Seminars in neurology
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Intraarterial therapy for acute ischemic stroke (AIS) was originally described five decades ago. Since then, the endovascular management of AIS endovascular therapy has advanced swiftly, and a promising body of evidence informing patient selection and interventional techniques has accrued. The authors discuss the evolution of endovascular therapy for AIS, including a review of recently published landmark clinical trials.
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Seminars in neurology · Nov 2013
ReviewManagement of arterial vasospasm following aneurysmal subarachnoid hemorrhage.
Despite recent advances, cerebral vasospasm and delayed cerebral ischemia (DCI) still represent a major cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Although a significant portion of the morbidity and mortality associated with aSAH is related to the initial hemorrhagic ictus, cerebral vasospasm and DCI are still the leading cause of poor outcomes and death in the acute posthemorrhage period, causing long-term disability or death in more than one in five of all patients who have suffered aSAH and initially survived. Management of patients following aSAH includes four major considerations: (1) prediction of patients at highest risk for development of DCI, (2) prophylactic measures to reduce its occurrence, (3) monitoring to detect early signs of cerebral ischemia, and (4) treatments to correct vasospasm and cerebral ischemia once it occurs. The authors review the pertinent literature related to each, including both the current management guidelines supported by the literature as well as novel management strategies that are currently being investigated.
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Acute continuous vertigo presentations are among the most feared presentations in medicine. Although a self-limited disorder is the typical cause, a life-threatening stroke can also occur. Differentiating a self-limited disorder from a life-threatening stroke can be a challenge. ⋯ A focused oculomotor examination is a necessary component of the assessment, but is underused in routine care. The author describes the challenges to diagnosing stroke in cases of acute continuous vertigo and provides an approach to inform decision making at the bedside. Future research is necessary to validate clinical decision support, assess generalizability, and demonstrate its impact on meaningful outcomes.
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Stroke in the distribution of the posterior circulation may present as acute onset spontaneous vertigo and imbalance. Although vertigo due to posterior circulation stroke is usually associated with other neurologic symptoms or signs, small infarcts in the cerebellum or brainstem can present with vertigo without other localizing symptoms. Approximately 17% of patients with isolated posterior inferior cerebellar artery territory infarction presented with isolated vertigo, nystagmus, and postural unsteadiness. ⋯ Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the anterior inferior cerebellar artery). In this case, evaluation of isolated audiovestibular loss may prevent the progression of acute vertigo and hearing loss into more widespread areas of infarction in the posterior circulation. In this article, the clinical syndromes and signs of acute vestibular syndrome due to posterior circulation stroke involving the brainstem and cerebellum are summarized.
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Seminars in neurology · Jul 2013
ReviewClinical characteristics of cervicogenic-related dizziness and vertigo.
Cervical vertigo has long been a controversial entity and its very existence as a medical entity has advocates and opponents. Supporters of cervical vertigo claim that its actual prevalence is underestimated due to the overestimation of other diagnostic categories in clinics. ⋯ A clinical entity named subclinical vertebrobasilar insufficiency appears in the context of cervical osteoarticular changes. Migraine-associated vertigo may explain why some patients suffering from cervical pain have vertigo while others do not.