Rehabilitation approaches to stroke.

This article describes the state of the science in stroke rehabilitation dealing with three main topics: (1) General approach to stroke rehabilitation (stroke services and stroke units), (2) Neurophysiological and pharmacological interventions (facilitation of brain repair mechanisms) and (3) Experimental approaches (neuronal transplantation). Stroke rehabilitation is an active process beginning during acute hospitalisation, progressing to a systematic program of rehabilitation services and continuing after the individual returns to the community. There is world-wide consensus that stroke patients should be treated at specialised stroke unit with specially trained medical and nursing staff, co-ordinated multidisciplinary rehabilitation and education programs for patients and their families. Stroke Unit has been shown to be associated with a long-term reduction of death and of the combined poor outcomes of death and dependency, independent of patients age, sex, or variations in stroke unit organisations. No study has clearly shown to what extent the beneficial effect is due to specific rehabilitation strategies. New imaging studies in stroke patients indicate altered post stroke activation patterns, which suggest some functional reorganisation. Reorganisation may be the principle process responsible for recovery after stroke. It is assumed that different post ischaemic interventions like physiotherapy, occupational therapy, speech therapy, electrical stimulation, etc. facilitates such changes. Scientific evidence demonstrating the values of specific rehabilitation interventions after stroke is limited. Comparisons between different methods in current use have so far mostly failed to show that any particular physiotherapy, occupational therapy, speech therapy or stroke rehabilitation strategy is superior to another. Clinical data are strongly in favour of early mobilisation and training. Pharmacological interventions in animals revealed that norepinephrine, amphetamine and other alpha-adrenergic stimulating drugs can enhance motor performance after unilateral ablation of the sensory motor cortex. The clinical data in humans are rather contradictory. Neural grafting and neurogenesis are new potential modes of stroke therapy. Neural grafting enhanced functional outcome and reduced thalamic atrophy in rats only when combined with housing in enriched environments. Recent studies have shown that stem cells can differentiate to neurons in the adult human dentate gyrus in vivo.

Surgical or endovascular treatment of carotid stenosis.

Carotid endarterectomy (CEA) is a proved standard treatment in stenosis of high-grade carotid artery stenosis. On the basis of new experience, percutaneous transluminal angioplasty with stent (PTAS) has gradually been established as an alternative method to carotid endarterectomy. The aim of the three-month investigation was to evaluate PTAS, CEA and conservative medicamentous therapy. A group of 75 patients (78 stenoses) with symptomatic and asymptomatic stenoses of the carotid artery of 70 and more percent were evaluated within a unicentric retrospective study. The period of investigation commenced in August 1999, and lasted 14 months. The patients were treated by PTAS (23 patients), CEA (23 patients). Two patients were treated by bilateral stenting. One patient was subdued to both operation and endovascular treatment, while the former treatment was performed on one side and the latter on the contralateral side. This patient was included into both surgical and endovascular groups. The rest of the patients were treated solely by medicamentous therapy (30 patients). During the period of 30 days after the intervention, one patient in both PTAS and CEA groups (4.3%) developed a severe ipsilateral infarction. Recurrent stenoses were recorded in two patients from the PTAS group (8.7%) (sonographically more than 50%), and in one patient from the CEA group (4.3%). Immediately after stent implantation, 12 patients (52.2%) developed pinlike ischemic lesions observed by means of diffusion-weighted MR imaging (DWI). Hyperintensive signals did not lead to any neurologic deficits. After 3 months, none of the latter lesions were found in any of the patients. In the group treated by conservative therapy, only one of the patients (3%) developed a mild infarction. After the evaluation of our experience with peri-interventional PTAS and CEA complications in our small group of investigated patients, it is possible to state that the performance of both methods can be comparably successful. However, at the moment we cannot consider PTAS as an equivalent method. (Tab. 6, Fig. 2, Ref. 33.).

Discordance of technetium-99m-HMPAO and technetium-99m-ECD SPECT in herpes simplex encephalitis.

UNLABELLED: Technetium-99m-hexamethyl propyleneamine oxime (HMPAO) and 99mTc-ethyl cysteinate dimer (ECD) accumulate in brain tissue in proportion to regional cerebral blood flow in healthy subjects and in patients with a variety of neurological diseases. We report on four patients with herpes simplex encephalitis and the discordance between these two approved cerebral perfusion imaging radiopharmaceuticals. CONCLUSION: SPECT images showed unilateral regional increase of 99mTc-HMPAO uptake and decrease of 99mTc-ECD uptake in the affected temporal lobe.

[Thrombolysis in acute occlusion of cerebral blood vessels]. / Thrombolyse beim akuten Verschluss zerebraler Gefässe.

Thrombolysis may achieve recanalization in cases of occlusion of the cerebral vessels. If therapy is initiated in good time, development of cerebral infarction may be at least partially prevented. Thrombolytic treatment was performed in 14 patients at the Wagner-Jauregg Hospital within a period of one year. Urokinase was given locally, while rtPA was applied locally and/or systemically. 4 patients had an occlusion of the internal carotid artery, 6 an occlusion of the middle cerebral artery, and 4 an occlusion of the basilar artery. Complete recanalization was achieved in 6 patients, partial recanalization in 4, and no recanalization in 4. The neurological outcome of the cases with complete recanalization was good with the exception of one patients who died. Partial recanalization resulted in a fair outcome in 2 patients, while the other 2 died. 3 out of the 4 patients in whom no recanalization was achieved died. Our findings show that this form of therapy may considerably improve the natural history of the disease, provided recanalization is achieved in good time. They encourage us to continue this form of therapy and to work at improving the therapeutic criteria.