Arteriosclerosis and the promise of GPIIb/IIIa inhibitors in stroke

Ischemic mechanisms in pa2000Mar;58(1)1-10 studied for more than 150 years. Antiplatelet agents did show benefit in secondary prevention. Aspirin is the most common antiaggregant in clinical use today. However, the benefit produced by the "best" antiplatelet regimen in stroke prevention is lower than 40%. The adherence of circulating platelets to the subendothelium is mediated by glycoprotein (GP) residing on the cell's surface. GPIIb/IIIa is the most important platelet membrane receptor that mediates the process of platelet aggregation, and thrombus formation. Thus, new drugs that block the GPIIb/IIIa receptor have recently emerged. Clinical trials using these agents have shown effectiveness in acute coronary syndromes. However, the absence of studies in cerebrovascular disease and the potential hemorrhagic complications questioned their use in stroke prevention. We review the clinical trials using the new GPIIb/IIIa agents in myocardial ischemia, and consider the potential implications for cerebrovascular disease.     

Intracerebral Hemorrhage from Cerebral Venous Thrombosis

Cerebral venous thrombosis (CVT) is an uncommon cause of stroke with the incidence of 0.5 % from all strokes. The clinical presentation with cerebral hemorrhage constitutes a diagnostic challenge. Approximately one- third of CVT patients developed intracerebral hemorrhage (ICH). Associated factors include older age, female sex, acute onset (48 h), headache, decreased level of consciousness, seizure, elevated blood pressure and papilledema. MRI and MR venogram is the most recommend diagnostic modality in CVT. Anticoagulation therapy is the most commonly accepted treatment even in patients with ICH related CVT. Mechanical thrombectomy/thrombolysis may be considered in patients with neurological deterioration despite intensive medical treatment. Intracerebral hemorrhage in the context of CVT is usually associated with poorer outcomes compared to CVT without ICH.     

Spontaneous and reflex movements in brain death

Spontaneous and reflex movements may be found in patients with brain death (BD). The authors prospectively evaluated their frequency using a standardized protocol. Among 38 patients who fulfilled criteria for BD, the authors found 15 (39%) with spontaneous or reflex movements. The most common movement was finger jerks. Undulating toe flexion sign, triple flexion response, Lazarus sign, pronation-extension reflex, and facial myokymia also were seen. These movements may be more common than reported and do not preclude the diagnosis of BD.     

经颅彩色编码超声检查(TCCS)在临床神经病学中的应用价值

自从1982年Aaslid首次应用以来,经颅多普勒超声已成为临床工作中评估颅内血流动力学状况的一种常规手段,并在实验工作中用于功能多普勒超声检查领域的研究.进入90年代后,这一技术得到进一步发展,B型超声与脉冲多普勒超声的结合使得颅脑组织结构的可视化超声观察成为可能,这就是经颅彩色编码超声检查(TCCS)技术.文章旨在从临床医生的立场对TCCS技术的应用现状进行回顾总结.在对检查方法和正常值进行描述后,重点讨论急性缺血性脑梗死发病后短时间内的急诊诊断,结合临床资料和CT检查结果对卒中进行快速鉴别诊断(症状出现3 h内)有助于对tPA溶栓治疗的正确决策.还讨论了TCCS在各种适应证中进行常规床旁随访检查的重要性,以及患者的友好性和效价比.最后,文章对颅内结构多维超声研究领域的未来发展前景进行了展望.     

Timing of Direct Enteral Tube Placement and Outcomes after Acute Stroke

Background: Direct enteral feeding tube (DET) placement for dysphagia after stroke is associated with poor outcomes. However, the relationship between timing of DET placement and poststroke mortality and disability is unknown. We sought to determine the risk of mortality and severe disability in patients who receive DET at different times after stroke. Methods: We used the Ontario Stroke Registry and linked administrative databases to identify patients with acute ischemic stroke or intracerebral hemorrhage between 2003 and 2013 who received DET (gastrostomy or jejunostomy) during their hospital admission. We grouped patients by week of DET placement and evaluated mortality at 30 days and 6 months after DET insertion, and disability at discharge. We used Cox proportional hazard models and multiple logistic regression to determine the association between time from admission to DET placement and outcomes, adjusting for patient and hospital factors. Results: In the study sample of 1367 patients, the median time from admission to DET placement was 17 days. After adjustment, each week of delay to DET placement was associated with lower mortality at 30 days (adjusted hazard ratio [aHR] .88, 95% confidence interval [CI] .79-.98), but not at 6 months (aHR .98, 95% CI .91- 1.05), and a higher likelihood of severe disability at discharge (adjusted odds ratio 1.35, 95% CI 1.13- 1.60). Conclusions: Later DET placement after stroke was associated with lower 30-day mortality but higher severe disability at discharge. Further research is needed to understand the reasons for these observations and to optimize patient selection and timing of DET.