Frontiers Of Neurology And Neuroscience[JOURNAL]
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200 papers
Neurology in the Vietnam War.
Gunderson CH, Daroff RB
Front Neurol Neurosci · 2016 · PMID 27035455 · Publisher ↗
Between December 1965 and December 1971, the United States maintained armed forces in Vietnam never less than 180,000 men and women in support of the war. At one time, this commitment exceeded half a million soldiers, sa...
Between December 1965 and December 1971, the United States maintained armed forces in Vietnam never less than 180,000 men and women in support of the war. At one time, this commitment exceeded half a million soldiers, sailors, and airmen from both the United States and its allies. Such forces required an extensive medical presence, including 19 neurologists. All but two of the neurologists had been drafted for a 2-year tour of duty after deferment for residency training. They were assigned to Vietnam for one of those 2 years in two Army Medical Units and one Air Force facility providing neurological care for American and allied forces, as well as many civilians. Their practice included exposure to unfamiliar disorders including cerebral malaria, Japanese B encephalitis, sleep deprivation seizures, and toxic encephalitis caused by injection or inhalation of C-4 explosive. They and neurologists at facilities in the United States published studies on all of these entities both during and after the war. These publications spawned the Defense and Veterans Head Injury Study, which was conceived during the Korean War and continues today as the Defense and Veterans Head Injury Center. It initially focused on post-traumatic epilepsy and later on all effects of brain injury. The Agent Orange controversy arose after the war; during the war, it was not perceived as a threat by medical personnel. Although soldiers in previous wars had developed serious psychological impairments, post-traumatic stress disorder was formally recognized in the servicemen returning from Vietnam.
The Influence of the Two World Wars on the Development of Rehabilitation for Spinal Cord Injuries in the United States and Great Britain.
Lanska DJ
Front Neurol Neurosci · 2016 · PMID 27035365 · Publisher ↗
During World War I, physical and occupational therapies became important adjuncts to surgical practice, particularly for orthopedic casualties, but there was little progress in the management of severe brain and spinal c...
During World War I, physical and occupational therapies became important adjuncts to surgical practice, particularly for orthopedic casualties, but there was little progress in the management of severe brain and spinal cord injuries (SCIs), largely because of the very high mortality of such injuries at that time. During World War II (WWII), rehabilitation was greatly expanded into an integrated, comprehensive multidisciplinary program in the U.S. military, largely because of the efforts of Howard Rusk (1901-1989), initially in the Army Air Corps and later across all of the services. With Bernard Baruch's (1870-1965) assistance, Rusk was also successful in swaying President Franklin Delano Roosevelt (1882-1945) to support rehabilitation for injured veterans and to give official standing to rehabilitation medicine in the military and the Veterans Administration after WWII. Such WWII developments in rehabilitation medicine had a profound effect on the care, functional outcomes, and survival of veterans with SCIs. Neurosurgeon Donald Munro's (1898-1978) prototype SCI unit at Boston City Hospital in 1936 influenced the U.S. Army to establish several SCI centers during WWII and influenced urologist Ernest Bors (1900-1990) to pioneer SCI care in Veterans Administration medical centers after WWII. In Britain, the organizational leadership of George Riddoch (1888-1947) led to the development of SCI units that saw their greatest development by Ludwig Guttmann (1899-1980) at Stoke-Mandeville Hospital in Aylesbury, near London. These SCI centers provided a comprehensive spectrum of care, including medical, neurological, and surgical management; psychological counseling; and rehabilitation focused on improving self-care, mobility, and re-assimilation into society. After WWII, military developments in comprehensive rehabilitation were promulgated to and developed in the revitalized Veterans Administration and then disseminated to civilian populations.
Neurological Impact of World War I on the Artistic Avant-Garde: The Examples of André Breton, Guillaume Apollinaire and Blaise Cendrars.
Bogousslavsky J, Tatu L
Front Neurol Neurosci · 2016 · PMID 27035346 · Publisher ↗
World War I erupted at a time when artistic avant-gardes were particularly thriving across Europe. Young poets, writers, painters and sculptors were called to arms or voluntary enrolled to fight, and several of them died...
World War I erupted at a time when artistic avant-gardes were particularly thriving across Europe. Young poets, writers, painters and sculptors were called to arms or voluntary enrolled to fight, and several of them died during the conflict. Among others, it dramatically changed their creative output, either through specific wounds or through personal encounters and experiences. These individual events then significantly modified the course of the literary and artistic avant-garde movements. Three particularly illustrative examples of avant-garde French poets are presented here: André Breton (1896-1966), Guillaume Apollinaire (1880-1918) and Blaise Cendrars (1887-1961). The deep source of the surrealist movement can indeed be found in André Breton's involvement as an auxiliary physician with critical interest in neuropsychiatry, which caused him to discover automatic writing. Guillaume Apollinaire's right temporal subdural hematoma strongly modified his emotional state and subsequent artistic activities. Alternatively, after losing his right, writing hand, Blaise Cendrars not only substituted it with a phantom but also rapidly switched from poetry to novels after he learnt to write with his left hand.
Publications on Peripheral Nerve Injuries during World War I: A Dramatic Increase in Knowledge.
Koehler PJ
Front Neurol Neurosci · 2016 · PMID 27035152 · Publisher ↗
Publications from French (Jules Tinel and Chiriachitza Athanassio-Bénisty), English (James Purves-Stewart, Arthur Henry Evans and Hartley Sidney Carter), German (Otfrid Foerster and Hermann Oppenheim) and American (Charl...
Publications from French (Jules Tinel and Chiriachitza Athanassio-Bénisty), English (James Purves-Stewart, Arthur Henry Evans and Hartley Sidney Carter), German (Otfrid Foerster and Hermann Oppenheim) and American (Charles Harrison Frazier and Byron Stookey) physicians from both sides of the front during World War I (WWI) contributed to a dramatic increase in knowledge about peripheral nerve injuries. Silas Weir Mitchell's original experience with respect to these injuries, and particularly causalgia, during the American Civil War was further expanded in Europe during WWI. Following the translation of one of his books, he was referred to mainly by French physicians. During WWI, several French books were in turn translated into English, which influenced American physicians, as was observed in the case of Byron Stookey. The establishment of neurological centres played an important role in the concentration of experience and knowledge. Several eponyms originated during this period (including the Hoffmann-Tinel sign and the Froment sign). Electrodiagnostic tools were increasingly used.
Neuropsychiatric Disturbances, Self-Mutilation and Malingering in the French Armies during World War I: War Strain or Cowardice?
Tatu L, Bogousslavsky J
Front Neurol Neurosci · 2016 · PMID 27035133 · Publisher ↗
Between 1914 and 1918, war strain appeared under a number of guises and affected, to varying extents, the majority of French soldiers. The most frequent form of war strain was war psychoneurosis, but war strain also indu...
Between 1914 and 1918, war strain appeared under a number of guises and affected, to varying extents, the majority of French soldiers. The most frequent form of war strain was war psychoneurosis, but war strain also induced more paroxystic disorders, such as acute episodes of terror, self-mutilation, induced illnesses and even suicide. Fear was the constant companion of soldiers of the Great War: soldiers were either able to tame it or overwhelmed by an uncontrollable fear. Nonetheless, over the course of the war, some aspects of fear were recognised as syndromes. The French health service poorly anticipated the major consequences of war strain, as with many other types of injuries. After the establishment of wartime neuropsychiatric centres, two main medical stances emerged: listening to soldiers empathetically on the one hand and applying more repressive management on the other. For many physicians, the psychological consequences of this first modern war were synonymous with malingering or cowardice in the face of duty. The stance of French military physicians in relation to their command was not unequivocal and remained ambivalent, swaying between medico-military collusion and empathy towards soldiers experiencing psychological distress. The ubiquity of suspected malingering modified the already porous borders between neuropsychiatric disorders and disobedience. Several war psychoneurotic soldiers were sentenced by councils of war for deserting their posts in the face of the enemy and were shot. Many soldiers suspected of self-mutilation or suffering from induced illnesses were also sentenced and executed without an expert assessment of their wound or their psychological state.
New Insights in Minimally Invasive Surgery for Intracerebral Hemorrhage.
Wang WM, Jiang C, Bai HM
Front Neurol Neurosci · 2015 · PMID 26588789 · Publisher ↗
The poor clinical outcome of acute intracerebral hemorrhage (ICH) relates closely to the bleeding amount per unit of time and the hematoma position in the brain. Removal of an intracerebral hematoma in time can effective...
The poor clinical outcome of acute intracerebral hemorrhage (ICH) relates closely to the bleeding amount per unit of time and the hematoma position in the brain. Removal of an intracerebral hematoma in time can effectively improve clinical prognosis. Minimally invasive surgery (MIS) for the treatment of ICH is the main clinical method that is currently used, despite the lack of large-scale, clinical, multi-center, randomized controlled trials. This article comprehensively reviews the history and development of MIS for ICH and analyzes various roles of MIS in ICH treatment. General CT image-guided surgery with the local use of thrombolysis techniques is a major MIS method used in current ICH treatment.
New Insights into Blood Pressure Control for Intracerebral Haemorrhage.
Manning LS, Robinson TG
Front Neurol Neurosci · 2015 · PMID 26588787 · Publisher ↗
Although blood pressure (BP) levels may rise in the weeks preceding intracerebral haemorrhage (ICH), in contrast to findings in the ischaemic stroke population, the initial post-ICH BP is often much higher than the last...
Although blood pressure (BP) levels may rise in the weeks preceding intracerebral haemorrhage (ICH), in contrast to findings in the ischaemic stroke population, the initial post-ICH BP is often much higher than the last pre-morbid level. Elevated BP is therefore common in acute ICH, often with markedly elevated levels, and is associated with poor outcomes, though the exact pathophysiological mechanisms remain unclear. The Antihypertensive Treatment of Acute Cerebral Haemorrhage (ATACH) trial and the INTEnsive blood pressure Reduction in Acute Cerebral haemorrhage Trial (INTERACT) demonstrated that early and intensive lowering of elevated BP in the acute ICH period is feasible and safe. Importantly, recent CT perfusion studies have shown that early, intense BP reduction does not reduce cerebral blood flow or promote cerebral ischaemia. The recent, large INTERACT2 trial confirmed the safety of early BP lowering in ICH and suggested that intensive target-driven BP reduction may improve outcomes, with a non-significant trend towards reduced death and major disability and a significant favourable shift of scores on the modified Rankin scale compared with guideline-based treatment. BP lowering in acute ICH may reduce haematoma growth, particularly when target levels are achieved early and are sustained, though the evidence is partly conflicting. Other aspects of BP may also be important following acute ICH, with maximum systolic BP and systolic BP variability being independent predictors of poor outcomes in a recent study. This chapter gives an overview of the current evidence regarding BP in ICH and covers the following topics: the incidence of elevated BP in acute ICH and the patterns of BP observed before and after the event; the effect of elevated BP on outcomes in ICH and the potential underlying pathophysiological mechanisms; the safety and feasibility of BP lowering; the effects of BP lowering on clinical and radiological outcomes; other important aspects of BP in ICH; and the choice of antihypertensive agent.
Surgical Craniotomy for Intracerebral Haemorrhage.
Mendelow AD
Front Neurol Neurosci · 2015 · PMID 26588582 · Publisher ↗
Craniotomy is probably indicated for patients with superficial spontaneous lobar supratentorial intracerebral haemorrhage (ICH) when the level of consciousness drops below 13 within the first 8 h of the onset of the haem...
Craniotomy is probably indicated for patients with superficial spontaneous lobar supratentorial intracerebral haemorrhage (ICH) when the level of consciousness drops below 13 within the first 8 h of the onset of the haemorrhage. Once the level drops below 9, it is probably too late to consider craniotomy for these patients, so clinical vigilance is paramount. While this statement is only backed up by evidence that is moderately strong, meta-analysis of available data suggests that it is true in the rather limited number of patients with ICH. Meta-analyses like this can often predict the results of future prospective randomised controlled trials a decade or more before the trials are completed and published. Countless such examples exist in the literature, as is the case for thrombolysis in patients with myocardial infarction in the last millennium: meta-analysis determined the efficacy more than a decade BEFORE the last trial (ISIS-2) confirmed the benefit of thrombolysis for myocardial infarction. Careful examination of the meta-analysis' Forest plots in this chapter will demonstrate why this statement is made at the outset. Other meta-analyses of surgery for ICH have also indicated that minimal interventional techniques using topical thrombolysis or endoscopy via burrholes or even twist drill aspiration may be particularly successful for the treatment of supratentorial ICH, especially when the clot is deep seated. Ongoing clinical trials (CLEAR III and MISTIE III) should confirm this in the fullness of time. There are 2 exceptions to these generalisations. First, based on trial evidence, aneurysmal ICH is best treated with surgery. Second, cerebellar ICH represents a special case because of the development of hydrocephalus, which may require expeditious drainage as the intracranial pressure rises. The cerebellar clot will then require evacuation, usually via posterior fossa craniectomy, rather than craniotomy. Technical advances suggest that image-guided surgery may improve the completeness of surgical evacuation and outcomes, regardless of which surgical technique is employed.
Evidence-Based Critical Care of Intracerebral Hemorrhage: An Overview.
Küppers-Tiedt L, Steiner T
Front Neurol Neurosci · 2015 · PMID 26588581 · Publisher ↗
Outcome of intracerebral hemorrhage (ICH) is still poor and siginificantly influenced by complications during the acute phase, so optimized neurocritical care is crucial. Vital parameters, neurological status and laborat...
Outcome of intracerebral hemorrhage (ICH) is still poor and siginificantly influenced by complications during the acute phase, so optimized neurocritical care is crucial. Vital parameters, neurological status and laboratory values of ICH-patient should be monitored very closely with special attention on blood pressure and intracranial pressure. Systolic blood pressure should be kept <140 mm Hg and intracranial pressure <20 mm Hg. Administration of hemostatic agents in spontaneous ICH without intake of anticoagulants is actually not recommended out of clinical trials. Neurosurgical treatment of ICH is still an individual decision. Patients with a higher level of consciousness may profit from an early operation.
Ventriculostomy and Lytic Therapy for Intracerebral Hemorrhage.
Ziai WC, Nyquist PA, Hanley DF
Front Neurol Neurosci · 2015 · PMID 26588329 · Publisher ↗
Intraventricular hemorrhage (IVH) frequently complicates intracranial hemorrhage (ICH) and is a significant independent contributor to morbidity and mortality, yet therapy directed at ameliorating intraventricular clotti...
Intraventricular hemorrhage (IVH) frequently complicates intracranial hemorrhage (ICH) and is a significant independent contributor to morbidity and mortality, yet therapy directed at ameliorating intraventricular clotting has been limited and until recently, has not been subject to systematic evaluation. Thrombolytic therapy with placement of an external ventricular drain for management of severe IVH secondary to ICH has been investigated in multiple observational studies, small randomized controlled trials and several meta-analyses, soon to culminate with the completion of the 500 patient CLEAR IVH randomized controlled trial. We review conventional and lytic therapeutic approaches to severe IVH in the setting of small ICH, articulating the scope of the problem, management issues, and relevant questions for future research.
Emergency Imaging of Intracerebral Haemorrhage.
Alobeidi F, Aviv RI
Front Neurol Neurosci · 2015 · PMID 26588327 · Publisher ↗
Spontaneous intracerebral haemorrhage (ICH) is a devastating condition with high mortality and morbidity despite advances in neurocritical care. Early deterioration is common in the first few hours after ICH onset, secon...
Spontaneous intracerebral haemorrhage (ICH) is a devastating condition with high mortality and morbidity despite advances in neurocritical care. Early deterioration is common in the first few hours after ICH onset, secondary to rapid haematoma expansion and growth. Rapid diagnosis and aggressive early management of these patients are therefore crucial. Imaging plays a key role in establishing the diagnosis and the underlying aetiology of ICH, identifying complications and predicting patients who are at high risk for haematoma expansion. In this chapter, we present an evidence-based imaging framework for the management of spontaneous ICH in the acute setting. Non-enhanced computed tomography is long established as the gold standard for ICH diagnosis but has limitations in demonstrating the underlying aetiology in cases of secondary ICH. There is now growing evidence for the ability of non-invasive angiography to establish the underlying aetiology and to predict further haematoma expansion. The presence of small enhancing foci within the haematoma on computed tomography angiography (CTA), the CTA Spot Sign, has been prospectively validated as a predictor of haematoma expansion. Early identification of patients at risk of haematoma expansion allows for the appropriate escalation of care to a neurosurgical team, admission to a neurocritical care unit, appropriate supportive therapy and targeted novel medical and surgical interventions. Catheter angiography, which remains the gold standard for identifying underlying secondary vascular lesions, should be used in selected cases. However, non-invasive vascular imaging should be considered as an important step in the diagnosis and early management of secondary ICH patients. Previous concerns related to the radiation dose, contrast-induced nephropathy and cost are addressed in this chapter. Recently, animal models have enabled the qualitative assessment of haematoma expansion, and our increased understanding of ICH may inform future trials of targeted medical and surgical therapies.
Ultra-Early Hemostatic Therapy for Intracerebral Hemorrhage: Future Directions.
Wartenberg KE, Mayer SA
Front Neurol Neurosci · 2015 · PMID 26588167 · Publisher ↗
Hematoma expansion after initial bleeding is associated with many risk factors, such as anticoagulation, diagnosis by computed tomography (CT) shortly after symptom onset, liver disease, and a high initial blood pressure...
Hematoma expansion after initial bleeding is associated with many risk factors, such as anticoagulation, diagnosis by computed tomography (CT) shortly after symptom onset, liver disease, and a high initial blood pressure, among others, and with increased mortality and poor long-term functional outcomes. Contrast extravasation on CT angiogram, termed 'the spot sign', and on delayed-contrast CT scans (13-59%) may help to identify impending intracerebral hemorrhage growth and may open a window of opportunity for therapeutic interventions. The spot sign score, the prediction score for hematoma expansion, and the BRAIN score were developed to assess the probability of hematoma expansion at 24 h. Therapeutic interventions to promote hemostasis are currently limited to intensive blood pressure control and antagonization of the effect of antiplatelets and anticoagulation. Ultra-early hemostasis for ICH not associated with coagulopathy may include administration of recombinant factor VIIa and tranexamic acid to selected patients based on the presence of a spot sign on the CT angiogram is currently under investigation.
Epidemiology of Intracerebral Haemorrhage.
Poon MT, Bell SM, Al-Shahi Salman R
Front Neurol Neurosci · 2015 · PMID 26588164 · Publisher ↗
INTRODUCTION: Intracerebral haemorrhage (ICH) has an overall incidence of 24.6 per 100,000 person-years and is associated with a high case fatality. Understanding the risk factors for ICH occurrence informs primary preve...
INTRODUCTION: Intracerebral haemorrhage (ICH) has an overall incidence of 24.6 per 100,000 person-years and is associated with a high case fatality. Understanding the risk factors for ICH occurrence informs primary prevention strategies. This article provides an update on the current global patterns of ICH incidence and the common and emerging risk factors associated with ICH. METHODS: We searched Ovid Medline (from 1980 to Oct 2014) for systematic reviews that addressed the epidemiology of ICH and for recent original studies that revealed new insights into the frequency of and the risk factors associated with ICH. RESULTS: The incidence of ICH has not changed over the last 30 years, and this consistency is thought to be due to changes in the risk factor profiles of ICH patients. It appears that ICH is more common in men and during the winter months. ICH affects Asian populations more frequently than other populations. In addition to the known risk factors of hypertension and increasing age, alcohol consumption, the presence of the apolipoprotein ε2 or ε4 allele, extremes of body mass index, diabetes, and ophthalmic conditions have been suggested to be associated with ICH. Factors associated with a reduced risk of ICH include hypercholesterolaemia and a diet high in fruits and vegetables. CONCLUSIONS: The overall incidence of ICH has remained unchanged, but its regional incidence varies by race, sex, season and geographical location. In high income countries, the beneficial effect of improving blood pressure control may be counterbalanced by the increased use of antithrombotic drugs. Emerging modifiable risk factors include alcohol consumption, body mass index, diabetes, and fruit and vegetable intake, all of which may be amenable to interventions for the primary prevention of ICH (as well as many other diseases).
New Insights into Nonvitamin K Antagonist Oral Anticoagulants' Reversal of Intracerebral Hemorrhage.
Yasaka M
Front Neurol Neurosci · 2015 · PMID 26588018 · Publisher ↗
The nonvitamin K antagonist oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban are associated with an equal or lower incidence of stroke and systemic embolism and a much lower incidence of intrac...
The nonvitamin K antagonist oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban are associated with an equal or lower incidence of stroke and systemic embolism and a much lower incidence of intracranial hemorrhage and hemorrhagic stroke than warfarin is, without the need for routine laboratory monitoring. However, reversal strategies are not currently established in the case of NOAC-related hemorrhagic stroke. In emergency situations, well-defined management for NOAC-related hemorrhagic stroke may improve clinical outcomes. Thus, in this chapter, general measures initially required to prevent the expansion of intracerebral hematomas, charcoal administration to reduce NOAC absorption from the gastrointestinal tract, application of hemodialysis to remove dabigatran, and coagulation factor therapy including 4-factor prothrombin complex concentrate and recombinant activated factor VII are reviewed. The specific reversal agents idarucizumab, which is a monoclonal antibody against dabigatran; andexanet alfa, a recombinant human factor Xa decoy for Xa inhibitors; and PER977, a small synthetic molecule for reversal of both Xa and thrombin inhibitors, are currently under development. These agents will facilitate the clinical management of NOAC-associated hemorrhagic stroke and other severe bleeding.
Cerebral Microbleeds: Detection, Associations and Clinical Implications.
Yakushiji Y
Front Neurol Neurosci · 2015 · PMID 26587900 · Publisher ↗
Vigorous investigations for cerebral microbleeds (CMBs) have been made since the late 1990s. CMBs on paramagnetic-sensitive magnetic resonance sequences correspond pathologically to clusters of hemosiderin-laden macropha...
Vigorous investigations for cerebral microbleeds (CMBs) have been made since the late 1990s. CMBs on paramagnetic-sensitive magnetic resonance sequences correspond pathologically to clusters of hemosiderin-laden macrophages and have emerged as an important new imaging marker of cerebral small vessel disease, including intracerebral hemorrhage (ICH). The prevalence of CMBs varies according to the specific disease settings (stroke subtypes and dementing disorders) and is highest (60%) in ICH patients. The associations of CMBs with aging, hypertension and apolipoprotein E genotype are consistent with the two major underlying pathogeneses of CMBs: hypertensive arteriopathy and cerebral amyloid angiopathy (CAA). The distributional patterns of CMBs might help us to understand the predominant small vessel disease pathogenesis in the brain; the strictly lobar type of CMBs often reflects the presence of advanced CAA, while the other types of CMBs, such as 'deep or infratentorial CMBs', including the mixed type, are strongly associated with hypertension. CMBs might be associated with cognitive function (especially executive function), gait performance, and cerebrovascular events (spontaneous, antithrombotic drug-related or post-thrombolysis ICH). In the field of CAA, an understanding of CAA-related CMBs might help to guide decision making with regard to new therapeutic approaches, including the use of monoclonal antibodies against vascular amyloid. These concepts of CMBs might allow us to advance research on ICH as well as for dementia.
Reperfusion-Related Intracerebral Hemorrhage.
Hayakawa M
Front Neurol Neurosci · 2015 · PMID 26587772 · Publisher ↗
The efficacy of intravenous thrombolysis (IVT) for acute ischemic stroke patients has been well established worldwide, with endovascular therapy performed in patients who have failed or are ineligible for IVT and who hav...
The efficacy of intravenous thrombolysis (IVT) for acute ischemic stroke patients has been well established worldwide, with endovascular therapy performed in patients who have failed or are ineligible for IVT and who have major vessel occlusion. The most feared complication of acute stroke reperfusion therapy is intracerebral hemorrhage (ICH), as these patients have a poor clinical outcome and high mortality. The fundamental mechanisms responsible for reperfusion-related ICH include increased permeability and disruption of the blood-brain barrier. Recombinant tissue plasminogen activator may exacerbate the blood-brain barrier disruption through its pharmacological action during IVT. Furthermore, interactions between the device and the vessel walls and contrast intoxication may also be related to ICH, which includes the occurrence of subarachnoid hemorrhage after endovascular therapy. Numerous factors have been reported to be associated with or to be able to predict ICH, and several scoring systems have been developed for predicting symptomatic ICH (sICH) after IVT. However, a scoring system with enough power to detect an unacceptably high risk of sICH or to provide information on when to withdraw IVT has yet to be definitively established. In current clinical practice, acute stroke patients without contraindications for IVT who have been identified by conventional computed tomography scans normally undergo IVT, irrespective of any clinical predictors of ICH after IVT. Strategies that have been suggested for preventing reperfusion-related ICH in high-risk patients include intensive blood pressure control, tight glycemic control, and the avoidance of early aggressive antithrombotic therapy. If sICH, and especially massive parenchymal hematoma, does occur, hematoma expansion needs to be prevented through the use of tight blood pressure control and other methods. Although evidence of efficacy has yet to be established, surgical removal is performed not only for the purpose of saving lives but also for improving the functional outcome. In order to develop therapeutic strategies for reperfusion-related ICH that will lead to an improved stroke prognosis, further studies are warranted.
Prognosis and Outcome of Intracerebral Haemorrhage.
Moulin S, Cordonnier C
Front Neurol Neurosci · 2015 · PMID 26587771 · Publisher ↗
Spontaneous intracerebral haemorrhage (ICH) accounts for approximately 15% of all strokes and is a leading cause of disability, with a one-month mortality rate of 40%. Whereas factors predicting short-term mortality are...
Spontaneous intracerebral haemorrhage (ICH) accounts for approximately 15% of all strokes and is a leading cause of disability, with a one-month mortality rate of 40%. Whereas factors predicting short-term mortality are well known, data regarding long-term outcome are scarce and imprecise. The two main underlying vasculopathies responsible for ICH, i.e. deep perforating vasculopathy and cerebral amyloid angiopathy, might have an impact on the overall prognosis of ICH survivors. ICH survivors are at high risk of epileptic seizures, depression and cognitive impairment, which may influence their functional outcome. Lobar location of an ICH, frequently due to cerebral amyloid angiopathy, partly determines the long-term risk of recurrent haemorrhage. Because of common vascular risk factors, patients with ICH are also at considerable risk of serious ischaemic events. Risks of future ischaemic events may be as high as that of recurrent ICH, raising the relevance of antithrombotic treatment in ICH survivors. Future studies of long-term follow-up after ICH are needed to determine predictors of outcome, including biomarkers of the underlying vasculopathies, to tailor preventive strategies to survivors.
Emergency Reversal Strategies for Anticoagulation and Platelet Disorders.
Levi M
Front Neurol Neurosci · 2015 · PMID 26587647 · Publisher ↗
Bleeding is the most important adverse effect of antithrombotic treatment and may be a major cause of morbidity, longstanding debilitation, and even mortality. In the case of severe hemorrhage in a patient who uses antic...
Bleeding is the most important adverse effect of antithrombotic treatment and may be a major cause of morbidity, longstanding debilitation, and even mortality. In the case of severe hemorrhage in a patient who uses anticoagulant agents, it may be crucial to reverse anticoagulant treatment. Conventional anticoagulants such as vitamin K antagonists can be neutralized by the administration of vitamin K or prothrombin complex concentrates, whereas heparin and heparin derivatives can be counteracted by protamine sulfate. The antihemostatic effect of aspirin and other antiplatelet strategies can be corrected by the administration of platelet concentrate and/or desmopressin. Recently, a new generation of anticoagulants with a greater specificity toward activated coagulation factors as well as new antiplatelet agents have been introduced, and these drugs show efficacy and safety profiles that are at least as good as those of conventional agents in clinical studies. A limitation of these new agents may be the lack of a specific strategy to reverse their effects if a bleeding event occurs, although experimental studies show encouraging results for some of these agents.
Surgical Strategies for Acutely Ruptured Arteriovenous Malformations.
Martinez JL, Macdonald RL
Front Neurol Neurosci · 2015 · PMID 26587641 · Publisher ↗
Brain arteriovenous malformations (AVMs) are focal neurovascular lesions consisting of abnormal fistulous connections between the arterial and venous systems with no interposed capillaries. This arrangement creates a hig...
Brain arteriovenous malformations (AVMs) are focal neurovascular lesions consisting of abnormal fistulous connections between the arterial and venous systems with no interposed capillaries. This arrangement creates a high-flow circulatory shunt with hemorrhagic risk and hemodynamic abnormalities. While most AVMs are asymptomatic, they may cause severe neurological complications and death. Each AVM carries an annual rupture risk of 2-4%. Intracranial hemorrhage due to AVM rupture is the most common initial manifestation (up to 70% of presentations), and it carries significant morbidity and mortality. This complication is particularly important in the young and otherwise healthy population, in whom AVMs cause up to one-third of all hemorrhagic strokes. A previous rupture is the single most important independent predictor of future hemorrhage. Current treatment modalities for AVM are microsurgery, endovascular embolization, and radiosurgery. In acutely ruptured AVMs, early microsurgical excision is usually avoided. The standard is to wait at least 4 weeks to allow for patient recovery, hematoma liquefaction, and inflammatory reactions to subside. Exceptions to this rule are small, superficial, low-grade AVMs with elucidated angioarchitecture, for which early simultaneous hematoma evacuation and AVM excision is feasible. Emergent hematoma evacuation with delayed AVM excision (unless, as mentioned, the AVM is low grade) is recommended in patients with a decreased level of consciousness due to intracranial hemorrhage, posterior fossa or temporal lobe hematoma of >30 ml, or hemispheric hematoma of >60 ml. The applicability of endovascular techniques for acutely ruptured AVMs is not clear, but feasible options, until a definitive treatment is determined, include occluding intranidal and distal flow-related aneurysms and 'sealing' any rupture site or focal angioarchitectural weakness when one can be clearly identified and safely accessed. Radiosurgery is not performed in acutely ruptured AVMs because its therapeutic effects occur in a delayed fashion.
Ultrasound-induced blood-brain barrier opening for drug delivery.
Alonso A
Front Neurol Neurosci · 2015 · PMID 25531667 · Publisher ↗
Treatment of central nervous system (CNS) diseases is highly limited due to the presence of the blood-brain barrier (BBB), which prevents the entry of approximately 99% of potential therapeutic agents into the CNS. Focus...
Treatment of central nervous system (CNS) diseases is highly limited due to the presence of the blood-brain barrier (BBB), which prevents the entry of approximately 99% of potential therapeutic agents into the CNS. Focused ultrasound (FUS) in combination with microbubbles can lead to a transient and focal opening of the BBB, thus enabling the passage of therapeutic agents across the BBB. Mechanical ultrasound effects, such as stable and inertial cavitation, contribute to BBB opening, possibly via transient disintegration of tight junctions. Facilitation of transcellular passage through vesicle transport may also be influenced. FUS-induced BBB opening can be performed without tissue damage, given an optimal set of ultrasound parameters. However, the risk of parenchymal damage or microhaemorrhage increases with increasing acoustic energy. To date, several therapeutic substances, such as chemotherapeutics, antibodies, plasmids and viral vectors, have successfully been delivered to the CNS by FUS-induced BBB opening in animal models, including non-human primates. Translation to a clinical application is pending.
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