RESUMEN
Statins may improve outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH) but randomized controlled trials, including all patients with aSAH whatever their clinical severity, were negative. We studied whether pravastatin improved neurologic outcome in patients with early good neurological status, whose prognosis is related to secondary lesions as delayed cerebral ischemia (DCI). We conducted a single-center study of cases and historical controls in a neurocritical care unit. We included consecutive patients with aSAH from 2011 to 2016 with early good neurological status defined by a WFNS score ≤ 3 on the third day. Patients treated before 2014 with oral pravastatin (40 mg/day for 14 days) as a standard of care were matched using propensity score to patients treated after 2014 without pravastatin. Good neurologic outcome was defined by a Glasgow Outcome Scale ≥ 4 at neurocritical care unit discharge. We included 270 patients (135 patients with pravastatin), mostly treated with coiling (94.1%). Demographic, initial and subacute features were the same in the 2 groups. More patients experienced good outcome in the pravastatin group than in the control group (94.8% vs 74.2%; OR 7.16 95% CI [3.07 - 16.72], p < 0.001). There was no difference in the occurrence of DCI in the 2 groups. In our study, outcome on neurocritical care discharge was better in patients with early good neurological status treated with pravastatin. Another randomized controlled trial should be conducted on this subtype of population.
Asunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Isquemia Encefálica/complicaciones , Isquemia Encefálica/tratamiento farmacológico , Isquemia Encefálica/epidemiología , Estudios de Casos y Controles , Infarto Cerebral/complicaciones , Humanos , Pravastatina/uso terapéutico , Pronóstico , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/tratamiento farmacológico , Resultado del TratamientoRESUMEN
Aneurysmal subarachnoid hemorrhage (SAH) is a rare event affecting relatively young patients therefore leading to a high social impact. The management of SAH follows a biphasic course with early brain injuries in the first 72 hours followed by a phase at risk of secondary deterioration due to delayed cerebral ischemia (DCI) in 20 to 30% patients. Cerebral infarction from DCI is the most preventable cause of mortality and morbidity after SAH. DCI prevention, early detection and treatment is therefore advocated. Formerly limited to the occurrence of vasospasm, DCI is now associated with multiple pathophysiological processes involving for instance the macrocirculation, the microcirculation, neurovascular units, and inflammation. Therefore, the therapeutic targets and management strategies are also evolving and are not only focused on proximal vasospasm. In this review, we describe the current knowledge of DCI pathophysiology. We then discuss the diagnosis strategies that may guide physicians at the bedside with a multimodal approach in the unconscious patient. We will present the prevention strategies that have proven efficient as well as future targets and present the therapeutic approach that is currently being developed when a DCI occurs.
Asunto(s)
Isquemia Encefálica , Hemorragia Subaracnoidea , Vasoespasmo Intracraneal , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiología , Isquemia Encefálica/terapia , Infarto Cerebral , Humanos , Microcirculación , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/diagnóstico , Hemorragia Subaracnoidea/terapia , Vasoespasmo Intracraneal/diagnóstico , Vasoespasmo Intracraneal/epidemiología , Vasoespasmo Intracraneal/etiologíaRESUMEN
OBJECTIVE: Delayed cerebral ischemia (DCI) is the most important and preventable morbidity cause after subarachnoid hemorrhage (SAH). Therefore, DCI early detection is a major challenge. Yet, neurological examination can be unreliable in poor grade SAH patients. EEG provides information from most superficial cortical area, with ischemia-related changes. This study aims at defining an alpha-theta/delta (AT/D) ratio decrease thresholds to detect DCI. METHODS: We used EEG with a montage matching vascular territories (right and left anterior central and posterior) and compared them to follow-up brain imaging. RESULTS: 15 SAH patients (Fischerâ¯≥â¯3, World Federation of Neurological Surgeons scale ≥4, 9 DCI) were monitored during 6.4 [4-8] days (minâ¯=â¯2d, maxâ¯=â¯13d). AT/D changes could follow three different patterns: (1) prolonged or (2) transient decrease and (3) no decrease or progressive increase. A regional 30% decrease outlasting 3.7â¯h reached 100% sensitivity and 88.9% specificity to detect DCI. Only 22.6% were in a zone of uncertain diagnosis (3.7-8.04â¯h). These prolonged decreases, with a loss of transient changes, started in cortical areas evolving toward DCI, and preceded intracranial changes when available. CONCLUSION: Although this study has a small sample size, prolonged AT/D decrease seems to be a reliable biomarker of DCI. SIGNIFICANCE: cEEG changes are likely to precede cerebral infarction and could be useful at the bedside to detect DCI before irreversible damage.
Asunto(s)
Isquemia Encefálica/diagnóstico , Electroencefalografía/métodos , Hemorragia Subaracnoidea/complicaciones , Isquemia Encefálica/etiología , Isquemia Encefálica/fisiopatología , Diagnóstico Precoz , Femenino , Humanos , Masculino , Persona de Mediana Edad , Sensibilidad y Especificidad , Hemorragia Subaracnoidea/fisiopatologíaAsunto(s)
Enfermedades de las Arterias Carótidas/etiología , Trombosis Intracraneal/complicaciones , Embolia Pulmonar/etiología , Accidente Cerebrovascular/etiología , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Arteria Carótida Interna/diagnóstico por imagen , Arteria Carótida Interna/patología , Femenino , Humanos , Trombosis Intracraneal/diagnóstico por imagen , Persona de Mediana Edad , Embolia Pulmonar/diagnóstico por imagen , Accidente Cerebrovascular/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
The introduction of direct oral anticoagulants (DOA) in the early stage of cerebral infarction after thrombolysis may reduce the recurrence rate but raises safety concern. We sought to study the feasibility and safety of the introduction of rivaroxaban or dabigatran in this context. Thirty-four consecutive patients admitted for ischemic stroke related to non-valvular atrial fibrillation in whom DOA were given within the first two weeks following intravenous rt-PA were studied. A clinical and radiological monitoring protocol was established to ensure the safety of the prescription. None of the patients experienced symptomatic hemorrhagic transformation or a symptomatic recurrent ischemic event after early rivaroxaban or dabigatran introduction.
Asunto(s)
Antitrombinas/uso terapéutico , Isquemia Encefálica/tratamiento farmacológico , Dabigatrán/uso terapéutico , Inhibidores del Factor Xa/uso terapéutico , Fibrinolíticos/uso terapéutico , Hemorragias Intracraneales/inducido químicamente , Rivaroxabán/uso terapéutico , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Anciano , Anciano de 80 o más Años , Antitrombinas/administración & dosificación , Antitrombinas/efectos adversos , Fibrilación Atrial/sangre , Fibrilación Atrial/complicaciones , Dabigatrán/administración & dosificación , Dabigatrán/efectos adversos , Esquema de Medicación , Inhibidores del Factor Xa/administración & dosificación , Inhibidores del Factor Xa/efectos adversos , Femenino , Fibrinolíticos/administración & dosificación , Humanos , Hemorragias Intracraneales/diagnóstico por imagen , Tiempo de Internación , Masculino , Proyectos Piloto , Radiografía , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/uso terapéutico , Recurrencia , Estudios Retrospectivos , Rivaroxabán/administración & dosificación , Rivaroxabán/efectos adversos , Índice de Severidad de la Enfermedad , Trombofilia/tratamiento farmacológico , Trombofilia/etiología , Activador de Tejido Plasminógeno/administración & dosificaciónAsunto(s)
Trastornos de Deglución/etiología , Síndrome Medular Lateral/complicaciones , Anciano de 80 o más Años , Trastornos de Deglución/diagnóstico , Diagnóstico Diferencial , Humanos , Síndrome Medular Lateral/diagnóstico , Síndrome Medular Lateral/patología , Masculino , Bulbo Raquídeo/irrigación sanguínea , Bulbo Raquídeo/patologíaRESUMEN
Muscular dystrophies are genetic muscular disease with disability. Heart failure is a classical complication mainly in Duchenne muscular dystrophy (DMD). We report 2 cases of severe acute heart failure revealed by abdominal discomfort in a patient with DMD and in a patient with gamma-sarcoglycanopathy.
Asunto(s)
Insuficiencia Cardíaca/etiología , Distrofia Muscular de Duchenne/complicaciones , Sarcoglicanopatías/complicaciones , Dolor Abdominal/etiología , Enfermedad Aguda , Adulto , Insuficiencia Cardíaca/diagnóstico , Humanos , MasculinoAsunto(s)
Procedimientos Endovasculares/efectos adversos , Malformaciones Arteriovenosas Intracraneales/terapia , Hemorragias Intracraneales/etiología , Mielitis Transversa/etiología , Neuromielitis Óptica/etiología , Adulto , Acuaporina 4/inmunología , Autoanticuerpos/análisis , Autopsia , Resultado Fatal , Humanos , Malformaciones Arteriovenosas Intracraneales/diagnóstico , Hemorragias Intracraneales/diagnóstico , Hemorragias Intracraneales/cirugía , Masculino , Mielitis Transversa/diagnóstico , Mielitis Transversa/inmunología , Mielitis Transversa/terapia , Neuromielitis Óptica/diagnóstico , Neuromielitis Óptica/inmunología , Neuromielitis Óptica/terapia , Procedimientos Neuroquirúrgicos/efectos adversos , Reoperación , Rotura EspontáneaRESUMEN
INTRODUCTION: Paraneoplastic movement disorders are rare. Reported cases frequently describe association with anti-CV2/CRMP5 antibodies. CASE REPORT: We report a case of an 80-year-old man who developed sensorial neuronopathy, following by movement disorders mimicking chorea and obsessive-compulsive and behavioral disorders. These manifestations were first considered to be associated with a prostatic adenocarcinoma but PET and surgical biopsy revealed a mediastinal small cell lung carcinoma classically associated with anti-CV2/CRMP5 antibodies. CONCLUSION: This case demonstrates that in a context of paraneoplastic neurological syndrome, search for a classically associated cancer is necessary in order to institute adapted treatment early, even if another tumor is obvious.
Asunto(s)
Autoanticuerpos/inmunología , Trastornos Mentales/complicaciones , Proteínas del Tejido Nervioso/inmunología , Polineuropatía Paraneoplásica/complicaciones , Anciano de 80 o más Años , Corea/complicaciones , Corea/diagnóstico por imagen , Dislipidemias/complicaciones , Electrodiagnóstico , Fluorodesoxiglucosa F18 , Humanos , Hidrolasas , Imagen por Resonancia Magnética , Masculino , Neoplasias del Mediastino/complicaciones , Neoplasias del Mediastino/patología , Trastornos Mentales/etiología , Proteínas Asociadas a Microtúbulos , Infarto del Miocardio/complicaciones , Trastorno Obsesivo Compulsivo/etiología , Trastorno Obsesivo Compulsivo/psicología , Polineuropatía Paraneoplásica/diagnóstico por imagen , Polineuropatía Paraneoplásica/etiología , Tomografía de Emisión de Positrones , Radiofármacos , Carcinoma Pulmonar de Células Pequeñas/complicaciones , Carcinoma Pulmonar de Células Pequeñas/patología , Tomografía Computarizada por Rayos XRESUMEN
Neurosarcoidosis is a rare disease that can involve all the nervous system with variable clinical onset and prognosis. The initial therapeutic approach is mainly based on corticosteroids and immunosuppressive agents. Treatment of refractory forms of neurosarcoidosis is not well established and emerging immunomodulating drugs like infliximab have been recently tested. The clinical report of a new case of neurosarcoidosis responding to infliximab is followed by a review of the new therapeutic agents available for the treatment of refractory neurosarcoidosis.