Curr Treat Option Ne
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Curr Treat Option Ne · Sep 2003
Potential Role of Neuroprotective Agents in the Treatment of Patients with Acute Ischemic Stroke.
Currently, intravenous recombinant tissue plasminogen activator is the only US Food and Drug Administration-approved therapy for acute ischemic stroke. Although efficacious, its usefulness is limited, mainly because of the very limited time window for its administration. Neuroprotective treatments are therapies that block the cellular, biochemical, and metabolic elaboration of injury during or after exposure to ischemia, and have a potential role in ameliorating brain injury in patients with acute ischemic stroke. ⋯ Recent innovations in strategies of preclinical drug development and clinical trial design that rectify past defects hold great promise for neuroprotective investigation, including novel approaches to accelerating time to initiation of experimental treatment, use of outcome measures sensitive to treatment effects, and trial testing of combination therapies rather than single agents alone. Although no neuroprotective agent is of proven benefit for focal ischemic stroke, several currently available interventions have shown promising results in preliminary trials and may be considered for cautious, off-label use in acute stroke, including hypothermia, magnesium sulfate, citicoline, albumin, and erythropoietin. Overall, the prospects for safe and effective neuroprotective therapies to improve stroke outcome remain promising.
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Surgical therapy for Parkinson's disease (PD) has been a treatment option for over 100 years. Advances in the knowledge of basal ganglia physiology and in techniques of stereotactic neurosurgery and neuroimaging have allowed more accurate placement of lesions or "brain pacemakers" in the sensorimotor regions of target nuclei. This, in turn, has led to improved efficacy with fewer complications than in the past. ⋯ These include embryonic mesencephalic tissue transplantation, human embryonic stem cell transplantation, and gene-derived methods of intracerebral implantation of growth factors and dopamine- producing cell lines. It will be important to determine whether DBS, if performed before the onset of motor response complications to medical therapy, may prevent this stage of disease altogether or delay it for a significant period of time. The same question applies to the future with restorative therapy.
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The International Headache Society applies the term exertional headache to head pain precipitated by exertion. The Society recognizes cough headache and sexual headache as distinct diagnoses. All three types of headache share characteristics and mechanisms, and together may be considered as headache provoked by exertional factors ( Table 1). ⋯ The consensus to date is that secondary HAPEF resolves if the underlying illness can be treated; primary HAPEF responds well to prophylactic treatment. Treatment strategy varies little among headaches precipitated by cough, sex, or other forms of exertion. Avoidance strategies, sometimes combined with medication (particularly indomethacin), can effectively treat headaches produced by exertional factors in most cases.
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Four percent to 5% of the general population suffers from chronic daily or near daily headache. A majority of them are chronic migraine (transformed migraine), and the rest are chronic tension-type headaches. Prophylactic treatments of migraine and chronic tension-type headache are far from satisfactory because of lack of good efficacy, intolerable side effects, development of tachyphylaxis over long-term use, and drug interactions. ⋯ Botulinum toxin type A is well tolerated and totally free of many long-term side effects, which are seen with other prophylactic agents. The clinician may be well advised to consider botulinum toxin type A in the most refractory forms of chronic headaches including chronic migraine and chronic tension-type headache. Appropriate injection techniques, selection of injection sites, and appropriate doses are necessary for success.
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When evaluating a patient with a complaint of double vision, it is important to distinguish monocular versus binocular diplopia, which are differentiated by asking the patient to cover each eye separately. In the setting of binocular double vision, one of the two images disappears when either eye is covered, because diplopia is the result of ocular misalignment. On the other hand, monocular double vision resolves when the affected eye is covered, but remains when the opposite eye is occluded. ⋯ The main treatment objective of binocular diplopia is to restore the largest area of single binocular vision. Ideally, patients would be able to achieve single vision in all fields of gaze, but this is not always possible. The majority of patients are treated with either prism lenses or eye muscle surgery.