Ischemic Stroke Feske, Steven K.
The American journal of medicine,
December 2021, 2021-12-00, 20211201, Letnik:
134, Številka:
12
Journal Article
Recenzirano
This concise review of the epidemiology, pathophysiology, evaluation, acute management, and prevention of ischemic stroke targets internists, family practitioners, and emergency physicians who manage ...patient with stroke.
The late 20th and early 21st centuries have seen a reduction in stroke risk resulting from lifestyle changes such as widespread smoking cessation and more regular exercise, advances in the treatment ...of hypertension and hyperlipidemia, and better control of the vascular complications of diabetes.
1
Antiplatelet agents have played a major role as well. According to a meta-analysis from the Antithrombotic Trialists’ Collaboration, antiplatelet therapies reduce the relative risk of stroke by approximately 25%, or the absolute risk by 3.6 percentage points, over a period of 2 years.
2
The medical cost for this benefit is a slightly increased risk of major . . .
Encephalopathy due to reversible cerebral edema is an important cause of neurologic morbidity accompanying many disorders. Although controversy remains concerning the pathophysiologic trigger, the ...mechanism of this disorder ultimately depends on failure of the blood-brain barrier to maintain the compartmentalization of intravascular fluid. This failure of the blood-brain barrier depends primarily on the capillary hydrostatic pressure, under the influence of the systemic blood pressure, and on the integrity of the structures that make up the blood-brain barrier, most importantly the vascular endothelium, under the influence of various diseases and toxic medications. Although typical clinical contexts and presentations have been well defined, many patients have atypical features that pose a diagnostic challenge. Therefore, awareness of this clinical variability is important for prompt diagnosis. This review discusses the history and pathophysiology of posterior reversible encephalopathy syndrome and then addresses its clinical diagnosis and management.
IMPORTANCE Many clinical trials focus on restricting hematoma expansion following acute intracerebral hemorrhage (ICH), but selecting those patients at highest risk of hematoma expansion is ...challenging. OBJECTIVE To develop a prediction score for hematoma expansion in patients with primary ICH. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study at 2 urban academic medical centers among patients having primary ICH with available baseline and follow-up computed tomography for volumetric analysis (817 patients in the development cohort and 195 patients in the independent validation cohort). MAIN OUTCOMES AND MEASURES Hematoma expansion was assessed using semiautomated software and was defined as more than 6 mL or 33% growth. Covariates were tested for association with hematoma expansion using univariate and multivariable logistic regression. A 9-point prediction score was derived based on the regression estimates and was subsequently tested in the independent validation cohort. RESULTS Hematoma expansion occurred in 156 patients (19.1%). In multivariable analysis, predictors of expansion were as follows: warfarin sodium use, the computed tomography angiography spot sign, and shorter time to computed tomography (≤6 vs >6 hours) (P < .001 for all), as well as baseline ICH volume (<30 reference, 30-60 P = .03, and >60 P = .005 mL). The incidence of hematoma expansion steadily increased with higher scores. In the independent validation cohort (n = 195), our prediction score performed well and showed strong association with hematoma expansion (odds ratio, 4.59; P < .001 for a high vs low score). The C statistics for the score were 0.72 for the development cohort and 0.77 for the independent validation cohort. CONCLUSIONS AND RELEVANCE A 9-point prediction score for hematoma expansion was developed and independently validated. The results open a path for individualized treatment and trial design in ICH aimed at patients at highest risk of hematoma expansion with maximum potential for therapeutic benefit.
Stroke in Pregnancy Sells, Christina Mijalski; Feske, Steven K
Seminars in neurology,
12/2017, Letnik:
37, Številka:
6
Journal Article
Recenzirano
Pregnancy and the postpartum period confer an increased risk of stroke. The risk appears to be increased for all strokes during the puerperium and for hemorrhagic strokes during pregnancy. During ...pregnancy, physiologic systems are under increased stress to accommodate the growing fetus, which results in substantial hemodynamic, cardiovascular, hematologic, immunologic, and structural connective tissue changes that account for much of this increased risk. In addition, preeclampsia-eclampsia has major effects on the vascular system, and this disorder, unique to pregnancy, is another major contributor to this risk. The common independent vascular risk factors for stroke, such as hypertension, diabetes, hyperlipidemia, and smoking, may also be present to contribute to the risks conferred by pregnancy. Though uncommon, stroke during pregnancy and in the postpartum period causes substantial morbidity and mortality in affected women, and it poses a significant risk to the fetus. This review will discuss the epidemiology of pregnancy-associated stroke, specific risk factors and mechanisms, clinical presentation and management, and future directions.
OBJECTIVE:To compare rates of intracerebral hemorrhage (ICH) in HIV-infected and uninfected individuals in a large clinical care cohort and to assess risk factors associated with ICH.
METHODS:We ...identified incident ICH in HIV-infected and uninfected control cohorts from the Partners Health Care system using ICD-9-CM codes. We constructed Cox proportional hazards models to estimate adjusted hazard ratios for HIV infection and other predictors of ICH.
RESULTS:The incidence rate of ICH was 2.29 per 1,000 person-years in HIV-infected individuals compared with 1.23 per 1,000 person-years in uninfected individuals, with an unadjusted incidence rate ratio of 1.85 (95% confidence interval 1.37–2.47, p < 0.001). In a multivariable model, HIV infection was independently associated with a higher hazard of ICH, although its effect diminished with increasing age. Female sex was associated with a lower hazard of ICH in the uninfected cohort but not in the HIV cohort. CD4 count <200 × 10 cells/L and anticoagulant use were predictive of ICH.
CONCLUSIONS:HIV infection conferred an increased adjusted hazard of ICH, which was more pronounced in young patients and in women.
BACKGROUND:Cardiovascular disease is increased among HIV-infected patients, but little is known regarding ischemic stroke rates. We sought to compare stroke rates and determine stroke risk factors in ...HIV-infected versus non-HIV-infected patients.
METHODS:An HIV cohort and matched non-HIV comparator cohort seen between 1996 and 2009 were identified from a Boston health care system. The primary endpoint was ischemic stroke, defined using International Classification of Diseases (ICD) codes. Unadjusted stroke incidence rates were calculated. Cox proportional hazards modeling was used to determine adjusted hazard ratios (HRs).
RESULTS:The incidence rate of ischemic stroke was 5.27 per 1000 person-years in HIV-infected compared with 3.75 in non-HIV-infected patients, with an unadjusted HR of 1.40 95% confidence interval (CI)1.17 to 1.69, P < 0.001. HIV remained an independent predictor of stroke after controlling for demographics and stroke risk factors (HR1.21, 95% CI1.01 to 1.46, P = 0.043). The relative increase in stroke rates (HIV vs. non-HIV) was significantly higher in younger HIV patients (incidence rate ratio4.42, 95% CI1.56 to 11.09, age 18–29; 2.96, 1.69–4.96, age30–39; 1.53, 1.06–2.17, age40–49), and in women HR2.16 (95% CI1.53 to 3.04) for women vs. HR1.18 (95% CI0.95 to 1.47) for men. Among HIV patients, increased HIV RNA (HR1.10, 95% CI1.04 to 1.17, P = 0.001) was associated with an increased risk of stroke.
CONCLUSIONS:Stroke rates were increased among HIV-infected patients, independent of common stroke risk factors, particularly among young patients and women.
Images show tortuosity and ectasia of both internal carotid arteries with septa of the right (C) and left (D) internal carotid arteries suggesting past arterial dissections (white arrows). ...Fluorodeoxyglucose positron emission tomography (18F-FDG PET) showing patchy increased radiopharmaceutical uptake along the infrarenal aorta involving the proximal common iliac arteries (white arrowheads). Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research.
PDF
