Background Intracranial hemorrhage is the most feared and lethal complication of oral anticoagulation. We review the frequency, predictors, and prognosis of this most common neurological complication of oral anticoagulation. Summary of Review Anticoagulation to conventional intensities increases the risk of intracranial hemorrhage 7- to 10-fold, to an absolute rate of nearly 1%/y for many stroke-prone patients. Most (70%) anticoagulant-related intracranial hemorrhages are intracerebral hematomas (approximately 60% are fatal); the bulk of the remainder are subdural hematomas. Predictors of anticoagulant-related intracerebral hematoma are advanced patient age, prior ischemic stroke, hypertension, and intensity of anticoagulation. In approximately half of anticoagulated patients with intracerebral hematoma the bleeding evolves slowly over 12 to 24 hours, and emergency reversal of anticoagulation is crucial. Conclusions Both patient factors and anticoagulation intensity importantly influence the rate of antic...

Oral Anticoagulants and Intracranial Hemorrhage Facts and Hypotheses

In 1991, about 500 000 Americans had a stroke (400 000 had an ischemic stroke) and more than 143 000 died. More than 3 000 000 people in the .Ignited States have survived a stroke. In 1994 the annual economic costs of stroke due to health care expenses and lost productivity are estimated to be nearly $20 billion. In spite of these human and financial costs, stroke unfortunately has not received a great deal of attention, and its management has been marred by an element of nihilism. Caplan concludes that past failures to establish effective therapies for stroke are due to problems in clinical trial design, lack of interest in care of stroke, and lack of available technologies to evaluate patients. However, with advances in diagnosis and treatment, stroke can now be managed as the life-threatening emergency that it is. In 1993 the American Heart Association included emergent stroke care as part of its special resuscitation situations for basic and advanced life support. This report builds on that statement. The goal of this special report is to provide information about the current management of acute ischemic stroke. It also provides recommendations for initial care (within 24 hours of stroke) based on currently available data from clinical trials. In the future, many therapies for stroke will be linked to very early (within 6 hours) intervention. No recommendations about rehabilitation or chronic medical or surgical measures to prevent recurrent stroke are made. To prepare this report, the members of the Stroke Council used the rules of evidence for specific treatments that have been used by other panels (Table I). These rules give greater credence to the results of well-designed clinical trials than to anecdotal case reports or case series. The current recommendations will eventually be altered

Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association.

New criteria for the diagnosis of multiple sclerosis (MS) were published as the result of an internationally formed committee. To increase the specificity of diagnosis and to minimize the number of false diagnoses, the committee recommended the use of both clinical and paraclinical criteria, the latter involving information obtained from magnetic resonance imaging, evoked potentials, and cerebrospinal fluid (CSF) analysis. Although rigorous magnetic resonance imaging requirements were provided, the "new criteria paper" fell short in terms of guidelines as to how the CSF analysis should be performed and simply equated the IgG index with isoelectric focusing, without any justification. The spectrum of parameters analyzed and methods, for CSF analysis differ worldwide and often yield variable results in terms of sensitivity, specificity, accuracy, and reliability, with no decided "optimal" CSF test for the diagnosis of MS. To address this question specifically, an international panel of experts in MS and CSF diagnostic techniques was convened and the result was this article, representing a consensus of all the participants. These recommendations for establishing a standard for the evaluation of CSF in patients suspected of having MS should greatly complement the new criteria in ensuring that a correct diagnosis of MS is being made.

https://jamanetwork.com/journals/jamaneurology/articlepdf/788592/nnr40039.pdf

Recommended Standard of Cerebrospinal Fluid Analysis in the Diagnosis of Multiple Sclerosis: A Consensus Statement

New criteria for the diagnosis of multiple sclerosis (MS) were published as the result of an internationally formed committee. To increase the specificity of diagnosis and to minimize the number of false diagnoses, the committee recommended the use of both clinical and paraclinical criteria, the latter involving information obtained from magnetic resonance imaging, evoked potentials, and cerebrospinal fluid (CSF) analysis. Although rigorous magnetic resonance imaging requirements were provided, the “new criteria paper” fell short in terms of guidelines as to how the CSF analysis should be performed and simply equated the IgG index with isoelectric focusing, without any justification. The spectrum of parameters analyzed and methods for CSF analysis differ worldwide and often yield variable results in terms of sensitivity, specificity, accuracy, and reliability, with no decided “optimal” CSF test for the diagnosis of MS. To address this question specifically, an international panel of experts in MS and CSF diagnostic techniques was convened and the result was this article, representing a consensus of all the participants. These recommendations for establishing a standard for the evaluation of CSF in patients suspected of having MS should greatly complement the new criteria in ensuring that a correctdiagnosisofMSisbeingmade.

http://lib.ajaums.ac.ir/booklist/archives of neurology_june_6_25.pdf

Recommended Standard of Cerebrospinal Fluid Analysis in the Diagnosis of Multiple Sclerosis

Atypical imaging features of multiple sclerosis lesions include size >2 cm, mass effect, oedema and/or ring enhancement. This constellation is often referred to as ‘tumefactive multiple sclerosis’. Previous series emphasize their unifocal and clinically isolated nature, however, evolution of these lesions is not well defined. Biopsy may be required for diagnosis. We describe clinical and radiographic features in 168 patients with biopsy confirmed CNS inflammatory demyelinating disease (IDD). Lesions were analysed on pre- and post-biopsy magnetic resonance imaging (MRI) for location, size, mass effect/oedema, enhancement, multifocality and fulfilment of Barkhof criteria. Clinical data were correlated to MRI. Female to male ratio was 1.2 : 1, median age at onset, 37 years, duration between symptom onset and biopsy, 7.1 weeks and total disease duration, 3.9 years. Clinical course prior to biopsy was a first neurological event in 61%, relapsing–remitting in 29% and progressive in 4%. Presentations were typically polysymptomatic, with motor, cognitive and sensory symptoms predominating. Aphasia, agnosia, seizures and visual field defects were observed. At follow-up, 70% developed definite multiple sclerosis, and 14% had an isolated demyelinating syndrome. Median time to second attack was 4.8 years, and median EDSS at follow-up was 3.0. Multiple lesions were present in 70% on pre-biopsy MRI, and in 83% by last MRI, with Barkhof criteria fulfilled in 46% prior to biopsy and 55% by follow-up. Only 17% of cases remained unifocal. Median largest lesion size on T2-weighted images was 4 cm (range 0.5–12), with a discernible size of 2.1 cm (range 0.5–7.5). Biopsied lesions demonstrated mass effect in 45% and oedema in 77%. A strong association was found between lesion size, and presence of mass effect and/or oedema (P 5 cm was associated with a slightly higher EDSS at last follow-up, long-term prognosis in patients with disease duration >10 years was better (EDSS 1.5) compared with a population-based multiple sclerosis cohort matched for disease duration (EDSS 3.5; P < 0.001). Given the retrospective nature of the study, the precise reason for biopsy could not always be determined. This study underscores the diagnostically challenging nature of CNS IDDs that present with atypical clinical or radiographic features. Most have multifocal disease at onset, and develop RRMS by follow-up. Although increased awareness of this broad spectrum may obviate need for biopsy in many circumstances, an important role for diagnostic brain biopsy may be required in some cases.

/pdf/clinical-and-radiographic-spectrum-of-pathologically-385ffo3iel.pdf

Clinical and radiographic spectrum of pathologically confirmed tumefactive multiple sclerosis

Directional Doppler examination (DD) with flow registration over the supraorbital and supratrochlear arteries and over the carotid artery in the neck was adopted to 99 carotid arteries in 56 patients without previous knowledge of angiography results, and thereafter DD and angiography findings were compared. On subgrouping of the angiography results into internal carotid artery (ICA) stenosis less than 50%, greater than 50%, and occlusion, a correct diagnosis was obtained by DD on 90 vessels (91%). All 11 ICA occlusions were correctly diagnosed by DD. The incorrect results obtained with DD were as follows: Four ICA stenosis less than 50% were classified as stenosis greater than 50%; four stenosis greater than 50% were classified as less than 50%; one stenosis greater than 50% was classified as occlusion. DD is a useful noninvasive screening method for the detection of occlusion and greater than 50% stenosis of ICA.

Comparison between directional Doppler and angiography in the diagnosis of internal carotid artery disease

Immunoglobulin abnormalities in multiple sclerosis: Relation to clinical parameters: Disability, duration and age of onset

A modified technique of isoelectric focusing on thin-layer polyacrylamide gel followed by immunofixation with monospecific antisera was used to identify individual cerebrospinal fluid (CSF) and serum proteins and to define the oligoclonal reaction observed in multiple sclerosis (MS). "Normal" IgG gave about 20 to 30 bands at pH 3.5 to 9.5, IgA about 10 bands at pH 3.5 to 6.4, beta-trace protein a smear at pH 3.5 to 8.5, and gamma-trace protein 1 or 2 bands at pH 8.0, 9.5 or both. Up to 11 oligoclonal IgG bands migrating between pH 6.5 and 9.5 were found in CSF from 26 of 27 consecutive patients with MS and also in 20 of the corresponding sera, although at lower numbers and concentrations. In 26 patients, 1 or more of the bands corresponding to normal polyclonal IgG were stronger in CSF than in serum. These data support the hypothesis that two colonies of lymphocytes are activated intrathecally, one of them synthesizing oligoclonal and the other polyclonal IgG. Up to 11 mostly faint bands of free light chains, predominantly of lambda type and migrating between pH 3.5 and 9.5, were found in 8 of 9 CSF specimens from patients with MS.

Oligoclonal IgG and free light chains in multiple sclerosis demonstrated by thin-layer polyacrylamide gel isoelectric focusing and immunofixation

Agarose gel electrophoresis and immunofixation of CSF and serum from 39 patients with multiple sclerosis (MS) revealed oligoclonal IgG in the CSF in all cases and oligoclonal IgA and IgM in 1 patient each. IgG kappa bands only were found in 10 patients, while no patient had IgG lambda bands alone. IgG kappa bands predominated in 20 patients and IgG lambda bands in 5, while 4 patients had the same number of IgG kappa and IgG lambda bands. Twenty-seven patients also displayed IgG bands with kappa and lambda present simultaneously. Bands of free lambda chains were found in 7 patients, while free kappa chain bands were not seen. One or 2 faint IgG bands in 4 patients constituted the only serum abnormality. In 4 additional MS patients selected on the basis of normal findings on agarose gel electrophoresis of the CSF, immunofixation did not reveal oligoclonal Ig, while isoelectric focusing showed bands in 1. Immunofixation is recommended for proving the presence of oligoclonal Ig in CSF and for characterizing oligoclonal Ig into classes and types of light chains.

Immunoglobulin class and light chain type of oligoclonal bands in CSF in multiple sclerosis determined by agarose gel electrophoresis and immunofixation

Isoelectric focusing and agarose gel electrophoresis of CSF and serum revealed similar frequencies of oligoclonal bands in multiple sclerosis (100% with both methods), infectious CNS disorders (38 and 23%) and other neurological diseases (8 and 10%). In selected cases with unsure CSF oligoclonal bands on agarose gel electrophoresis, isoelectric focusing displayed definite oligoclonal bands. In contrast to agarose gel electrophoresis, isoelectric focusing revealed evidence for oligoclonal bands in serum as well as in CSF in 41% of the multiple sclerosis patients, indicating diffusion from CSF to serum. In 4 cases with gammaglobulin bands appearing in both CSF and serum on agarose gel electrophoresis, isoelectric focusing revealed normal CSF and serum protein patterns at pH above 6.4 where most IgG is migrating.

Comparison between agarose gel electrophoresis and isoelectric focusing of CSF for demonstration of oligoclonal immunoglobulin bands in neurological disorders.

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Papers

Comparison between directional Doppler and angiography in the diagnosis of internal carotid artery disease

Immunoglobulin abnormalities in multiple sclerosis: Relation to clinical parameters: Disability, duration and age of onset

Oligoclonal IgG and free light chains in multiple sclerosis demonstrated by thin-layer polyacrylamide gel isoelectric focusing and immunofixation

Immunoglobulin class and light chain type of oligoclonal bands in CSF in multiple sclerosis determined by agarose gel electrophoresis and immunofixation

Comparison between agarose gel electrophoresis and isoelectric focusing of CSF for demonstration of oligoclonal immunoglobulin bands in neurological disorders.