PubMed · 9617986
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B L Low, S A Chong. 1998. Treating poststroke pathologic crying with fluoxetine.. https://doi.org/10.1097/00004714-199806000-00012
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A 50-year-old man was transferred to our hospital for investigation of cerebellar infarction, thought to have been caused by cardiac thromboembolism. We assumed that the cardiac thromboembolism had occurred as a late complication of a percutaneous transvenous mitral commissurotomy (PTMC) performed 7 years earlier. An echocardiogram and thoracic computed tomography revealed a protruding thrombus in the left atrium and an emergency operation was performed. The protruding thrombus was found to originate from the scar that penetrated into the intra-atrial muscular septum caused by the PTMC. After removing the thrombus, the scar was covered with normal endothelium and the mitral valve was replaced with a 27-mm St. Jude Medical prosthetic valve. We think that the thromboembolism was caused by mitral valve restenosis, atrial fibrillation, and endothelial injury in the interatrial septum during PTMC. Therefore, long-term follow-up and appropriate medication is recommended after PTMC, since restenosis and thrombosis are likely to occur.
PURPOSE OF REVIEW: Stroke thrombolysis is in the process of moving from academic centers into community-based standard therapy in experienced centers. Recently published data on patient selection, imaging and other technical or organizational advances are reviewed in order to improve the safety and efficacy of stroke thrombolysis and identify areas in which more study is needed. RECENT FINDINGS: During the past year, several open series were published on the application of thrombolysis in community-based settings, which have mostly reproduced the outcome described in randomized, placebo-controlled recombinant tissue plasminogen activator cohorts. New information has been produced to identify the clinical parameters that are associated with good and adverse outcomes after stroke thrombolysis. Elevated blood glucose decreases the likelihood of a good outcome and increases that of cerebral hemorrhagic change, but the effect of early glucose reduction needs to be investigated. Non-contrast computed tomography still prevails as the standard imaging method in patient selection, but computed tomography angiography can be added within a reasonable time to furnish vascular diagnosis. Perfusion-weighted imaging is used to quantify the fraction of brain tissue salvaged by intravenous thrombolysis, and may be used in the future to select patients with still viable penumbral brain tissue, even beyond a 3-h time-window, if efficacy can be proved. SUMMARY: Thrombolysis with recombinant tissue plasminogen activator is well tolerated and effective within 3 h of symptoms, and new trials will determine if extension of this time-window or new target populations for thrombolysis, such as children with stroke, can be substantiated. An unfinished task remains in the education of health personnel; imperatives stemming from pathophysiology need to penetrate attitudes on acute stroke at all levels before acute therapies such as thrombolysis can have an impact on stroke outcome in general.
PURPOSE OF REVIEW: A growing number of studies suggest that there is a close relationship between sleep-disordered breathing (SDB) and stroke. Since the prevalence of SDB is high among acute stroke patients and since oxygen desaturations are potentially dangerous, SDB may influence not only stroke risk, but also stroke outcome and recurrence. This review summarizes recent data on this issue, pointing out existing evidence but also defining issues that still need to be clarified. RECENT FINDINGS: Recent studies further supported the hypothesis of a link between SDB and stroke: (1) although stroke occurs most frequently in the morning hours, i.e. shortly after awakening, stroke events take place predominantly during sleep in SDB patients; (2) a large cross-sectional study confirmed the association of SDB not only with coronary heart disease but also with stroke; (3) several works suggest that SDB may increase stroke risk through various mechanisms including blood pressure swings, endothelial dysfunctions, prothrombotic coagulation shifts, pro-inflammatory states, increased platelet aggregation and atherosclerosis; (4) one study in acute stroke patients demonstrated that SDB is associated with early neurological worsening although not with final stroke outcome; (5) treatment trials with continuous positive airway pressure (CPAP) have demonstrated mild reductions of diastolic and systolic blood pressure in SDB patients, an effect that is expected, however unproven, to decrease stroke risk. SUMMARY: Despite considerable progress regarding our understanding about the role of SDB in vascular disease, further studies are needed to determine whether cerebrovascular morbidity is related to SDB independent of associated vascular risk factors, whether SDB has indeed a negative impact on stroke progression and whether CPAP treatment ameliorates stroke outcome.