Drugs in secondary stroke prevention.

After an ischaemic stroke or transient ischaemic attack, patients have a high risk of having another stroke. Secondary stroke prevention includes antiplatelet therapy, statins and antihypertensives Aspirin, clopidogrel, or a combination of aspirin with dipyridamole are first-line options for secondary stroke prevention in the absence of atrial fibrillation Dual antiplatelet therapy has a benefit in the first three weeks after stroke, but patients should change to a single antiplatelet drug after this time Anticoagulants are indicated if the patient has atrial fibrillation. Avoid combinations of anticoagulants and antiplatelet drugs Patients should be started on statins after an ischaemic stroke. High doses are recommended even if cholesterol concentrations are normal Antihypertensive drugs are recommended for all patients with systolic blood pressures greater than 140/90 mmHg. ACE inhibitors, calcium channel blockers and diuretics are first-line options.

Lymphocytic Hypophysitis Presenting as Bilateral Abducens Nerve Palsy: A Case Report.

Lymphocytic hypophysitis (LYH) is a neuroendocrine disorder characterised by autoimmune inflammation of the pituitary gland with varying degrees of pituitary dysfunction, visual field defects and ocular motility disturbance. The authors report an interesting case of a 50-year-old woman presenting with intermittent bilateral abduction deficits. Neuroimaging and histopathological findings are presented. To the authors' knowledge, this is the first report of recurrent horizontal binocular diplopia and complete bilateral internal carotid artery occlusion in association with LYH.

Long-term Ergotamine Derivative Therapy for Migraine Associated with Pachymeningitis and Sixth Cranial Nerve Palsy.

Chronic use of ergotamine derivatives has been well described in the literature to cause retroperitoneal, pleural, pericardial and valvular fibrosis. While acute migraine treatment advances have resulted in a reduction of ergotamine derivatives prescribing, they are still considered appropriate for some patients. We report a case of diffuse pachymeningitis with symptomatic right sixth cranial nerve palsy who had a history of long-term Cafergot© suppository use. To the best of our knowledge, this is the first case to temporally associate ergotamine derivatives with pachymeningitis.

Fulminant thymomatous AMPAR-antibody limbic encephalitis with hypertonic coma, bruxism, an isoelectric electroencephalogram and temporal cortical atrophy, with recovery.

Autoimmune encephalitides are a potentially devastating group of treatable disorders with a wide variety of clinical presentations. The most studied autoimmune encephalitis is caused by antibodies to the N-methyl-D-aspartate glutamate receptor. A rarer cause is due to antibodies against the evolutionarily related α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR). The full assortment of electroencephalogram (EEG) and clinical descriptions of the latter are yet to be fully described. A 44-year-old woman with impaired consciousness and subsequent coma characterised by an isoelectric EEG was diagnosed with AMPAR-antibody limbic encephalitis. MRI revealed temporal T2 hyperintensities that improved with immunosuppression, although leaving marked cortical atrophy. Gradual clinical improvement saw the development of aggressive bruxism requiring botulinum toxin injection with eventual meaningful clinical recovery. This case expands the clinical spectrum of AMPAR limbic encephalitis to include aggressive bruxism, and highlights that despite poor clinical and EEG findings at the outset, recovery is still possible.

Postural orthostatic tachycardia syndrome: the Mayo clinic experience.

OBJECTIVE: To evaluate the prevalence and pathogenetic mechanisms of postural orthostatic tachycardia syndrome (POTS). PATIENTS AND METHODS: We reviewed the medical records of patients with POTS seen at the Mayo Clinic in Rochester, Minn, from January 1, 1993, through December 31, 2003. All patients were required to have had a full autonomic reflex screen. The results of the following additional tests were evaluated: thermoregulatory sweat test, plasma catecholamine measurement, serum ganglionic (a3) acetylcholine receptor antibody detection, and 24-hour urinary sodium measurement. RESULTS: We identified 152 patients (86.8% female; mean +/- SD age, 30.2+/-10.3 years) with a mean duration of symptoms of 4.1 years. The mean orthostatic heart rate increment was 44 beats/min. Half the patients had sudomotor abnormalities (apparent on both the quantitative sudomotor axon reflex test and thermoregulatory sweat test), and 34.9% had significant adrenergic impairment, indicating that at least half of the patients had a neuropathic pattern of POTS. In 13.8% of patients, onset was subacute, and ganglionic acetylcholine receptor antibody was detected in 14.6%, suggesting an autoimmune origin in at least 1 in 7 patients. Hyperadrenergic status was documented in 29.0% of patients (standing plasma norepinephrine level 2600 pg/mL), and at least 28.9% were presumably hypovolemic (24-hour urinary sodium level <100 mEq/24h). The lack of correlation between urinary sodium and standing norepinephrine levels suggests that mechanisms other than hypovolemia accounted for the hyperadrenergic state. CONCLUSION: Our findings suggest a neuropathic basis for at least half the cases of POTS and that a substantial percentage of cases may be autoimmune. Hyperadrenergic and hypovolemic correlates are likely compensatory or exacerbating.

Pulmonary function tests and blood gases in worsening myasthenia gravis.

The aim of this study was to determine whether pulmonary function tests have a role in predicting the need for ventilation support in myasthenia gravis. Medical records were reviewed for 42 patients with severe myasthenia gravis who required 55 admissions to the intensive care unit. Patients with a vital capacity of more than 20 ml/kg, a maximal expiratory pressure more than 40 cm H(2)O, or a maximal inspiratory pressure more negative than -40 cm H(2)O are unlikely to require mechanical ventilation. A decline of 30% or more in maximal inspiratory pressure predicted a group at higher risk of requiring mechanical or noninvasive ventilation. Hypercapnia was frequent and was more common in patients who required mechanical ventilation. Worsening of these pulmonary function and blood gas values in patients with myasthenia gravis may guide decisions about intubation and ventilatory support.