Intracranial atherosclerotic disease: an update.

The consensus conference on intracranial atherosclerosis provides a comprehensive review of the existing literature relevant to the epidemiology, diagnosis, prevention, and treatment of intracranial atherosclerosis, and identifies principles of management and research priorities. Patients who have suffered a stroke or transient ischemic attack attributed to stenosis (50-99%) of a major intracranial artery face a 12 to 14% risk for subsequent stroke during the 2-year period after the initial ischemic event, despite treatment with antithrombotic medications. The annual risk for subsequent stroke may exceed 20% in high-risk groups. In patients with intracranial atherosclerotic disease, short-term and long-term anticoagulation is not superior to antiplatelet treatment. Overall, the subgroup analyses from randomized trials provide evidence about benefit of aggressive atherogenic risk factor management. Intracranial angioplasty with or without stent placement has evolved as a therapeutic option for patients with symptomatic intracranial atherosclerotic disease, particularly those with high-grade stenosis with recurrent ischemic symptoms, medication failure, or both. A multicenter randomized trial is currently under way to compare stent placement with intense medical management for patients with high-grade symptomatic intracranial atherosclerotic disease.

Consensus conference on intracranial atherosclerotic disease: rationale, methodology, and results.

The consensus conference on intracranial atherosclerotic disease (ICAD) identifies principles of management, and research priorities in various aspects upon which leading experts can agree (using "Delphi" method). ICAD is more prevalent in Asian, Hispanic, and African-American populations. Patients who have had a stroke or transient ischemic attack (TIA) attributed to stenosis (50-99%) of a major intracranial artery face a 12-14% risk of subsequent stroke during the 2-year period after the initial ischemic event, despite treatment with antithrombotic medications. The annual risk of subsequent stroke may exceed 20% in high-risk groups. The medical treatment of patients with symptomatic ICAD is directed toward: 1. Prevention of intraluminal thrombo-embolism, 2. plaque stabilization and regression, and 3. management of atherogenic risk factors. In patients with ICAD, short-term and long-term anticoagulation (compared with aspirin) have not shown to be beneficial. The current guidelines recommend that aspirin monotherapy, the combination of aspirin and extended release dipyridamole, and clopidogrel monotherapy (rather than oral anticoagulants) are all acceptable options in patients with non-cardioembolic ischemic stroke and TIA. Overall, the subgroup analysis from randomized trials provides evidence about benefit of aggressive atherogenic risk factor management among patients with ICAD. Intracranial angioplasty with or without stent placement has evolved as a therapeutic option for patients with symptomatic ICAD, particularly those with high-grade stenosis with recurrent ischemic symptoms and/or medication failure. A matched comparison between medical-treated patients in the Warfarin Aspirin Symptomatic Intracranial Disease (WASID) study and stent-treated patients in the National Institutes of Health intracranial stent registry concluded that stent placement may offer benefit in patients with 70-99% stenosis. The 5-year, multicenter, prospective, randomized Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis study supported by the National Institutes of Health is currently comparing stent placement with intense medical management with intense medical management alone in patients with high-grade symptomatic intracranial stenosis. The proceedings of the consensus conference provide a template for standardizing management of patients with ICAD and determining research priorities.

Evaluation of an anesthetic pump for postoperative care after shoulder surgery.

In theory, a prolonged, local infusion of anesthetic into a surgical field should reduce postoperative pain. Recently, disposable products have become available to implement this, but the balance between cost and benefit is controversial. This study evaluated such a device in two specific types of arthroscopic surgery of the shoulder: decompression of the subacromial space and repair of a torn labrum in the glenohumeral joint. Placement of the catheter into the glenohumeral joint resulted in problems in removing the device from some cases so that application is not recommended. When the catheter was placed in the subacromial space, the infusion pump was associated with significantly shorter stays in the recovery room, but there was no benefit over placebo with regard to pain, demand for rescue narcotic, or recovery of motion. Furthermore, use of the device presented some inconveniences to the surgical staff and the patient. It was concluded that use of this particular device in these particular applications is not justified.