Murray Flaster

Poststroke Depression: A Review Emphasizing the Role of Prophylactic Treatment and Synergy with Treatment for Motor Recovery

Abstract Neuropsychiatric manifestations are common post stroke. Depression has a prevalence rate of 9% to 34% in the initial 3 to 6 months following stroke and is the most common neuropsychiatric sequel of stroke. Poststroke depression (PSD) has a significant adverse impact on the course of rehabilitation following stroke, resulting in overall impaired functional outcome. An increased risk of suicide and increased mortality have been reported. The association of depression and stroke is wellestablished, highly complex, and multifactorial in origin, and the etiology of PSD involves size, location and number of lesions, stroke subtype, stroke severity, social handicap, and family support. Additionally, depression itself is an independent risk factor for stroke. In this article, we review the complex pathogenesis of PSD and summarize pharmacological treatment options. Because of recent important results that may relate to underlying cellular restorative processes, we focus on early prophylactic treatment, particularly as it involves selective serotonin uptake inhibitors (SSRIs). There is a recently recognized synergy between functional recovery and depression prophylaxis. New evidence that antidepressants, and SSRIs in particular, can make a substantial contribution to stroke recovery is explored.

Advances and controversies in the management of cerebral venous thrombosis.

Cerebral venous thrombosis (CVT) is a rare form of stroke found most often in young women of reproductive age, often associated with oral contraceptive use, genetic or acquired thrombophilia, pregnancy, dehydration, or infection. CVT should be considered in any young patient who presents with an unexplained headache in combination with known hypercoagulable state, focal neurologic deficits, seizure, lobar hemorrhage, or bilateral thalamic or basal ganglionic edema. Acute treatment is with unfractionated heparin or low-molecular-weight heparin. It is important to provide supportive treatment. Outcomes are good compared with other types of stroke. Pediatric patients, excluding neonates, have similar presentation, treatment, and outcomes as adults.

Central poststroke pain: current diagnosis and treatment.

Abstract Central post-stroke pain syndrome (CPSP) is a debilitating sequel that can follow thalamic sensory stroke. Less well recognized, CPSP follows lateral medullary stroke and parietal cortical stroke and may develop anywhere along the spinothalamic or trigemino-thalamic pathways. Patients describe sharp, stabbing, or burning pain and experience hyperpathia and especially allodynia. Although CPSP was first described over 100 years ago, CPSP is too frequently under-recognized. It is treatable disorder. Pharmacological therapy, magnetic stimulation, and invasive electrical stimulation are reviewed and recommendations made.

Central and Extrapontine Myelinolysis Affecting the Brain and Spinal Cord. An Unusual Presentation of Pancreatic Encephalopathy

Pancreatic encephalopathy refers to a gamut of neuropsychiatric symptoms complicating acute pancreatitis. Osmotic myelinolysis is a known complication of pancreatic encephalopathy. We evaluated a 58-year-old woman with pancreatic encephalopathy associated to pontine and extrapontine myelinolysis involving the brain and spinal cord. To our knowledge, this is the first clinic pathological case report of pancreatic encephalopathy involving the spinal cord.

Direct thrombin inhibitors and factor Xa inhibitors in patients with cerebrovascular disease.

Stroke is a leading cause of cardiovascular morbidity and mortality worldwide. Approximately, 795,000 strokes occur in the USA each year, 610,000 of which are first events, and 185,000 of which are recurrent events. Of all strokes, 87% are ischemic strokes. Novel anticoagulants serve as an alternative antithrombotic intervention in patients with ischemic cerebrovascular disease. This paper reviews the role of the novel anticoagulants, dabigatran, rivaroxaban and apixaban, in stroke prevention among patients with nonvalvular atrial fibrillation.

Statins in hemorrhagic stroke

Statin therapy has a major impact on the treatment of coronary artery disease and also has an impact on the treatment of ischemic stroke. Both clinical and experimental studies support the concept of statin actions beyond those of lipid lowering per se (pleiotrophic effects). In this article, we briefly review the clinical, experimental and biological data on the actions of statins and then review the literature regarding the impact of statin use on the two major forms of hemorrhagic stroke: aneurysmal subarachnoid hemorrhage and intracranial hemorrhage (ICH). We make recommendations regarding acute statin therapy, statin withdrawal and chronic statin therapy, including a possibly negative impact – the increased incidence of ICH associated with the use of higher doses of statin in patients with a prior history of stroke. Epidemiological data on the association between low total cholesterol or low levels of low-density cholesterol, hypertension and the incidence of ICH appear relevant and are also discussed. We speculate on the relationship between data derived from randomized controlled trials employing statin and ICH epidemiology.

Right Brain: A reading specialist with alexia without agraphia Teacher interrupted

Reading to children was a source of fulfillment in the life of M.P., a 40-year-old aunt, kindergarten teacher, and reading specialist. Whether in the classroom, the reading room, or the living room, M.P. found joy in the dual role of teacher and storyteller. For her, it was an important means of relating to those under her care. But all of that changed when, on a Thursday morning, M.P. found herself standing at the front of her class and holding in her hands an indecipherable mystery.

Primary stroke center concept: strengths and limitations.

The American Heart Association estimates that, as of calendar year 2010, approximately 795,000 people in the USA will have experienced a new or recurrent stroke, out of which 610,000 were new attacks (Heart Disease and Stroke Statistics – 2010 Update, 2010). Stroke is the third leading cause of death in United States and a major cause of disability. There are almost three million survivors of stroke, most of whom are disabled with a societal cost of approximately

Commonly asked questions in transient ischemic attack

30 billion (US dollars; Heart Disease and Stroke Statistics – 2010 Update, 2010). Over the last two decades, there have been major advances have been made in the early diagnosis of stroke and timely treatment. In 1996, the US Food and Drug Administration (USFDA) approved intravenous tissue plasminogen activator (IV tPA) for the treatment of acute ischemic stroke within 3 h of onset of symptoms (The National Institute of neurological Disorders and Stroke rt-PA Stroke Study Group, 1995). Despite the approval, only 1.8–4.1% of patients with acute ischemic stroke received IV tPA (Katzan et al., 2000). The failure to administer tPA in a timely fashion was evident from a paper, in calendar year 2000, showing that only 34% of academic hospitals had defined stroke protocols and only 18% had rapid identification methods for patients presenting with acute stroke symptoms (Johnson et al., 2001). A subsequent assessment of statewide acute stroke care in Illinois demonstrated that although 93.2% of residents in Illinois lived in a county with at least one acute care facility with tPA treatment protocol, there were many acute care receiving facilities outside of Greater Chicago Metropolitan Area which did not have a neurologist or a neurosurgeon available (Ruland et al., 2002).

Stroke- and pregnancy-induced hypertensive syndromes.

With the advent of modern neuroimaging techniques, transient ischemic attack (TIA) has been redefined as, “a transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischemia, without acute infarction.” If infarct is evident on neuroimaging, the event is a stroke. It is important to recognize and correctly diagnose TIA and minor stroke because of the substantial early risk of stroke. Much of the early stroke risk is attributable to large artery atherosclerosis. Stroke-risk stratification in TIA patients can be done based on clinical grounds using an ABCD2 score. There is, however, abundant data to support inclusion of neuroimaging in stroke-risk determination, which can also be combined with a clinical risk assessment. The hybrid ABCDE⊕ score further refines early stroke risk. Rapid assessment and treatment in the emergency department or in specially designed ‘TIA clinics’ appear to reduce stroke rate.