Annals of Indian Academy of Neurology
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  Citation statistics : Table of Contents
   2008| January  | Volume 11 | Issue 5  
    Online since July 8, 2008

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Stroke in central nervous system infections
Francisco Javier Carod-Artal
January 2008, 11(5):64-78
Background: Stroke subtypes and etiology may differ between developing and developed countries. Infections are a relatively common cause of stroke in tropical regions. Objective: To review the main infectious diseases associated with stroke. Discussion: Prevalence of stroke in HIV patients is around 1%. Pathogenic mechanisms include HIV vasculopathy, vasculitis, cardioembolism, acquired hypercoagulability, and the effect of opportunistic infections. Treatment with protease inhibitors has been associated with premature atherosclerotic vascular disease. Emerging viral infections that are associated with stroke include viral hemorrhagic fevers, Japanese encephalitis, dengue, and West Nile virus. Vasculitis involving perforating vessels of the brain is a cerebrovascular complication of tuberculous meningitis. Small, medium, and large arteries of the anterior circulation can be involved. A progressive intracranial arteriopathy after Leptospira interrogans infection has been described, which involves the large intracranial arteries. Cerebrovascular complications of mycosis are associated with large vessel vasculitis, direct vessel damage by invasion or embolization, and subarachnoid hemorrhage due to mycotic aneurysm rupture. Pathological findings of cerebral malaria include diffuse cerebral edema, perivascular ring hemorrhages, white matter necrosis, parenchyma petechial hemorrhages, occlusion of brain vessels, and sequestration of infected erythrocytes in cortical and perforating arteries. Stroke can occur in subarachnoid neurocysticercosis and the lesions in such cases consist mostly of deep lacunar infarctions resulting from endarteritis of small penetrating arteries. Cardiac arrhythmias, congestive heart failure, apical aneurysm, and mural thrombus are the conditions that predispose patients with American trypanosomiasis to cardioembolism. Gnathostoma spinigerum infestation is a cause of hemorrhagic stroke in Asia. Conclusion: Infectious and tropical diseases should be included in the differential diagnoses of stroke.
  6 18,972 788
Cerebral venous thrombosis: Update on clinical manifestations, diagnosis and management
Didier Leys, Charlotte Cordonnier
January 2008, 11(5):79-87
Cerebral venous thrombosis (CVT) has a wide spectrum of clinical manifestations that may mimic many other neurological disorders and lead to misdiagnoses. Headache is the most common symptom and may be associated with other symptoms or remain isolated. The other frequent manifestations are focal neurological deficits and diffuse encephalopathies with seizures. The key to the diagnosis is the imaging of the occluded vessel or of the intravascular thrombus, by a combination of magnetic resonance imaging (MRI) and magnetic resonance venography (MRV). Causes and risk factors include medical, surgical and obstetrical causes of deep vein thrombosis, genetic and acquired prothrombotic disorders, cancer and hematological disorders, inflammatory systemic disorders, pregnancy and puerperium, infections and local causes such as tumors, arteriovenous malformations, trauma, central nervous system infections and local infections. The breakdown of causes differs in different parts of the world. A meta-analysis of the most recent prospectively collected series showed an overall 15% case-fatality or dependency rate. Heparin therapy is the standard therapy at the acute stage, followed by 3-6 months of oral anticoagulation. Patients with isolated intracranial hypertension may require a lumbar puncture to remove cerebrospinal fluid before starting heparin when they develop a papilloedema that may threaten the visual acuity or decompressive hemicraniectomy. Patients who develop seizures should receive antiepileptic drugs. Cerebral venous thrombosis - even pregnancy-related - should not contraindicate future pregnancies. The efficacy and safety of local thrombolysis and decompressive hemicraniectomy should be tested
  3 16,067 1,063
Very early mobilization following acute stroke: Controversies, the unknowns, and a way forward
Julie Bernhardt
January 2008, 11(5):88-98
Evidence that organized stroke-unit care results in better outcome has led to positive changes in stroke service delivery around the world. It is well accepted that stroke rehabilitation should commence as early as possible for optimal recovery to be achieved. Exactly how early rehabilitation should start is controversial. Early mobilization (getting up out of bed within 24 h of stroke onset) is a well-established feature of acute stroke care in many Scandinavian hospitals. Elsewhere in the world, stroke protocols enforce bed rest for the first few days or foster long periods of bed rest after stroke. This paper aims to provide an overview of the topic of very early mobilization (VEM). It is divided into three sections: section 1 reviews the effects of bed rest and outlines arguments both for and against enforced bed rest after stroke; in section 2, VEM as a treatment for stroke and the limitations of existing literature in the field are described; and section 3 outlines the systematic approach that has been taken by our team of clinical researchers to the study the effect of VEM after stroke. Conclusion: VEM represents a simple, easy-to-deliver intervention, requiring little or no equipment. It is potentially deliverable to 85% of the acute stroke population and, if proven to be effective, may help reduce the significant personal and community burden of stroke. As current opinion about when mobilization should begin is divided, one way to move forward is through the conduct of a large high-quality clinical trial (such as A Very Early Rehabilitation Trial (AVERT)). Although some inroads have been made, further research in this field is clearly warranted
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Role of transcranial Doppler ultrasonography in acute stroke
Vijay K Sharma, N Venketasubramanian, Dheeraj K Khurana, Georgios Tsivgoulis, Andrei V Alexandrov
January 2008, 11(5):39-51
Background: Transcranial Doppler (TCD) ultrasonography is the only noninvasive examination that provides a reliable evaluation of intracranial blood flow patterns in real-time, adding physiological information to the anatomical information obtained from other neuroimaging modalities. TCD is relatively cheap, can be performed bedside, and allows monitoring both in acute emergency settings as well as over prolonged periods; it has a high temporal resolution, making it ideal for studying dynamic cerebrovascular responses. Objective: To define the role of TCD in the evaluation of patients with acute ischemic stroke. Material and methods: We have analyzed the existing literature on the protocols for performing TCD in the evaluation of patients with acute cerebral ischemia. Extended applications of TCD in enhancing intravenous thrombolysis in acute stroke, emboli monitoring, right-to-left shunt detection, and vasomotor reactivity have also been described. Results: In acute cerebral ischemia, TCD is capable of providing rapid information about the hemodynamic status of the cerebral circulation, monitoring recanalization in real-time and, additionally, has a potential for enhancing tissue plasminogen activator (TPA)-induced thrombolysis. Extended applications of TCD make it an important and valuable tool for evaluating stroke mechanisms, for planning and monitoring treatment, and for determining prognosis. Discussion and conclusion: TCD has an established clinical value in the diagnostic workup of stroke patients and is suggested as one of the essential components of a comprehensive stroke center. TCD is also an evolving ultrasound method with increasing diagnostic value and a therapeutic potential in cerebral ischemia
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Stroke in India: A silent epidemic
Jeyaraj Durai Pandian
January 2008, 11(5):2-3
  1 5,090 465
Bedside assessment of stroke and stroke mimics
Souvik Sen, Stephen M Oppenheimer
January 2008, 11(5):4-11
Following ischemic stroke, interventions to bring about reperfusion must be implemented within the recognized timeframe; this means that timely clinical recognition of this condition is vital. The process of diagnosis begins with the initial bedside assessment of the patient to be followed by appropriate imaging studies. However, because reperfusion therapy may be attended by significant adverse consequences, and since imaging may be negative for many hours after stroke onset, the clinician must be aware of conditions that mimic cerebral ischemia. Depending on the timing and nature of ancillary testing, stroke mimics can be identified in 3-30% of patients presenting with the acute onset of a neurological deficit. These mimics include metabolic, traumatic, migrainous, neoplastic, endocrine, convulsive, and psychiatric disorders. Interestingly, the nature of these mimics, their frequency of occurrence, and presentation may vary between different geographical regions; however, detailed information regarding such variations is not available at present. This review provides an overview of the conditions that can masquerade as stroke, and includes information that may aid in their early detection or, at the very least, serve to warn the clinician that the patient is presenting with something other than cerebral ischemia.
  1 10,710 671
Recent advances in intra-arterial thrombolysis
Eric M Bershad, Jose I Suarez
January 2008, 11(5):30-38
Thrombolytic therapy has revolutionized acute ischemic stroke (AIS) treatment; however it is clear that intravenous (IV) thrombolytic therapy has certain limitations, including a short-time window for use, poor specificity for the site of arterial occlusion, and suboptimal recanalization rates. Some of these problems may be circumvented by using intra-arterial (IA) thrombolysis. In this article, we will discuss the various thrombolytic agents being used in AIS, their mechanisms of actions and doses, and the rationale for use of IA therapy as opposed to IV thrombolysis, and review the clinical trials using IA thrombolysis. We will also discuss other approaches to IA thrombolysis, including mechanical and other endovascular techniques
  1 7,570 444
Acute stroke care in India
Sanjeev V Thomas
January 2008, 11(5):1-1
  - 1,853 210
The role of the speech language pathologist in acute stroke
Cindy Dilworth
January 2008, 11(5):108-118
Dysphagia and communication impairment are common consequences of stroke. Stroke survivors with either or both of these impairments are likely to have poorer long-term outcomes than those who do not have them. Speech-language pathologists (SLP) play a significant role in the screening, formal assessment, management, and rehabilitation of stroke survivors who present with dysphagia and/or communication impairment. Early diagnosis and referral is critical, as is intensive intervention as soon as the patient is able to participate. The SLP is also responsible for educating carers and staff in strategies that can support the patient and for making appropriate environmental modifications (e.g. altering diet consistencies or providing information in an aphasia-friendly format) to optimize the stroke survivor's participation, initially, in the rehabilitation program and, subsequently, within the community.
  - 27,636 481
The role of neuroimaging in acute stroke
Rajinder K Dhamija, Geoffrey A Donnan
January 2008, 11(5):12-23
Background: There is a need for early recognition, diagnosis, and therapy in patients with acute stroke. The most important therapies are thrombolysis or aspirin in hyperacute ischemic stroke and, for secondary prevention, antiplatelet agents, statins, ACE inhibitors (for lowering blood pressure), warfarin, and carotid endarterectomy or stenting. Imaging technology has a crucial role to play in the diagnosis and treatment of stroke. In recent years, significant advances have been made due to the availability of physiological imaging using a variety of techniques, ranging from computerized tomography (CT) to magnetic resonance imaging (MRI), which enable clinicians to define brain anatomy and physiology in greater detail than ever before. Objective: In this article we discuss the imaging techniques currently available for patients with acute stroke, with an emphasis on the utility of these techniques for diagnosis and refining patient selection for early interventions. This is placed in the context of the needs of developing countries . Discussion: Although noncontrast CT (NCCT) remains the most commonly used imaging modality to differentiate between ischemic and hemorrhagic stroke, to identify early CT changes, and to rule out stroke mimics, it is not sensitive enough to identify the infarct core or the mechanism of ischemic stroke. MRI, including magnetic resonance angiography (MRA), is the most useful imaging modality for the evaluation of acute stroke; it provides information about the mechanism as well as the vascular territory of the stroke. MRI also provides complete information about the status of tissue through diffusion-weighted imaging (DWI) and about arterial patency by means of MRA. DWI shows acute lesions within minutes of onset of ischemia, while MRA can evaluate extracranial as well as intracranial vessels Evaluation of the proportion of penumbra vs infarcted tissue is another issue to be considered when instituting thrombolysis, and its clinical usefulness is being assessed in a number of ongoing trials. Penumbral tissue can be identified by perfusion MRI. CT perfusion (CTP) is an emerging alternative, providing similar information about the penumbra and infarct core. A combined approach of NCCT, CT angiography (CTA), and CTP is now being employed at many centers and is known as multimodal CT imaging (MMCT). MMCT provides information about the pathophysiology of acute stroke which is comparable to that provided by MRI, and the technique has the potential to refine patient selection for thrombolysis.
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Intravenous thrombolytic therapy in acute ischemic stroke: The art and science of treatment decision making
PN Sylaja, Andrew M Demchuk
January 2008, 11(5):24-29
Intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) within 3 h of symptom onset is currently approved for treatment of acute ischemic stroke. Those who present within 3 h and have a vascular occlusion and a good CT scan are the ideal candidates for thrombolysis. Clinical trials and phase IV data has shed substantial light on the factors associated with more favorable outcomes with tPA. In the 3-6 h time window, cerebral perfusion information can be used for selection of patients for thrombolytic therapy. In many special circumstances, such as seizure at stroke onset, stroke on awakening, age more than 80 years, and patients with rapidly improving symptoms, the decision to treat depends on expert judgment. Due to the narrow time window, the fear of bleeding complications, and doubts regarding its effectiveness, tPA is still underused. Constant efforts are required to educate the public on the fact that stroke is a treatable emergency.
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Role of occupational therapy after stroke
Tennille J Rowland, Deirdre M Cooke, Louise A Gustafsson
January 2008, 11(5):99-107
Internationally recognized best practice care in the early management and rehabilitation of individuals following stroke includes multidisciplinary assessment and treatment by a coordinated team of health care professionals that includes occupational therapists. Occupational therapists assess the impact of changes in motor function, sensation, coordination, visual perception, and cognition on a person's capacity to manage daily life tasks. Intervention improves participation in meaningful roles, tasks, and activities; remediates deficits; minimizes secondary complications; and provides education and support to the patient and caregivers. Occupational therapists' focus on independence and function, individual goal-setting, and their specialist skills in task adaptation and environmental modification underpin the profession's contribution to the multidisciplinary stroke rehabilitation team. The aim of this paper is to provide an overview of occupational therapy practice in stroke patients.
  - 126,612 1,310
Cardioembolic stroke: An update on etiology, diagnosis and management
Megan C Leary, Louis R Caplan
January 2008, 11(5):52-63
Stroke and ischemic heart diseases are among the most common causes of death and disability throughout the world. Even more worrisome is the suggestion that stroke rates may further increase in certain developing nations. The purpose of this article is to review the particular subtype of stroke known as cardioembolic stroke. A cardioembolic stroke occurs when the heart pumps unwanted materials into the brain circulation, resulting in the occlusion of a brain blood vessel and damage to the brain tissue. The etiology, clinical manifestations, diagnosis and management of cardioembolic stroke are reviewed.
  - 85,870 1,064
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