Nature reviews. Neurology
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Intracerebral hemorrhage (ICH) is a major public-health problem worldwide. No proven treatments are available for this condition, which is associated with high rates of morbidity and mortality. Only 20% of individuals who survive ICH are independent at 6 months. ⋯ Many questions remain unanswered regarding the clinical management of ICH, although in the past 10 years completed medical and surgical clinical trials-examining hemostatic therapy, blood pressure control and/or hematoma evacuation-have refined our understanding of the goals of such management. Ongoing clinical trials, which have built on the lessons of past studies, hold promise for the development of effective, scientifically proven treatments for ICH. In this Review, we discuss clinical trials for ICH that have been completed in the past 10 years, the contributions of these studies to the clinical management of ICH, and the ongoing trials that might further improve clinical care.
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Medically refractory focal epilepsy is potentially curable by surgery. This Review considers the application of recent advances in structural and functional brain imaging to increase the number of patients with epilepsy who are treated surgically, and to reduce the risk of complications arising from such intervention. Current optimal MRI of brain structure can identify previously undetectable lesions, with voxel-based and quantitative analyses further increasing the diagnostic yield. ⋯ Tractography can visualize the main cerebral white matter tracts, thereby predicting and reducing surgery risk. Currently, displays of the optic radiation and pyramidal tracts are the most relevant for epilepsy surgery. Reliable integration of structural and functional data into surgical image-guidance systems is being pursued, and promises safer neurosurgery for epilepsy in the future.
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Nature reviews. Neurology · Mar 2010
ReviewHyperglycemia in acute ischemic stroke: pathophysiology and clinical management.
Patients with acute ischemic stroke frequently test positive for hyperglycemia, which is associated with a poor clinical outcome. This association between poor glycemic control and an unfavorable prognosis is particularly evident in patients with persistent hyperglycemia, patients without a known history of diabetes mellitus, and patients with cortical infarction. To date, however, only one large clinical trial has specifically investigated the effect of glycemic control on stroke outcome. ⋯ Here we review the available evidence linking hyperglycemia to a poor clinical outcome in patients with ischemic stroke. We highlight the pathophysiological mechanisms that might underlie the deleterious effects of hyperglycemia on acute stroke prognosis and systematically review the literature concerning tight glycemic control after stroke. Finally, we provide directions on the use of insulin treatment strategies to control hyperglycemia in this patient group.
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Nature reviews. Neurology · Sep 2009
Review Case ReportsA case of postpartum cerebral angiopathy with subarachnoid hemorrhage.
A 33-year-old woman experienced a thunderclap headache immediately postpartum. The headache recurred over the next 10 days, and the patient also developed generalized tonic-clonic seizures. A subarachnoid hemorrhage was demonstrated on a head CT scan. ⋯ NSAIds and opioid analgesics administered on postpartum day 3 provided partial headache relief. The next day, a blood patch was performed and intravenous caffeine, fluid and opioid analgesia were given to treat a suspected dural puncture headache. Following diagnosis of postpartum cerebral angiopathy on postpartum day 10, nimodipine was initiated to treat the vasospasm, and the headache was treated with opioid analgesics and toradol, followed by naproxen. The patient also received a 3-day course of intravenous magnesium sulfate.
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Despite the proven benefits of thrombolysis for patients presenting with acute ischemic stroke, only a limited number of patients receive thrombolytic therapy. The reason for the low treatment rate is that thrombolysis is only effective a few hours after the onset of ischemic stroke, so delays in patients being admitted to hospital and being diagnosed mean that the therapeutic window is often missed. Major factors that lead to prehospital delay include the general public's lack of knowledge of stroke symptoms and their poor understanding of the appropriate course of action following a stroke. ⋯ Deficiencies in the identification of stroke by emergency medical services and general practitioners also contribute to prehospital delay. Aggressive, combined educational programs aimed at the general public, general practitioners, and medical and paramedical hospital staff can lead to increased stroke treatment rates. In this Review, we explore the extent of prehospital delay in stroke, identify the factors that affect the time taken for patients to reach hospital, and describe strategies designed to reduce the delay.