Neurologic Complications of Fat Embolism Syndrome.

PURPOSE OF REVIEW: Fat embolism syndrome (FES) is a rare disorder with potentially devastating neurologic complications. This article reviews the history, pathophysiology, clinical features, diagnosis, and treatment of FES with a focus on its neurologic aspects. RECENT FINDINGS: The neurologic complications of FES are more commonly recognized with current diagnostic testing and increase awareness of the disorder. FES may present initially with neurologic manifestations. Prompt diagnosis of FES and of its neurologic manifestations could be lifesaving. This includes respiratory support and management of neurological complications. The classic clinical triad of pulmonary insufficiency, neurologic disturbances, and petechial skin rash typically presents 24 to 72 h following an initial insult, most commonly a traumatic long bone fracture. Early onset (< 24 h) and delayed onset (> 72 h) have been described. Neurologic manifestations may include ischemic/hemorrhagic strokes, retinal ischemia, seizures, autonomic dysfunction, and diffuse brain injury. Diagnosis remains clinical. Management consists mainly of supportive care.

Management of Blood Pressure After Acute Ischemic Stroke.

PURPOSE OF REVIEW: The present manuscript examines the significance of blood pressure elevation in patients with acute ischemic stroke, the physiologic principles worthy of consideration during its treatment, and the recent empirical evidence that should guide management protocols. It also provides a sound and practical approach to treatment along the time continuum, with particular relevance to reperfusion strategies. RECENT FINDINGS: The existing evidence shows that both insufficient and excessive blood pressures are detrimental to the outcome of patients with acute ischemic stroke. This "U-shaped" relation, however, relates to measurements at the time of presentation, and clinical studies lack detail and specificity relative to differential measurements along the time continuum, particularly prior to and following reperfusion. Extrapolating from recent series, it is possible to construct treatment protocols balanced for effectiveness and safety. The management of blood pressure after acute ischemic stroke is an important, complex, and challenging aspect of care, requiring a thorough understanding of cerebrovascular physiology. Along the time continuum, the therapeutic priorities start with the preservation of penumbral tissue prior to reperfusion and then follow with the limitation of the damaging effects of excessive blood pressure readings after reperfusion, optimizing the chances of improved outcomes.

Correction to: Management of Blood Pressure after Acute Ischemic Stroke.

The original version of this article unfortunately contained a mistake.

Telemedicine in stroke care and rehabilitation.

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 deficits.

Pearls on primary stroke center.

Stroke is a leading cause of morbidity and mortality in the United States. The Brain Attack Coalition (BAC) provided goals and standards for development of primary and comprehensive stroke centers. There are over 800 primary stroke centers certified by The Joint Commission. This article provides a practical summary of recommendations to develop a primary stroke center, including some pearls that result from the experience of our institution in the field.

Prevention of venous thromboembolism in patients with hemorrhagic stroke.

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.

Antithrombotic therapy for stroke prevention in patients with heart failure.

OPINION STATEMENT: Congestive heart failure (CHF) is associated with an increased risk of stroke mainly due stasis leading to increased risk of thrombus formation in the left ventricle and subsequent cerebral embolism. CHF patients are also at increased risk of atrial fibrillation (AF) that also leads to cerebral embolism. Aggressive medical management to prevent cardiac decompensation and maintain sinus rhythm is indicated in CHF patients. All patients with CHF and AF should be anticoagulated with warfarin or one of the newer oral anticoagulants. There is no clear indication for anticoagulation in CHF patients due to ischemic cardiomyopathy who are in sinus rhythm. Based on data from the WARCEF study (see below), those patients with CHF due to non-ischemic etiologies who are in sinus rhythm and have a left ventricular ejection fraction (LVEF) less than 30 % to 35 % may benefit from warfarin for the reduction of ischemic stroke risk, but warfarin does not increase survival. Whether warfarin is particularly beneficial for CHF patients who have a prior history of stroke or transient ischemic attack (TIA) is unknown. If, however, there is high enough suspicion that the stroke was of cardioembolic origin in patients with low LVEF, then anticoagulation would possibly be a reasonable option for prevention of recurrent stroke or TIA. Warfarin is indicated for stroke prophylaxis among those CHF patients who have an implanted mechanical device. The role of newer anticoagulants in patients with CHF who do not have AF is unknown at this time. Theoretically, there should be no reason against using these agents in place of warfarin in selected patients, particularly those with highly variable International Normalized Ratios (INR) in the context of warfarin therapy, but the newer anticoagulants have not yet been studied among CHF patients without concomitant AF.

Neurologic complications of cardiac disease in athletes.

Athletic participation at all levels of proficiency is an encouraged activity. Physicians evaluating athletes are tasked with assessing the benefits and risks of participating in vigorous physical activity and should engage in shared decision making with the athlete. Identifying the neurologic sequelae is an essential part of the assessment that is often not covered. This chapter will review the association of a wide range of cardiac disorders that can be related to or associated with subsequent neurologic sequelae, along with a brief overview of recommendations for management. Prevalent neurological complications of cardiac disease in athletes include stroke and seizures. There are also certain channelopathies that result in concurrent cardiac dysrhythmias and epilepsy. In addition, physiologic cardiac rhythm changes and the athlete's heart are discussed in the context of the differential diagnoses of subsequent cardiac and neurologic disease. The primary objective of this chapter is to prepare the physician for accurate recognition of cardiac disease in athletes that could result in neurologic complications if not diagnosed and managed early on.

Sequential Bilateral Vertebral Artery Dissections with Prompt Resolution of Initial Insult.

Vertebral arterial dissection is a known cause of stroke in young adults. There has been a multitude of cases of bilateral vertebral dissections, including progression from one vertebral artery to another. This case reports the curious sequential nature of the healing of a previously dissected vertebral artery with subsequent dissection of the collateral vertebral artery. Follow-up neuroimaging evaluation performed several months later showed healed bilateral vertebral artery. The potential trigger was neck cracking.

Stroke due to Paradoxical Embolization Related to Fibroid Uterus Enlargement Compressing the Right Common Iliac Vein.

Stroke in young women is commonly cryptogenic or associated with an underlying hypercoagulable state (e.g., hormonal contraception). Paradoxical embolization has been postulated as a potential risk factor for stroke in young adults. Many sources of venous thrombosis leading to paradoxical embolization have been described. There have been few reported cases of uterine enlargement leading to iliac vein compression and paradoxical embolization. We present the case of a young adult woman who had a left middle cerebral artery infarction related to patent foramen ovale and right common iliac vein compression from an enlarged fibroid uterus.

Leucine-Rich Glioma Inactivated-1 and Voltage-Gated Potassium Channel Autoimmune Encephalitis Associated with Ischemic Stroke: A Case Report.

Autoimmune encephalitis is associated with a wide variety of antibodies and clinical presentations. Voltage-gated potassium channel (VGKC) antibodies are a cause of autoimmune non-paraneoplastic encephalitis characterized by memory impairment, psychiatric symptoms, and seizures. We present a case of VGKC encephalitis likely preceding an ischemic stroke. Reports of autoimmune encephalitis associated with ischemic stroke are rare. Several hypotheses linking these two disease processes are proposed.

Commonly asked questions in the management of perioperative stroke.

Certain surgical interventions increase stroke risk. Perioperative stroke significantly increases perioperative morbidity and mortality. Several interventions, such as perioperative continuation of antithrombotic therapy during selected surgical interventions, may decrease stroke risk without significantly increasing rates of adverse effects. Commonly asked questions in the management of perioperative stroke includes: What are the mechanisms of perioperative stroke? What are the stroke risk factors and perioperative risks? What is the perioperative stroke risk with discontinuation of antithrombotic medications? What risk modifications strategies can be implemented to decrease perioperative stroke risk? What is the role of neuroimaging in the management of perioperative stroke? What is the evidence for the management of perioperative acute ischemic stroke? This article provide an evidence-based review to these questions and comments on potential interventions in the management of these patients.

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.

Platelet antiaggregants in stroke prevention.

Antiplatelet agents are one of the main interventions for recurrent ischemic stroke prevention. Their time of use, dosage, and combination of therapy have different effects in terms of stroke risk reduction and adverse effects. This review provides an evidence-based update of the latest on antiplatelet therapy for stroke prevention.

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.

Diabetic peripheral neuropathy and the management of diabetic peripheral neuropathic pain.

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.

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 × 10(9)/L and 65 000 × 10(9) /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.

Cocaine induced hippocampi infarction.

A middle age man presented with disorientation and memory impairment due to bilateral hippocampal strokes secondary to cocaine use. This is the second report of cocaine induced hippocampi ischaemic strokes. In contrast to the previous report, this middle age man did not have cardiac arrest.

Central and extrapontine myelinolysis affecting the brain and spinal cord. An unusual presentation of pancreatic encephalopathy.

Pancreatic encephalopathy refers to a gamut of neuropsychiatric symptoms complicating acute pancreatitis. Osmotic myelinolysis is a known complication of pancreatic encephalopathy. We evaluated a 58-year-old woman with pancreatic encephalopathy associated to pontine and extrapontine myelinolysis involving the brain and spinal cord. To our knowledge, this is the first clinic pathological case report of pancreatic encephalopathy involving the spinal cord.