Contemporary Antiplatelet and Anticoagulant Therapies for Secondary Stroke Prevention: A Narrative Review of Current Literature and Guidelines.

PURPOSE OF REVIEW: Stroke is a leading cause of death and disability worldwide. The annual incidence of new or recurrent stroke is approximately 795,000 cases per year in the United States, of which 87% are ischemic in nature. In addition to the management of modifiable high-risk factors to reduce the risk of recurrent stroke, antithrombotic agents (antiplatelets and anticoagulants) play an important role in secondary stroke prevention. This review will discuss the published literature on the use of antiplatelets and anticoagulants in secondary prevention of acute ischemic stroke and transient ischemic attack (TIA), including their pharmacology, efficacy, and adverse effects. We will also highlight the role of dual antiplatelet therapy (DAPT) in secondary stroke prevention, along with supporting literature. RECENT FINDINGS: Single antiplatelet therapy (SAPT) with aspirin or clopidogrel reduces the risk of recurrent ischemic stroke in patients with non-cardioembolic ischemic stroke or TIA. However, as shown in recent trials, short-term DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than SAPT in patients with minor acute non-cardioembolic stroke or high-risk TIA. Although short-term DAPT is highly effective in preventing recurrent stroke, a more prolonged course can increase bleeding risks without additional benefit. DAPT for 90 days, followed by aspirin monotherapy for patients with large vessel intracranial atherosclerotic disease, is suitable for secondary stroke prevention. However, patients need to be monitored for both minor (e.g., bruising) and major (e.g., intracranial) bleeding complications. Conversely, oral warfarin and newer direct oral anticoagulant (DOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban are the agents of choice for secondary stroke prevention in patients with non-valvular cardioembolic strokes. DOACs may be preferred over warfarin due to decreased bleeding risks, including ICH, lack of need for international normalized ratio monitoring, no dietary restrictions, and limited drug-drug interactions. The choice between different antiplatelets and anticoagulants for prevention of ischemic stroke depends on the underlying stroke mechanism, cytochrome P450 2C19 polymorphisms, bleeding risk profile, compliance, drug tolerance, and drug resistance. Physicians must carefully weigh each patient's relative benefits and bleeding risks before initiating an antiplatelet/anticoagulant treatment regimen. Further studies are warranted to study the optimal duration of DAPT in symptomatic intracranial atherosclerosis since the benefit is most pronounced in the short term while the bleeding risk remains high during the extended duration of therapy.

Etiologic mechanisms in an adapted family-based preventive intervention for underage alcohol use in Mexico: Results of an exploratory pilot study.

Alcohol use represents a global health problem, especially for Latin American youth. As part of the Global Smart Drinking Goals campaign, a family-based preventive intervention was adapted and piloted in Mexico based on an existing evidence-based program, Guiding Good Choices. In this study, we explored the malleability and session-specific mean-level changes in protective and risk factors targeted by the adapted family intervention as related to the prevention of underage alcohol use and abuse. The sample consisted of 177 parents working at four private local companies who had children between the ages of 8 and 16. Data were collected before and after each program session. Linear mixed-effects models were used to examine growth trajectories and session-specific mean differences for selected etiologic factors. Significant effects on protective and risk factors were found. Among protective factors, positive family involvement showed the most considerable linear growth over time, while clear standards for youth showed the largest within-session increase. The greatest linear decrease in risk was observed for family conflict, which also showed the greatest pre-, and post-session reduction. Our findings suggest that the adapted program helped families develop protection against, and reduce risk of, alcohol use in their adolescent children. Results from this exploratory pilot study provide support for further rigorous evaluation and dissemination of the adapted intervention for Hispanic families.

Predictors of Engagement and Attendance of a Family-Based Prevention Program for Underage Drinking in Mexico.

Underage drinking represents a major global health problem. Given the crisis that underage drinking represents, Tomando Buenas Decisiones, a family-based prevention program, was adapted and piloted in Mexico based on the existing Guiding Good Choices program. Although family-based interventions in the USA are promising for preventing underage drinking, little is known about how adapted versions of these interventions may work in low-middle income countries, such as in Latin America. The present study examined whether baseline individual, familial, and cultural factors predict participants' engagement and attendance in an adapted program for preventing underage drinking in Zacatecas, Mexico. The study was conducted with a sample of 178 parents who participated in the adapted program and were employed at local private companies. Latent growth curve modeling was used to analyze (a) change in engagement, (b) predictors of engagement, and (c) predictors of attendance. Results indicated that perceived engagement evidenced a significant linear increase throughout the intervention. Participants' familism values, such as perceived family as referents and family support, at baseline predicted both initial levels of and change in engagement. Perceived familial obligation also predicted change in engagement. Attendance was negatively predicted by male gender, by perceived stress, and by perceived familial obligations among women only. Poor family management, and perceived familial obligations among men, positively predicted attendance. Our findings have important implications for the conceptualization of engagement and attendance in family-based preventive interventions for underage drinking among Hispanics. Researchers interested in implementing interventions in Latin America can use these findings to better comprehend how and for whom adapted family-based preventive interventions work.

Global Metabolomic Profiling Reveals Disrupted Lipid and Amino Acid Metabolism Between the Acute and Chronic Stages of Ischemic Stroke.

BACKGROUND: Stroke is a major cause of serious disability in the United States. Previous studies found multiple associations of serum metabolites with acute ischemic stroke (AIS) compared to controls, but few of them evaluated metabolome in a longitudinal fashion. Therefore, we compared the metabolome of the acute and chronic stages of ischemic stroke. METHODS: We evaluated 1295 serum metabolites from the cohort of 60 stroke patients at acute and chronic stages by performing global metabolomics using ultra-high-performance liquid chromatography/mass spectrometry (LC-MS) and gas chromatography/mass spectrometry (GC-MS). We used Orthogonal Partial Least Square-Discrimination Analysis (OPLS-DA) to inspect group disparity and a mixed regression model to compare metabolites in the acute and chronic stages with Two-Stage Benjamini & Hochberg (TSBH) and Bonferroni correction for multiple testing. RESULTS: The OPLS-DA revealed significant separation of acute and chronic stage metabolites. Mixed regression identified 228 metabolites with TSBH, and 29 metabolites with Bonferroni correction different in acute and chronic stages. At the acute stage, there was a consistent increase of the metabolites of mono/diacylglycerols, sphingolipids, medium/long-chain fatty acids, and amino acids glycine, valine, and tyrosine. At the same time, there was a consistent decrease of the metabolites of acyl-choline related fatty acids, phospholipids, and amino acids alanine, aspartate, and tyramine. Additionally, we identified eight novel metabolites significantly altered at the acute stage of stroke. CONCLUSION: Our pilot study demonstrated significant alterations in metabolomic patterns between the acute and chronic stages of stroke, validating some case-control findings. Future investigation in a larger independent cohort is warranted to identify early biomarkers of acute ischemic stroke.

Immune-Mediated Disorders Affecting the Spinal Cord and the Spine.

PURPOSE OF REVIEW: To review the most recent advances and provide a description of the most common autoimmune diseases causing myelitis and selective spine disorders. The ultimate goal of this article is to facilitate the prompt recognition of these diseases. RECENT FINDINGS: The recent discovery of biomarkers such as aquaporin 4 (AQP4) and myelin oligodendrocyte glycoprotein (MOG) antibodies has changed our understanding of autoimmune diseases affecting the spinal cord as well as their treatment and outcomes. Autoimmune neurology is an increasingly evolving field that encompasses a broad spectrum of autoimmune-inflammatory diseases of the central nervous system (CNS) and peripheral nervous system (PNS). Autoimmune disorders of the spinal cord are a heterogeneous group of myelopathies with a broad differential diagnosis and many of them have been recently identified. Prompt recognition of these myelopathies is important as some of them are treatable, which could improve patient outcomes and prevent disability.

Dietary Insights in Neurological Diseases.

PURPOSE OF REVIEW: Dietary interventions may play a role in the pathophysiology of common neurological disorders such as Alzheimer's disease, Parkinson's disease, stroke, migraines, multiple sclerosis, and epilepsy. This article describes the most common and impactful dietary regimens for commonly encountered neurological disorders. RECENT FINDINGS: Plant-based, low-fat, high-fiber diets, rich in antioxidants and other lifestyle interventions may reduce the burden and disability of common neurological disorders. The ketogenic diet, the diet of choice for the treatment of refractory epilepsy, is such an example. Diverse neurological disorders demonstrate several common pathophysiological mechanisms including increased oxidative stress, neuroinflammation, and disrupted metabolism. Dietary interventions can potentially influence these pathophysiological processes and thus favorably alter clinical outcomes. Adequate dietary choices should be considered as part of a continuum of healthy lifestyle choices.

Dialysis disequilibrium syndrome in neurosurgery: literature review and illustrative case example.

INTRODUCTION: The dialysis disequilibrium syndrome (DDS) is a complication in those undergoing dialysis for chronic kidney disease (CKD) or acute kidney injury (AKI), characterized by nonspecific symptoms that may progress to coma and death secondary to cerebral edema. This syndrome is associated with rapid change in electrolytes during dialysis with changes in intracranial pressure (ICP) and may have a higher incidence in the elderly neurosurgical patient population. METHODS: Literature review and illustrative case example. RESULTS: A 62-year-old female presented with acute mental status change during hemodialysis (HD), with a history of a nonsurgical acute subdural hematoma (SDH) 10 days prior. Imaging showed a conversion of the acute SDH to chronic SDH of 12.2 mm in size with a 14.1 midline shift, for which she underwent a hemicraniectomy with SDH evacuation, with a gradual return to baseline. The literature review identified 5 publications meeting the inclusion criteria. Major theories of DDS include a reverse urea effect, intracerebral acidosis, idiogenic osmoles, and local inflammation. This complication may occur more frequently in the elderly neurosurgical patient population, likely due to age-related comorbidities, preexisting neurological insult, and increased permeability of the blood-brain barrier (BBB), leading to cerebral edema. CONCLUSION: DDS is a rare and potentially fatal complication of HD that may have a higher incidence in the elderly neurosurgical patient population, yet remains to be fully understood. Further study is recommended to characterize the pathophysiological mechanism and incidence of DDS in neurosurgical patients.

Recent advances in the management of transient ischemic attacks.

Transient ischemic attack (TIA) constitutes an important clinical condition, indicating the presence of considerable risk for a subsequent ischemic stroke. Its prompt diagnosis and management have the potential for reducing the risk of neurologic disability, highlighting the critical need to prioritize the care of patients with TIA. The risk of ischemic stroke following a TIA is directly related to its etiopathogenesis, and recognizable causes are commonly categorized within one of three domains: cerebrovascular pathology, cardiac dysfunction, and hematologic disorders. Therefore, the clinical approach to patients suspected of having suffered a TIA demands a comprehensive evaluation, including testing of possible etiologic conditions in all three of these domains, best carried out in an expedited fashion since the stroke risk is greatest in the hours and days that follow the index event. The present is a review of the existing literature addressing the diagnosis, evaluation, prioritization, and management strategies available to clinicians who provide care to patients with TIA.

Management dilemmas in acute ischemic stroke and concomitant acute pulmonary embolism: Case series and literature review.

BACKGROUND: Pulmonary embolism (PE) and acute ischemic stroke (AIS) are common disorders with high morbidity and mortality, rarely presenting simultaneously. There is a paucity of data regarding the management of this uncommon presentation. The treatment of these two entities is complex in the acute phase due to the concomitant need for thrombolysis in AIS and anticoagulation for PE. METHODS: We retrospectively reviewed confirmed ischemic stroke cases to identify patients presented with simultaneous PE from June 2018 to May 2019. Additionally, a literature review was performed. Two reviewers assessed the manuscripts' quality, and relevant data regarding clinical course and management was extracted. RESULTS: We reviewed 439 patient charts, identifying two cases of concomitant AIS and PE. Additionally, twelve articles (n = 15 subjects) fulfilled our literature review criteria for a total of 17 cases, including ours. Intravenous anticoagulation (70.5%) was the most frequent intervention targeting both disorders. Therapies such as intravenous thrombolysis (23.53% (n = 4)) and mechanical thrombectomy (23.53% (n = 4)) were specific in AIS. Catheter-directed thrombolysis (5.88%) was used for PE. Clinical outcomes were favorable (asymptomatic or mild disable symptoms) in 47.05% (N = 8) of patients, while 41.17% had poor outcomes (severe disable symptoms or death). CONCLUSIONS: AIS and PE stand for a challenge when they present simultaneously. The evaluation of risks and benefits of therapies such as intravenous thrombolysis, mechanical thrombectomy, and catheter-directed-thrombolysis in the clinical context is essential. According to our review, the ischemic stroke burden guides systemic anticoagulation decisions over interventional procedures when the hemodynamic status remains unaffected.

Neurologic complications of implantable devices.

Technologies for repairing cardiac structures or sustaining cardiac function with implantable devices have helped patients with an ever-expanding array of cardiac conditions. Patients are surviving and thriving with cardiac conditions that would formerly have been disabling or fatal. With the implantation of devices in the heart, however, comes the inevitable risk of neurological complications. This chapter focuses on devices implanted in the chambers or valves of the heart itself, including prosthetic heart valves, closure devices for patent foramen ovale, atrial appendage occluder devices, short-term implantable circulatory assist devices, and long-term ventricular assist devices, but excluding coronary artery stents or extracardiac devices. Further, it considers the procedural and postprocedural risks of the devices, leaving the discussion of clinical effectiveness of the devices to other chapters of this book.

Safer Stroke-Dx Instrument: Identifying Stroke Misdiagnosis in the Emergency Department.

BACKGROUND: Missed or delayed diagnosis of acute stroke, or false-negative stroke (FNS), at initial emergency department (ED) presentation occurs in ≈9% of confirmed stroke patients. Failure to rapidly diagnose stroke can preclude time-sensitive treatments, resulting in higher risks of severe sequelae and disability. In this study, we developed and tested a modified version of a structured medical record review tool, the Safer Dx Instrument, to identify FNS in a subgroup of hospitalized patients with stroke to gain insight into sources of ED stroke misdiagnosis. METHODS: We conducted a retrospective cohort study at 2 unaffiliated comprehensive stroke centers. In the development and confirmatory cohorts, we applied the Safer Stroke-Dx Instrument to report the prevalence and documented sources of ED diagnostic error in FNS cases among confirmed stroke patients upon whom an acute stroke was suspected by the inpatient team, as evidenced by stroke code activation or urgent neurological consultation, but not by the ED team. Inter-rater reliability and agreement were assessed using interclass coefficient and kappa values (κ). RESULTS: Among 183 cases in the development cohort, the prevalence of FNS was 20.2% (95% CI, 15.0-26.7). Too narrow a differential diagnosis and limited neurological examination were common potential sources of error. The interclass coefficient for the Safer Stroke-Dx Instrument items ranged from 0.42 to 0.91, and items were highly correlated with each other. The κ for diagnostic error identification was 0.90 (95% CI, 0.821-0.978) using the Safer Stroke-Dx Instrument. In the confirmatory cohort of 99 cases, the prevalence of FNS was 21.2% (95% CI, 14.2-30.3) with similar sources of diagnostic error identified. CONCLUSIONS: Hospitalized patients identified by stroke codes and requests for urgent neurological consultation represent an enriched population for the study of diagnostic error in the ED. The Safer Stroke-Dx Instrument is a reliable tool for identifying FNS and sources of diagnostic error.

Oximetría de pulso como método de rastreo para macroangiopatía en diabéticos tipo 2: estudio prospectivo realizado en el hospital Luis Vernaza, de abril a septiembre de 2005 / Pulse oxymetry as a research method for diabetes 2 macroangiopathy: prospective study carried out in Luis Vernaza hospital, from abril to september/ 2005

Introducción: Con esta investigación queremos conseguir un método de rastreo alternativo para el estudio de la vasculopatía periférica que sea útil, exacto, sencillo de aplicar, no invasivo y que brinde veracidad en sus resultados. Métodos: Estudio prospectivo en el que se enrolaron 30 pacientes a los que se realizó la historia clínica, el ABI (Ankle-Brachial Index) y la medición de la saturación de oxígeno en el dedo índice y en el primer dedo del pie. El ABI fue considerado anormal con un valor menor de 0.9 y la saturación de oxígeno del primer dedo del pie fue considerada anormal, si la diferencia era mayor del 2 en comparación con el dedo índice y con el pie elevado 12 pulgadas. Posteriormente comparamos dichos resultados. Resultados: Encontramos una correlación entre ABI y Oximetría de pulso de – 0.39; igualmente detectamos la siguiente relación: a mayor edad y tiempo de diabetes, existieron valores mayores de desaturación de O2 en miembros inferiores, acompañados de valores menores de ABI, existiendo una correlación entre ellos de 88 según la tendencia que exhibieron los resultados. Conclusiones: La oximetría de pulso de miembros inferiores tanto en decúbito dorsal como elevada 12 pulgadas es tan exacta y segura como el ABI (Ankle-Brachial Index) en el rastreo de enfermedad arterial periférica en diabéticos tipo 2; y, la combinación de los dos, incrementa la sensibilidad.

Introduction: With this research we want to achieve an alternative useful, precise, simple to administer, non-invasive tracing method for the study of peripheral vasculopathy. That method should also give truthful results. Methods: Prospective study for which 30 patients were signed on and all of them had case history, Ankle-Brachial Index (ABI) and measurement of oxygen saturation in the index finger and in the first toe. ABI was taken as abnormal if it is lower than 0.9 and oxygen saturation of the first toe was taken as abnormal if difference was higher than 2 compared with that of the index finger, with the foot raised 12 inches. Later those results were compared. Results: A correlation of -0.39 was found between ABI and pulse oxymetry. It was also detected this relation: the older the patient and the longer he (her) has had diabetes, the higher his (her) O2 desaturation in lower limbs, with lower ABI. Correlation: 88 according to the trend showed by the results. Conclusions: Lower limbs pulse oxymetry both face up and 12 inches up is so precise and definite as it is ABI (Ankle-Brachial Index) in the searching of a peripheral arterial disease in type 2 diabetics; and if both are used in combination, sensitivity increases.