Spotlight on Medical complications of stroke

Medical complications following stroke account for significant morbidity and mortality. These clinical conditions need to be recognized and managed effectively for a more favorable outcome. Direct effects of ischemic stroke account for most deaths within the first week. Other medical complications that include cardiac abnormalities, infections, and venous thromboembolism increase mortality thereafter. These clinical conditions need to be recognized and managed effectively for a more favorable outcome.

In this article, Dr. Adrian Marchidann of SUNY Stony Brook University Hospital discusses the medical complications of stroke-related deficits, their workup, and treatment modalities.

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Spotlight on Sleep, stroke, and vascular dementia

In this article, Dr. Antonio Culebras of SUNY Upstate Medical University at Syracuse highlights the importance of obstructive sleep apnea as a risk factor for stroke and vascular dementia. Rehabilitation and recovery of stroke are less successful in the presence of sleep apnea. Habitual short and long sleep durations, long-standing night shift work, and periodic leg movements of sleep negatively affect cerebrovascular morbidity and mortality. Vascular dementia may be a complication of uncontrolled sleep apnea with hypoxemia.

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Spotlight on Cerebellar infarction and cerebellar hemorrhage

Cerebellar infarct and hemorrhage account for about 2% of all strokes. Both conditions are critical neurologic disorders with potential catastrophic outcomes. They frequently present with headache, nausea and vomiting, dizziness, and a striking difficulty standing or walking. Their management often requires surgical intervention, and the prognosis is usually good when the intervention is performed before the patient becomes comatose.

In this article, Dr. Winnie Lau and Dr. J Dedrick Jordan of the University of North Carolina School of Medicine discuss the clinical presentations associated with the different vascular territories within the cerebellum, the potential to confuse its presentation with peripheral causes of vertigo, and the usefulness of the head thrust test to differentiate between peripheral and central causes of dizziness.

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Spotlight on Stroke therapy

The treatment of acute ischemic stroke is considered an emergency. The clock starts with the interruption of blood flow to the brain. The goal of each therapeutic intervention is to reestablish blood flow to viable brain tissue to reduce the degree of injury. Since the FDA approval of intravenous tPA for acute ischemic stroke in 1996, the options for treatment have increased considerably. Despite the advances, the key to good clinical outcomes remains the same: rapid identification of patients coupled with fast assessment and treatment.

In this article, Dr. Carolyn Brockington, Director of the Stroke Center at Mount Sinai St. Luke’s and Mount Sinai Hospital, provides the latest information on the treatment and management of acute ischemic stroke.

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Spotlight on Basilar artery stroke

Infarcts in the distribution of the basilar artery are perhaps the most feared and devastating of all ischemic strokes. However, an important minority of patients can have good outcomes, especially with time-sensitive treatment approaches. In this article, Dr. Sean Ruland, Dr. Jose Biller, Dr. Cara Joyce, and Dr. Camilo R Gomez, all of Stritch School of Medicine at Loyola University Chicago, review 4 distinct syndromes of basilar artery stroke, including proximal and middle basilar artery occlusions, top of the basilar artery syndrome, basilar artery branch occlusions, and dolichoectasia of the basilar artery.

Pertinent vertebral and basilar artery anatomy and physiology are discussed. Emerging assessment and treatment strategies for acute basilar artery occlusion and strategies for prevention of recurrent basilar artery stroke are reviewed, and potential causes of posterior circulation ischemic stroke are highlighted. Finally, pediatric ischemic stroke in the posterior circulation and intravenous thrombolytic use in children and during pregnancy are also discussed.

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Spotlight on Basal ganglia hemorrhage

Basal ganglia intracerebral hemorrhage remains among the most deadly of stroke types. Intracerebral hemorrhage in the basal ganglia is usually caused by hypertension. Patients presenting within the first few hours have a high risk of hemorrhage expansion and neurologic deterioration. Prognosis is based on multiple factors, including volume and location of hemorrhage, age, level of consciousness, presence of intraventricular hemorrhage, and warfarin use.

This update highlights some important clinical trial results on intracerebral hemorrhage, including blood pressure management and surgical interventions. Dr. Adrian Marchidann of SUNY Downstate Medical Center discusses these advances and updates on the epidemiology and pathophysiology of intracerebral hemorrhage.

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Spotlight on Stroke associated with sickle cell disease

In this article, Dr. Fenwick Nichols of the Medical College of Georgia reviews the risk of stroke in children with sickle cell anemia (HbSS). Stroke occurs in 11% of children with the disease by 20 years of age. The author reviews the pathophysiology of stroke in sickle cell disease and discusses ways to identify those at high risk for stroke.

Transcranial Doppler (TCD) measurement of the time-averaged mean of the maximum blood flow velocities in the distal internal carotid and proximal middle cerebral artery has proven to be the best predictor of stroke risk in this population. The author discusses the TCD technique used in the examination of children with sickle cell disease for both initial examination as well as follow-up examinations. He also reviews the effectiveness of transfusion therapy for prevention of stroke in this population and discusses possible alternative therapies, including hydroxyurea and bone marrow transplantation, for stroke prevention in this high-risk population. Finally, the author reviews publications on the risk associated with elevated anterior cerebral artery velocities, reports on encephalo-arterio-duro-synangiosis in patients with homozygous sickle cell anemia with moyamoya, and reviews the parameters that affect TCD velocity and potentially impact stroke risk in this population. Recent trials in HbSS, including SWITCH, TWITCH, and a controlled trial of transfusions for silent cerebral infarcts in sickle cell anemia are reviewed, and a report of successful implantation of an antisickling beta-globin gene into autologous hematopoietic stem cells in a 13-year-old with HbSS is discussed.

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Spotlight on Stroke in young adults

Current epidemiological data suggest that strokes are occurring at a younger age. As many as 1 out of every 6 strokes occurs in a young adult (18 to 50 years old). Heterogeneity in incidence rates, stroke subtypes, and etiology among younger stroke victims in both developed and developing countries is often noted. Certain historical features and clinical manifestations may occasionally serve as clues toward specific stroke etiologies; nevertheless, determination of etiology, particularly of ischemic strokein the young, poses many challenges due to a broad array of potential causes, both common and uncommon.

In this article, Dr. Jorge Moncayo-Gaete of the International University of Ecuador and Dr. Julien Bogousslavsky of the Swiss Medical Network emphasize areas in which the differential diagnosis of stroke and etiologies (including those in pregnancy and puerperium) differs from that in older adults. The authors also note relevant information concerning prognosis of young adults with stroke.

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Spotlight on Patent foramen ovale

In this article, Dr. Shadi Yaghi and Dr. Shawna Cutting of the Warren Alpert Medical School of Brown University discuss patent foramen ovale, a highly prevalent anomaly occurring in 25% to 30% of the general population.

Patent foramen ovale represents the postnatal persistence of the normally present foramen ovale, a flap valve structure formed by the septum primum and septum secundum in the fetus. Although it is generally asymptomatic, studies have found associations with ischemic stroke and migraine. The best treatment strategy for patent foramen ovale in the setting of ischemic stroke or migraine remains unclear. Randomized controlled trials on patent foramen ovale closure showed no benefit for secondary stroke prevention or migraine improvement.

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Spotlight on Cerebral venous thrombosis

Cerebral venous thrombosis is a rare but important cause of stroke that is often missed or delayed in diagnosis. Dr. David Liebeskind of the University of California in Los Angeles provides literature on the topic.

The clinical manifestations are myriad, and a high level of suspicion must be maintained in order to effectively and expeditiously identify this disorder. Infectious and noninfectious processes may cause cerebral venous thrombosis. In adults, about half of cases are associated with pregnancy and the puerperium, but numerous unusual etiologies must be considered in the remainder of patients. Anticoagulation is the mainstay of therapy in the presence of either ischemic or hemorrhagic stroke; in some dire cases, more aggressive approaches such as thrombolysis or mechanical clot disruption may be undertaken.

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