Recommendations for Management of Patients with Carotid Stenosis

Stroke is a one of the leading causes of morbidity and mortality in the world. Carotid atherosclerosis is recognized as an important factor in stroke pathophysiology and represents a key target in stroke prevention; multiple treatment modalities have been developed to battle this disease. Multiple randomized trials have shown the efficacy of carotid endarterectomy in secondary stroke prevention. Carotid stenting, a newer treatment option, presents a less invasive alternative to the surgical intervention on carotid arteries. Advances in medical therapy have also enabled further risk reduction in the overall incidence of stroke. Despite numerous trials and decades of clinical research, the optimal management of symptomatic and asymptomatic carotid disease remains controversial. We will attempt to highlight some of the pivotal trials already completed, discuss the current controversies and complexities in the treatment decision-making, and postulate on what likely lies ahead. This paper will highlight the complexities of decision-making optimal treatment recommendations for patients with symptomatic and asymptomatic carotid stenosis

Incidencija cerebrovaskularnih bolesti u Zagrebu tijekom prošloga desetljeća

During the last decade Croatia was faced with war and population migration that entailed socioeconomic changes, modification of lifestyle, risk factors and health care, thus influencing the incidence and outcome of stroke. Data on patients admitted to University Department of Neurology in the years 1990 and 1999 were compared to estimate the incidence and prevalence of stroke and stroke subtypes, risk factors and outcome. In 1999, the number of stroke patients was almost twofold that recorded in 1990 and stroke patients were by 5 years younger. In 1999, there were more first-ever strokes (the incidence of crude first stroke increased by 57%), whereas the number of recurrent strokes increased in men and decreased in women. The proportion of ischemic stroke and subarachnoid hemorrhage did not significantly change, whereas parenchymatous hemorrhage increased in women. Hypertension was more common (83% versus 62%), whereas the prevalence of other risk factors did not change significantly. Patients were more often discharged for home care instead of rehabilitation center care. Mortality decreased in men and increased in women, whereas case fatality and crude mortality decreased leading to an increased stroke burden.Tijekom prošloga desetljeća Hrvatska je bila zahvaćena ratnim zbivanjima koja su donijela mnoge političke, socioekonomske i kulturološke promjene. Promjena načina života svakako je utjecala na modifikaciju čimbenika rizika, pa tako i na incidenciju i ishod moždanog udara. U ovom istraživanju uspoređeni su podatci o incidenciji, prevalenciji, vrstama i ishodu moždanog udara kod bolesnika koji su primljeni na Kliniku za neurologiju tijekom prijeratne 1990. i poslijeratne 1999. godine. U 1999. godini bilo je skoro dvostruko više bolesnika, incidencija prvog moždanog udara porasla je za 57%, dok je broj ponovljenih moždanih udara porastao u muškaraca, a pao u žena. Udio ishemijskog moždanog udara i subarahnoidnog krvarenja nije se statistički značajno promijenio, dok je broj parenhimnih krvarenja kod žena porastao. Hipertenzija se javljala češće (83% naprama 62%), dok se zastupljenost drugih čimbenika rizika nije promijenila. Bolesnici su se u 1999. češće otpuštali na kućnu njegu nego na rehabilitaciju. Opća smrtnost i smrtnost u muškaraca je u 1999. godini pala, dok je kod žena bila u porastu

Incidencija cerebrovaskularnih bolesti u Zagrebu tijekom prošloga desetljeća

During the last decade Croatia was faced with war and population migration that entailed socioeconomic changes, modification of lifestyle, risk factors and health care, thus influencing the incidence and outcome of stroke. Data on patients admitted to University Department of Neurology in the years 1990 and 1999 were compared to estimate the incidence and prevalence of stroke and stroke subtypes, risk factors and outcome. In 1999, the number of stroke patients was almost twofold that recorded in 1990 and stroke patients were by 5 years younger. In 1999, there were more first-ever strokes (the incidence of crude first stroke increased by 57%), whereas the number of recurrent strokes increased in men and decreased in women. The proportion of ischemic stroke and subarachnoid hemorrhage did not significantly change, whereas parenchymatous hemorrhage increased in women. Hypertension was more common (83% versus 62%), whereas the prevalence of other risk factors did not change significantly. Patients were more often discharged for home care instead of rehabilitation center care. Mortality decreased in men and increased in women, whereas case fatality and crude mortality decreased leading to an increased stroke burden.Tijekom prošloga desetljeća Hrvatska je bila zahvaćena ratnim zbivanjima koja su donijela mnoge političke, socioekonomske i kulturološke promjene. Promjena načina života svakako je utjecala na modifikaciju čimbenika rizika, pa tako i na incidenciju i ishod moždanog udara. U ovom istraživanju uspoređeni su podatci o incidenciji, prevalenciji, vrstama i ishodu moždanog udara kod bolesnika koji su primljeni na Kliniku za neurologiju tijekom prijeratne 1990. i poslijeratne 1999. godine. U 1999. godini bilo je skoro dvostruko više bolesnika, incidencija prvog moždanog udara porasla je za 57%, dok je broj ponovljenih moždanih udara porastao u muškaraca, a pao u žena. Udio ishemijskog moždanog udara i subarahnoidnog krvarenja nije se statistički značajno promijenio, dok je broj parenhimnih krvarenja kod žena porastao. Hipertenzija se javljala češće (83% naprama 62%), dok se zastupljenost drugih čimbenika rizika nije promijenila. Bolesnici su se u 1999. češće otpuštali na kućnu njegu nego na rehabilitaciju. Opća smrtnost i smrtnost u muškaraca je u 1999. godini pala, dok je kod žena bila u porastu

Stroke prevention: recent achievements and new challenges

Stroke remains a major health problem despite the great efforts made worldwide to fight against it. Despite therapeutic achievements to treat ischemic stroke patients in stroke units with tissue plasminogen activator (tPA), prevention remains the most powerful strategy to cure this complex disease. Stroke is a heterogeneous and multi-factorial disease caused by the combination of vascular risk factors, environment, and genetic factors. These risk factors can be subdivided into non-modifiable (age, sex, race-ethnicity, genetic variations and predispositions) and modifiable (hypertension, diabetes, dyslipidemia, atrial fibrillation, carotid artery stenosis, smoking, poor diet, physical inactivity and obesity). The metabolic syndrome, a cluster of metabolic risk factors within an individual, has been recognized as and important factor associated with an increased risk of stroke. Recently, a great emphasis has been given to the investigations of genetic factors and stroke risk, which may lead to the discovery of new biomarkers for prevention, diagnosis and to the alternative strategies for stroke treatment. In this review we sought to discuss the main risk factors for stroke and the current strategies of stroke prevention

Debljina intime medije karotidnih arterija: zamjenski biljeg ateroskleroze

Atherosclerosis is chronic, progressive disease of the arterial wall with onset decades prior to its clinical manifestations. Carotid intima-media thickness (IMT) measurement by ultrasound is an important tool for evaluation of early stages of atherosclerosis. Also, carotid intima-media thickness can be used for assessment of therapeutic effect of various regimens. Carotid IMT is sensitive marker of atherosclerosis. The causal relationship between carotid IMT and the clinical endpoint has been established on the basis of epidemiological studies and clinical trials. The strength of carotid IMT as a marker of atherosclerosis is enhanced by the fact that it may yield pathophysiological information at an early stage of atherogenic process.Ateroskleroza je kronična progresivna bolest stjenke arterija koja počinje desetljećima prije kliničkih manifestacija. Mjerenje zadebljanja intime i medije karotidnih arterija ultrazvukom je značajna metoda za procjenu ranijih stadija ateroskleroze. Osim toga, mjerenje zadebljanja intime i medije karotidnih arterija može poslužiti za procjenu učinka različitih terapijskih postupaka. Zadebljanje intime i medije karotidnih arterija je osjetljiv pokazatelj ateroskleroze. Utvrđena je uzročna povezanost zadebljanja intime i medije karotidnih arterija i kliničkog ishoda temeljem epidemioloških studija i kliničkih pokusa. Značaj zadebljanja intime i medije karotidnih arterija kao pokazatelja ateroskleroze je povećan činjenicom da može pružiti patofiziološke podatke o ranim stadijima aterogenog procesa

Preporuke za liječenje dijabetične polineuropatije

Diabetes is a chronic disease that requires continual medical care and patient self-management education in order to prevent acute complications and to reduce the risk of longterm complications. Diabetes is the leading known cause of neuropathy in developed countries, and neuropathy is the most common complication and the leading source of morbidity and mortality in diabetes patients. Diabetic polyneuropathy is primarily symmetric sensory neuropathy, initially affecting distal lower extremities. Patients have evidence of nerve damage at the time their diabetes is diagnosed in 10%-18% of cases, suggesting that even early impairment of glucose handling, classified as prediabetes, is associated with neuropathy. It is important to appreciate that there are other causes of neuropathy; these should be considered if there is any aspect of the history or clinical presentation suggesting features atypical of diabetic neuropathy. Diagnosis of diabetic neuropathy should be established according to clinical manifestations of the disease, laboratory findings (altered glucose metabolism) and results of electrophysiological examinations. Treatment of painful diabetic polyneuropathy rests on a two-pronged approach: modification of the underlying disease and control of pain symptoms. The goals of painful diabetic polyneuropathy pharmacotherapy should be reduction of pain for maximum relief commensurate with acceptable side effects and restoration/ improvement in functional measures and quality of life.Dijabetes spada u skupinu kroničnih bolesti koja zahtijeva stalno medicinsko praćenje te izobrazbu bolesnika o mjerama prevencije kako bi se spriječio razvoj komplikacija. U razvijenim zemljama dijabetes je vodeći uzrok neuropatija, a neuropatije su jedna od najčešćih komplikacija dijabetesa, te najveći uzrok pobola i smrtnosti u bolesnika s dijabetesom. U trenu kada se postavi dijagnoza dijabetesa 10%-18% bolesnika već ima oštećenje živaca, što govori u prilog činjenici da čak i početni poremećaji metabolizma glukoze pod zajedničkim nazivnikom preddijabetes mogu uzrokovati neuropatiju. Kod postavljanja dijagnoze dijabetične neuropatije treba isključiti i druge uzroke neuropatija ako se radi o atipičnoj kliničkoj slici ili nekim drugim istodobnim bolestima. Dijagnoza se postavlja u skladu sa smjernicama, a na osnovi kliničke slike, laboratorijskih nalaza (poremećaj metabolizma glukoze) i rezultata elektrofizioloških pretraga. Liječenje bolne dijabetične polineuropatije temelji se na dva dugoročna načela, a to su liječenje osnovne bolesti (dijabetes) i liječenje bolne sastavnice. Osnovni ciljevi liječenja bolne sastavnice su smanjenje boli uz prihvatljive rizike i nuspojave uzimanja specifičnih lijekova te poboljšanje kvalitete života