[Vascular surgery in the prevention of stroke]
MOGÁN István1, NEMES Atilla2, NAGY Zoltán3
JULY 20, 1993
Clinical Neuroscience - 1993;46(07-08)
MOGÁN István1, NEMES Atilla2, NAGY Zoltán3
JULY 20, 1993
Clinical Neuroscience - 1993;46(07-08)
[In Hungary the prevalence of cerebrovascular disorders has increased so that each year vascular reconstruction surgery is needed in 2800 cases. However, only a quarter of these eligible patients are operated. After a thorough examination if all the indications for carotid surgery are met, more and more patients will end up in vascular reconstruction units. Angiography and surgery are recommended if the carotid artery stenosis is asymptomatic and is more than 90%. Also, under special conditions an asymptomatic carotid stenosis may caused by indicate surgery (before coronary by-pass operation, etc.). Another indication is a transient ischemic attack, if carotid artery lesion and the stenosis is above 70%. Ulcerated plaques also need surgery because they are a likely source of emboli. After stroke surgery may be necessary if the angiologic status is unstable and further ischemic events, that may lead to disability are expected. An acute stroke rarely calls for surgery. In contrast to this, immediate surgery is needed after repeated, TIA, or crescendo TIA because the risk of stroke is very high in these cases. Finally, sometimes surgery is indicated because of the occlusion of internal and common carotid artery. With vertebrobasilar vascular reconstruction, we do not have enough experience. Cerebrovascular syndromes due to supraaortic vascular lesions are other indications for reconstruction surgery. However, surgery is never a satisfactory substitute for pharmacological treatment.]
The vestibular end organ, in spite of its small size, has extremely rich interconnections with other parts of the nervous system. The vestibular system can be damaged at the end organ, along the vestibular nerve, in its brain stem representations and in its cerebellar projections. The nature of the pathological process damaging the vestibular system is manifold: neoplastic, inflammatory, vascular, nutritional and degenerative. Neural complications of AIDS may also involve the vestibular system. The lesions may be focal, multifocal and diffuse. While in the past the results of neurootological examinations could only be correlated with post mortem findings, NMI opens new horizons for neurootological and topoanatomical correlative studies.
[In 22 patients with subarachnoid hemorrhage secondary to ruptured intracranial aneurysms serial neurological evaluations, transcranial Doppler examinations and computer tomographic scans were performed. Transcranial Doppler flow velocities were significantly elevated for the group with vasospasm on posthemorrhage day 2. The maximum blood flow velocities were recorded between days 9 and 18, with normalization occurring within the following 3 weeks. Increase in velocity preceded clinical symptoms and could therefore be used as a prognostic factor for the management of patients with subarachnoid hemorrhage. The data also indicated that the extent and location of blood in the subarachnoid space determine the severity and location of vasospasm.]
[18 intraspinal lipomas were operated, mostly in childhood. Surgery seems to be indicated unavoidably in view of preoperative clinical progression and postoperative improvement. Prior MR investigation was indispensable to the surgical procedure.]
[Clinical details are presented of 5 patients with a giant carotid aneurysm in whom both the occlusion of the aneurysm and the parent internal carotid artery were performed with an extra-intracranial arterial bypass. In the first case ligature of the giant carotid-ophthalmic aneurysm narrowed the parent artery critically and hemiplegia developed. The bypass operation did not improve the clinical outcome. In the second case the occlusion of the aneurysm was performed after an extra-intracranial anastomosis and in spite of the severely narrowed carotid artery the postoperative course was uneventful. In three cases of giant intracavernous aneurysm the occlusion of the carotid artery on the neck and just proximal to the ophthalmic artery was performed in the presence of an arterial bypass. All of the anastomoses were patent and no ischemic event developed during the follow up period. On the basis of these experiences the authors suggest that, if the preoperative tests (TCD, EEG, SPECT) reveal impending ischemic lesion after carotid compression, surgery should be performed with the combination of extra-intracranial bypass.]
[A review is given of the methods utilized in evaluating of regional cerebral blood content, both in animal experiments of and the clinical studies with emphasis on the importance and methodological problems of these measurements. A new, double radiolabel method is presented, which is suitable to determine blood content in tissue chunks of 10–30 mg. Red cells are labeled in vivo by 55Fe. The labelled donor” red cells are mixed with 1251-labelled serum albumin and injected intravenously to experimental rats. Red cell and plasma distribution spaces are measured after 3 min circulation time. Regional blood volumes range from 7-30 ul/g, with lowest values in the white matter. Tissue (microvascular) hematocrit is 25-30% lower than large vessel hematocrit.]
Background: This overview provides a summary of the applications of transcranial Doppler (TCD) in ischemic stroke. Results: A fast-track neurovascular ultrasound protocol has been developed for detecting occlusion or stenosis. The technique is more reliable in the carotid area than in the posterior circulation. By monitoring the pulsatility index the increased intracranial pressure can be diagnosed. TIBI score was developed for grading residual flow. TCD has been shown to accurately predict complete or any recanalization. Regarding recanalization, TCD has a sensitivity of 92%, a specificity of 88%, a positive predictive value of 96%, a negative predictive value of 78% and an overall accuracy of 91%, respectively. Sonothrombolysis seemed to be a promising application but randomized controlled trials have shown that it does not improve clinical outcome. TCD examination can detect microembolic signals (MES) which are associated with an increased risk of stroke. Microemboli were detected in symptomatic and asymptomatic carotid artery stenosis and during carotid endarterectomy. The number of microemboli can be decreased by antithrombotic therapy. Contrast enchanced examination and Valsalva maneuver with continuous TCD monitoring can accurately screen for right-to-left shunt.
[Introduction - There are no previously published cases about intravenously applied recombinant tissue plasminogen activator in acute ischemic stroke during puerperium. Case presentation - We report a 40-year-old woman with postpartum acute ischemic stroke caused by multiple cervical artery dissections treated by systemic thrombolysis and endovascular intervention. Discussion - There are only limited data regarding thrombolytic treatment in acute stroke during pregnancy and puerperium. Current acute stroke treatment guidelines - while considering pregnancy as a relative exclusion criterion - do not deal with the postpartum state. Conclusion - As the condition is rare, randomized controlled trials are not feasible, therefore further reports on similar cases could eventually help us suggest guidelines or at least propose recommendations for the acute thrombolytic treatment of strokes occurring in pregnancy and puerperium.]
Hypertension and nephrology
[The reason of the unfavourable life expectancy of patients with chronic kidney disease (CKD) is not only the development of end-stage renal failure but the frequent appearance of cardiovascular diseases (CVD). Chronic kidney damage itself is a cardiovascular risk state and the occurrence of CVD/associated diseases is significantly higher in chronic kidney failure. Beside risk stratification and valid treatment of CVD (hypertension, diabetes mellitus, ischemic heart disease e.g.) we and the international nephrological community have left the cerebrovascular diseases of CKD patients out of consideration. However, up to 50% of patients suffering a stroke will die immediately, only 10% of stroke survivors can continue his/her profession, but the others will be permanently disabled. High blood pressure is a strong predictor of stroke and of other CVD in most of the patients. In stroke risk reduction it is particularly important to reach the target blood pressure values. The main object of the “Live under 140/90 mmHg” programme of the Hungarian Society of Hypertension is to familiarize with target blood pressure itself and how to reach target blood pressure. In 2010, prevention, early diagnosis and management of stroke are the most important challenges of this programme (The Brain Control Programme). We think it is advisable to prepare and publish a clinical practice guideline in collaboration with stroke societies which is similar to the guidelines of international societies and of the Hungarian Society of Stroke but specific for CKD patients. This guideline would help to give a uniform, up-to-date treatment for the cerebrovascular diseases of CKD patients.]
Background - Acute mortality rate of stroke in Hungary is significantly higher than in Western Europe, which is likely to be partially attributable to suboptimal treatment. Subjects and methods - We examined the use of acute vascular imaging and mechanical thrombectomy for acute ischaemic stroke patients. We collected data on 20 consecutive patients from Hungarian stroke centres before 31st August 2016. Results - Out of the reported 410 patients, 166 (40.4%) underwent CT angiography and 44 (10.7%) had mechanical thrombectomy. Conclusion - Only about 1/3 of acute ischaemic stroke patients eligible for thrombectomy actually had it. The underlying reasons include long onset-to-door time, low utilization of acute vessel imaging and a limited neurointervention capacity needing improvement.
[Dizziness is one of the most common causes of medical visits. Management of the dizzy patient may be challenging both for the general practitioner, in emergency departments, and special clinics, as behind a seemingly homogeneous clinical presentation several very different etiologies may occur. Research of the last two century enriched our knowledge about physiology and pathophysiology of the vestibular system. Much knowledge is now available about the labyrinth being able to sense head motions and gravity, processing of afferent vestibular stimuli, reflectory oculomotor and postural control, or recovery of the vestibular system. Based on scientific results new beside tests have been introduced including provocation maneuvers for detecting ectopic otoliths in different semicircular canals, head impulse test to examine function of the vestibulo-ocular reflex, and the HINTS+ battery for differentiation of peripheral or central origin of an acute vestibular syndrome. Technical innovations like videooculography and vestibular evoked myogenic potentials enable us to selectively and side-specifically examine the function of all six semicircular canals and two otolith organs. Pathomechanism of disorders with vertigo and dizziness became more clear resulting in the development or amendment of diagnostic criteria of several vestibular disorders including vestibular migraine, Menière’s disease, benign paroxysmal positional vertigo, persistent postural-perceptual dizziness, bilateral vestibulopathy. Broader knowledge about the pathomechanism promoted the development of new therapeutic methods like different repositioning maneuvers in benign paroxysmal positional vertigo, pharmaceutical therapies, vestibular rehabilitation, and psychotherapy. We aimed to summarize the novelties in the field of oto-neurology.]
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Lege Artis Medicinae[LAM 30: 1990–2020. Facing the mirror: Three decades of LAM, the Hungarian medicine and health care system]
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