Sarkis Morales-Vidal

Diabetic Peripheral Neuropathy and the Management of Diabetic Peripheral Neuropathic Pain

Abstract Diabetic peripheral neuropathy (DPN) affects approximately half of patients with diabetes. Neuropathic pain is a major complaint of patients with diabetic polyneuropathy. Diabetic peripheral neuropathy can also lead to autonomic dysfunction. This article provides an outline of the clinical subtypes, pathophysiological features, and diagnosis of DPN. Disease–modifying treatments are reviewed, with particular attention paid to DPN pain management.

Management of Arterial Blood Pressure in Acute Ischemic and Hemorrhagic Stroke

It is essential to control arterial blood pressure (BP) in both hemorrhagic and ischemic stroke patients to decrease morbidity following an acute event and decrease the long-term risk of stroke recurrence. Pathophysiology of BP control is dependent on understanding key relationships of cerebral blood flow and cerebral perfusion pressure. In the long term, hypertensive control decreases the rate of incident and recurrent hemorrhagic and ischemic stroke. In the acute setting, neither when to start antihypertensive medication nor the optimal BP target goals for short- and long-term control are well defined. There are several different drug classes available for BP control, with considerable debate as to which drugs are preferred for stroke patients. Medication selection and target BP depend on individual patient characteristics, including type of stroke, medical comorbidities, and timing of interventions in the context of the acute or postacute phases of stroke.

Ischemic Stroke in the Setting of Chronic Immune Thrombocytopenia in an Elderly Patient—A Therapeutic Dilemma

Chronic immune thrombocytopenia (ITP) carries a poor prognosis in the elderly patients. Increasing evidence proposes that a subgroup of patients with chronic ITP may be more susceptible to ischemic stroke. An 84-year-old Caucasian man with multiple ischemic stroke risk factors presented with acute onset of slurred speech, confusion, and unsteady gait. Physical examination and neurologic imaging were consistent with a new left thalamic infarct. Platelet counts ranged between 40 000 × 109/L and 65 000 × 109 /L. Antiplatelet therapy for his newly acquired stroke was not initiated considering his low platelet counts and for mildly symptomatic thrombocytopenia, and the patient was discharged home. Both hematologic and neurologic guidelines for the management of chronic ITP and stroke have contradictory goals. Although anticoagulation is mandated in acute stroke, ITP causes low platelet counts that increase bleeding complications.

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.

Telemedicine in stroke care and rehabilitation.

Abstract Telemedicine allows prompt assessment of acute stroke patients. This new technology has increased the administration of intravenous recombinant tissue plasminogen activator (rtPA) to eligible patients. In addition, telemedicine is being utilized in the rehabilitation of patients with cerebrovascular disease. This article will review the use of telemedicine in patients with acute ischemic stroke and its implementation in telerehabilitation to patients with residual neurologic déficit.

Prevention of Venous Thromboembolism in Patients with Hemorrhagic Stroke

Abstract Deep venous thrombosis (DVT) and pulmonary embolism (PE) are part of the spectrum of venous thromboembolism (VTE). It is one of the most frequent medical complications in stroke patients. The risk of VTE is even higher after hemorrhagic stroke. This article reviews various screening methods, diagnostic techniques, and pharmacologic as well as nonpharmacologic means of preventing VTE after hemorrhagic stroke.

Autopsy Proven Peripheral Nervous System Neurolymphomatosis Despite Negative Bilateral Sural Nerve Biopsy

Neurolymphomatosis (NL) refers to a lymphomatous infiltration of peripheral nerves associated with central nervous system or systemic lymphoma, or alternatively, neurodiagnostic evidence of nerve enhancement and/or enlargement beyond the dural sleeve in the setting of primary central nervous system lymphoma or systemic lymphoma. NL is a rare complication of systemic cancer with heterogeneous clinical presentations and an elusive diagnosis. Diagnosis usually requires the demonstration of infiltrating malignant lymphocytes in the peripheral nerve. Infiltration of brain parenchyma, meninges or Virchow–Robin spaces is characteristic of systemic disease at autopsy. We describe a patient presenting with biopsy negative NL affecting exclusively the peripheral nervous system at autopsy.

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

Telestroke: Time is Brain and the Time is Now

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).