Seminars in Cerebrovascular Diseases and Stroke最新文献

Dural arteriovenous fistulas (DAVFs) represent important, often misdiagnosed causes of neurological dysfunction. Because these lesions do not always present with “stroke-like” syndromes, the vascular etiology of some DAVF symptoms may not be recognized. In addition, DAVFs cause focal neurological dysfunction remote from the location of the nidus, which also leads to diagnostic confusion. Noninvasive neuroimaging has made diagnosis easier, but neurologists must maintain a high index of suspicion to avoid overlooking these treatable lesions. This article reviews the pathophysiology and clinical presentations of DAVFs affecting the eye, spinal cord, and brain.

Spontaneous cervical epidural hematomas, an infrequent cause of neck pain, are more common in patients with vascular malformations or coagulation disorders. Treatment usually involves emergent surgical decompression. A 65-year-old woman on warfarin because of right lower extremity deep venous thrombosis and history of myelofibrosis, presented to the emergency department with neck pain, weakness and numbness of her right arm. Cervical spine films were negative. MRI of the spine showed a hyperintense lesion on T1 weighted images, extending from C3-T1, consistent with an epidural hematoma. INR was 1.8. Her neck pain, weakness and numbness improved slowly over two weeks time. She recovered without surgery.

The surgical treatment of dural arteriovenous fistulas at the beginning of the 21st century remains a cornerstone of treatment of these difficult lesions. The rapid advancement of endovascular treatments has allowed combined strategies with endovascular and surgical treatments to successfully treat previously untreatable lesions with minimal morbidity and mortality. There are also dural arteriovenous fistula types which remain preferentially treatable with surgery, and surgical expertise in this area remains an essential component of any treatment team. Advances in the surgical treatment of these lesions are based also on a better understanding of the natural history of these lesions, which dictates the importance of definitive treatment if at all possible. Modern imaging has also significantly advanced our understanding of these complex lesions.

Public awareness of stroke is improving. However, public knowledge of acute stroke symptoms and the need to seek immediate medical attention for those symptoms continues to lag despite various educational endeavors. Knowledge of stroke risk factors is better, reflecting an overlap with risk factors for coronary heart disease, but there is still a gap in awareness. Clearly, there is need for additional improvements in educational strategies to the lay public.

Physician knowledge and attitudes regarding acute stroke and stroke prevention are increasing. However, awareness about best practices for diagnosing and managing stroke is still very limited. The approach of many physicians to stroke diagnosis and treatment even for such well-studied areas such as TPA for acute stroke, anticoagulation for atrial fibrillation, carotid endarterectomy, and antithrombotic therapy is still very haphazard. There is great potential for improving stroke outcomes simply by improving physician awareness about currently existing “evidence-based medicine” regarding cerebrovascular disease.

This article will examine the role of the pre-hospital provider in the care and transport of the stroke patient. Utilizing the concept of the “chain of recovery,” I will discuss how the interventions and recognition of the patient experiencing an acute “brain attack” can be enhanced by pre-hospital providers.