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There are few data on platelet function in intracerebral hemorrhage (ICH). We prospectively enrolled 69 patients with ICH and measured platelet function on admission. Aspirin use before ICH was associated with reduced platelet activity. Less platelet activity was associated with intraventricular hemorrhage (516.5 [interquartile range (IQR), 454-629.25] vs 637 [IQR, 493-654] aspirin reaction units; p = 0.04) and death at 14 days (480.5 [IQR, 444.5-632.5] vs 626 [IQR, 494-652] aspirin reaction units; p = 0.04). Objective measures of platelet function on admission are associated with intraventricular hemorrhage and death after ICH.

Objective: Fever is associated with worse outcome after subarachnoid hemorrhage, but there are few prospective data to quantify this relationship., Methods: We prospectively enrolled consecutive aneurysmal or cryptogenic subarachnoid hemorrhage patients and recorded the highest core temperature each calendar day for Day 0 (the day of hemorrhage) through Day 13. Fever burden was defined as the daily highest core temperature minus 100.4 degrees F, summed from admission through Day 13 (temperatures <100.4 degrees F did not contribute to or subtract from fever burden). Outcomes were assessed at 14 days or at the time of hospital discharge with the National Institutes of Health Stroke Scale and modified Rankin Scale, and at 28 days and 3 months with the modified Rankin Scale. Improvement was analyzed with repeated measures analysis of variance., Results: We prospectively enrolled 94 patients. From 14 days to 28 days to 3 months, functional improvement was related to cumulative fever burden, admission neurological grade, aneurysm obliteration procedure, admission computed tomographic score, vasospasm, and external ventricular drainage. Good-grade patients had worse functional outcomes with increased fever burden, and poor-grade patients improved more over time when fever burden was higher (time by World Federation of Neurological Surgeons grade by fever burden interaction, P < 0.001). Patients with vasospasm (P = 0.04) and patients with higher computed tomographic scores (P = 0.002) had worse 14-day outcomes but improved more over time. Bacteremia and ventriculitis were uncommon (

Patients with recent ischemic stroke or transient ischemic attack (TIA) face a high risk of recurrent stroke as well as an increased risk of myocardial infarction and sudden cardiac death. In the absence of a clearly established indication for long-term anticoagulation, such as atrial fibrillation, antiplatelet agents are the antithrombotic drugs of choice for preventing recurrent vascular events. For many years, aspirin (ASA) has been the first-line therapy for patients at high risk of vascular ischemic events. Two large clinical trials have established the superiority of the combination of ASA and extended-release dipyridamole (ASA/ERDP) over ASA alone in patients with recent noncardioembolic ischemic stroke or TIA. Clopidogrel, another antiplatelet agent, is a reasonable alternative to ASA, but its superiority to ASA in patients with a history of stroke has not been as clearly established. The combination of ASA and clopidogrel, which is effective in patients with acute coronary syndrome, has not been shown to be either effective or safe, compared with either agent alone, in stroke patients, although there may be some benefit to this combination in patients with acute TIA. The results from a large randomized trial comparing ASA/ERDP with clopidogrel, anticipated soon, will further assist clinicians in choosing among available antiplatelet agents.

Introduction: This article describes two patients with major ischemic stroke symptoms who had extremely small areas of acute brain infarction, suggestive of acute intrahemispheric diaschisis. Both patients were using narcotic analgesics during their stroke, and in both cases the clinical deficits improved dramatically with naloxone., Discussion: We postulate that the narcotics amplified the ischemic stroke symptoms and that this effect was antagonized by naloxone., Conclusion: This suggests that the opiate system may be involved in the process of intrahemispheric diaschisis.

Reconstruction of the radial border of the index metacarpophalangeal (MCP) joint after band saw amputation is described. The entire radial MCP collateral ligament unit was cleanly retained within the amputated segment, still attached to wafers of corticocancellous bone from the radial aspect of the metacarpal head and base of the proximal phalanx. Acute bone to bone osteosynthesis of the amputated segment led to successful osseous integration of both bone fragments and restoration of stability of the joint. Surgical repair of the radial collateral ligament of the index MCP joint is crucial in achieving an optimal outcome after such an injury.

Background: While treating an unusual amputation caused by a meat band saw in a 35-year-old butcher, we sought information from the medical literature that would be useful to other physicians who might encounter similar occupational injuries., Methods: Using the Medline database and relevant search terms, we reviewed the literature concerning occupational saw blade injuries and porcine microbiology as they related to this injury., Results: Among meat workers using powered cutting equipment, hand injuries and distal fingertip amputations appear to be common. The greatest risk for a wound infection after open exposure to raw pork meat appears primarily related to environmental flora rather than enteric-borne porcine pathogens., Conclusions: Decision-making strategy when formulating a treatment plan for debridement or reconstruction of saw blade amputations should rely on a detailed understanding of the injury and occupational environment to achieve an optimal patient outcome. When considering operative and antibiotic treatment for porcine meat-related amputation injury, surgeons should adhere to open fracture-related guidelines, since porcine-borne illnesses are most often caused by ingestion rather than transcutaneous inoculation.

Introduction: Presenting symptoms of aneurysmal subarachnoid hemorrhage (SAH) and reversible cerebral vasoconstriction syndrome (RCVS) may overlap. Patients with RCVS often harbor unruptured aneurysms. We report a case of RCVS in a patient with an unruptured intracranial aneurysm. The development of diffuse vasoconstriction after aneursym clipping in the absence of any subarachnoid blood was initially confusing, until subtle vasoconstriction before clipping was seen retrospectively., Results: We obtained perfusion and diffusion MRI studies on this patient, which shed light on the pathophysiology of RCVS., Conclusion: It is important for physicians who care for patients with aneurysmal SAH to recognize RCVS, as the treatments for these two conditions are different.

Neurologists often assess the risk of stroke from general surgical procedures in patients who have cerebrovascular disease. Common questions for neurologists include: Should a symptomatic or an asymptomatic carotid stenosis be revascularized before general surgery? What is the risk of surgery in patients who have stenoses in the cervicocephalic vasculature? What is the risk of recurrent stroke in patients who have a history of stroke requiring surgery? Can antithrombotic therapy be interrupted for surgery? and How soon after a stroke may elective surgeries be performed? Although definite answers to these questions are lacking, available clinical evidence and knowledge of cerebrovascular pathophysiology can help inform recommendations.

The epidemiologic link between increased low-density-lipoprotein (LDL) cholesterol and ischemic stroke is controversial. However, recent trials make it clear that LDL reduction by statin agents in high-risk patients reduces the risk of ischemic stroke. The risk of first stroke is reduced within 1 to 2 years of statin therapy in patients at high risk for ischemic vascular disease. Patients with any history of cerebrovascular disease who are treated with statins have a reduced risk of coronary ischemic events and of all major vascular ischemic events, independent of any history of coexisting coronary artery disease. In particular, patients with recent transient ischemic attack or ischemic stroke show significantly reduced risks of both recurrent stroke and coronary events when they are treated with high-dose statin therapy. Most patients with ischemic cerebrovascular disease should be placed on statin drugs. However, most stroke patients are not currently treated to recommended levels with these agents, providing ample room for improvement in physician performance.

Reversible cerebral vasoconstriction syndromes (RCVS) comprise a set of conditions having in common the apoplectic onset of headache mimicking subarachnoid hemorrhage, focal or multifocal neurologic deficits with a predilection for visual processing disorders, multifocal vasoconstriction on cerebral angiography, noninflammatory spinal fluid, and a generally benign prognosis. RCVS may occur in the setting of the puerperium, after intracranial surgery, in association with prescription or illicit drug use, in migraineurs, or without a clear trigger. Distinction from central nervous system vasculitis is important and is often possible using routine clinical assessment, without brain biopsy. No treatments are of proven value in RCVS. Empiric treatments include the use of calcium channel blockers, steroids, induced hypertension or blood pressure lowering, and rarely endovascular therapy. The key to successful management is accurate diagnosis and cognizance of the tendency of RCVS to resolve without long-term immunosuppressive treatment.

Intracerebral hemorrhage (ICH) is the most deadly form of stroke, and its acute treatment has suffered from a lack of guidance by reliable clinical trial data. In the past year, however, important clinical trials have helped point toward effective acute management. Studies have shown that magnetic resonance imaging is as accurate as computed tomography in diagnosing acute ICH, although this study is not always feasible in critically ill patients. Ultra-early hemostatic therapy has shown promise in limiting early hematoma expansion and rebleeding. The role of early surgery in patient management has been partially clarified. Finally, a novel treatment for intraventricular hemorrhage has shown promise in speeding clot resolution. All of these advances provide grounds for optimism that multimodal, evidence-based treatment of acute ICH will be reality in the near future.

Background: The mitochondrial DNA gene encoding subunit 5 of complex I (ND5) has turned out to be a hot spot for mutations associated with mitochondrial encephalomyopathy with lactic acidosis and strokelike episodes (MELAS) and various overlap syndromes., Objective: To describe a novel mutation in the ND5 gene in a young man man with an overlap syndrome of MELAS and myoclonus epilepsy with ragged-red fibers., Design: Case report., Patient: A 25-year-old man had recurrent strokes, seizures, and myoclonus. His mother also had multiple strokes. A muscle biopsy specimen showed no ragged-red fibers but several strongly succinate dehydrogenase-reactive blood vessels., Results: Biochemical analysis showed isolated complex I deficiency and molecular analysis revealed a novel heteroplasmic mutation (G13042A) in the ND5 gene., Conclusions: These data confirm that ND5 is a genetic hot spot for overlap syndromes, including MELAS and strokelike and myoclonus epilepsy with ragged-red fibers.

Introduction: Treatment of acute ischemic stroke with systemic thrombolysis in the presence of a proximal thrombo-embolic source carries a theoretical risk of thrombus fragmentation and recurrent embolization. Intracardiac thrombus has received the most attention as a potential source of recurrent emboli, and in the past, it was considered a relative contra-indication to tissue plaminogen activator (t-PA) treatment. More recent data show that recurrent embolization from a cardiac source during t-PA infusion is rare., Case Report: This article describes recurrent symptomatic basilar artery embolization during t-PA infusion from acute thrombus in the proximal cervical vertebral artery., Discussion: This case provides evidence that intravenous t-PA must be used cautiously in the presence of large proximal thrombo-embolic sources and that intraluminal thrombus in a large cervical artery should be considered one such source.

The phenomenon of reversible cerebral arterial segmental vasoconstriction has been associated with several conditions including pregnancy and puerperium ("postpartum angiopathy"), thunderclap headache, and use of vasoconstrictive medications. Patients with cerebral vasoconstriction typically present with sudden, severe, and recurrent ("thunderclap") headaches and can develop strokes. Cerebral vasoconstriction syndromes are under- recognized, are poorly characterized, and are frequently misdiagnosed as primary cerebral vasculitis. This article presents an illustrative case report and reviews the historical aspects, clinical and imaging characteristics, etiology, differential diagnosis, management, and prognosis of cerebral vasoconstriction syndromes.

Introduction: Capsular warning syndrome (CWS) carries a significant risk of permanent stroke. There are no proven therapies for preventing completed stroke in this unstable situation., Methods: Clinical observation in two patients with aspirin-resistant CWS treated with a loading dose of oral clopidogrel., Results: Both patients had excellent neurological outcome, although one sustained an asymptomatic brain infarction., Conclusion: High-dose oral clopidogrel plus aspirin merits formal evaluation in high-risk transient brain ischemia such as CWS, preferably in a randomized trial compared to aspirin alone.

Advances in neurologic therapeutics and intensive care medicine have expanded the arsenal of treatments available for the critical care of ischemic stroke. Several agents are available for acute reperfusion of the ischemic brain. These include intravenous recombinant tissue-plasminogen activator (rtPA), which is effective in a 3-hour time window, and intra-arterial thrombolytics, which may be effective within 6 hours. In addition, newer agents such as Ancrod and abciximab may be effective within the acute time period. Efforts to prevent secondary brain injury in critically ill patients with stroke often include prevention and reduction of fever, induced hypertension, and mechanical ventilation. Finally, death due to severe brain edema after massive hemispheric infarction can often be prevented with surgical or medical intervention. Unfortunately, there is a critical lack of well-designed clinical studies to guide the clinician in the use of these interventions. In addition, there is concern that some of these interventions may preserve life at the cost of quality of life. This article reviews the evidence behind these approaches to the critical care of ischemic stroke.

Juvenile rheumatoid arthritis occurs quite rarely, but should be suspected in a child presenting with arthralgias and systemic signs of sepsis. Once diagnosed, treatment necessitates a multidisciplinary approach to address the social, medical, and surgical issues. Current research into serologic methods of diagnosis shows great promise for better classifying patients, which ultimately will facilitate treatment. Recent well-designed randomized trials are providing better objective information on pharmacologic treatment alternatives. Surgery is reserved for recalcitrant cases that fail medical and occupational therapy. The goals of surgery in children with JRA are to delay or prevent joint destruction and closure of the epiphysis, to prevent or correct deformity, to decrease pain, and to maintain growth and joint motion.

Carpal tunnel syndrome (CTS) is a common affliction of the upper extremity with the classic symptoms of numbness in the radial three and one-half digits, and pain often secondary to repetitive motions. The 1990s have seen a surge in the incidence of CTS, possibly because of increased awareness, recognition, or an increased prevalence of repetitive motion-type disorders. Furthermore, with the increasing use of computers, more people are sitting at keyboards entering text and data, which may lead to more cases of CTS. Recently, the technique of endoscopic carpal tunnel release has gained increased notoriety. The reported benefits include decreased surgical time, decreased postoperative attention, early return to work, diminished pillar pain, and increased thenar strength.

The use of pulsed electromagnetic fields (PEMF) is gaining acceptance for the treatment of ununited fractures. The results of 44 articles published in the English language literature have been compiled to assess the effectiveness of PEMF vs surgical therapy. For ununited tibial fractures, 81% of reported cases healed with PEMF vs 82% with surgery. After multiple failed surgeries, the success rate of PEMF is reported to be greater than with surgery; this discrepancy increases with additional numbers of prior surgeries. In infected nonunions, the results of surgical treatment decreased by 21% and were less than the results utilizing PEMF (69% vs 81%). In open fractures, surgical healing exceeded PEMF (89% vs 78%), whereas in closed injuries PEMF cases healed more frequently (85% vs 79%). In general, PEMF treatment of ununited fractures has proved to be more successful than noninvasive traditional management and at least as effective as surgical therapies. Given the costs and potential dangers of surgery, PEMF should be considered an effective alternative. Experience supports its role as a successful method of treatment for ununited fractures of the tibia.

Little has been written about physicians' attitudes toward patient record requests. We had predicted that physicians would not welcome such requests and would respond to them defensively. Of the 280 physicians at a university affiliated medical center included in this study, 67 per cent thought that patients were motivated to ask for their hospital charts because they wanted more information or further treatment. Only 16 per cent of the physicians said that the requests were prompted by litigious motives, and 23 per cent thought that they came from the need to obtain secondary gain. A majority of the physicians, 62 per cent, viewed the requests as an opportunity to treat or educate, but 83 per cent felt that reading the hospital record could be harmful to patients. The financial and interpersonal aspects of patient education through a response to chart requests are discussed in the final section of this article.

The dialysis exercise is a small group decision-making clinical simulation which has been completely successful as an educational technique. The success of the exercise stems from its ability to engage students cognitively and affectively while teaching problem solving skills. This complete learning package is presented, together with comments on our experience, for use in other settings.

This study reviews 563 medical and surgical consultations to a general hospital psychiatric unit over three years. In addition to an analysis of the consultations by service and month, consulted patients are compared with nonconsulted patients by age, sex, and diagnosis. Parallels are drawn to psychiatric consultations are reported in the consultation-liaison literature to medical and surgical patients. Two important findings from the present study are that depressed patients received significantly (P less than 0.01) fewer consultations than expected, and that 49% of one year's consultations were for active medical problems not related to the reason for psychiatric admission.

Computerized tomography (CT) provides an accurate diagnostic tool for evaluating tilt and subluxation of the patella. Using a previously described technique, this study reviews 62 computerized tomograms, including those of 21 patients before and after lateral release or anteromedial tibial tubercle transfer. One patient was evaluated before and after soft-tissue realignment of the patella. Additional CT studies were evaluated to establish the most appropriate reference line for determining patellar tilt. Results show that lateral retinacular release effectively reduces abnormal patellar tilting as determined by CT. Anteromedial tibial tubercle transfer similarly reduces abnormal tilt. Patellar subluxation may improve substantially following either lateral release or anteromedial tibial tubercle transfer, but this study suggests that correction of subluxation is less consistent than reduction of abnormal tilt with tibial tubercle transfer or lateral release alone. Once articular degeneration has progressed to the point of facet collapse, lateral release fails to restore normal tilt.

A study of the visiting patterns of a general hospital psychiatric unit was undertaken to determine what difference could be detected between visited and unvisited patients. The physical rehabilitation floor at the same hospital was used as a "control." The results indicate that no significant differences could be found between the two groups of psychiatric patients but that a surprisingly large number, 40%, were not visited at all. A comparison of the visiting rates to both services favors rehabilitation 2:1 with visitors coming from a much greater distance than to psychiatry. A discussion of the data raises questions about the social isolation of psychiatric patients. The dynamics of visiting are assessed in light of their tratment implications for patients in both the hospital and the community.

The relationship between obesity and 18 different disease conditions was examined in a cross-sectional study of 73,000 weight-conscious women (TOPS Club members). The women reported an average of 1.6 disease conditions each (based on their responses on a questionnaire). Age-specific rates of occurrence for the age group 30-49 years were calculated for each disease condition. The conditions that were found to be significantly (P smaller than 0.001) correlated with obesity were diabetes, high blood pressure, gallbladder disease, gout, thyroid disease, heart disease, arthritis, and jaundice. When the crude relative risks of obesity for each disease condition were calculated, diabetes was found to be the highest (4.5), high blood pressure was second (3.3), and gallbladder disease was third (2.7).

Liaison psychiatry is traditionally practiced on the medical and surgical floors of the general hospital. The need for liaison psychiatry on the inpatient psychiatric unit as opposed to its usual setting was realized when the medical care requirements of hospitalized psychiatric patients was assessed. In many general hospitals this medical care is provided by a psychiatrist in consultation with medical and surgical colleagues. Over a three-year period at the Medical Center Hospital of Vermont 563 medical/surgical consultations were provided to the inpatient psychiatric unit. To utilize these consultations most effectively, the role best suited for the psychiatrist was that of liaison-consultee. Case examples are used to demonstrate the effectiveness of employing liaison skills in the treatment of somatic problems on the inpatient psychiatric unit. The educational implications of learning the liaison model in this context are discussed.

Ventriculocholecystic shunts are not commonly used for the treatment of hydrocephalus. We present a case of a child who underwent such a procedure and died of unusual complications. This case represents a unique juxtaposition of uncommon neurosurgical entities and complications including acquired communicating hydrocephalus, bilious ventriculitis secondary to a ventriculocholecystic shunt, and pulmonary edema. The unusual features of this case are discussed and emphasis is placed on the pathophysiologic findings.

Imaging ultrasonography was performed during 23 brain and five spinal cord operations with real-time B-mode instruments. Criteria for the utilization of ultrasound at neurosurgical procedures were identified in terms of assistance in the diagnosis or better definition of lesions. The diagnosis criteria were detection and exclusion. Because of the accuracy of preoperative imaging, usually little further help was provided by operative ultrasonography in detecting previously totally unknown abnormalities or excluding lesions found on positive studies. The definition criteria were localization, distinction of tissue features, and assessment of spatial relations. Operative ultrasonography was most useful when applied on the basis of these definition criteria. Operative ultrasonography was considered to be useful in 22 of 28 operations (79 per cent) in which it assisted in exposing, accessing, and extirpating disease.

Of 452 patients seen during one year on a medical-school-affiliated general hospital psychiatric unit, 26 requested to see their charts. These patients tended to be younger, more likely to have character disorders, and less likely to have an affective disorder than patients who did not make chart requests. The apparent increase in the number of patients who ask to see their records may be linked to increasing medical consumerism. Rather than causing therapists to become defensive, record requests should provide an opportunity for education and treatment. The authors outline methods of interpreting and responding to chart requests.