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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Cerebrovascular disease in pregnancy poses challenges to clinicians because of the difficulty in diagnosing the underlying etiology as well as the potential fetal toxicity of diagnostic testing and treatment. The underlying etiology for stroke in the pregnant patient must be aggressively sought and is critical to appropriate therapy: 1) If the arterial ischemic event in a pregnant patient remains cryptogenic, then either low-dose aspirin or another antithrombotic agent should be used. 2) Unfractionated heparin, or preferably, low molecular weight heparin, should be used to treat patients with a clearly identified etiology for which there is a specific clinical indication with at risk or symptomatic doses. Warfarin may be used in occasional cases when heparin is contraindicated (heparin-induced thrombocytopenia) and should be limited to the period after organogenesis in the second and third trimesters. 3) Using a heparin-warfarin-heparin alternating schedule to offset adverse events is impractical, because with each change in medications sustained anticoagulation cannot be easily obtained.
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PMID:Cerebrovascular Disease in Pregnancy. 1277 2

Recent observational data suggest that mild or moderate heart failure is associated with an annual risk of stroke of approximately 1.2%. Indeed, it is possible that the major cause of sudden death in chronic heart failure is not related to arrhythmias, but to vascular occlusion. Anticoagulation may reduce the rate of embolic events, but there is controversy about the mandatory use of antithrombotic therapy for all patients with ventricular dysfunction in sinus rhythm. At present antithrombotic therapy is indicated only in "high risk" subgroups of patients: atrial fibrillation, mobile/protruding/irregular thrombi, acute post-myocardial infarction thrombi or a recent history of thromboembolism. Actually there is no evidence to recommend the use of aspirin to prevent thromboembolism in patients with ventricular dysfunction in sinus rhythm. Further trials of both antiplatelet agents and anticoagulation are sorely needed and we are waiting for the results of large trials such as the WATCH trial (Warfarin and Antiplatelet Therapy in Chronic Heart Failure) and the WARCEF trial (Warfarin Versus Aspirin in Reduced Ejection Fraction). The future appears promising due to the advent of a new oral direct thrombin inhibitor, ximelagatran, with good efficacy and safety profile for the treatment and prevention of thromboembolism.
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PMID:[Antithrombotic prophylaxis in patients with ventricular dysfunction: critical review of the literature and new perspectives]. 1278 54

Antiphospholipid Syndrome (APS) has been widely recognized as a risk factor for the recurrence of both thrombosis and pregnancy losses; however the optimal treatment of patients is debatable. The aim of this paper was to establish a consensus among experts on the treatment of APS in pregnancy. A questionnaire that described possible different clinical situations was sent to the International Advisory Board of the 10th International Congress on Antiphospholipid Antibodies. Sixteen experts from different medical branches and different geographic areas sent their replies. The consensus was that treatment for APS pregnant patients should be low molecular weight heparin (LMWH) and low dose aspirin (LDA). The dosage, and frequency of LMWH depends on different situations, including the body weight and past history. Patients with previous thromboses usually receive two injections per day. Warfarin can also be used from 14 to 34 weeks, for patients with previous stroke or severe arterial thromboses. The use of intravenous immunoglobulin (IVIG) seems to be restricted to patients with pregnancy losses despite conventional treatment. The experts usually advised barrier methods of contraception, intrauterine device (if the patient is not taking corticosteroids) or progestins. Oral contraception with oestrogens was usually avoided.
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PMID:Treatment of pregnant patients with antiphospholipid syndrome. 1535 30

Patients with acute stroke caused by atherosclerotic carotid artery occlusion (ACAO) should receive intravenous tissue plasminogen activator if they meet eligibility criteria. Patients with acute stroke caused by ACAO who are not eligible for intravenous tissue plasminogen activator should receive aspirin. Heparin or heparin-like drugs do not improve outcome and should not be used. Therapy for prevention of recurrent stroke in patients with ACAO should consist of lifestyle modifications, risk factor intervention, and aspirin. Other antiplatelet drugs should be considered in patients with contraindication to aspirin. Warfarin is not indicated. Extracranial-intracranial bypass surgery provides no benefit over medical therapy in preventing recurrent stroke in a general population of patients with ACAO or in any subgroups selected by clinical or arteriographic criteria. Extracranial-intracranial bypass surgery in patients selected by hemodynamic criteria should only be performed as part of a randomized controlled clinical trial. Other surgical or endovascular procedures have no proven value in treating or preventing stroke caused by ACAO. Asymptomatic carotid occlusion has a benign prognosis, and requires no specific treatment other than lifestyle modification and risk factor intervention.
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PMID:Atherosclerotic Carotid Artery Occlusion. 1289 1

Current guidelines relating to the primary prevention of stroke in non-valvular atrial fibrillation are primarily based on randomised trials comparing warfarin with placebo. Warfarin is recommended in the majority of patients. However, weaknesses in the design and performance of these trials tend to overestimate the treatment effect. Furthermore, the inclusion of highly selected patients with a low percentage of elderly subjects, low bleeding risk, short follow-up periods and high discontinuation rates makes it impossible to generalize the results and apply them to general practice. Trials directly comparing warfarin with aspirin are the most reliable when it comes to comparing treatment efficacy. These trials have included a similar number of patients but a larger percentage of elderly patients and they comprise more years of observation and end-point events compared with the placebo-controlled warfarin trials. The results show that warfarin is not convincingly superior to aspirin in terms of stroke prevention. Warfarin can only be recommended in patients with a high risk of thromboembolic events.
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PMID:[Choice of antithrombotic therapy in atrial fibrillation, a daily challenge. No convincing evidence that warfarin is better than acetylsalicylic acid]. 1296 19

Patients with acute stroke caused by atherosclerotic carotid artery occlusion (ACAO) should receive intravenous tissue plasminogen activator if they meet eligibility criteria. Patients with acute stroke caused by ACAO who are not eligible for intravenous tissue plasminogen activator should receive aspirin. Heparin or heparin-like drugs do not improve outcome and should not be used. Therapy for prevention of recurrent stroke in patients with ACAO should consist of lifestyle modifications, risk factor intervention, and aspirin. Other antiplatelet drugs should be considered in patients with contraindication to aspirin. Warfarin is not indicated. Extracranial-intracranial bypass surgery provides no benefit over medical therapy in preventing recurrent stroke in a general population of patients with ACAO or in any subgroups selected by clinical or arteriographic criteria. Extracranial-intracranial bypass surgery in patients selected by hemodynamic criteria should only be performed as part of a randomized controlled clinical trial. Other surgical or endovascular procedures have no proven value in treating or preventing stroke caused by ACAO. Asymptomatic carotid occlusion has a benign prognosis, and requires no specific treatment other than lifestyle modification and risk factor intervention.
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PMID:Atherosclerotic Carotid Artery Occlusion. 1457 27

Life style modification has been shown to reduce stroke risk. In patients with risk factors several drugs have proven their efficacy. The most effective medications are antihypertensives, antidiabetics, statins and antithrombotics. In the prevention of recurrent stroke in patients with a noncardioembolic ischemic stroke antiplatelet agents are used. Aspirin or a combination aspirin/dipyridamol are the first-line agents. Clopidogrel is recommended for patients with aspirin intolerance, several risk factors or recurrent cerebrovascular events. Warfarin has demonstrated efficacy in stroke prevention in patients with cardioembolic stroke, cerebral venous thrombosis and antiphospholipid antibody syndrome. Other, less well established indications for warfarin in the secondary prevention of stroke are: symptomatic intracranial artery stenosis; large aortic atheroma and extracranial carotid or vertebral artery dissection.
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PMID:[Stroke prevention]. 1457 20

A 24-year-old man known to have a double outlet right ventricle, status post-modified Fontan procedure at age 10, taking coumadin after having a stroke one year prior, presented with a massive pulmonary embolism and hemodynamic instability. Locally delivered tPA was unsuccessful, and the pulmonary artery thrombus was finally removed with a thrombectomy catheter (Angiojet thrombectomy); the patient recovered soon thereafter. This is the first report of the successful use of a thrombectomy catheter in a patient with pulmonary emboli and an occluded Fontan conduit.
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PMID:A pulmonary embolism treated with the Angiojet technique in a patient with double outlet right ventricle. 1469 24

Five types of drug therapy can be considered after stroke: antiplatelet therapy, anticoagulation with heparin or warfarin, blood-pressure-lowering therapy with ACE-inhibitors and diuretics, and finally cholesterol-lowering with statins. Aspirin therapy is the best-documented treatment to avoid another stroke, both in the acute and the long-term perspective. Warfarin treatment is fairly well documented for stroke patients with atrial fibrillation. Heparin therapy increases the risk for serious haemorrhage. Blood-pressure-lowering with a combined ACE-inhibitor and diuretic regimen has been shown to reduce the recurrence rate in younger patients with hemorrhagic as well as ischemic stroke. Statin therapy could be offered to younger stroke patients with a history of coronary heart disease. The increased occurrence of malignant diseases during statin therapy in elderly patients in one study deserves further investigations.
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PMID:[Drug therapy after stroke should be evidence-based. Organizational, economic and ethical decisions direct the choice of treatment]. 1471 39

Systemic embolism is a frequent cause of stroke. At the beginning of the last decade by introduction of transesophageal echocardiography and other imaging techniques atheromatosis of the aortic arch has been recognized as an important source of embolism. Formerly in the pre-TEE era, this entity was included into cryptogenic strokes. Aortic atheromas are found in about one quarter of patients presenting with embolic events. The severity of atherosclerosis graded by TEE correlates with the risk for future embolism, especially if mobile lesions or superimposed thrombi are present. Independent of plaque extension, patients with unstable plaques characterized by echo-lucency, inhomogenity, lacking of calcifications, ulceration, mobile parts and concomitant spontaneous echo contrast within the aorta have a higher risk for embolic events. However, the diagnosis of aortic atheromatosis is mostly established if an embolic event has already occurred. Therefore, it is important to identify patients at risk, especially before they undergo interventions with manipulation at the aorta like coronary bypass surgery. Risk factors are age above 70, diabetes mellitus, hyperlipidemia, arterial hypertension, aortic calcifications on standard chest X-ray, elevated serum levels of C-reactive protein, other inflammatory markers, and an activated coagulation. Randomized studies for treatment of patients with severe aortic atheromatosis are not yet existing. Warfarin has been shown to prevent stroke in patients with mobile atheromas and superimposed thrombi, but there are case reports about aggravation of cholesterol embolism under warfarin treatment. It is concluded from other atherosclerotic manifestations that plaque stabilizing treatment with statins and ACE inhibitors is also beneficial.
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PMID:Atheromatous disease of the thoracic aorta and systemic embolism. Clinical picture and therapeutic challenge. 1474 Feb 36


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