Assessing the impact of sleep restriction on the attention and executive functions of medical students: a prospective cohort study.

OBJECTIVE: To compare the performance of medical students regarding attention and executive functions during a period of sleep restriction (insufficient sleep; period of classes) and a period of free sleep (sufficient sleep; vacation period). BACKGROUND: Sleep deprivation is associated with poor academic outcomes. Few studies have assessed the cognitive changes associated with sleep deprivation due to insufficient sleep syndrome in students and how they occur in real-life situations. METHODS: This was a prospective cohort study. Medical students were assessed at two moments (class and vacation). The interval between assessments was 30 days. The Pittsburgh Sleep Quality Index, the Consensus Sleep Diary, the Montreal Cognitive Assessment, the Psychomotor Vigilance Test (PVT) and the Wisconsin Sorting Cards Test were used. RESULTS: Forty-one students were assessed, 49% were female, with a median age of 21 (20; 23) years. There was a lower number of hours slept (5.75 (5.4; 7.0) vs 7.33 (6.0; 8.0) hours; p = 0.037), and a significantly poorer performance in the PVT (mean reaction time, p = 0.005; Minor lapses, p = 0.009) during the period of classes when compared to the vacation period. There was a correlation between the variation in hours of sleep of the two assessments and a variation in minor lapses in the two assessments (Ro: -0.395; p = 0.011; Spearman's correlation). CONCLUSIONS: Students had fewer hours of sleep and more reduced attention during the period of classes than during the vacation period. This decrease in sleeping hours was correlated with more impaired attention.

2023 Guidelines on the Diagnosis and Treatment of Insomnia in Adults - Brazilian Sleep Association.

Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P - Patient, problem, or population; I - Intervention; C - Comparison, control, or comparator; O - Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.

Cannabinoids in Neurology - Position paper from Scientific Departments from Brazilian Academy of Neurology.

Cannabinoids comprehend endocannabinoids, phytocannabinoids, and synthetic cannabinoids, with actions both in the central and peripherical nervous systems. A considerable amount of publications have been made in recent years, although cannabis has been known for over a thousand years. Scientific Departments from the Brazilian Academy of Neurology described evidence for medical use in their areas. Literature is constantly changing, and possible new evidence can emerge in the next days or months. Prescription of these substances must be discussed with patients and their families, with knowledge about adverse events and their efficacy.

Cannabinoids in Neurology - Position paper from Scientific Departments from Brazilian Academy of Neurology / Canabinoides em Neurologia - Artigo de posicionamento dos Departamentos Científicos da Academia Brasileira de Neurologia

ABSTRACT Cannabinoids comprehend endocannabinoids, phytocannabinoids, and synthetic cannabinoids, with actions both in the central and peripherical nervous systems. A considerable amount of publications have been made in recent years, although cannabis has been known for over a thousand years. Scientific Departments from the Brazilian Academy of Neurology described evidence for medical use in their areas. Literature is constantly changing, and possible new evidence can emerge in the next days or months. Prescription of these substances must be discussed with patients and their families, with knowledge about adverse events and their efficacy.

RESUMO Os canabinoides compreendem os endocanabinoides, fitocanabinoides e os canabinoides sintéticos e desempenham ações no sistema nervoso central e periférico. Uma quantidade enorme de publicações tem sido lançada nos últimos anos, embora a cannabis seja conhecida por milênios. Os Departamentos Científicos da Academia Brasileira de Neurologia descreveram as evidências do uso médico em suas áreas. A literatura está em constantes mudanças e possíveis novas evidências podem surgir nos próximos dias ou meses. A prescrição dessas substâncias deve ser discutida com os pacientes e suas famílias, com conhecimento sobre eventos adversos e sua eficácia.

Impact of COVID-19 pandemic on the sleep quality of medical professionals in Brazil.

INTRODUCTION: Coronavirus pandemic began in China in 2019 (COVID-19), causing not only public health problems but also great psychological distress, especially for physicians involved in coping with the virus or those of the risk group in social isolation, and this represents a challenge for the psychological resilience in the world population. Studies showed that health professionals had psychological symptoms such as depression, anxiety, insomnia, stress, among others. OBJECTIVES: To investigate the quality of sleep and the prevalence rate of sleeping disorders among physicians during COVID-19 pandemic, and identify the psychological and social factors associated with the condition. METHODS: A cross-sectional study of an online questionnaire was applied for physicians in Brazil. Among the 332 participants included, 227 were women. Sociodemographic assessment was used in the questionnaire, as well as the scale of impact on the events of modifications caused by COVID-19, assessment on sleep quality (PSQI), presence and severity of insomnia (ISI), depressive symptoms (PHQ-9), and anxiety (GAD-7). RESULTS: Most physicians (65.6%) had changes in sleep. Poor sleep quality was reported by 73.1%, depressive symptoms were present in 75.8%, and anxiety in 73.4%. CONCLUSION: Our study found that more than 70% of the physicians assessed had impaired sleep quality, characterizing insomnia symptoms during COVID-19 outbreak. Related factors included an environment of isolation, concerns about COVID-19 outbreak and symptoms of anxiety and depression. Special interventions are needed to promote health professionals' mental well-being and implement changes in this scenario.

Spinal neuroschistosomiasis caused by Schistoma mansoni: cases reported in two brothers.

BACKGROUND: Spinal neuroschistosomiasis (SN) is one of the most severe clinical presentations of schistosomiasis infection and an ectopic form of the disease caused by any species of Schistosoma. In Brazil, all cases of this clinical manifestation are related to Schistosoma mansoni, the only species present in the country. Although many cases have been reported in various endemic areas in Brazil, this is the first time in the literature that SN is described in two brothers. CASE PRESENTATION: Two cases of SN were accidentally diagnosed during an epidemiological survey in an urban area endemic for schistosomiasis transmission. Both patients complained of low back pain and muscle weakness in the lower limbs. Sphincter dysfunction and various degrees of paresthesia were also reported. The patients' disease was classified as hepato-intestinal stage schistosomiasis mansoni at the onset of the chronic form. A positive parasitological stool test for S. mansoni, clinical evidence of myeloradicular damage and exclusion of other causes of damage were the basic criteria for diagnosis. After treatment with praziquantel and corticosteroid, the patients presented an improvement in symptoms, although some complaints persisted. CONCLUSIONS: It is important to consider SN when patients come from areas endemic for transmission of schistosomiasis mansoni. Clinical physicians and neurologists should consider this diagnostic hypothesis, because recovery from neurological injuries is directly related to early treatment. As, described here in two brothers, a genetic predisposition may be related to neurological involvement. Primary care physicians should thus try to evaluate family members and close relatives in order to arrive at prompt schistosomiasis diagnosis in asymptomatic individuals and propose treatment in an attempt to avoid progression to SN.

Daytime sleepiness and Parkinson's disease: the contribution of the multiple sleep latency test.

Background. Sleep disorders are major nonmotor manifestations of patients with Parkinson's disease (PD), and excessive daytime sleepiness (EDS) is one of the most common symptoms. Objective. We reviewed a current literature concerning major factors that influence EDS in PD patients, using Multiple Sleep Latency Test (MSLT). Methods. A Medline search found 23 studies. Results. The presence of EDS was observed in 12.7% to 47% in patients without complaints of daytime sleepiness and 47% to 66.7% with complaints of daytime sleepiness. Despite being recognized by several authors, major factors that influence EDS, such as severity of motor symptoms, use of dopaminergic medications, and associated sleep disturbances, presented contradictory data. Conclusions. Available data suggest that the variability of the results may be related to the fact that it was conducted with a small sample size, not counting the neuropathological heterogeneity of the disease. Thus, before carrying out longitudinal studies with significant samples, careful analysis should be done by assigning a specific agent on the responsibility of EDS in PD patients.

Interictal dysphoric disorder: a frequent psychiatric comorbidity among patients with epilepsy who were followed in two tertiary centers / Transtorno disforico interictal: uma comorbidade psiquiatrica frequente entre pacientes com epilepsia acompanhados em dois servicos terciarios

Psychiatric disorders are frequent among patients with epilepsy. Data in the literature have shown a heterogeneous clinical presentation of psychiatric disorders in patients with epilepsy. Interictal dysphoric disorder could be a specific psychiatric comorbidity associated with epilepsy, primarily in patients treated in tertiary centers. Objective The present study aimed to determine the prevalence of interictal dysphoric disorder among patients with epilepsy who were followed in two tertiary epilepsy services in Brazil. Method Sixty-five patients with epilepsy completed the Portuguese version of the Interictal Dysphoric Disorder Inventory. Results Thirty-three (50.7%) patients fulfilled the diagnostic criteria for interictal dysphoric disorder, although all participants answered positively to having at least one key symptom. Conclusion The high rate of patients with epilepsy who fulfilled the diagnosis of interictal dysphoric disorder confirms an association between epilepsy and psychiatric disorders. However, there is clearly a need to improve diagnostic tools to allow better differentiation between interictal dysphoric disorder and other psychiatric disorders. .

Transtornos psiquiátricos são frequentes entre pacientes com epilepsia. Estudos evidenciam apresentações clínicas heterogêneas neste grupo. O transtorno disfórico interictal pode um transtorno específico destes pacientes, particularmente naqueles acompanhados em centros terciários. Objetivo Determinar a prevalência de transtorno disfórico interictal entre pacientes com epilepsia atendidos em dois serviços terciários de epilepsia do Brasil. Método Sessenta e cinco pacientes foram convidados a responder a versão brasileira do Interictal Dysphoric Disorder Inventory adaptado e validado para o Português. Resultados Trinta e três pacientes (50,7%) preencheram critérios para transtorno disfórico interictal, embora todos os entrevistados tenham afirmado que são acometidos por ao menos um dos sintomas-chave. Conclusão A alta prevalência de transtorno disfórico interictal em pacientes com epilepsia pode ser um indício da associação entre epilepsia e transtornos psiquiátricos. No entanto, é necessário melhorar a acurácia dos instrumentos de diagnóstico para poder diferenciar casos de transtorno disfórico interictal de outros transtornos psiquiátricos. .

Multiple sclerosis in South America: month of birth in different latitudes does not seem to interfere with the prevalence or progression of the disease.

OBJECTIVE: To assess whether the month of birth in different latitudes of South America might influence the presence or severity of multiple sclerosis (MS) later in life. METHODS: Neurologists in four South American countries working at MS units collected data on their patients' month of birth, gender, age, and disease progression. RESULTS: Analysis of data from 1207 MS patients and 1207 control subjects did not show any significant variation in the month of birth regarding the prevalence of MS in four latitude bands (0-10; 11-20; 21-30; and 31-40 degrees). There was no relationship between the month of birth and the severity of disease in each latitude band. CONCLUSION: The results from this study show that MS patients born to mothers who were pregnant at different Southern latitudes do not follow the seasonal pattern observed at high Northern latitudes.

Multiple sclerosis in South America: month of birth in different latitudes does not seem to interfere with the prevalence or progression of the disease / Esclerose multipla na America do Sul: mes de nascimento em diferentes latitudes nao parece interferir com a prevalencia ou progressao da doenca

Objective To assess whether the month of birth in different latitudes of South America might influence the presence or severity of multiple sclerosis (MS) later in life. Methods Neurologists in four South American countries working at MS units collected data on their patients' month of birth, gender, age, and disease progression. Results Analysis of data from 1207 MS patients and 1207 control subjects did not show any significant variation in the month of birth regarding the prevalence of MS in four latitude bands (0–10; 11–20; 21–30; and 31–40 degrees). There was no relationship between the month of birth and the severity of disease in each latitude band. Conclusion The results from this study show that MS patients born to mothers who were pregnant at different Southern latitudes do not follow the seasonal pattern observed at high Northern latitudes. .

Objetivo Avaliar se o mês de nascimento em diferentes latitudes da América do Sul pode influenciar a presença ou gravidade da esclerose múltipla (EM) na vida. Método Neurologistas de quatro países da América do Sul trabalhando em unidades de EM coletaram os dados de seus pacientes com referência ao mês de nascimento, gênero, idade e progressão da doença. Resultados A análise dos dados mostrou que, para 1207 pacientes com EM e 1207 controles, não havia diferença significativa no mês de nascimento com relação à prevalência de EM em quatro zonas de latitude (0–10; 11–20; 21–30; e 31–40 graus). Não houve relação entre o mês de nascimento e a gravidade da doença em nenhuma destas zonas. Conclusão Os resultados deste estudo mostram que pacientes com EM nascidos de mães grávidas em diferentes latitudes sul não seguem o padrão dos resultados sazonais encontrados nas latitudes norte. .

Interictal dysphoric disorder: a frequent psychiatric comorbidity among patients with epilepsy who were followed in two tertiary centers.

UNLABELLED: Psychiatric disorders are frequent among patients with epilepsy. Data in the literature have shown a heterogeneous clinical presentation of psychiatric disorders in patients with epilepsy. Interictal dysphoric disorder could be a specific psychiatric comorbidity associated with epilepsy, primarily in patients treated in tertiary centers. OBJECTIVE: The present study aimed to determine the prevalence of interictal dysphoric disorder among patients with epilepsy who were followed in two tertiary epilepsy services in Brazil. METHOD: Sixty-five patients with epilepsy completed the Portuguese version of the Interictal Dysphoric Disorder Inventory. RESULTS: Thirty-three (50.7%) patients fulfilled the diagnostic criteria for interictal dysphoric disorder, although all participants answered positively to having at least one key symptom. CONCLUSION: The high rate of patients with epilepsy who fulfilled the diagnosis of interictal dysphoric disorder confirms an association between epilepsy and psychiatric disorders. However, there is clearly a need to improve diagnostic tools to allow better differentiation between interictal dysphoric disorder and other psychiatric disorders.

Effects of nasal continuous positive airway pressure treatment on oxidative stress and adiponectin levels in obese patients with obstructive sleep apnea.

BACKGROUND: Obesity and obstructive sleep apnea (OSA) are both associated with the prevalence of major cardiovascular illnesses and certain common factors they are considered responsible for, such as stress oxidative increase, sympathetic tonus and resistance to insulin. OBJECTIVE: The aim of the present study was to compare the effect of continuous positive airway pressure (CPAP) on oxidative stress and adiponectin levels in obese patients with and without OSA. METHODS: Twenty-nine obese patients were categorized into 3 groups: group 1: 10 individuals without OSA (apnea-hypopnea index, AHI or=20) who did not use CPAP; group 3: 9 patients with moderate to severe OSA (AHI >or=20) who used CPAP. RESULTS: Group 3 showed significant differences before and after the use of CPAP, in the variables of diminished production of superoxide, and increased nitrite and nitrate synthesis and adiponectin levels. Positive correlations were seen between the AHI and the superoxide production, between the nitrite and nitrate levels and the adiponectin levels, between superoxide production and the HOMA-IR, and between AHI and the HOMA-IR. Negative correlations were found between AHI and the nitrite and nitrate levels, between the superoxide production and that of nitric oxide, between the superoxide production and the adiponectin levels, between AHI and the adiponectin levels, and between the nitrite and nitrate levels and the HOMA-IR. CONCLUSIONS: This study demonstrates that the use of CPAP can reverse the increased superoxide production, the diminished serum nitrite, nitrate and plasma adiponectin levels, and the metabolic changes existing in obese patients with OSA.

Study into the use of continuous positive airway pressure in obstructive sleep apnoea-hypopnoea syndrome patients with daytime drowsiness.

BACKGROUND: Obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is a respiratory disorder with high morbidity and mortality. Continuous positive airway pressure (CPAP) is the most commonly prescribed conservative treatment for adults with OSAHS. CPAP therapy normalises or decreases OSAHS symptoms and can reduce and prevent OSAHS complications. AIMS: To evaluate adherence to nasal CPAP treatment and CPAP impact on daytime drowsiness. METHOD: A sample of 20 patients evaluated for daytime drowsiness using the Epworth sleepiness scale and interviewed for adherence to nasal CPAP use. RESULTS: There was a significant decrease in the level of daytime sleepiness of the patients users of nasal CPAP (p=0.017); patients not using nasal CPAP experienced a decrease without statistical significance (p=0.162). 100% of CPAP users reported benefits and 50% of these reported related discomforts. CONCLUSIONS: Patients with OSAHS that use CPAP have a greater reduced level of sleepiness than those who do not use it.

[Obstructive sleep apnea contribution to oxidative stress in obesity]. / Contribuição da apnéia obstrutiva do sono para o estresse oxidativo da obesidade.

OBJECTIVE: The aim of this paper was to check the influence of obstructive sleep apnea (OSA) on obesity oxidative stress and CPAP (Continuous Positive Airway Pressure) effect on oxidative stress and in these patients. METHODS: Twenty nine male patients considered obese (BMI > 30 kg/m(2)) were divided into 3 groups: a) Group I: 10 OSA free patients (apnea-hipopnea index (AHI) < 5); b) Group 2: 10 with moderate to serious OSA (AHI > 20); c) Group 3: 9 with OSA from moderate to serious (AHI > 20) using CPAP, minimum 4 hours/night for 2 months. RESULTS: Significant differences before and after CPAP usage were observed in group 3 in the following variables: reduction of superoxide (SO) production [13.2 (10.3-19.6) vs. 10.5 (5.8-11.8) nmoles O2(-)/2 x 10(6) PMN] and increase in serum nitrite/nitrates levels [24.5 (16.7-33.5) vs. 49.5 (39.3-58.1) microM]. Positive correlation between Apnea-Hypopnea Index (AHI) and SO (r = 0,726) and negative correlation was observed between AHI and serum nitrite/nitrates levels (r = - 0.867). CONCLUSIONS: In conclusion, oxidative stress present in obesity is elevated by OSA and CPAP treatment can rise the levels of SO and can decrease serum nitrite/nitrates present in obese patients with OSA.

Contribuição da apnéia obstrutiva do sono para o estresse oxidativo da obesidade / Obstructive sleep apnea contribution to oxidative stress in obesity

OBJETIVO: O objetivo do trabalho foi verificar a influência da apnéia obstrutiva do sono (AOS) sobre o estresse oxidativo da obesidade e o efeito do pressão positiva de vias aéreas (CPAP) nestes pacientes. MÉTODOS: Os pacientes com IMC > 30 kg/m² foram divididos em: a) grupo 1: dez indivíduos sem AOS; b) grupo 2: dez portadores de AOS que não fizeram o uso do CPAP; e c) grupo 3: nove portadores de AOS que fizeram uso do CPAP durante dois meses. RESULTADOS: O grupo 3 apresentou, após o uso do CPAP, redução na produção de superóxido (SO) [13,2 (10,3-19,6) versus 10,5 (5,8-11,8) nmoles O2-/2×10(6) PMN] e aumento na síntese de nitritos e nitratos séricos [24,5 (16,7-33,5) versus 49,5 (39,3-58,1) µM]. Também foi verificada correlação positiva entre o índice apnéia-hipopnéia (IAH) e a produção de SO (r = 0,726) e negativa entre o IAH e os níveis de nitritos e nitratos séricos (r = -0,867). CONCLUSÕES: O estresse oxidativo presente na obesidade é exacerbado pela AOS e o uso do CPAP promove aumento nos níveis de nitritos e nitratos séricos, bem como reduções na produção de SO neste pacientes.

OBJECTIVE: The aim of this paper was to check the influence of obstructive sleep apnea (OSA) on obesity oxidative stress and CPAP (Continuous Positive Airway Pressure) effect on oxidative stress and in these patients. METHODS: Twenty nine male patients considered obese (BMI > 30kg/m²) were divided into 3 groups: a) Group I: 10 OSA free patients (apnea-hipopnea index (AHI) < 5); b) Group 2: 10 with moderate to serious OSA (AHI > 20); c) Group 3: 9 with OSA from moderate to serious (AHI > 20) using CPAP,, minimum 4 hours/night for 2 months. RESULTS: Significant differences before and after CPAP usage were observed in group 3 in the following variables: reduction of superoxide (SO) production [13,2 (10,3-19,6) vs. 10,5 (5,8-11,8) nmoles O2- /2x10(6) PMN] and increase in serum nitrite/nitrates levels [24,5 (16,7-33,5) vs. 49,5 (39,3-58,1) µM]. Positive correlation between Apnea-Hypopnea Index (AHI) and SO (r = 0,726) and negative correlation was observed between AHI and serum nitrite/nitrates levels (r = - 0,867). CONCLUSIONS: In conclusion, oxidative stress present in obesity is elevated by OSA and CPAP treatment can rise the levels of SO and can decrease serum nitrite/nitrates present in obese patients with OSA.

Medulloblastoma in adults: a series from Brazil.

We retrospectively reviewed 15 adult patients (11 males, median age 34 years; range 23-48) who had been treated and followed in our Institution since 1991 from the time of diagnosis until death or last follow-up in December 2001. Headache was the most frequent symptom (93%). The tumor was hemispheric in 11 patients. Complete resection was achieved in eight. CSF in 12 patients and craniospinal MRI in 6 did not show metastatic disease. Two patients refused adjuvant treatment and died with progressive disease. Thirteen patients received adjuvant craniospinal radiotherapy and 11 systemic chemotherapy. After initial treatment only 2 of the 13 patients relapsed in the posterior fossa. Recurrence was probably related to sub-optimal radiotherapy planning: inadequate low dose in the posterior fossa (37.5 Gy) and long delay in initiating treatment. Two of the 13 patients that received adjuvant treatment died: one from meningitis, and one from recurrent disease. Eleven patients remained alive, and disease-free with Karnofsky performance status ranging 80-100. The median overall survival was not reached after a median follow-up of 5.6 years (range 0.7-10.8 years). Estimated 1-, 5- and 10-year overall survival rates were 86.7%, 72.7%, and 72.7%, respectively. Adult medulloblastoma was predominant in males and the majority of patients had hemispheric tumors. Long-term survival was not uncommon. Although chemotherapy may be useful and well tolerated, radiotherapy remains the mainstay adjuvant treatment as suggested by our two recurrences associated with a delay or inadequate dose.

Gliomas múltiplos: casos ilustrativos de quatro formas de apresentação / Multiple gliomas: illustrative cases of 4 different presentations

Os gliomas múltiplos são relativamente raros e podem ser classificados didaticamente de acordo com: a) a época da apresentação, em precoces (quando presentes desde o diagnóstico inicial) ou tardios (quando presentes durante a evolução); e b) as características dos exames de imagem, em multifocais (quando há evidência de contiguidade das lesões) ou multicêntricos (quando não é possível identificar contiguidade das lesões). Entre os 212 pacientes com diagnóstico anatomopatológico de glioma, acompanhados prospectivamente no setor de neuro-oncologia de março/90 a setembro/99, 15 (7 por cento) apresentaram lesões múltiplas. Descrevemos 4 casos característicos de cada uma das possíveis apresentações: multicêntrico precoce, multicêntrico tardio, multifocal precoce e multifocal tardio, com ênfase nas características de imagem e possíveis diagnósticos diferenciais. O diagnóstico diferencial das lesões múltiplas no sistema nervoso central inclui doenças inflamatórias e infecciosas, além de metástases. A possibilidade de tratar-se de tumores de origem glial, entretanto, deve ser sempre lembrada, mesmo naqueles pacientes com diagnóstico de neoplasia sistêmica conhecida, conforme já descrito na literatura. O diagnóstico histológico se impõe, uma vez que as características de imagem não permitem diagnóstico de certeza.

Moyamoya disease: report of three cases in Brazilian patients

Moyamoya disease (MMD) is a chronic occlusive cerebrovascular disease of unknown etiology reported mainly in the Japanese. Most cases occur in children. The disease is rare in non-Oriental adults manifesting itself mostly as intracerebral hemorrhages. We describe MMD in 2 non-Oriental young adults and one adolescent that developed cerebral infarctions. The adults were medicated with aspirin and no medication was given to the adolescent. All patients did not deteriorate in a follow-up period from 1 to 4 years. Although rare, MMD is na important cause of stroke in young individuals and may well be underreported: only 18 patients have been reported till 1997 in Brazil. Neurologists should include MMD in differential diagnosis of ischemic and hemorrhagic strokes in young adults.