Posterior Circulation Stroke: Coma (More Than Time) is Brain.

BACKGROUND AND PURPOSE: Contrary to anterior circulation, the legitimacy of endovascular treatment in posterior circulation stroke is still being questioned. Finding reliable prognostic factors and determining how patient selection should be done has become top priority. METHODS: Observational and retrospective study from two Portuguese hospitals, including all consecutive patients with posterior circulation occlusions who underwent thrombectomy between January 1st 2015 and December 31st 2019. RESULTS: Out of a total of 126 patients, the median age was 74 (IQR 61-80) and 39.7% were female. A good clinical outcome (mRS ≤2) was associated with a lower incidence of coma (24,2% vs 66,7%, p < 0,001) and of sudden onset coma (3% vs 18%,=0,04), a lower NIHSS at admission (14 vs 19, p < 0,001), a higher pc-ASPECTS at admission (10 vs 9, p < 0,001) and at 24 h (8 vs 6, p < 0,001) and a higher BATMAN score (7 vs 6, p = 0,017). Differences in the times of symptom-onset-to-recanalization (496 vs 536, p = 0,19) and symptom-onset-to-coma (130 vs 195, p = 0,52) were not remarkable. When excluding NIHSS and pc-ASPECTS at 24 h, coma (p = 0,003; OR=0,22; 95% CI: 0,08-0,59) and the pc-ASPECTS at admission (p = 0,037; OR=1,63; 95% CI: 1,03-2,57) become independent predictors of good outcome. CONCLUSIONS: In strokes from the posterior circulation, coma, more than time, appears to be an important prognostic factor. The BATMAN and the pc-ASPECTS scores were also associated with clinical outcome and coma.

Diagnostic accuracy of Bilateral Inferior Petrosal Sinus Sampling: The Experience of a Tertiary Centre.

PURPOSE: To assess the accuracy of bilateral inferior petrosal sinus sampling both in the differential diagnosis of adrenocorticotrophic hormone dependent Cushing's syndrome and predicting the localization on the pituitary. METHODS: The authors evaluated all patients that undergone bilateral inferior petrosal sinus sampling in a tertiary centre, between January 1995 and March 2018. The probable diagnosis of Cushing's disease was made when the basal central/peripheral gradient was>2 and/or>3 after stimulation with corticotrophin releasing hormone. The localization was suggested when the inter-sinus gradient was>1.4. The results obtained were compared with the post operatory results: compatible histology and positive immunohistochemistry to adrenocorticotrophic hormone and/or the presence of criteria of cure. Sensitivity, specificity and predictive positive value were calculated. RESULTS: A total of 49 patients were evaluated (75.5% female; mean age 45.4±16.3 years old). Bilateral inferior petrosal sinus sampling was compatible with Cushing's disease in 27 out of 28 confirmed cases in histology or by criteria of cure, and was compatible with ectopic secretion in the 2 cases confirmed as ectopic secretion of adrenocorticotrophic hormone (sensitivity 96.4%; specificity 100%). The lateralization calculated was concordant with the results after surgery in 17 out of 27 patients with Cushing's disease - predictive positive value of 63%. Magnetic resonance had a higher predictive value to lateralization - 70.0%. CONCLUSIONS: Bilateral inferior petrosal sinus sampling is a safe and reliable procedure to diagnose Cushing's disease, with great sensitivity and specificity. Nevertheless, the capacity of this procedure to lateralize the lesion inside the pituitary is limited.

[Reversible cerebral vasoconstriction syndrome: an important cause of stroke in the puerperium]. / Síndrome de vasoconstrição cerebral reversível: uma causa importante de acidentes vasculares cerebrais no puerpério.

Reversible cerebral vasoconstriction syndrome is a rare cerebrovascular disorder characterized by cerebral arterial segmental vasoconstriction, usually spontaneously reversible. This disease can occur in the postpartum period, manifesting itself through acute neurologic symptoms, and the imaging studies play a fundamental role in its diagnosis. Although classically considered a benign and self-limiting disease, it may present less favorable courses with significant associated morbidity and mortality. We describe a case of reversible cerebral vasoconstriction syndrome in the puerperium, with progressive cerebral vasospasm causing ischemic and hemorrhagic strokes. We intend to make an alert to the potential complications of this entity that demand intense clinical and imaging surveillance.

A síndrome de vasoconstrição cerebral reversível é uma doença cerebrovascular rara caracterizada por vasoconstrição segmentar das artérias cerebrais, mais frequentemente espontaneamente reversível. Pode ocorrer no período pós-parto, manifestando-se através de sintomas neurológicos agudos, sendo que os exames de imagem desempenham um papel fundamental para o seu diagnóstico. Embora classicamente considerada uma doença autolimitada e benigna, pode apresentar cursos menos favoráveis com importante morbilidade e mortalidade associada. Descrevemos um caso de síndrome de vasoconstrição cerebral reversível no puerpério, com vasospasmo cerebral progressivo causando lesões vasculares cerebrais isquémicas e hemorrágicas. Pretendemos deste modo chamar a atenção para as potenciais complicações desta entidade que implicam uma vigilância clínica e imagiológica intensa.

[Subocclusive transvenous approach of dural arteriovenous fistula]. / Tratamento suboclusivo por via transvenosa de fístulas arteriovenosas durais.

INTRODUCTION: Dural arteriovenous fistulae (DAVF) are usually acquired and when presented with cortical venous drainage are associated with high risk of hemorrhage. They can be treated by arterial or venous embolization, by surgery or by the combination of both techniques. Transvenous approach induces venous sinus thrombosis increasing the risk of venous stroke and/or hemorrhage. OBJECTIVE: Review of all the cases of transvenous embolization of lateral sinus arteriovenous fistulas treated in our department. Our main objective is to evaluate the clinical/imaging results of this treatment and the second goal is to discuss possible advantages of the subocclusive approach in the first session of transvenous treatment. RESULTS: The authors present six clinical cases of DAVF with the following clinical symptoms: visual disturbances (3); ear pulsatile bruit (3); headaches (2); subarachnoid hemorrhage (1); subjective hearing loss (1); optic disc edema (1); hemiparesis (1). Angiographic classification was: Cognard IIa, (3), IIab (2) e IV (1), all of the lateral sinus. The main afferent branches arised from: ipsilateral ECA (6); ipsilateral ICA (6); ipsilateral VA (6); contralateral ECA (5); contralateral VA (5); contralateral ICA (3); ipsilateral PCA (1). Transarterial approach was the first approach in all patients with satisfactory but transient results. It was always followed by transvenous embolization of the lateral sinus with GDC coils. Subocclusive approach was achieved in five patients with the persistence of some afferent arteries. Follow-up angiography in four of them showed "spontaneous" thrombosis of the lateral sinus with clinical and angiographic cure. Thrombosis occurred once during the initial transvenous procedure. There were no complications or new neurological signs or symptoms in any patient. CONCLUSIONS: Transvenous treatment of DAVF has led to technical and clinical success without procedure complications. We think that subocclusive approach of the venous sinus with coils can cause less hemodynamic changes with a slower thrombosis rate and less complications, unchanging the angiographic and clinical resolution.

[Aneurysmal malformation of the vein of Galen in adults]. / Malformação aneurismática da veia de galeno no adulto.

We present an adult male harbouring a vascular malformation, manifested by haemorrhage, which localization, arterial feeders and venous drainage, match the pattern of choroidal type vein of Galen aneurysmal malformations seen in babies, excepting the absence of anterior choroidal arteries participation. A few cases of vein of Galen aneurysmal malformations were already reported in adults, but haemorrhage was never well documented. This haemorrhage may have a pathogenesis similar to those of pial arteriovenous malformations.