Assuntos

RESUMO

Decline of the cognitive functions necessary for activities of daily living results in a spectrum ranging from benign forgetfulness and minimal cognitive impairment to dementia. The latter is characterized by personality and behavioral changes. Alzheimer's disease is the most frequent cause of dementia affecting almost one of two people older than 80 years. Lewy body and cerebrovascular disease are also frequent causes of cognitive decline. Recent studies have revealed genetic aspects of Alzheimer's disease and the role of certain enzymes in the pathophysiology of fibrillary amyloid deposition. The aim in cognitive disease is an early diagnosis to initiate therapy and adapting measures in the patient's daily routines. The diagnosis is basically clinical with neuroimaging and neuropsychological tests' support. The EEG, SPECT, LP and other studies are only useful in a few specific scenarios. At present, a few promising therapies are being evaluated. Family support is of vital importance.

Assuntos

RESUMO

Decline of the cognitive functions necessary for activities of daily living results in a spectrum ranging from benign forgetfulness and minimal cognitive impairment to dementia. The latter is characterized by personality and behavioral changes. Alzheimers disease is the most frequent cause of dementia affecting almost one of two people older than 80 years. Lewy body and cerebrovascular disease are also frequent causes of cognitive decline. Recent studies have revealed genetic aspects of Alzheimers disease and the role of certain enzymes in the pathophysiology of fibrillary amyloid deposition. The aim in cognitive disease is an early diagnosis to initiate therapy and adapting measures in the patients daily routines. The diagnosis is basically clinical with neuroimaging and neuropsychological tests support. The EEG, SPECT, LP and other studies are only useful in a few specific scenarios. At present, a few promising therapies are being evaluated. Family support is of vital importance.

RESUMO

Decline of the cognitive functions necessary for activities of daily living results in a spectrum ranging from benign forgetfulness and minimal cognitive impairment to dementia. The latter is characterized by personality and behavioral changes. Alzheimer’s disease is the most frequent cause of dementia affecting almost one of two people older than 80 years. Lewy body and cerebrovascular disease are also frequent causes of cognitive decline. Recent studies have revealed genetic aspects of Alzheimer’s disease and the role of certain enzymes in the pathophysiology of fibrillary amyloid deposition. The aim in cognitive disease is an early diagnosis to initiate therapy and adapting measures in the patient’s daily routines. The diagnosis is basically clinical with neuroimaging and neuropsychological tests’ support. The EEG, SPECT, LP and other studies are only useful in a few specific scenarios. At present, a few promising therapies are being evaluated. Family support is of vital importance.

RESUMO

OBJECTIVE: To analyze the different presentations of ischemic cerebrovascular disease and develop algorithms for treatment in those different possible settings. DEVELOPMENT: We present an analysis of the publications in which the clinical, diagnostic and therapeutic features of aorto-emboli and cardio-emboli (patent foramen ovale, septal aneurysm, bacterial endocaritis, etc.) have been defined. We suggest an algorithm with general parameters for the use of anticoagulants in cerebrovascular disease. Subsequently we specifically consider the decision as to the moment to start anticoagulation, selection of the type of anticoagulant, dosage, route of administration and duration of the treatment. Because of the implications for treatment, we assess the therapeutic options when haemorrhagic infarcts occur. CONCLUSIONS: Based on studies in the literature showing benefit in individualized cerebrovascular disorders, and the anecdotic experiences of Drs. Miller Fisher, Caplan, Pessin and the writer, over the past 40 years using anticoagulants in the different clinical settings described, some parameters for treatment are proposed. We emphasize that whilst patients with different types of cerebrovascular disease are all grouped together under the unifying term 'stroke', the various treatments evaluated will probably be shown to be inefficient or deleterious. The line of treatment suggested in this review is based on the definition of the different cerebrovascular scenarios according to their aetiology and mechanisms, so as to obtain the most suitable treatment in each case.

Assuntos

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OBJECTIVE: To analyze the available scientific evidence regarding treatment with thrombolytic agents in patients with cerebrovascular disease and present this in the context of daily practice. DEVELOPMENT: Publication of the NINDS study of treatment with t-PA for acute cerebral ischemia led to approval of this treatment for cerebrovascular disease. However, this therapy is associated with a significant frequency of hemorrhagic complications. We analyzed the most relevant studies on the use of thrombolytic drugs. The results of their intravenous and intra-arterial administration were compared with regard to the frequency of recanalization and hemorrhagic complications. We evaluated the results of physician's surveys on the use of t-PA since publication of the NINDS study. These results are interpreted in the context of the potentially generalized use of this treatment. CONCLUSIONS: Although in the NINDS study, administration of i.v. t-PA within three hours of an arterial occlusion resulted in a lower frequency of disability at three months, these results cannot be extrapolated to all medical settings. Until there is a more precise definition of the type of thrombolytic agent, dosage, route of administration, therapeutic window and concomitant use of other drugs, thrombolytic agents should preferably be used in centres specialized in the treatment of cerebrovascular disorders.

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OBJECTIVE: Provide a management strategy for the evaluation and treatment of extracranial internal carotid artery disease. BACKGROUND: Despite 50 years that have elapsed since the first carotid artery endarterectomy, surgical indications in symptomatic and asymptomatic carotid artery disease remain controversial. DESIGN: The most important studies on the treatment of symptomatic and asymptomatic internal carotid artery disease were reviewed. Special scenarios were analyzed including: intraluminal thrombus, carotid artery occlusion, dissection, ulceration, fibromuscular dysplasia, re-stenosis post endarterectomy and carotid artery disease coexisting with coronary artery disease. The current status of carotid angioplasty was discussed briefly. CONCLUSIONS: A patient-individualized approach based on the aforementioned studies and personal experience is provided. Endarterectomy is recommended in greater than 70% ICA symptomatic stenosis, in certain patients with 50 to 69% symptomatic stenosis, and exceptionally in asymptomatic patients, patients with associated coronary artery disease, ulceration, intraluminal thrombus and other less frequent scenarios.

Assuntos

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OBJECTIVE: To analyze the available data in the literature so as to suggest a scheme for use when anticoagulating patients with ischemic vascular disease. DEVELOPMENT: We analyzed the most relevant publications on the use of anticoagulation in cerebrovascular disease, published since 1940. Studies and meta-analysis of anticoagulation--oral, intravenous using heparin and subcutaneous using low molecular weight heparin--in acute and recurrent stroke. This data on anticoagulation was then applied to different aspects of cerebrovascular disease such as disease of the great intracranial and extracranial vessels (dissection, occlusion and intraluminal thrombus), the penetrating vessels, venous system, hypercoagulation states and particular therapeutic uses such as anticoagulation in cerebral hemorrhage, and the use of thrombolytic agents. CONCLUSIONS: Anticoagulants are frequently used in cerebrovascular disease in spite of the lack of studies giving first level support of its efficacy (randomized studies with low false positive and false negative errors) and the fact that some studies have failed to confirm the efficacy of this treatment. With the analysis presented, we have tried to show that the failure to define the role of anticoagulants is mainly due to limitations in design of the methods used in the studies carried out. The basic shortcoming has been the search for one single treatment which could be effective for the entire spectrum of cerebrovascular disease.

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We reviewed the clinical and neuropathologic findings in 21 patients who had seizures after orthotopic liver transplants. Tonic-clonic seizures were the most common seizure type. Six patients developed status epilepticus. In 9 patients, seizures occurred within 1 week following transplantation. We found CNS lesions that were probably responsible for the occurrence of seizures in most patients; some had more than 1 finding. Neuropathologic examination revealed ischemic or hemorrhagic strokes in 18 patients, central pontine myelinolysis in 5, and CNS infections in 5. Multiple metabolic abnormalities were a contributing factor to the onset of seizures in some patients.

Assuntos

RESUMO

Eight adults and 3 children out of 85 patients who had neuropathologic examination after death following orthotopic liver transplantation showed central pontine myelinolysis (CPM). Four patients also had extrapontine myelinolysis. Eight patients had significant serum sodium changes. In 5, the fluctuation occurred perioperatively and 4 had a clinical picture consistent with CPM, although no patient had this as an antemortem diagnosis. We emphasize the role of hepatic dysfunction as a cause of CPM and recommend careful monitoring of electrolytes in the perioperative period of patients undergoing liver transplantation.

Assuntos