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Indirect revascularization remains an appropriate solution for carefully selected patients with cerebral large vessel steno-occlusive disease, and multiple variations of surgical technique are patient specific. Indirect revascularization may benefit from clinical trials with larger patient populations for validation in specific pathologies and offers the advantages of lower surgical complication rates and reduced risk of pathologic responses to altered cerebral flow dynamics. SUMMARY Surgical solutions to reduce stroke risk provide important alternatives in appropriately selected patients and should be considered in addition to medical management and lifestyle modification for optimizing patient outcomes.PURPOSE OF REVIEW This article reviews the evidence base and recommendations for medical management for secondary stroke prevention. RECENT FINDINGS Recent developments for secondary stroke prevention include evidence to support the use of short-term dual antiplatelet therapy after minor stroke and transient ischemic attack, direct oral anticoagulants for nonvalvular atrial fibrillation, reversal agents for direct oral anticoagulant-associated hemorrhage, and aspirin rather than presumptive anticoagulation with a direct oral anticoagulant for embolic stroke of undetermined source. SUMMARY Most strokes are preventable. The mainstays of medical management for secondary stroke prevention include antihypertensive therapy; antithrombotic therapy, with antiplatelet agents for most stroke subtypes or anticoagulants such as warfarin or a direct oral anticoagulant for cardioembolic stroke specifically; cholesterol-lowering therapy, principally with statins, but with potential roles for ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors in selected patients; and glycemic control to prevent microvascular complications from diabetes mellitus or pioglitazone in selected patients with insulin resistance but not diabetes mellitus.PURPOSE OF REVIEW This article describes restorative therapies to improve patient outcomes after stroke. read more These therapies contrast with acute stroke treatments such as recombinant tissue plasminogen activator (rtPA) and thrombectomy that target clots, aim to salvage threatened brain tissue to limit injury, and have a time window measured in hours. Restorative therapies target the brain, aim to promote plasticity within surviving brain tissue, and have a time window measured in days to weeks or longer. RECENT FINDINGS A number of drugs are under study. Preclinical studies are providing attractive therapeutic candidates for translation, such as the C-C chemokine receptor 5 inhibitor maraviroc. Some drug studies have used a pragmatic approach, which is premature for the nascent field of neural repair. Substantial data support the utility of activity-dependent therapies, including constraint-induced movement therapy, with recent studies supporting the need for very high doses to generate the best functional gains. While stem cell therapies are at an early stage, mounting preclinical evidence supports the efficacy of mesenchymal stem cells; some initial human studies are supportive. Several types of brain stimulation have been examined, and in some cases initial studies are promising. SUMMARY Improved insights into stroke recovery and its treatment have the potential to reduce disability in a large segment of stroke survivors.PURPOSE OF REVIEW This article reviews current knowledge on epidemiology, risk factors and causes, diagnostic considerations, management, and prognosis of ischemic stroke in young adults (those 55 years old and younger). RECENT FINDINGS The incidence of ischemic stroke in young adults has been increasing since the 1980s, which has occurred in parallel with increasing prevalence of vascular risk factors and substance abuse among the younger population. Young adults have a considerably wider range of risk factors than older patients, including age-specific factors such as pregnancy/puerperium and oral contraceptive use. Behavioral risk factors such as low physical activity, excess alcohol consumption, and smoking are factors as well. More than 150 identified causes of early-onset ischemic stroke exist, including rare monogenic disorders. Several recent advances have been made in diagnosis and management of stroke in young adults, including molecular characterization of monogenic vasculitis due to deficiency of adenosine deaminase 2 and transcatheter closure of patent foramen ovale for secondary prevention. Compared with the background population of the same age and sex, long-term mortality in patients remains fourfold higher with cardiovascular causes underlying most of the deaths. The cumulative rate of recurrent stroke extends up to 15% at 10 years. Patients with atherosclerosis, high-risk sources of cardioembolism, and small vessel disease underlying their stroke seem to have the worst prognosis regarding survival and recurrent vascular events. Young stroke survivors also often have other adverse outcomes in the long term, including epilepsy, pain, cognitive problems, and depression. SUMMARY Systematic identification of risk factors and causes and the motivation of patients for long-term prevention and lifestyle changes are of utmost importance to improve the prognosis of early-onset ischemic stroke.PURPOSE OF REVIEW This article reviews sex differences in stroke risk and presentation, with a particular emphasis on the unique risk factors women experience throughout the lifespan. RECENT FINDINGS Although prior studies suggested women have worse outcomes after stroke, it is now clear that age, prestroke functional status, and comorbidities explain many of the differences between men and women in stroke severity, functional outcomes, and mortality. Several meta-analyses and large cohort studies have evaluated the risk factors for women related to reproductive factors and found that fewer years between menarche and menopause, pregnancy complications (preeclampsia/eclampsia, preterm delivery, and stillbirth), oophorectomy, hormone replacement therapy use, and younger age at menopause all increase the risk of stroke. Although the nonreproductive risks of stroke overlap between men and women, those with greater impact on women include age, hypertension, atrial fibrillation, socioeconomic status, and depression. SUMMARY Significant sex differences are observed in risk factors of stroke and stroke outcome. Including this information in the clinical assessment of the individual patient may support development of more effective prevention plans.PURPOSE OF REVIEW This article discusses cryptogenic stroke and the results of recent randomized trials that can inform its evaluation and management. RECENT FINDINGS Most cryptogenic strokes appear embolic, leading to the term embolic stroke of undetermined source. It was previously thought that embolic stroke of undetermined source was a single, therapeutically relevant entity, the underlying sources of which would respond to anticoagulant therapy; however, two large randomized trials found no benefit with anticoagulation compared to antiplatelet therapy for secondary stroke prevention after embolic stroke of undetermined source. A single antiplatelet drug remains the recommended long-term antithrombotic treatment for secondary stroke prevention in embolic stroke of undetermined source. However, three caveats should be considered with regard to cryptogenic stroke. First, those with minor stroke symptoms presenting early after onset should receive 3 weeks of dual antiplatelet therapy. Second, all patients with cryptogenic stroke should be monitored for atrial fibrillation. Third, patients 60 years of age or younger with a patent foramen ovale (PFO) should be carefully evaluated to determine whether the PFO may have caused the stroke and whether they might benefit from PFO closure. SUMMARY More personalized strategies may soon be available to guide treatment of cryptogenic stroke. In the meantime, it is hoped that the application of recent findings from clinical trials will reduce stroke recurrence in this important population.PURPOSE OF REVIEW This article reviews the clinical significance and neuroimaging characteristics of cerebral small vessel disease and the impact on neurologic disease and current and potential therapeutic approaches. RECENT FINDINGS Cerebral small vessel disease is increasingly prevalent and highly heterogeneous in neuroimaging and clinical presentation. Small subcortical infarcts, lacunes, cerebral microbleeds, cortical microinfarcts, and white matter hyperintensity of presumed vascular origin represent the major neuroimaging markers of small vessel disease. Increasing small vessel disease burden is associated with risk of incident stroke and dementia, as well as other neuropsychiatric symptoms. Current research strategies are targeting elucidation of the mechanisms of small vessel disease pathogenesis and pursuing clinical trials of therapeutic agents to reduce the clinical manifestations of cerebral small vessel disease. SUMMARY Cerebral small vessel disease is common in aging adults and represents a major risk factor for multiple acute and chronic neurologic diseases. Increased awareness of cerebral small vessel disease as a modifiable risk factor holds potential for reducing neurologic disease morbidity and mortality across diverse populations in the United States and worldwide.PURPOSE OF REVIEW This article reviews the actual indications for mechanical thrombectomy in patients with acute ischemic stroke and how the opportunities for endovascular therapy can be expanded by using the concept of clinical-imaging or perfusion-imaging mismatch (as a surrogate for salvageable tissue) rather than time of ischemia. RECENT FINDINGS Six randomized controlled trials undoubtedly confirmed the benefits of using endovascular thrombectomy on the clinical outcome of patients with stroke with large vessel occlusion within 6 hours from symptom onset compared with those receiving only standard medical care. In a meta-analysis of individual patient data, the number needed to treat with endovascular thrombectomy to reduce disability by at least one level on the modified Rankin Scale for one patient was 2.6. Recently, the concept of "tissue window" versus time window has proved useful for selecting patients for mechanical thrombectomy up to 24 hours from symptom onset. The DAWN (DWI or CTP Assessment Wipatients with limited signs of early ischemic changes on neuroimaging. Two clinical trials completely disrupted the time window concept in acute ischemic stroke, showing excellent clinical outcomes in patients treated up to 24 hours from symptom onset. Time of ischemia is, on average, a good biomarker for tissue viability; however, the window of opportunity for treatment varies across different individuals because of a range of compensatory mechanisms. Adjusting time to the adequacy of collateral flow leads to the concept of tissue window, a paradigm shift in stroke reperfusion therapy.PURPOSE OF REVIEW This article describes how imaging can be used by physicians in diagnosing, determining prognosis, and making appropriate treatment decisions in a timely manner in patients with acute stroke. RECENT FINDINGS Advances in acute stroke treatment, including the use of endovascular thrombectomy in patients with large vessel occlusion and, more recently, of IV thrombolysis in an extended time window, have resulted in a paradigm shift in how imaging is used in patients with acute stroke. This paradigm shift, combined with the understanding that "time is brain," means that imaging must be fast, reliable, and available around the clock for physicians to make appropriate clinical decisions. CT has therefore become the primary imaging modality of choice. Recognition of a large vessel occlusion using CT angiography has become essential in identifying patients for endovascular thrombectomy, and techniques such as imaging collaterals on CT angiography or measuring blood flow to predict tissue fate using CT perfusion have become useful tools in selecting patients for acute stroke therapy.
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