Cerebrovascular diseases
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Cerebrovascular diseases · Jan 2014
ReviewTime is Penumbra: imaging, selection and outcome. The Johann jacob wepfer award 2014.
The foundation of modern therapy for ischaemic stroke involves reperfusion of the ischaemic penumbra and salvage of threatened but potentially viable brain tissue. Work on imaging of the penumbra and clinical trials using penumbral evaluation or selection have been a major focus of our collaborative work over several decades. We review the original description of the ischaemic penumbra, its measurement using a variety of imaging techniques, the duration of the penumbra and its potential salvage up to 48 h after stroke onset. ⋯ Major reperfusion times were associated with reduced growth of the ischaemic core and improved clinical outcomes. Our current trial programme involves the application of penumbral imaging to attempt to extend the time window for intravenous tPA and treat wake-up strokes, to test the benefits of endovascular therapy in patients who have already received tPA but still have both substantial penumbra and an occluded vessel, and, finally, to use penumbral imaging to define a responder population in a phase III trial testing intravenous tenecteplase versus tPA within the current 4.5-hour time window. We believe that confirmation of these trial hypotheses will substantiate the role of multimodal imaging of the penumbra as a routine part of acute stroke management.
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Cerebrovascular diseases · Jan 2014
Multicenter StudyThe serum level of brain natriuretic peptide increases in severe subarachnoid hemorrhage thereby reflecting an increase in both cardiac preload and afterload.
The increase of serum brain natriuretic peptide (sBNP) is well known in patients with severe subarachnoid hemorrhage (SAH). However, the pathophysiology between the clinical severity of SAH and the sBNP secretion is still not clear. The aim of this study is thus to clarify the cardiovascular pathophysiological mechanisms of sBNP secretion in severe SAH patients. ⋯ In severe SAH patients, sBNP elevation was significantly associated with the increase of both cardiac preload and afterload. sBNP may be a good severity biomarker in SAH patients, reflecting the systemic impact it makes on cardiovascular preload and afterload.
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Cerebrovascular diseases · Jan 2014
ReviewThrombolysis in acute stroke patients with cerebral small vessel disease.
Thrombolytic treatment is of proven benefit in acute ischemic stroke. The term cerebral small vessel disease (SVD) refers to a group of pathological processes affecting the small arteries, arterioles, venules and capillaries of the brain, and encompasses both ischemic and hemorrhagic lesions. Lacunar stroke, an expression of SVD, is associated with an unfavorable long-term prognosis for an increased risk of death, recurrent stroke and cognitive dysfunction. Nonetheless, the efficacy and safety of intravenous thrombolysis in patients with lacunar stroke has been debated for two main reasons. First, among all ischemic stroke subtypes, lacunar strokes have been considered the most benign. Second, the efficacy of a pharmacological reperfusion has been questioned given the absence of a clear demonstration of thrombosis. Intracerebral hemorrhage (ICH) remains the most devastating and unpredictable complication related to thrombolysis, and neuroimaging evidence of SVD is nowadays recognized as one of the risk factors for thrombolysis-related ICH. ⋯ The studies herein reviewed show that thrombolysis is an effective treatment in acute lacunar stroke, and that the presence of cerebral SVD increases the risk of ICH during thrombolysis but does not represent an absolute exclusion criterion. In the future, it can be assumed that the use of MRI on a routine basis might lead to a better quantitative definition of SVD and its correlates, permitting a step forward in thrombolysis decision making.
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Cerebrovascular diseases · Jan 2014
Functional status three months after the first ischemic stroke is associated with long-term outcome: data from a community-based cohort.
The impact of public health interventions to reduce disability after stroke may be underestimated if only the modest effects on short-term disability are measured. We estimated the impact of differences in short-term functional outcome on long-term functional outcome. ⋯ In patients with ischemic stroke who survive to 3 months, a three grade simplified mRS summarizes the patient risk profile and stroke characteristics. These data confirm that modest differences in the functional status at 3 months are associated with significant differences in survival and functional status over 7 years follow-up and have implications for health care planning and the health economic assessment of treatments for acute stroke.
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Cerebrovascular diseases · Jan 2014
Observational StudyThrombelastography maximal clot strength could predict one-year functional outcome in patients with ischemic stroke.
Elevated maximal clot strength, measured by thrombelastography (TEG) maximum amplitude (MA) has been associated with a higher risk for ischemic events in patients with coronary artery diseases. However, it has not been investigated in patients with cerebrovascular diseases. In the current study, we aimed to evaluate the predictive ability of TEG-MA in assessing the risk for ischemic event recurrence and the functional outcome after index ischemic stroke. ⋯ We found that higher TEG-MA levels could predict an unfavorable functional outcome after index ischemic stroke. Further, large-scale studies are required to investigate the relationship between MA levels and risk of recurrent ischemic events in ischemic stroke patients.