Lancet neurology
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Between 6.5% and 15.0% of all strokes occur in patients already in hospital, many of whom are there for surgical procedures or cardiac disorders. This important group of patients could potentially be assessed more rapidly than others and could be candidates for interventional therapies. However, delays in recognition and assessment are common, possibly related to comorbidities and the complexities of hospital practice. ⋯ In the postoperative setting, intra-arterial thrombolysis is feasible and reasonably safe in carefully selected patients. Experimental agents and the manipulation of physiological variables are other treatment possibilities that could be applied early in this group of patients. Increasing the awareness by hospital physicians of such interventions may be an important factor that reduces delays in assessment of patients who have stokes while in hospital.
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Ischaemic stroke is an important cause of death and dependency in industrialised countries; it has a high incidence (affecting up to 0.2% of the population each year) and is commonly lethal or disabling. One in six patients die in the first month after ischaemic stroke, and half of survivors are permanently disabled despite best efforts to rehabilitate them and to prevent complications, recurrent stroke, and other serious vascular events. Optimisation of the early, and ongoing, management of patients with acute ischaemic stroke is pivotal to the reduction of both case fatality and long-term disability. ⋯ Guidelines for the early management of patients with ischaemic stroke have recently been published by the Stroke Council of the American Stroke Association (ASA; Adams and co-workers, Stroke 2003; 34: 1056-83) and the European Stroke Initiative (EUSI; European Stroke Initiative Executive Committee and Writing Committee, Cerebrovasc Dis 2003; 16: 311-38). Although transatlantic differences might create different interpretations, priorities, and views, the guidelines are remarkably similar, even regarding controversial issues. We believe this is not only because both groups have had the opportunity to discuss many of the controversial issues at international meetings, but also because both groups have endorsed the concept of evidence-based medicine and have based their recommendations on similar classifications of the levels of evidence for the effectiveness of interventions. This is a triumph for evidence-based medicine and a major step towards unification of acute stroke management worldwide. WHERE NEXT?: There are three main challenges in stroke management. To increase the body of reliable evidence from large randomised controlled trials (RCTs) of the safety, effectiveness, and cost of promising treatments (eg, thrombolysis, antithrombotic therapy, neuroprotection, and interventional recanalisation, alone and in combination) in a wide range of patients around the world. To facilitate the widespread development of stroke units, delivery of organised stroke care, and emergency transport of patients with stroke to appropriate stroke centres. And finally, to improve the uptake of effective therapies into clinical practice (eg, by widely disseminating the ASA and EUSI guidelines).
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Hemiballism is a rare movement disorder that presents with unilateral flinging movements of the limbs. In traditional teaching, it has been characterised as almost pathognomonic of a lesion in the subthalamic nucleus (STN). The prognosis was described as grave, with severe disability and death in many cases. ⋯ The prognosis is benign in most cases, with almost all patients responding well to treatment and many having spontaneous remission, although long-term prognosis of cerebrovascular disease may not be so good. There have also been recent insights into the pathophysiology of hemiballism, which have emphasised the importance of altered firing patterns in basal-ganglia structures. Recent studies have pointed to previously unrecognised causes, particularly non-ketotic hyperosmolar hyperglycaemia and complications of HIV infection, that may account for a substantial proportion of cases of hemiballism.
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Symptoms of abnormal autonomic-nervous-system function occur commonly in Parkinson's disease (PD). Orthostatic hypotension in patients with parkinsonism has been thought to be a side-effect of treatment with levodopa, a late stage in the disease progression, or, if prominent and early with respect to disordered movement, an indication of a different disease, such as multiple system atrophy. ⋯ Post-mortem studies confirm this distinction. Because PD involves postganglionic sympathetic noradrenergic lesions, the disease seems to be not only a movement disorder with dopamine loss in the nigrostriatal system of the brain, but also a dysautonomia, with norepinephrine loss in the sympathetic nervous system of the heart.