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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Spotlight on Stroke therapy

Stroke treatment is an emergency, and options for treatment have increased since the FDA approval of intravenous t-PA use in acute ischemic stroke in 1996. In this recently updated article, Dr. Carolyn Brockington, Director of the Stroke Center at St. Luke’s-Roosevelt Hospital, provides information about the scientific basis and adverse effects of acute stroke as well as prevention strategies and treatment guidelines. Also discussed is the use of combination antiplatelet therapy in patients with minor stroke or transient ischemic attack and the latest on blood pressure management in the setting of intracerebral hemorrhage.

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Spotlight on MELAS

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a multisystem disorder characterized by: (1) stroke-like episodes, typically before age 40 years; (2) encephalopathy, characterized by seizures, dementia, or both; and (3) evidence of a mitochondrial myopathy with lactic acidosis, ragged-red fibers, or both.

Although at least 30 distinct mitochondrial DNA mutations have been associated with MELAS, about 80% of patients have the m.3243A>G tRNALeu(UUR) gene mutation. One study has suggested that screening urinary epithelial cells for the m.3243A>G mutation may be the most sensitive non-invasive diagnostic test for MELAS.

In this article, Dr. Thomas Klopstock of Ludwig Maximilian University of Munich discusses the clinical manifestations, pathogenesis, and diagnosis of this multisystem disorder. He puts particular emphasis on work showing (1) that the m.3243A>G mutation may sometimes arise “de novo”; (2) that there is nitric oxide deficiency in MELAS underpinning the current recommendations of arginine supplementation in the treatment and prophylaxis of stroke-like episodes; and (3) that the advent of mitochondrial replacement technologies may enable affected women to have a genetically-related child with a greatly reduced risk of mtDNA disease in the near future.

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Spotlight on Pregnancy and stroke

Stroke during pregnancy is an uncommon but serious cause of morbidity and mortality. In this article, Dr. Adrian Marchidann of SUNY Health Science Center discusses the etiologies of pregnancy-specific ischemic and hemorrhagic strokes, diagnostic approaches, and therapeutic challenges. The updated article includes the revised definition of preeclampsia and the recommendations for its treatment; new data on the risk of hemorrhage of cavernous hemangioma, arteriovenous malformation, and aneurysm; and the recommendations for antiplatelet and anticoagulation management for secondary stroke prevention during pregnancy and puerperium.

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Spotlight on Affective disorders in neurologic disease

In this article, Dr. Sergio Starkstein of the University of Western Australia and Dr. Jaime Pahissa of the Instituto Universitario CEMIC review the frequency, diagnostic strategies, clinical correlates, mechanism, differential diagnoses, and management of affective disorders in frequent acute and chronic neurologic disorders, such as stroke, traumatic brain injury, dementia, Parkinson disease, Huntington disease, multiple sclerosis, and epilepsy. Studies using sophisticated neuroimaging techniques have provided important clues regarding the mechanism of depression and disinhibition in neurologic conditions. Randomized clinical trials have been reported for depression in stroke, Parkinson disease, and Alzheimer disease as well as for the prevention of depression after stroke.

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Spotlight on Sleep and stroke

It may be difficult to differentiate the sleepiness and other symptoms associated with obstructive sleep apnea from such acute manifestations of cerebrovascular disease as lethargy, apathy, and neglect, particularly with strokes in specific locations, such as bilateral paramedian thalamic infarctions. The spouse of a stroke victim may describe a lack of energy, falling asleep during activities, and fatigue. Additional questioning may elicit a history of snoring (with repetitive respiratory interruptions), restless sleep, nonrestorative sleep, and weight gain prior to or following the stroke.

In this article, Dr. Antonio Culebras of SUNY Upstate Medical University highlights the importance of obstructive sleep apnea as a risk factor for stroke. Rehabilitation and recovery 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.

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