Summary of Stroke meeting 2008 by L Caplan

again throwaway journal not cited
Dr Caplan emphasizes stroke care is not easily duplicated by nonexpert personnel. Strategies to improve recovery involve the following:
1. Manipulating transmitters -- ach, ne, ser da
2. Stimulating growth factors -- VEGF, NGF,erythropoeitin
3. Cell based treatment eg stem cells
4. Brain stimulation-- magnetic and electrical current
5. Robotic facilitation of movement
6. Brain imagery and eye movement to drive computer assisted functions
7. Novel PT such as treadmill gait training
8. Neuroprosthetics that facilitate/train limb functions

citicholine

based on an article by Jeff Saver in a throwaway therefore not cited. Citicholine is available as a supplement. Individual trials were negative or inconclusive, but a metaanalysis suggests less death and disability. Reinvestigation is underway. Citicholine is neuroprotective and neurorestorative. Saver suggests small studies show mild benefit in cognitive enhancement in vascular dementia, head trauma and possibly PD and ION

adding aspirin to coumadin

There was an analysis of the safety and efficacy of adding aspirin to warfarin
published as a
substudy of the SPORTIF trials, first author was Scott Kasner.

It showed that adding aspirin to either coumadin (or ximelagatran) in high risk
patients with hx of
stroke and atrial fibrillation (eg those with coexisting coronary disease) did
not lower the
ischemic event risk, but significantly raised the risk of major bleeding. Based
on that, I would be
very wary of adding aspirin at any dose to warfarin.

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hypertonic saline for impending herniation

The article on the beneficial effects of 3% Na on CT midline shift was based on
simple clinical findings - serum Na and Ct scan. **Qureshi AI, Suarez JI,
Bhardwaj A, Mirski M, Schnitzer MS, Hanley DF, Ulatowski JA.
Use of hypertonic (3%) saline/acetate infusion in the treatment of cerebral
edema: Effect on intracranial pressure and lateral displacement of the
brain.Crit Care Med. 1998 Mar;26(3):440-6

The first article on 23.4% and refractory - used clinical clinical exam, common
ICP monitors (bolts and ventric drain) and typical lab Na). **Suarez JI, Qureshi
AI, Bhardwaj A, Williams MA, Schnitzer MS, Mirski M, Hanley DF, Ulatowski
JA.Treatment of refractory intracranial hypertension with 23.4% saline. Crit
Care Med. 1998 Jun;26(6):1118-22

Among the report on functional outcome after reversal of transtentorial
herniation with brain resuscitation (including - use hypertonic saline) used GCS
and pupils and common clinical parameters. **Qureshi AI, Geocadin RG, Suarez JI,
Ulatowski JA.Long-term outcome after medical reversal of transtentorial
herniation in patients with supratentorial mass lesions.Crit Care Med. 2000
May;28(5):1556-64.

And recently, the use of 23.4% Na bolus to reverse transtentorial herniation -
was again based on bedside clinical finding of GCS change, pupillary size and
light reactivity, serum Na monitoring. **Koenig MA, Bryan M, Lewin JL 3rd,
Mirski MA, Geocadin RG, Stevens RD. Reversal of transtentorial herniation with
hypertonic saline. Neurology. 2008 Mar 25;70(13):1023-9. Epub 2008 Feb 13.

Hypertonic saline is readily available and seems to be very beneficial (yes I
understand that we lack level 1 RCT); it maybe even be better than mannitol and
it helped us realize that the dreadful event of transtentorial herniation is
reversible and survivable. So we must do our best to make this treatment
available in as many ICUs and appropriate patients as possible.

Certainly, we should encourage more research to understand this problem and the
use of LICOX or other similar technologies is a promising direction. It is great
that many top centers are using this as a research or adjunct tool but until
more definite data comes, I believe that these devices should not be made to
define or limit the care we provide.

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Need to recognize interference of NSIAA's and ASA with each other

Gengo FM, Rubin L, Robson M, Gengo MF, Mager DE Ranika MR, Bates VE Effects
> of Ibuprofen on the Magnitude and Duration of Aspirin’s Inhibition of
> Platelet Aggregation: Clinical Consequences in Stroke Prophylaxis 2008 Vol
> 48 Number 9 Journal of Clinical Pharmacology p 117 123

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EC IC bypass

International trial showed not benefit over medication. COSS trial (carotid artery occlusion study) is looking at EC IC bypass for patients with an occluded artery who are not candidates for CEA or intervention.

Cholesterol measurement conversion

LDL should be < 70-100 mg/dL, to convert to mmol/L, multiply by 0.0259. SPARCL used atorvastatin.

Patients with low HDL or high triglycerides, consider ezetimibe, niacin or gemfibrozil. Should be > 50.