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Volume 8, No 1/2 - 2011

Volume 8, No 1/2 - 2011

Table of Contents

Hypertension-Related Eye Abnormalities and the Risk of Stroke Evaluation Update
Many studies have shown that hypertensive ocular funduscopic abnormalities are clearly related to stroke, even after controlling for blood pressure and other vascular risk factors. Retinal abnormalities indicative of a breakdown of the bloodñretina barrier confer a greater increase in risk for stroke than sclerotic retinal changes. Similar retinal changes also have a positive relationship to stroke mortality. In addition, hypertensive ocular fundus abnormalities are reported to be associated with an increased risk for cognitive impairment, cerebral atrophy, progression of magnetic resonance imaging-defined white matter lesions, and subclinical infarction. Recent advances in fundus photography allow for improved accuracy and consistency in interpretation of funduscopic lesions, and improve the feasibility of screening for these abnormalities in at-risk patient populations. Evaluating the ocular fundus for signs of hypertensive retinopathy, in combination with an assessment of the presence or absence of other known vascular risk factors, may allow clinicians to further individualize a risk profile for stroke to each individual patient, thus permitting more accurate risk stratification and, potentially, guiding treatment strategies. [Rev Neurol Dis. 2011;8(1/2):1-9 doi: 10.3909/rind0274] © 2011 MedReviewsÆ, LLC
A Practical Review and Approach to Poststroke Seizures Management Update
Much confusion still exists about when to treat seizures related to stroke and what agents to use. Seizures may occur in the setting of ischemic stroke, intracranial hemorrhage, subarachnoid hemorrhage, and other cerebrovascular lesions. The epidemiology of poststroke seizures and patients at higher risk for developing poststroke epilepsy are identified. The utility of electroencephalography (EEG), continuous and video EEG monitoring, and management and treatment of those patients who develop epilepsy are discussed. [Rev Neurol Dis. 2011;8(1/2):10-15 doi: 10.3909/rind0266 © 2011 MedReviewsÆ, LLC
The Effect of Pregnancy on Seizure Control and Antiepileptic Drugs in Women With Epilepsy Treatment Update
Epilepsy is one of the most common neurologic conditions seen by obstetricians, primary care physicians, and neurologists. It is present in three to five per 1000 births, and most women with epilepsy (WWE) can expect to have a normal pregnancy and delivery. The clinicianís goal is to establish the best seizure control with the fewest possible number of antiepileptic drugs (AEDs) prior to pregnancy. Clinicians need to be aware of how the pharmacokinetic features of AEDs change during the pregnancy and postpartum period. During pregnancy AED concentrations may decrease, thereby increasing the risk of seizure deterioration. Levels of some AEDs must be monitored and the doses adjusted routinely during pregnancy and after birth. Understanding and applying these principles will ensure better seizure control during and after pregnancy and minimize the risk to the mother and the fetus due to recurrent seizures and fluctuating AED levels. This review emphasizes significant changes in pharmacokinetics of AEDs, the importance of monitoring serum concentration of AEDs, and routine dose adjustment prior to conception and during pregnancy and the postpartum period. [Rev Neurol Dis. 2011;8(1/2):16-22 doi: 10.3909/rind0270] © 2011 MedReviewsÆ, LLC
Prognosis in Intracerebral Hemorrhage Management Update
Intracerebral hemorrhage (ICH) is the most devastating type of stroke with the greatest mortality rate. Unfortunately there are no clinically proven therapies, and treatment is typically supportive. Given the poor prognosis, many families are faced with the decision to limit or withdraw care from those who have had an ICH. Many clinical grading systems have been developed to help stratify patients with ICH and aid in predicting prognosis. The ICH scale was the first to be developed to predict 30-day mortality and has been validated by different cohorts around the world. Since its inception in 2001, numerous other scales have been developed to predict mortality, and more importantly, functional outcome. However, in the development of these scales, patients who had care withdrawn were included in the analysis. It has been shown that the concept of poor prognosis leads to do-not-resuscitate orders, less invasive care, and eventually death. Most of these patients have care withdrawn within the first two hospital days, despite evidence to suggest early interventions may improve outcomes. As a result, the most recent guidelines suggest waiting more than 24 hours before deciding to withdraw care. The use and interpretation of these ever-advancing scales may allow physicians to better predict outcome and assist families in making important care-related decisions. [Rev Neurol Dis. 2011;8(1/2):23-29 doi: 10.3909/rind0276] © 2011 MedReviewsÆ, LLC
Penetrating Artery Territory Pontine Infarction Disease State Review
Pontine infarcts account for 25% of lacunar strokes. The primary morphologies are wedge-shaped tegmental, basal, and tegmentobasal infarcts, caused by disease of the paramedian basilar branches, and smaller, circumscribed lacunar infarcts attributed to lipohyalinosis. Roughly 60% of infarcts are paramedian. Both typical and atypical lacunar syndromes are seen with pontine infarcts, pure motor hemiparesis being the most common, followed by sensorimotor stroke and ataxic hemiparesis. Eye movement abnormalities and neuropsychological deficits are also commonly seen. Short-term functional prognosis is usually good with lacunar morphology; rostral, lateral or tegmental locations predict a more favorable prognosis. [Rev Neurol Dis. 2011;8(1/2):30-38 doi: 10.3909/rind0277] © 2011 MedReviewsÆ, LLC
Management of Diabetic Small-Fiber Neuropathy With Combination L-Methylfolate, Methylcobalamin, and Pyridoxal 5_-Phosphate
Agents used to treat symptoms of diabetic peripheral neuropathy (DPN) are only palliative, not disease modifying. Although studies of monotherapy with L-methylfolate, methylcobalamin, or pyridoxal 5_-phosphate suggest that each of these bioavailable B vitamins may reverse the pathophysiology and symptoms of DPN, data on the efficacy of this combination therapy are limited. Therefore, we assessed the efficacy of an oral combination of L-methylfolate, methylcobalamin, and pyridoxal 5_-phosphate for improving epidermal nerve fiber density (ENFD) in the lower extremity of patients with DPN. Eleven consecutive patients with type 2 diabetes with symptomatic DPN were assessed for ENFD at the calf by means of skin punch biopsy and then placed on twice daily oral-combination L-methylfolate, methylcobalamin, and pyridoxal 5_-phosphate. After approximately 6 months of treatment, patients underwent follow-up biopsy. At the end of their treatment, 73% of patients showed an increase in calf ENFD, and 82% of patients experienced both reduced frequency and intensity of paresthesias and/or dysesthesias. This preliminary study suggests that combination L-methylfolate, methylcobalamin, and pyridoxal 5_-phosphate increases ENFD in patients with DPN. [Rev Neurol Dis. 2011;8(1/2):39-47 doi: 10.3909/rind0267] © 2011 MedReviewsÆ, LLC
Idiopathic Intracranial Hypertension
[Rev Neurol Dis. 2011;8(1/2):52-54 doi: 10.3909/rind0268] © 2011 MedReviewsÆ, LLC