What Do We Know About Intracranial Atherosclerosis?

What Do We Know About Intracranial Atherosclerosis?
A comprehensive review compactly conveys current knowledge.


This clinical update is a review of information about intracranial atherosclerosis discussed at a consensus meeting. Concise sections review the prevalence, risk factors, and natural courses of symptomatic and asymptomatic intracranial atherosclerosis, its diagnosis, and its treatment. The most extensive sections consider interventional treatment.

The authors mention recommendations, when available, concerning treatment. For example, for patients with symptomatic intracranial atherosclerosis, the American Heart Association/American Stroke Association recommends aspirin plus extended-release dipyridamole, or possibly clopidogrel alone, over aspirin alone. The review also touches on newer and experimental approaches.

Comment: The strength of this review is its very broad and up-to-date coverage of many aspects of intracranial atherosclerosis. The reference list is extensive. The short paragraphs cannot adequately convey many aspects of current knowledge. Although prevalence data are mentioned, the particularly high prevalence in Asian countries is not emphasized; in fact, the major intracranial arteries are the most frequent site of narrowing in individuals of Asian origin (J Clin Neurosci 2003; 10:30 and Gorelick P et al. Epidemiology. In: Kim JS et al. Intracranial Atherosclerosis. Wiley-Blackwell; 2008). Nor is the higher prevalence in women compared with men mentioned. Moreover, in some countries (e.g., Korea), the relative preponderance of intracranial over extracranial disease is changing, perhaps related to lifestyle changes. Japanese individuals have different frequencies and locations of atherosclerosis in Japan than they do in Hawaii and California (Stroke 1975; 6:539).

The review covers medical treatments, especially antithrombotic agents, only cursorily. It includes the main conclusion of the WASID trial regarding antithrombotics — that aspirin effectiveness was comparable to warfarin and that warfarin anticoagulation was associated with more hemorrhages and deaths. Omitted is the finding that patients whose anticoagulation was accomplished within the target international normalized ratio (INR) range had fewer strokes than the aspirin-treated group (N Engl J Med 2005; 352:1368). Hemorrhages occurred mainly when the INR was higher than targeted. Warfarin has proven difficult to use. Newer direct thrombin inhibitors (e.g., dabigatran) will undoubtedly be much easier to control and prescribe. Also not mentioned is a major conclusion of WASID: that risk-factor control and thorough management of lifestyle factors proved very effective and important in reducing unwanted outcomes of intracranial atherosclerosis.

— Louis R. Caplan, MD

Dr. Caplan is Professor of Neurology, Harvard Medical School, and Senior Neurologist, Stroke Service, Beth Israel Deaconess Medical Center, Boston.

Published in Journal Watch Neurology June 22, 2010

https://docs.google.com/fileview?id=0B278nGJMQBk7YWQzOTRjOWEtMjA3Yi00NDMyLWEwMzgtMmM2MjMzYTdlZWVi&hl=zh_TW

留言

張貼留言

這個網誌中的熱門文章

即便是用IGRA, 有時也要等大於三個月才能決定TB contact

圖片
接觸TB後，TST大抵上2-12週轉陽，IGRA大抵上6-10週，但IGRA可以長到3個月以上 TB Tests Can Have a Lengthy Window Period Two studies suggest that interferon- release assay conversion sometimes occurs more than 3 months after exposure to active tuberculosis. Increasingly, interferon- release assays (IGRAs) are being used for diagnosing latent tuberculosis (TB). Although the tuberculin skin test (TST) traditionally used for this purpose converts to positive within 2 to 12 weeks after an individual is exposed to someone with active TB, the interval for IGRA conversion has remained unclear. Current guidelines recommend repeating an initially negative IGRA after 6 to 10 weeks, but this recommendation is not based on controlled studies. Two recent investigations address this issue. Anibarro and colleagues conducted a longitudinal prospective analysis among contacts of TB patients in Spain. The 152 contacts received a TST and an IGRA at first visit; for individuals with negative or conflicting results, t
閱讀完整內容

白宮為了掌控醫療費用，傾向大型醫療，個體戶勢必受挫

所以一旦政府介入，中外醫療提供者都傾向大型化…… independent practice -> dreaming 診所評鑑??應該擋住! http://www.medscape.com/viewarticle/727420 Physicians Say White House Should Not Write Off Small Practices August 24, 2010 — In a newly published article, the White House is advising physicians to accept a life in Big Medicine — as a hospital employee or member of a large group practice — in the wake of healthcare reform. Some leaders of organized medicine, however, are objecting to the government message. "We're not ready to write off the small practices," J. Fred Ralston Jr, MD, president of the American College of Physicians, told Medscape Medical News. "We think there needs to be more than one delivery model." "America is not a one-size-fits-all country," added M. Todd Williamson, MD, a neurologist from Lawrenceville, Georgia, and spokesperson for a coalition of medical societies opposed to the new healthcare reform law, now called the Affordable Care Act. Dr. Ralston and Dr.
閱讀完整內容

老美接受LTBI treatment的人，不到一半完治，和duration成正比

This study shows that although acceptance of LTBI treatment is relatively high (83%), the proportion completing is low (47%). When the product of these two proportions is calculated, we see that completion was achieved by only 39% of persons who were offered LTBI treatment. The major risk factor for noncompletion was being prescribed the 9-month INH regimen. As shown in Figure 1, when the proportions completing the three most commonly prescribed regimens are compared, it can be seen that there is an inverse relationship between length of the regimen prescribed and the proportion completing treatment. The increased completion that we observed with the 4-month rifampin regimen is consistent with previous reports.[18–20] It is of interest to note that if completion of the 9-month regimen were defined as completion of at least 6 months of INH, the noncompletion rate of the 9-month regimen, 42.9%, would have been almost identical to that of the 6-month regimen, 44.8%. Thus, prescribing the
閱讀完整內容