Advances in spontaneous intracerebral haemorrhage.

OBJECTIVES: To assess the evidence and available literature on the clinical, pathogenetic, prognostic and therapeutic aspects of intracerebral haemorrhage. METHODS: The most important manuscripts and reviews on the subject were considered. Information was collected from Medline, Embase & National Library of Medicine over the last 40 years up to Oct 2011. The bibliographies of relevant articles were searched for additional references. The most up to date and randomised trials were given preference. Clinical guidelines including AHA/ASA, Royal college of Physicians, NICE, Scottish Intercollegiate guidelines and several others were taken into consideration. FINDINGS: There are numerous advances in the understanding of the pathogenesis and management, but hardly any change in the overall mortality in the last few decades. There is a poor understanding of the results of surgical trials that has resulted in a large drop in surgical intervention since 2007. INTERPRETATIONS AND IMPLICATIONS: Advances in neuroimaging and neurophysiology have improved our understanding of the mechanisms of neuronal injury and existence of perihaematomal 'tissue at risk'. Numerous new therapeutic targets have been identified. There is a lot of misunderstanding of the results of the newer surgical trials which need to be clarified. The importance of cerebral amyloid angiopathy and microbleeds in older patients is increasingly recognised. Control of hypertension is the most important public health measure. Stroke units provide the best outcomes for the patients.

Drug induced parkinsonism: a common cause of parkinsonism in older people.

Drug induced parkinsonism is the second most common cause of parkinsonism in older people after idiopathic Parkinson's disease (PD). Risk factors for developing drug induced parkinsonism include: older age; female gender; dose and duration of treatment; type of agent used; cognitive impairment; acquired immunodeficiency syndrome (AIDS); tardive dyskinesia; and pre-existing extrapyramidal disorder. In most patients parkinsonism is reversible upon stopping the offending drug, though it may take several months to resolve fully and in some patients it may even persist. In this case, one needs to consider the possibility of PD which has been unmasked by the offending drug, and treatment with dopaminergic agents may be warranted. Drug induced parkinsonism adversely affects the quality of life in older patients and is potentially reversible, highlighting the importance of early recognition of this condition. This article discusses the drugs implicated, as well as the epidemiology, pathophysiology, clinical features, and management of drug induced parkinsonism.

Cannabis and stroke: is there a link?

Stroke associated with drug abuse has been frequently reported, particularly in young patients. The most commonly implicated drugs include cocaine, heroine, and amphetamines. Despite its widespread abuse, cannabis associated stroke is only infrequently reported. The cause and effect association between cannabis use and stroke is not firmly established. Presuming that cannabis may cause stroke, potential pathophysiologic mechanisms are not known. In this paper, we shall review the literature linking cannabis use and stroke and possible mechanisms supporting this link.

Early neurological deterioration in acute ischaemic stroke: predictors, mechanisms and management.

Early neurological deterioration (END) in acute ischaemic stroke is a common event. The underlying mechanisms are heterogeneous. The clinical predictors of END include severity of the initial stroke, large vessel occlusion, diabetes mellitus, hypotension, and atrial fibrillation. Serial observations and detailed assessment by the trained staff in specialised stroke units are key to the successful management of these patients. Advances in brain and vascular imaging have provided insight into the underlying mechanisms, enabling clinicians to use preventative and therapeutic interventions specifically targeted at them, though several questions still remain unanswered. END has potentially serious consequences on the short term (morbidity and death) and long term (recovery from stroke) outcomes for the patient. Therefore, attempts to prevent and treat END should be made promptly and aggressively.

Haemorrhagic transformation in acute ischaemic stroke following thrombolysis therapy: classification, pathogenesis and risk factors.

Haemorrhagic transformation of cerebral infarction is a common and potentially serious occurrence following acute ischaemic stroke. Though often a "natural" evolution, particularly in acute embolic stroke, haemorrhagic transformation is a prime concern with the use of thrombolytic therapy for acute ischaemic stroke. The severity of haemorrhage may range from a few petechiae to a large haematoma with space occupying effect. The pathogenesis of haemorrhagic transformation is not well established, though ischaemia and reperfusion have been proposed to cause disruption of the blood-brain barrier leading to extravasation of blood. At the molecular level, free radicals and proteolotic enzymes (metalloproteinases) may cause tissue injury. Studies have identified a number of clinical, radiological, and biochemical parameters that may serve as potential predictors of increased risk for haemorrhagic transformation. The knowledge of these factors may help in improving patient selection for thrombolytic therapy.

Stroke in pregnancy and the puerperium.

Stroke is a recognised complication of pregnancy, contributing to more than 12% of all maternal deaths. Estimated incidence rates vary considerably from 4.3 to 210 strokes per 100,000 deliveries. Atherosclerosis is rare in young adults, and so other causes of stroke become increasingly likely. Aetiological factors important in pregnancy include hypercoagulability due to maternal physiological changes, pre-eclampsia and eclampsia, cerebral venous thrombosis, paradoxical embolism, postpartum cerebral angiopathy and peripartum cardiomyopathy. Management of patients with pregnancy-related stroke should generally proceed as for non-pregnant patients, although there are a number of important areas specific to pregnancy which will be considered here.

Psychosis in Parkinson's disease.

Psychosis is common in Parkinson's disease (PD), particularly in its later stages. The symptoms range from comparatively minor illusions, vivid dreams, and occasional, non-disturbing visual hallucinations to frank psychosis. The pathogenesis of psychosis in PD is not fully known. Management of psychosis in PD requires a multidisciplinary approach. Some of the newer atypical antipsychotics are effective against psychosis with no significant worsening of PD. Psychosis in PD is associated with poor quality of life for patients and the carers.

Carotid and vertebral artery dissection syndromes.

Cervicocerebral arterial dissections (CAD) are an important cause of strokes in younger patients accounting for nearly 20% of strokes in patients under the age of 45 years. Extracranial internal carotid artery dissections comprise 70%-80% and extracranial vertebral dissections account for about 15% of all CAD. Aetiopathogenesis of CAD is incompletely understood, though trauma, respiratory infections, and underlying arteriopathy are considered important. A typical picture of local pain, headache, and ipsilateral Horner's syndrome followed after several hours by cerebral or retinal ischaemia is rare. Doppler ultrasound, MRI/MRA, and CT angiography are useful non-invasive diagnostic tests. The treatment of extracranial CAD is mainly medical using anticoagulants or antiplatelet agents although controlled studies to show their effectiveness are lacking. The prognosis of extracranial CAD is generally much better than that of the intracranial CAD. Recurrences are rare in CAD.

Update on myasthenia gravis.

Myasthenia gravis is an autoimmune disorder caused by autoantibodies against the nicotinic acetylcholine receptor on the postsynaptic membrane at the neuromuscular junction and characterised by weakness and fatigability of the voluntary muscles. It has a bimodal peak of incidence with first peak in the third decade and the second peak in the sixth decade. It is probably underdiagnosed in the very old population. Our understanding of the pathogenesis, immunology, and molecular biology of myasthenia gravis has greatly improved in last three decades. It is almost always possible to establish the diagnosis of myasthenia gravis with the current tests. The modern treatment is highly successful and the mortality of treated myasthenia gravis is practically zero. However, there are still important gaps in our knowledge of the origin of myasthenia gravis, the factors that contribute to chronic disease, and the way to cure the disease. In this article the current knowledge of the various aspects of myasthenia gravis are outlined.

Long term motor complications of levodopa: clinical features, mechanisms, and management strategies.

Levodopa is the most effective symptomatic treatment of Parkinson's disease. However, after an initial period of dramatic benefit, several limitations become apparent including, "dopa resistant" motor symptoms (postural abnormalities, freezing episodes, speech impairment), "dopa resistant" non-motor signs (autonomic dysfunction, mood and cognitive impairment, etc), and/or drug related side effects (especially psychosis, motor fluctuations, and dyskinesias). Motor complications include fluctuations, dyskinesias, and dystonias. They can be very disabling and difficult to treat. Therefore, strategies should ideally be developed to prevent them. Though mechanisms underlying motor complications are only partially understood, recent work has revealed the importance of pulsatile stimulation of postsynaptic dopamine receptors and the disease severity. As a result of intermittent stimulation there occurs a cascade of changes in cell signalling leading to upregulation of the N-methyl-D-aspartate subtype of gamma-aminobutryric acid-ergic neurones. Modified preparations of levodopa (controlled release preparations, liquid levodopa), catecholamine-o-methyltransferase inhibitors, dopamine agonists, amantidine, and various neurosurgical approaches have been used in the prevention and/or treatment of motor complications. Current management of motor complications is less than satisfactory. With better understanding of the pathogenetic mechanisms, it is hoped that future therapeutic strategies will provide a safer and targeted treatment.

Acceptability of oesophagogastroduodenoscopy without intravenous sedation: patients' versus endoscopist's perception with special reference to older patients.

BACKGROUND: Unsedated oesophagogastroduodenoscopy (OGD) is considered by most endoscopists to be a quick, safe, and well tolerated procedure. Older patients are said to tolerate it better than younger patients. However, patients' perception of the discomfort for the unsedated OGD has not been well studied. OBJECTIVE: This study was undertaken to compare (1) patients' perception of discomfort with the endoscopist's perception of patients' discomfort for the unsedated OGD, (2) tolerability between older (> or =75 years) and younger (<75 years) patients. DESIGN AND SUBJECTS: A total of 130 consecutive patients attending a day case endoscopy unit were recruited for the study. The patients and endoscopist recorded their assessment using a visual analogue scale (VAS). The results were analysed using non-parametric tests. Thirty patients were excluded from the study based on exclusion criteria. Sixty three (57%) patients were aged > or =75 years and 37 (43%) were <75 years. RESULTS: A significant difference was noted between patients' perception of the discomfort and the endoscopist's assessment of the patient's discomfort as suggested by the overall higher VAS scores for patients (median 4.9, SD 2.6) than those of the endoscopist (median 2.2, SD 1.2), giving a significant difference in median VAS score of 3.4 (p<0.001). Older and younger patients had similar scores, with median (SD) VAS scores of 4.8 (2.5) for > or =75 years and 4.9 (2.8) for <75 years. The endoscopist's median scores for these two groups were 2.2 (1.2) and 2.1 (1.3), respectively. CONCLUSIONS: Patients' discomfort during OGD performed without sedation was greatly underestimated by the endoscopist. There was no significant difference in acceptability between old and the young patients.

Neuropsychiatric non-motor aspects of Parkinson's disease.

Parkinson's disease is often recognised as a motor disease characterised by rest tremor, rigidity, bradykinesia, and postural disturbances. However, there are several non-motor aspects of the disease that are of at least equal importance in the management of patients with Parkinson's disease. They include depression, cognitive impairment, anxiety, and psychosis among others. It is important to recognise them, as they are common and they contribute significantly to patients' morbidity, quality of life, and institutionalisation to long term care homes. In addition to the disease duration and severity, other factors including drugs may contribute to their occurrence. Pathogenesis of these aspects is not fully understood, though there has been a significant increase in the knowledge in recent years. Management of these aspects involves a multidisciplinary approach.