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Senile Dementia of the Binswanger's Type - Article
ABSTRACT: Senile dementia of the Binswanger's type is a term used to describe a dementia syndrome characterized by onset in the sixth or seventh decade of life, subcortical neurologic deficits, psychiatric disorders and evidence of hypertension or systemic vascular disease. The status of senile dementia of the Binswanger's type as a distinct entity is a matter of some controversy. The array of neuroimaging abnormalities and clinical findings attributed to this condition overlap with a number of other neuropathologies. Leukoaraiosis, or attenuation of subcortical white matter, seen on computed tomographic scans or magnetic resonance imaging of the brain, is a hallmark of senile dementia of the Binswanger's type. The clinical findings associated with Binswanger's disease are varied but typically include a progressive dementia, depression and "subcortical" dysfunction such as gait abnormalities, rigidity and neurogenic bladder. Treatment is largely supportive and includes a discussion about advanced directives, social support and antidepressant therapy. Control of hypertension and aspirin prophylaxis may help prevent further progression of white matter disease.
ABSTRACT: Factors associated with an increased risk of thromboembolic events in patients with atrial fibrillation (AF) include increasing age, rheumatic heart disease, poor left ventricular function, previous myocardial infarction, hypertension and a past history of a thromboembolic event. Patients with AF should be considered for anticoagulation or antiplatelet therapy based on the patient's age, the presence of other risk factors for stroke and the risk of complications from anticoagulation. In general, patients with risk factors for stroke should receive warfarin anticoagulation, regardless of their age. In patients who are under age 65 and have no other risk factors for stroke, either aspirin therapy or no therapy at all is recommended. Aspirin or warfarin is recommended for use in patients between 65 and 75 years of age with no other risk factors, and warfarin is recommended for use in patients without risk factors who are older than 75 years of age.
ABSTRACT: Clinical trials conducted during the past five years have yielded important results that have allowed us to refine our approach to stroke prevention. Treatment of isolated systolic hypertension prevents stroke and is generally well tolerated. New antiplatelet agents (clopidogrel and the combination of aspirin plus high-dose dipyridamole) have been shown to be effective in reducing vascular events in survivors of ischemic stroke, although aspirin remains the mainstay of antiplatelet therapy for stroke prevention. Several clinical trials support the benefit of lipid-lowering agents ("statins") in reducing stroke. Warfarin reduces stroke for high-risk patients with atrial fibrillation. Carotid endarterectomy is highly beneficial in reducing stroke for symptomatic patients with severe carotid stenosis (greater than 70 percent), but the benefit is less for symptomatic patients with a moderate degree of stenosis (50 to 69 percent) and for patients with asymptomatic carotid disease of any severity.
ABSTRACT: Optimal treatment of the patient who has sustained an acute ischemic stroke requires rapid assessment and early intervention. The leisurely approach to acute stroke management sometimes taken in the past should be replaced by an approach that treats stroke as a true medical emergency. Thrombolysis with tissue plasminogen activator has been labeled for the treatment of acute ischemic stroke, but it must be given within three hours of stroke onset. However, fibrinolytic therapy can be given safely to only a fraction of patients with acute stroke, and more broadly applicable therapies are needed. Recent evidence does not support the routine use of heparin in patients with acute stroke, and early use of aspirin offers only modest benefit. Neuroprotective therapies designed to interfere with cytotoxic events initiated by ischemia are undergoing clinical trials that should be completed within the next year. At present, only tissue plasminogen activator has been labeled for acute stroke treatment; however, other agents are on the horizon, and much can be done supportively to improve neurologic outcome. Because of the unique susceptibility of neurons to ischemia, minutes count. Thus, hospitals providing care for patients with acute stroke should organize clinical protocols and pathways for effective implementation of therapies.
ABSTRACT: Successful treatment of patients with ischemic stroke depends on the ability to treat within three hours of onset, because tissue plasminogen activator has not yet been proved effective beyond this time frame. The two major causes of delay in treatment are failure, on the part of the patient or family, to recognize stroke symptoms and failure to access the medical system most efficiently--by calling 911. Hospital stroke teams can shorten the time between patient arrival at the emergency department and treatment. Guidelines for the evaluation and treatment of potential stroke patients are presented, along with goal times for arrival-to-treatment intervals.
American Heart Association Issues Guidelines on Imaging in Transient Ischemic Attacks and Stroke - Special Medical Reports
The Calcium Channel Antagonist Controversy - Editorials
Current Hypertension Control Is Just Not Good Enough - Editorials
National Stroke Association Develops a Consensus Statement on Prevention of Stroke - Special Medical Reports