Stroke in women — from evidence to inequalities

Stroke is the second largest cause of disability-adjusted life-years lost worldwide. The prevalence of stroke in women is predicted to rise rapidly, owing to the increasing average age of the global female population. Vascular risk factors differ between women and men in terms of prevalence, and evidence increasingly supports the clinical importance of sex differences in stroke. The influence of some risk factors for stroke — including diabetes mellitus and atrial fibrillation — are stronger in women, and hypertensive disorders of pregnancy also affect the risk of stroke decades after pregnancy. However, in an era of evidence-based medicine, women are notably under-represented in clinical trials — despite governmental actions highlighting the need to include both men and women in clinical trials — resulting in a reduced generalizability of study results to women. The aim of this Review is to highlight new insights into specificities of stroke in women, to plan future research priorities, and to influence public health policies to decrease the worldwide burden of stroke in women

Disorders of consciousness after acquired brain injury: the state of the science

The concept of consciousness continues to defy definition and elude the grasp of philosophical and scientific efforts to formulate a testable construct that maps to human experience. Severe acquired brain injury results in the dissolution of consciousness, providing a natural model from which key insights about consciousness may be drawn. In the clinical setting, neurologists and neurorehabilitation specialists are called on to discern the level of consciousness in patients who are unable to communicate through word or gesture, and to project outcomes and recommend approaches to treatment. Standards of care are not available to guide clinical decision-making for this population, often leading to inconsistent, inaccurate and inappropriate care. In this Review, we describe the state of the science with regard to clinical management of patients with prolonged disorders of consciousness. We review consciousness-altering pathophysiological mechanisms, specific clinical syndromes, and novel diagnostic and prognostic applications of advanced neuroimaging and electrophysiological procedures. We conclude with a provocative discussion of bioethical and medicolegal issues that are unique to this population and have a profound impact on care, as well as raising questions of broad societal interest

Prognosis in disorders of consciousness

In patients with prolonged disorders of consciousness (DOC), clinical evolution is determined by several factors closely interacting with each other: etiology, patient's age (likely influencing the physiological process of recovery, e.g., brain plasticity), the duration of DOC (likely related to the severity of brain damage), the structural and functional integrity of neuronal populations (as assessed by neurophysiological and neuroimaging methods), and the presence of clinical complications that could impact care strategies. In the present chapter, we will offer a brief review of the most recent studies on clinical evolution of patients with prolonged DOC and of the longitudinal studies searching for robust prognostic markers in such patients. We will argue that some prognostic indicators for patients in vegetative state can be gathered in the rehabilitative phase, whereas reliable markers to characterize DOC patients who will present late recovery of responsiveness and consciousness have not been identified. Moreover, long-term evolution of patients in minimally conscious state has not been clearly established, and definite prognostic information is not available for these patients. For these reasons, prospective longitudinal systematic investigations of outcome in large groups of individual with prolonged DOC are needed to better clarify the natural recovery of DOC and to define prognostic markers useful to update current positions on medical, ethical, and legal issues connected with management and care of these patients