International Neurology

Robert P. Lisak, Daniel D. Truong, William M. Carroll, Roongroj Bhidayasiri, Robert P. Lisak, Daniel D. Truong, William M. Carroll, Roongroj Bhidayasiri

• Publisher: Wiley-Blackwell
• Year: 2016
• Print ISBN: 9781118777367
• eBook ISBN: 9781118777343
• Edition: 2
• Topic: Medicina
• Subtopic: Neurología

This unique textbook deals with the variations in the causes, presentations and treatment of neurological disease throughout human populations. International Neurology is an indispensable guide to the full range of neurological conditions you will see in your ever-changing patient population.

• Comprehensive coverage of neurological diseases and disorders with a clinical approach to diagnosis, treatment and management
• Truly international authorship distils expert knowledge from around the world
• Succinct, bite-sized, templated chapters allow for rapid clinical referral
• Further reading recommendations for each chapter guide readers requiring more depth of information
• Endorsed by the World Federation of Neurology

PART 1
Vascular Disorders

1
Overview of stroke

Christopher Li-Hsian Chen¹ and Chung Y. Hsu²

¹ Department of Pharmacology, National University of Singapore, Singapore

² China Medical University, Taichung, Taiwan

Stroke, encompassing both ischemic and hemorrhagic types, is a major health burden globally, affecting 15 million people each year. It is the second leading cause of death for people above the age of 60 years and the fifth leading cause for those aged 15 to 59 years. Stroke is the most common cause of adult disability and the second most important cause of dementia worldwide. According to World Health Organization (WHO) figures, global stroke deaths were 5.8 million in 2005 and are projected to increase to 6.5 million in 2015 and 7.8 million in 2030. Stroke is the most common disease that practicing neurologists manage. Stroke patients constitute approximately two-thirds of the inpatient neurology ward in virtually every hospital, with comprehensive neurology services in most countries around the world. With advances in evidence-based medicine, consensus on the diagnosis and treatment of selected types of strokes has gradually emerged across national boundaries.

Stroke mortality and incidence declined in developed countries during the 1980s and early 1990s, but this trend appears to have slowed recently. Despite the lack of reliable data on stroke statistics from several developing regions of the world, there are indications that the age-standardized mortality rate of stroke in developing nations may be substantially higher than in developed countries. The burden of stroke is accordingly greater due to relatively larger populations in developing countries. Furthermore, as a result of demographic transition, rapid urbanization, and industrialization, many developing regions show a trend of increased life expectancy, as well as a changing profile of risk factors for developing cardiovascular diseases, including stroke. This may contribute to a looming epidemic of stroke in medium- to low-income nations, as a greater population in these countries is at increased risk of stroke.

Stroke is a preventable disease. Implementation of effective primary and secondary prevention strategies is likely to have an enormous impact in reducing its burden. However, reducing stroke risk factors remains a challenging task, particularly in developing countries. It is appropriate that the WHO has set a priority on stroke prevention with the implementation of practical, accessible, cost-effective, and socially acceptable strategies.

Between the first and second editions of International Neurology, several important therapeutic advances have been made in the treatment of acute stroke and in stroke prevention: (1) endovascular intervention to remove blood clots in the proximal intracranial artery has been found to be safe and efficacious in patients with acute ischemic stroke beyond the approved therapeutic window of tPA (tissue plasminogen activator; 4.5 hours after stroke onset) and in particular in patients who failed intravenous tPA; (2) stroke prevention in patients with atrial fibrillation has been expanded from warfarin and/or heparin to novel oral anticoagulants that can spare patients frequent and inconvenient laboratory monitoring and show a favorable trend in reducing the risk of intracerebral hemorrhage, which is a serious side effect associated with traditional anticoagulants; (3) dual antiplatelets (aspirin plus clopidogrel) have been shown to be more effective than aspirin alone in preventing stroke in a critical period (within three weeks) after minor stroke and TIA.

Therapeutic attempts at applying neuroprotective agents, however, have failed in a series of large clinical trials and have highlighted the obstacles that remain to be overcome in translating promising therapeutic effects in animals in preclinical studies to clinical care for stroke patients based on evidence from clinical trials. Much soul searching has led to recommendations for improvements in the standards for preclinical studies including randomization, blinding, and sample-size calculations for interventional studies in animals, so as to improve the rigor of preclinical data and guide more appropriate selection of novel agents for trials in humans. The use of surrogate efficacy end points in early-phase studies has also been advocated so as to determine a possible efficacy signal before large, costly trials using clinical end points are undertaken. Neuroimaging has also been investigated as a means of selecting patients who would benefit most from treatment while minimizing the risk of serious side effects. Despite the slow rate of progress, it is essential that more clinical studies be undertaken to understand the pathophysiology of stroke, in order to develop appropriate clinical trial protocols to validate promising therapeutic strategies coming out of preclinical investigations.

In developing international standards for stroke prevention and therapy, the differences in stroke etiology and pathology among various ethnic groups cannot be overemphasized. Obvious examples are the higher incidence of intracerebral hemorrhage and higher prevalence of intracranial atherosclerosis in non-white populations, including people of Hispanic, Asian, and African origin. It is encouraging that recent major stroke trials have been expanded to cover non-Western countries. A notable example is the multinational stroke trial to explore the effect of rapid blood pressure lowering in reducing the risk of hematoma expansion following acute intracerebral hemorrhage.

Although modest progress has been made in improving functional recovery after stroke, more research effort is urgently required, including clinical trials to validate innovative rehabilitation measures. Cognitive impairment and consequent dementia after stroke remain a substantial burden in chronic care and there is a great need for developing evidence-based preventive and treatment strategies. It is essential that integrated stroke care covers not only treatment of patients in the acute setting, but also post-stroke care, including the prevention of stroke recurrence and complications as well as adequate rehabilitative measures to maximize functional recovery. The guidelines developed by the American Heart Association/American Stroke Association and recommendations from the World Stroke Organization encourage stroke prevention and the implementation of timely and adequate standards of care, especially in the acute setting and post-stroke. These are addressed in the relevant chapters to follow, each of which aims to provide an important source of reference to maintain high-quality stroke prevention and care.

2
Ischemic stroke and transient events, TIA

Lidia Yamada, Shelly Ozark, and Bruce Ovbiagele

Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA

The relevance of timely and appropriate management of a transient ischemic attack (TIA) lies in its frequent role as a forerunner of an impending stroke, which is a leading cause of death, disability, and dementia. We will outline in this chapter the historical context, epidemiology, clinical features, evaluation, and management of TIA patients.

History

Since the seventeenth century, the term “stroke” has represented acute non-traumatic lingering neurological deficits of vascular origin, but it was only in the 1950s that Charles Miller Fisher described the concept of symptomatic yet transient cerebral ischemia received attention. Indeed, it was in 1965 that a consensus term “transient ischemic attack” was introduced to better characterize the occurrence of acute focal, neurological symptoms due to vascular causes that would last “for a shorter period of time.” A key controversy over the ensuing 40 years involved agreeing on the actual length of this period of time. Although an arbitrary 24-hour window was originally chosen, several clinicians observed that most of these transient spells would actually last for just a few minutes, at the most no more than a few hours. Another aspect of contention that has arisen relatively more recently following the advent of multimodal neuroimaging has been whether a tissue-based definition of TIA is more precise and prognostic of stroke risk than a time-based definition. Several studies have revealed that a considerable number of TIA patients actually had initial radiographic evidence of ischemic brain injury, a finding that persisted on follow-up brain imaging in many cases. Thus, in 2009, a committee of experts proposed a new pathological definition of TIA, which emphasized a lack of sustained vascular brain injury: “a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infa...

Table of contents

• Cover
• Dedication
• Title page
• Copyright
• Editors
• List of contributors
• Foreword
• Endorsement from the World Federation of Neurology
• Preface
• PART 1 Vascular Disorders
• PART 2 Disorders of Cerebrovascular Autonomic Control
• PART 3 The Vasculitides
• PART 4 Inflammatory Vasculopathies
• PART 5 Paroxysmal Disorders
• PART 6 Dementia
• PART 7 Movement Disorders
• PART 8 Infectious Diseases
• PART 9 Prion Diseases and Neurovirology
• PART 10 Demyelinating Disorders
• PART 11 Specific toxicities and deficiencies
• PART 12 Peripheral Neuropathies
• PART 13 Neuromuscular Disorders
• PART 14 Neurogenetics
• PART 15 Neuro-otology
• PART 16 Neuro-ophthalmology
• PART 17 Neuro-oncology
• PART 18 Sleep Disorders
• PART 19 Spinal Cord Disorders
• PART 20 Pediatric Neurology
• PART 21 Central Nervous System Trauma, Pain, and Headache
• Index
• EULA