics.
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The initial management of a patient with suspected stroke necessitates a rapid and focused evaluation. Establishing the time of symptom onset, performing a focused neurologic examination, and interpreting ancillary tests facilitates delivery of acute stroke therapies to eligible patients. ⋯ Results from randomized clinical trials of intravenous thrombolysis, glucose management, and blood pressure management in acute ischemic stroke patients will be highlighted. External ultrasound as an adjunct to intravenous thrombolysis and treatment of those patients that wake up with stroke symptoms will also be discussed.
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The incidence of anticoagulant-associated intracerebral hemorrhage (AAICH) quintupled during the 1990 s, probably due to increased warfarin use for the treatment of atrial fibrillation. Anticoagulant-associated intracerebral hemorrhage now accounts for nearly 20% of all intracranial hemorrhage (ICH). Among patients using warfarin for atrial fibrillation, the annual risk of ICH in trials is 0.3 to 1.0%. ⋯ Recommended methods of warfarin reversal are administration of intravenous vitamin K and either prothrombin complex concentrates or fresh frozen plasma. Reversal of unfractionated heparin is accomplished with intravenous protamine sulfate. Surgical treatment of intracranial hemorrhage may be life saving in select cases, but has not reduced morbidity or mortality in large randomized trials.