Pathogenesis of extracranial cerebrovascular disease.

The extracranial vasculature is subject to a vast array of disease processes including atherosclerosis, dissection, inflammation, and mechanical compression. Our current understanding of the pathogenesis of these diseases is discussed.

Ischemia in the territory of a hypoplastic vertebrobasilar system.

BACKGROUND: Congenital variations in the configuration and size of the cerebral vessels may predispose to ischemic stroke. OBJECTIVES/METHODS: To illustrate that a hypoplastic basilar artery may lead to posterior circulation ischemia in adults, eight cases are reported from two university medical centers. RESULTS: Five men and three women with a mean age of 49.8 years are reported. Four of the patients had other conventional stroke risk factors. Two patients had brainstem strokes, and six had TIA. All patients had hypoplastic basilar arteries. Seven patients had at least one hypoplastic vertebral artery (bilateral in five cases), and six patients had both posterior cerebral arteries originating from the internal carotid arteries. CONCLUSIONS: A hypoplastic basilar artery is frequently accompanied by vertebral artery hypoplasia, and this can predispose adults to posterior circulation ischemia. This entity can be suspected on the basis of MR angiogram, but conventional angiography will provide definitive diagnosis. Optimal medical and surgical treatment of this condition is unresolved.

Diabetes mellitus and cerebrovascular disease.

In the past several years, a substantial amount of new information on the epidemiology and pathophysiology of diabetes and vascular disease has become available. Autopsy studies suggest that diabetic patients are susceptible to cerebral small-artery disease and lacunar infarction and may be at risk for large-artery atherosclerotic occlusive disease. Epidemiological studies show that diabetes is a risk factor for ischemic stroke. The pathogenesis of diabetes-associated stroke appears to be linked to excessive glycation and oxidation, endothelial dysfunction, increased platelet aggregation, impaired fibrinolysis and insulin resistance. Macrovascular complications may be prevented by simple primary prevention measures including exercise, weight loss and treatment of dyslipidemia. The role of tight glycemic control in reducing the risk of stroke is still uncertain. Many new insights and treatment strategies are expected in the future.

Calcific cerebral embolism in systemic calciphylaxis.

Calciphylaxis represents a rare complication of end-stage renal disease with hyperparathyroidism. We report the case of a 26-year-old woman with systemic calciphylaxis secondary to chronic renal failure who developed mitral annular calcification and a right middle cerebral artery stroke. The high-density lesion seen on CT scan of the brain probably represents a calcified cerebral embolus originating from the mitral valve.

Subarachnoid hemorrhage after thrombolytic therapy for acute myocardial infarction: a case report.

Intracranial hemorrhage is the most feared complication of thrombolytic therapy. This report describes a 42-year-old diabetic woman who presented with an acute myocardial infarction and suffered a subarachnoid hemorrhage after receiving recombinant tissue plasminogen activator. This report discusses this important but very rare complication of thrombolytic therapy.

Nonconvulsive status epilepticus after intravenous contrast medium administration.

PURPOSE: We describe a 52-year-old man with a glioblastoma multiforme who had a prolonged partial seizure immediately after undergoing a computed tomography (CT) scan of the head with intravenous contrast medium. METHODS: Earlier computed tomography (CT) had demonstrated a ring-enhancing hypodense mass. The patient was treated with a regimen of intravenous Tirapazamine and brain irradiation. After CT scan performed on the day of his second hospitalization, the patient became aphasic. EEG showed continuous high-voltage semirhythmic sharp and slow waves in the left posterior temporal and parietal regions consistent with status epilepticus (SE). Intravenous lorazepam and a loading dose of phenytoin were administered. RESULTS: On the next morning, the patient's condition had improved almost to baseline. He had no recurrent seizures. EEG at 2-month follow-up showed no epileptiform discharges. CONCLUSION: This appears to be the first reported case of contrast medium-induced status epilepticus.

Behavioral disturbance in severe Alzheimer's disease: a comparison of family member and nursing staff reporting.

OBJECTIVE: The purpose of this study is to describe the behavioral disturbances in a group of patients with severe Alzheimer's disease and to compare family members' and nursing staff members' perceptions regarding these behaviors. DESIGN: Cross-sectional survey. SUBJECTS: The 33 subjects resided in nine different long-term care facilities in the Rochester, NY area and were selected from a group of patients enrolled in a longitudinal research study of Alzheimer's disease, based on having severe disease. OUTCOME MEASURES: Caregivers were surveyed with a self-administered questionnaire. The primary outcome measures were the prevalences of 13 behaviors and the magnitude of caregiver concern reported by each group of caregivers. RESULTS: Compared with family members, nurses reported more concern with vegetative behaviors (incontinence, dietary change, and sleep disturbance; P = 0.055). There was statistical evidence that the number of behaviors reported by the nurses decreased with increasing disease severity (P = 0.002). Although not statistically significant, the magnitude of concern reported by the nurses also decreased with increasing disease severity (P = 0.063). Family members and nurses frequently disagreed about the presence of many behaviors exhibited by individual patients, and the responses of caregivers within the same group were highly variable. CONCLUSION: Institutionalized patients with severe Alzheimer's disease continue to exhibit troublesome behaviors although overall behavioral disturbance and concern appear to decrease with increasing disease severity. The assessment of these behaviors and their impact on caregivers can be very subjective, depending in part on the role of the caregiver.