Cerebrovascular diseases
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Cerebrovascular diseases · Jan 2009
ReviewHigh blood pressure in acute ischaemic stroke--broadening therapeutic horizons.
High blood pressure (BP) is present in 80% of patients with acute ischaemic stroke and is independently associated with poor outcome. Although this epidemiology suggests that BP should be lowered acutely, concerns about dysfunctional cerebral autoregulation suggest otherwise. Several small randomised trials have assessed cerebral blood flow with various antihypertensive classes and agents in acute ischaemic stroke. ⋯ Two larger trials reported that glucose-potassium-insulin therapy (GIST) or magnesium (IMAGES) lowered BP but had no effect on functional outcome. The INTERACT pilot trial studied patients with intracerebral haemorrhage and found that an intensive BP-lowering regime non-significantly reduced haematoma expansion. There are four large ongoing trials examining whether to continue or stop pre-stroke antihypertensive therapy (COSSACS, ENOS) or lower BP in acute stroke (ENOS, SCAST) or haemorrhage (INTERACT 2).
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Cerebrovascular diseases · Jan 2009
ReviewTelestroke networking offers multiple benefits beyond thrombolysis.
Patients with acute ischemic stroke (AIS) require immediate attention and stroke expertise, which is rarely offered by community hospitals. Telestroke networks were originally established for delivering thrombolysis to inhabitants of underserved regions where stroke expertise was not available 24/7. Rapidly expanding experience addresses the fact that thrombolysis, when given using telestroke consultation, is as safe and effective as when it is given in a stroke center. ⋯ Further benefits may be: to facilitate staff recruitment to spoke hospitals, to deliver expertise to developing countries, participation of spoke hospitals to acute stroke treatment trials and stroke prevention trials, and environmental effects. The magnitude of these benefits will become more obvious in the near future because this exciting field is progressing fast. The Finnish experience suggests that telestroke is a versatile tool for improving acute stroke care of inhabitants in underserved regions and it should be made more widely available.
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Cerebrovascular diseases · Jan 2009
ReviewOld and new anticoagulant agents for the prevention and treatment of patients with ischemic stroke.
Vitamin K antagonists are the only oral anticoagulants available and are considered as well-established treatment to prevent a first stroke or a recurrent stroke in patients with atrial fibrillation. The difficulties in the routine management of these patients cause an underuse of vitamin K antagonists. For long-term use, there is a need for safer and more effective oral anticoagulants that do not require routine monitoring of coagulation. ⋯ Direct thrombin inhibitors include ximelagatran and dabigatran etexilate. Although ximelagatran was withdrawn early because of liver toxicity, it provided convincing evidence that new oral anticoagulants have the potential to replace warfarin. However, even if these new drugs prove superior to dose-adjusted warfarin, their benefits must be substantial (retaining high efficacy with added safety and convenience) to offset their increased cost.
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Cerebrovascular diseases · Jan 2009
ReviewDiagnosis of intracerebral hemorrhage with transcranial ultrasound.
In acute stroke, different sonographic methods can be used to assess structural and hemodynamic compromise. Structural abnormalities of brain parenchyma such as primary intracerebral hemorrhage (ICH) and epiphenomena such as midline shift can be detected by native transcranial B-mode ultrasound. ⋯ According to recent data, ultrasound perfusion imaging provides additional information for the diagnosis of ICH and may differentiate ischemic from hemorrhagic stroke. This review summarizes the impact of these different transcranial ultrasound methods on diagnosis and monitoring of ICH.
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Cerebrovascular diseases · Jan 2009
Multicenter StudyResidual flow at the site of intracranial occlusion on transcranial Doppler predicts response to intravenous thrombolysis: a multi-center study.
We examined if transcranial Doppler (TCD) flow findings at the site of intracranial occlusions predict outcomes of stroke patients receiving intravenous rt-PA treatment. ⋯ The pretreatment residual flow at intracranial occlusion predicts the likelihood of complete recanalization, time of recanalization and long-term outcome. No detectable residual flow indicates the least chance to achieve recanalization and recovery with systemic thrombolysis and may support an early decision for combined endovascular rescue.