The demand for memory assessment is increasing due to the dementia CQUIN and increased public awareness of dementia. Drs Huwez, Perera and Ewins describe an innovative approach of pre-clinic imaging and investigation which removed the need for a follow-up appointment, and also resulted in increased availability of clinic slots.
A 60 year old woman with migraine, hypertension, and recently diagnosed temporal lobe epilepsy presented to the memory clinic with progressive memory impairment and …
Abstract This chapter describes how to prevent strokes and other vascular events. It explains how preventive measures should be tailored to the patient. Stroke survivors are at high risk of another stroke or other vascular events such as heart attacks. Important risk factors include blood pressure, cholesterol, smoking, blood sugar, atrial fibrillation and carotid stenosis. The chapter explores ways to reduce risk through lifestyle, general vascular prevention and stroke-specific interventions.
Abstract This chapter discusses the longer-term problems of stroke patients and their management. Some patients feel abandoned after leaving hospital. Services for stroke patients should identify and address longer-term needs. Some problems that occur early after stroke persist. Issues that emerge following hospital discharge include: difficulty in returning to work, driving, re-establishing interests, hobbies, and civic participation. Aphasia needs specialist long-term management and support that targets impairment, compensation, adjustment, and carer support. Community rehabilitation teams or stroke support workers can help reduce psychological distress.
Abstract What is rehabilitation?How to approach rehabilitationProblemsRehabilitation nursingTeamworkMonitoring progressPrognostication and prediction—trajectories of recoveryMobilitySpasticityDexterityShoulder painContinenceMoodCommunicationActivities of daily livingFalls and fracturesBody imageFamily and carer involvement in rehabilitationWhere to do rehabilitationAnticipating longer-term problemsSummary
To investigate whether the location and extent of the CT hyperdense artery sign (HAS) at presentation affects response to IV alteplase in the randomized controlled Third International Stroke Trial (IST-3).
Methods:
All prerandomization and follow-up (24–48 hours) CT brain scans in IST-3 were assessed for HAS presence, location, and extent by masked raters. We assessed whether HAS grew, persisted, shrank, or disappeared at follow-up, the association with 6-month functional outcome, and effect of alteplase. IST-3 is registered (ISRCTN25765518).
Results:
HAS presence (vs absence) independently predicted poor 6-month outcome (increased Oxford Handicap Scale [OHS]) on adjusted ordinal regression analysis (odds ratio [OR] 0.66, p < 0.001). Outcome was worse in patients with more (vs less) extensive HAS (OR 0.61, p = 0.027) but not in proximal (vs distal) HAS (p = 0.420). Increasing age was associated with more HAS growth at follow-up (OR 1.01, p = 0.013). Treatment with alteplase increased HAS shrinkage/disappearance at follow-up (OR 0.77, p = 0.006). There was no significant difference in HAS shrinkage with alteplase in proximal (vs distal) or more (vs less) extensive HAS (p = 0.516 and p = 0.580, respectively). There was no interaction between presence vs absence of HAS and benefit of alteplase on 6-month OHS (p = 0.167).
Conclusions:
IV alteplase promotes measurable reduction in HAS regardless of HAS location or extent. Alteplase increased independence at 6 months in patients with and without HAS.
Classification of evidence:
This study provides Class I evidence that for patients within 6 hours of ischemic stroke with a CT hyperdense artery sign, IV alteplase reduced intra-arterial hyperdense thrombus.
The effect of left ventricular volume (LVV) in relation to the left ventricular mass (LVM) was studied on the voltage electrocardiography (ECG) criteria of left ventricular hypertrophy (LVH). For this purpose, the sensitivity of numerous voltage criteria were assessed in patients with documented echocardiographic (echo) LVH with or without left ventricular dilatation. The ECG criteria that combined voltages in two leads were more sensitive than when a single voltage criterion was utilized. There was no characteristic pattern of increased voltages to differentiate between eccentric and concentric subtypes of LVH. However, the Cornell criteria were less affected by the LV geometry for detecting LVH with or without LV dilatation. This is probably due to the fact that they utilize the voltages in a precordial and a limb lead.
Classically, the ST-T configuration in the electrocardiogram of patients with left ventricular hypertrophy is said to have a typical pattern of ST depression together with asymmetrical T wave inversion (the so-called left ventricular strain pattern). However, many patients with left ventricular hypertrophy may also have ischaemic heart disease. To revise the electrocardiographic criteria for left ventricular hypertrophy the ST-T configuration in patients with left ventricular hypertrophy documented by echocardiography and with normal coronary arteries was assessed.24 patients were selected for this study. All had left ventricular hypertrophy documented by echocardiography, normal coronary arteries by cardiac catheterisation, and ST and/or T wave abnormalities in the lateral leads of their electrocardiogram. There were eight patients with aortic valve disease and 16 with hypertension who had coronary angiography as part of an investigation into the risk factors of sudden cardiac death caused by hypertensive left ventricular hypertrophy. No patient was receiving digitalis preparations or had electrolyte disturbances, and none had a previous myocardial infarction or ventricular conduction defect.Typical electrocardiographic evidence of left ventricular strain was found in approximately two thirds (63%) of patients and 95% of this subgroup had asymmetrical T wave inversion. Flat ST segment depression, with or without T wave inversion or isolated T wave inversion (symmetrical or asymmetrical) in the anterolateral leads, was seen in the remaining 37% of patients.These findings indicate that left ventricular hypertrophy without coronary artery disease can cause variable types of ST-T abnormalities in the anterolateral leads including the typical left ventricular strain pattern and non-specific ST-T changes. Non-specific abnormalities could not be distinguished from those of coronary artery disease and may adversely affect the accuracy of the electrocardiographic criteria for the diagnosis of left ventricular hypertrophy because they do not accord with the criteria for left ventricular strain.
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