Cardiogenic and aortal embolias are a clinically important source of brain stroke. They occur most frequently in patients with atrial fibrillation, and their prevalence in the group not receiving antithrombotic treatment amounts to about 5 per cent yearly. Cerebral embolism is also a complication of a recent myocardial infarction. In the latter case the embolus consists of blood clots forming in the left ventricle of the heart. Two other groups at risk for cerebral embolism are, firstly, patients with bacterial endocarditis, especially prior to antibiotic treatment, and secondly, those with artificial heart valves who for this reason should have a maintenance antithrombotic treatment for life. Transoesophageal echocardiography has indicated other sources of cerebral embolia, such as paradoxical embolus or aorto-arterial embolus, but their clinical importance requires further study.
Ultrasonographic diagnostics of vascular diseases is based on two phenomena: echo and Doppler effect. They allow to obtain the imaging of blood vessel walls and blood flow, to measure its rate and determine its direction. On the grounds of both these phenomena an absolutely safe technique was developed of intra- and extracranial arteries patency evaluation, permitting – in case of their considerable pathology – to detect the presence of collateral circulation and to trace its pathways. Since the technique is non-invasive and repeatable, the range of its applicability increases, including the monitoring of flow changes in various stages of disease, during surgery, or in the assessment of treatment effects.
The paper presents angiography using MRI and its clinical applications. Its physical rationale is discussed, with particular emphasis on the Time of Flight technique, or the so-called influx method used in vascular examination at the Neuroradiology Department, IPN. AngioMR is a non-invasive, relatively simple diagnostic method directly producing the image of blood vessels without contrasting agents administration and without any health risks for the patient. It seems to be an excellent complementary technique to the standard MRI examination.
The aim of the paper is to outline diagnostic possibilities of CT and MRI in the evaluation of angiogenic changes in cerebral structures. CT is a good diagnostic method in the case of hemorrhagic changes, especially in the acute stage of the disease, and in subarachnoid bleeding it is the procedure of choice. It enables also to examine patients in severe clinical status. MRI, as compared to CT, permits to detect ischaemic changes, shows even small pathological foci, and allows to make a complete diagnosis of posterior cranial cavity structures.
The effect of risk factors may be either direct, via morbidity, or indirect, via change in the natural course of the disease and increased mortality rate. The effect of some risk factors (including arterial hypertension, coronary heart disease, atrial fibrillation, diabetes, nicotinism, alcoholism, wrong diet) on brain stroke (BS) prevalence was outlined in an overview of the literature. Because of high mortality rates caused by BS in Poland, a prospective epidemiological study was carried out in Warsaw in the years 1991-1992, analyzing the effect of risk factors on mortality rate within 30 days from the onset of BS, and on the probability of survival over the following 12 months. In the sample under study the main risk factor increasing the BS mortality rate within 30 days from onset, besides age, severity of disorientation and neurological symptoms, was chronic spastic bronchitis (with risk increase index of 1.52, p<0.05). On the other hand, chances of survival over the following 12 months were significantly lower in patients with atrial fibrillation, right ventricle insufficiency, or myocardial infarction within 6 months prior to the BS onset.
Despite a marked development of diagnostic methods, it is still difficult to determine the etiopathogenesis of ischaemic cerebral stroke, although it is of crucial importance for treatment. Difficulties arise also with attempts at a clear and univocal classification of ischaemic brain strokes. (Eds.)
Systemic lupus erythematosus (SLE), all inflammatory disease of connective tissue, may affect also the nervous system (15-80% of cases). In the course of SLE a number of conditions are noted, including brain stroke, multi-infarct dementia, defects of cranial nerves, epileptic fits, extrapyramidal symptoms, polyneuropathies, and mental disorders. Among basic pathomechanisms of the nervous system impairment in SLE there are vascular dejects originating from immunological complexes accumulation in blood vessel walls. In SLE patients antiphospholipid antibodies are often found, contributing to arterial and venous thrombosis. The diagnosis of SLE as the cause of neurological disorders is of some prognostic value, since in the majority of cases an appropriate treatment results in the patients' clinical status amelioration and prolongation of their life expectancy.
An important risk factor for artherosclerosis, and consequently, for ischaemic heart disease and ischaemic cerebral stroke, consists in metabolic disorders of lipoproteins and lipids. Hyperlipidemias are divided into several types, depending on genetic and environmental factors. In addition to lipids level monitoring, prevention includes sensible diet, physical exercise, and abstinence from tobacco smoking. (Eds.)
Currently recognized risk factors for artherosclerosis are presented, with the emphasis on the role of lipid metabolism disorders. Moreover, possibilities of hyperlipidemia treatment are discussed (Eds.)
The aim of the International Stroke Trial (IST) is a reliable assessment of risks and benefits of a simple and easy treatment, i.e. acetylosalicylic acid, and subcutaneously heparin administration in the acute stage of brain stroke. The treatment may considerably reduce mortality and disability of patients after brain stroke. In the sample studied either aspirin (300 mg per 24 hours), or heparin (in two doses: small, 2 x 5000 units, or moderate, 2 x 12500 units), or a combination of the two pharmaceuticals are administered for 14 days during the acute stage of cerebral stroke. Some patients are randomly assigned to the "no medication" condition. Patients from Poland constitute 1,6% of the IST randomized sample. As of 1 September 1994, 74 patients with ischaemic brain stroke completed 14-day follow-up, while 30 patients – a 6-monthjollow up. Mortality rate within 14 days from brain stroke was 9,5%, amounting to 40% within the following 6 months.
After an ischaemic brain stroke or transient ischaemic attack (TIA) of the brain the risk of another stroke within the following 3 years ranges from 20 to 25%. Meta-analysis of data from many studies indicates that the risk of vascular incidents may be reduced in secondary prevention by 25 to 30 % with medication decreasing blood platelets activity. Therapeutic efficacy in the secondary prevention of stroke is confirmed only for Aspirin and Ticlopidine. Aspirin is the most popular drug, but in the case of intolerance to Aspirin or recurrence of vascular incidents in the course of Aspirin treatment, the drug of choice is Ticlopidine.
An overview of the literature on the treatment of brain stroke is presented. Despite numerous clinical studies, no drug has been found so far to be effective. The only confirmed efficient treatment method has been to provide the patient with appropriate care in a specialistic ward possibly soon, which allows to start his rehabilitation early and to undertake early treatment of general systemic disorders. Prevention, i.e. treatment reducing the effect of risk factors on brain stroke incidence is of crucial importance. The reduction of BS morbidity and mortality in highly industrialized countries is due mostly to an early diagnosis and appropriate treatment of hypertension, to change of lifestyle, healthy diet, and administration of antithrombotic and antiaggregating drugs both in the primary and secondary prevention.
Endotheline is a newly discovered peptide with a very strong vasospastic action. An overview of hitherto conducted research on the endotheline mechanism of action is presented, as well as various views on its role in the pathomechanism of vascular disorders of the nervous system.
Juvenile myoclonic epilepsy (JME), a syndrome belonging to the group of generalized itiopathic epilepsy, is described. Clinical characterization of the syndrome includes three types of epilieptic fits: loss of consciousness, myoclonic fits, and GM attacks – occurring in this order in adolescence, together with a specific EEG pattern. Despite its rather high prevalence rate, JME is seldom recognized. Reasons for this failure are analyzed. Moreover, detailed therapeutic recommendations are given and prognostic perspectives are outlined.
On the grounds of Polish and foreign literature the pathogenesis, neuropathological pattern, clinical symptoms and signs, additional tests and the prognosis in the Creutzfeld-Jakob disease are described. Besides, a serious risk is emphasized: a slow virus producing the Creutzfeld-Jakob disease may be contracted in the course of organ transplant surgery.
Older and more recent theories concerning the pathogenesis of migraine and other vascular headaches are presented, as well as various approaches to treatment of these conditions. Efficacy of pharmacotherapy in this area is discussed. (Eds.)