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BACKGROUND: Large vessel occlusion acute ischemic stroke prognosis improved following the 2015 endovascular therapy (EVT) trials. Blood-based biomarkers may improve outcome prediction. We aimed to assess plasma brain-derived tau (BD-Tau) performance in predicting post-EVT large vessel occlusion acute ischemic stroke outcomes. METHODS: We included 2 temporally independent prospective cohorts of anterior circulation in patients with large vessel occlusion acute ischemic stroke who successfully recanalized post-EVT. We measured plasma BD-Tau, GFAP (glial-fibrillary-acidic-protein), NfL (neurofilament-light-chain), and total-Tau upon admission, immediately, 24 hours, and 72 hours post-EVT. Twenty-four-hour neuroimaging and 90-day functional outcomes were independently assessed using the Alberta Stroke Program Early Computed Tomography Score (good outcome: >7 or unchanged) and the modified Rankin Scale (favorable outcome <3 or unchanged), respectively. Based on the first cohort (derivation), we built a multivariable logistic regression model to predict a 90-day functional outcome. Model results were evaluated using the second cohort (evaluation). RESULTS: In the derivation cohort (n=78, mean age=72.9 years, 50% women), 62% of patients had a good 24-hour neuroimaging outcome, and 45% had a favorable 90-day functional outcome. GFAP admission-to-EVT rate-of-change was the best predictor for early neuroimaging outcome but not for 90-day functional outcome. At admission, BD-Tau levels presented the highest discriminative performance for 90-day functional outcomes (area under the curve, 0.76 [95% CI, 0.65-0.87]; P<0.001). The model incorporating age, admission BD-Tau, and 24-hour Alberta Stroke Program Early Computed Tomography Score achieved excellent discrimination of 90-day functional outcome (area under the curve, 0.89 [95% CI, 0.82-0.97]; P<0.001). The score's predictive performance was maintained in the evaluation cohort (n=66; area under the curve, 0.82 [95% CI, 0.71-0.92]; P<0.001). CONCLUSIONS: Admission plasma BD-Tau accurately predicted 90-day functional outcomes in patients with large vessel occlusion acute ischemic stroke after successful EVT. The proposed model may predict functional outcomes using objective measures, minimizing human-related biases and serving as a simplified prognostic tool for AIS.
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BACKGROUND: Early outcome prediction after acute ischemic stroke (AIS) might be improved with blood-based biomarkers. We investigated whether the longitudinal profile of a multi-marker panel could predict the outcome of successfully recanalized AIS patients. METHODS: We used ultrasensitive single-molecule array (Simoa) to measure glial fibrillary acidic protein (GFAP), neurofilament light chain (NfL), total-tau (t-tau) and ELISA for brevican in a prospective study of AIS patients with anterior circulation large vessel occlusion successfully submitted to thrombectomy. Plasma was obtained at admission, upon treatment, 24 h and 72 h after treatment. Clinical and neuroimaging outcomes were assessed independently. RESULTS: Thirty-five patients (64.8%) had good early clinical or neuroimaging outcome. Baseline biomarker levels did not distinguish between outcomes. However, longitudinal intra-individual biomarker changes followed different dynamic profiles with time and according to outcome. GFAP levels exhibited an early and prominent increase between admission and just after treatment. NfL increase was less pronounced between admission and up to 24 h. T-tau increased between treatment and 24 h. Interestingly, GFAP rate-of-change (pg/ml/h) between admission and immediately after recanalization had a good discriminative capacity between clinical outcomes (AUC = 0.88, p < 0.001), which was higher than admission CT-ASPECTS (AUC = 0.75, p < 0.01). T-tau rate-of-change provided moderate discriminative capacity (AUC = 0.71, p < 0.05). Moreover, in AIS patients with admission CT-ASPECTS <9 both GFAP and NfL rate-of-change were good outcome predictors (AUC = 0.82 and 0.77, p < 0.05). CONCLUSION: Early GFAP, t-tau and NfL rate-of-change in plasma can predict AIS clinical and neuroimaging outcome after successful recanalization. Such dynamic measures match and anticipate neuroimaging predictive capacity, potentially improving AIS patient stratification for treatment, and targeting individualized stroke care.
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AVC Isquêmico , Acidente Vascular Cerebral , Biomarcadores , Proteína Glial Fibrilar Ácida , Humanos , Estudos Prospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , TrombectomiaRESUMO
BACKGROUND: Primary Central Nervous System Vasculitis (PCNSV) is responsible for 3%-5% of strokes before age 50. It presents with clinical, radiological, and pathological variability. Optimal management is unknown given the absence of randomized clinical trials. AIMS OF THE STUDY: Explore whether tocilizumab, an anti-interleukin-6 monoclonal antibody, is an effective treatment for refractory PCNSV. METHODS: Patients with PCNSV treated with tocilizumab in a single tertiary center were reviewed. RESULTS: Three patients were identified. In two of them, MRI-revealed ischemic lesions. The other presented with a subcortical hemispheric pseudotumoral lesion. Brain biopsy was inconclusive in two patients. Due to a significant number of relapses and clinical deterioration despite other immunosuppressive drugs, tocilizumab was initiated and induced a long remission period up to 44 months. Observed side effects were a fungic infection, neutropenia and thrombocytopenia (both transitory), and a pulmonary embolism in one of the cases. CONCLUSIONS: Tocilizumab might be a therapeutic option for PCNSV (Class IV evidence), given its efficacy and safety. We propose a novel pathway for diagnosis and therapeutics of PCNSV with the purpose of improving the diagnosis, monitoring, and prognosis of this heterogeneous disorder, setting the framework for future use of tocilizumab in this condition.
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Vasculite do Sistema Nervoso Central , Anticorpos Monoclonais Humanizados/uso terapêutico , Biópsia , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Vasculite do Sistema Nervoso Central/diagnóstico por imagem , Vasculite do Sistema Nervoso Central/tratamento farmacológicoRESUMO
[Figure: see text].
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COVID-19/complicações , Hemorragias Intracranianas/complicações , AVC Isquêmico/complicações , Trombose dos Seios Intracranianos/complicações , Trombose Venosa/complicações , Adulto , Idoso , COVID-19/epidemiologia , Feminino , Geografia , Gastos em Saúde , Humanos , Cooperação Internacional , Hemorragias Intracranianas/epidemiologia , AVC Isquêmico/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Risco , Trombose dos Seios Intracranianos/epidemiologia , Resultado do Tratamento , Trombose Venosa/epidemiologia , Adulto JovemRESUMO
Background and Purpose- Time to reperfusion is fundamental in reducing morbidity and mortality in acute stroke. We aimed to demonstrate that direct transfer to angio-suite (DTAS) of patients with suspected large vessel occlusion stroke improves workflow times and outcomes. Methods- A case-control matched study of the first 79 DTAS patients with confirmed large vessel occlusion (cases) and 145 no-DTAS patients (controls). DTAS protocol included a cone beam computed tomography in the angio-suite to rule out intracerebral hemorrhage for those patients with no prior neuroimaging in a referring center. Cases and controls were matched by location of vessel occlusion, age, baseline National Institutes of Health Stroke Scale (NIHSS) score and time from symptoms onset to Comprehensive Stroke Center arrival. Dramatic clinical improvement was defined as a decrease in NIHSS score of >10 points or final NIHSS score of ≤2. Favorable outcome was defined as modified Rankin Scale score of ≤2 at 90 days. Results- During an 18 months period a total of 97 patients were directly transferred to the angio-suite after admission: 11 (11.6%) showed an intracerebral hemorrhage on cone beam computed tomography, 7 (7.2%) did not have a large vessel occlusion on initial angiogram, and 79 (76.3%) had a large vessel occlusion and received endovascular treatment (cases). There were no differences in age, baseline NIHSS score, level of occlusion and time from onset-to-door between cases and controls. The median door-to-groin time (16 [12-20] versus 70 [45-105] minutes; P<0.01) and onset-to-groin times (222 [152-282] versus 259 [190-345] minutes; P<0.01) were shorter in the DTAS group. At 24 hours, DTAS patients presented lower NIHSS score (7 [4-16] versus 14 [4-20]; P=0.01), higher rate of dramatic improvement (50.6% Vs. 31.7%; P=0.04), and higher rate of favorable clinical outcome at 90 days (41% versus 28%; P=0.05). A logistic regression model adjusting for all matching variables showed that DTAS protocol was independently associated with 3 months favorable outcome (odds ratio, 2.5; 95% CI, 1.2-5.3; P=0.01). Conclusions- DTAS is an effective strategy to reduce workflow time which may significantly increase the odds of achieving a favorable outcome.
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Doenças das Artérias Carótidas/cirurgia , Procedimentos Endovasculares/métodos , Infarto da Artéria Cerebral Média/cirurgia , Transferência de Pacientes/métodos , Tempo para o Tratamento/estatística & dados numéricos , Insuficiência Vertebrobasilar/cirurgia , Fluxo de Trabalho , Idoso , Idoso de 80 Anos ou mais , Doenças das Artérias Carótidas/diagnóstico por imagem , Estudos de Casos e Controles , Angiografia Cerebral , Tomografia Computadorizada de Feixe Cônico , Feminino , Unidades Hospitalares , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Reperfusão , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Resultado do Tratamento , Insuficiência Vertebrobasilar/diagnóstico por imagemRESUMO
BACKGROUND: Accurate prediction of functional outcomes is crucial in stroke management, but this remains challenging. OBJECTIVE: To evaluate the performance of the generative language model ChatGPT in predicting the functional outcome of patients with acute ischemic stroke (AIS) 3 months after mechanical thrombectomy (MT) in order to assess whether ChatGPT can used to be accurately predict the modified Rankin Scale (mRS) score at 3 months post-thrombectomy. METHODS: We conducted a retrospective analysis of clinical, neuroimaging, and procedure-related data from 163 patients with AIS undergoing MT. The agreement between ChatGPT's exact and dichotomized predictions and actual mRS scores was assessed using Cohen's κ. The added value of ChatGPT was measured by evaluating the agreement of predicted dichotomized outcomes using an existing validated score, the MT-DRAGON. RESULTS: ChatGPT demonstrated fair (κ=0.354, 95% CI 0.260 to 0.448) and good (κ=0.727, 95% CI 0.620 to 0.833) agreement with the true exact and dichotomized mRS scores at 3 months, respectively, outperforming MT-DRAGON in overall and subgroup predictions. ChatGPT agreement was higher for patients with shorter last-time-seen-well-to-door delay, distal occlusions, and better modified Thrombolysis in Cerebral Infarction scores. CONCLUSIONS: ChatGPT adequately predicted short-term functional outcomes in post-thrombectomy patients with AIS and was better than the existing risk score. Integrating AI models into clinical practice holds promise for patient care, yet refining these models is crucial for enhanced accuracy in stroke management.
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BACKGROUND: Perihematomal edema (PHE) is a marker of secondary brain injury in patients with intracerebral hemorrhage (ICH) and is associated with increased inflammatory markers and neurological disability. This study aims to assess the effect of the neutrophile-to-lymphocyte ratio (NLR) and systemic inflammatory response syndrome (SIRS) on PHE measurements and functional status in patients with ICH. METHODS: We included 215 patients with primary ICH and the primary outcomes were absolute and relative PHE, and edema extension distance (EED). A favorable functional outcome was defined as a modified Rankin Scale (mRS) score 0-2 measured 3 months after ICH. RESULTS: Median age was 73.0 years (interquartile range 66-80) and 54.4% patients were males. Fifty-nine patients were functionally independent at 90 days (mRS 0 to 2). NLR and SIRS were not predictors of absolute, relative PHE, and EED when adjusted for multiple confounders. However, admission NLR was independently associated with an unfavorable functional outcome at 90 days (aOR = 0.38; 95% CI 0.17-0.87; p = 0.021). CONCLUSIONS: NLR and SIRS are not independent predictors of absolute and relative PHE measurements following ICH. Nevertheless, NLR predicts long-term disability in ICH patients. Further research is needed to understand the mechanisms by which inflammation causes neurological injury in ICH.
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Hemorragia Cerebral , Neutrófilos , Masculino , Humanos , Idoso , Feminino , Hemorragia Cerebral/complicações , Edema , Linfócitos , Síndrome de Resposta Inflamatória Sistêmica/complicaçõesRESUMO
The use of antidepressants has been increasing globally, resulting in their presence in the aquatic environment, mainly by municipal wastewaters. This fact has aroused concern in the scientific community since these biologically active compounds can affect non-target organisms that have physiological systems regulated by these pharmaceuticals. However, the current knowledge on the toxicological effects of antidepressants on aquatic ecosystems is limited. Considering the increasing consumption pattern, quantification studies and toxicity studies, the present work aimed to review the available literature, published in the last seven years, addressing levels of antidepressants and their metabolites in rivers, surface waters, tap water, and wastewater treatment plants, as well, the effects reported in fish and invertebrates. Overall, the available laboratory studies showed that antidepressants can act at different levels of biological organisation, with detrimental effects at the individual level (e.g., survival, growth, and morphology, behaviour, and reproduction). However, the effects of prolonged exposures to environmentally relevant concentrations of these substances, a more realistic scenario, are unknown. Based on short-term studies, the long-term effects of pharmaceuticals at environmentally relevant concentrations (alone and in the presence of other environmental contaminants) should be studied.
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Organismos Aquáticos , Poluentes Químicos da Água , Animais , Antidepressivos/toxicidade , Ecossistema , Monitoramento Ambiental , Preparações Farmacêuticas , Poluentes Químicos da Água/análise , Poluentes Químicos da Água/toxicidadeRESUMO
We aimed to provide practical recommendations for the screening of subclinical atrial fibrillation (AF) in patients with ischaemic stroke or transient ischaemic attack (TIA) of undetermined origin. These guidelines are based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Five relevant Population, Intervention, Comparator, Outcome questions were defined by a multidisciplinary module working group (MWG). Longer duration of cardiac rhythm monitoring increases the detection of subclinical AF, but the optimal monitoring length is yet to be defined. We advise longer monitoring to increase the rate of anticoagulation, but whether longer monitoring improves clinical outcomes needs to be addressed. AF detection does not differ from in- or out-patient ECG-monitoring with similar monitoring duration, so we consider it reasonable to initiate in-hospital monitoring as soon as possible and continue with outpatient monitoring for more than 48 h. Although insertable loop recorders (ILR) increase AF detection based on their longer monitoring duration, comparison with non-implantable ECG devices for similar monitoring time is lacking. We suggest the use of implantable devices, if feasible, for AF detection instead of non-implantable devices to increase the detection of subclinical AF. There is weak evidence of a useful role for blood, ECG and brain imaging biomarkers for the identification of patients at high risk of AF. In patients with patent foramen ovale, we found insufficient evidence from RCT, but prolonged cardiac monitoring in patients >55 years is advisable for subclinical AF detection. To conclude, in adult patients with ischaemic stroke or TIA of undetermined origin, we recommend longer duration of cardiac rhythm monitoring of more than 48 h and if feasible with IRL to increase the detection of subclinical AF.
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PURPOSE: Although classically classified as a non-inflammatory condition, an inflammatory basis for keratoconus (KC) appears to be a growing evidence. Recently, it has been shown that KC patients have an increased choroidal thickness (CT). Among inflammatory disorders, atopy has been associated with KC development; therefore, the aim of this study was to evaluate if the increased CT in patients with KC is related to atopy. METHODS: This is an analytical cross-sectional study of patients with KC. Patients were classified as atopic and non-atopic according to their atopy history (allergic rhinoconjunctivitis (AR), asthma (AA) and/or atopic dermatitis (AD)) and were also classified based on their eye rubbing habits. Choroidal profile of all subjects was evaluated using a Spectralis optical coherence tomography (OCT) device with enhanced depth imaging (EDI) mode. CT was measured and compared between groups at the center of the fovea and at 500 µm intervals along a horizontal section. A multivariable analysis, adjusted for sex, age, spherical equivalent, history of medication and atopy, was performed to assess the influence of atopy in CT. RESULTS: Of the 80 patients included, 51 were atopic and 29 non-atopic. Atopic patients showed a thicker choroid in every measured location than the non-atopic patients (mean subfoveal CT 391.53 µm vs 351.17 µm, respectively), although the differences were not statistically different. The multivariable analysis revealed that being atopic makes the choroid statistically thicker, on average, 55.14 µm, when compared to non-atopic patients (p=0.043). Furthermore, patients who are frequent eye rubbers have significantly thicker choroids than non-rubbers (p=0.004). CONCLUSION: Although some results do not reach statistical significance, atopic KC patients seem to have thicker choroids compared with non-atopic KC patients, suggesting a possible role for atopy in the choroidal profile of KC. This constitutes a completely new sight in this field of research that needs further investigation.
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The hemodynamic consequences of a persistent reduced ejection fraction and unknown cardiac output on the brain have not been thoroughly studied. We sought to explore the status of the mechanisms of cerebrovascular regulation in patients with heart failure with reduced (HFrEF) and recovered (HFrecEF) ejection fraction. We monitored cerebral blood flow velocity (CBFV) with transcranial Doppler and blood pressure. Cerebral autoregulation, assessed by transfer function from the spontaneous oscillations of blood pressure to CBFV and neurovascular coupling (NVC) with visual stimulation were compared between groups of HFrEF, HFrecEF and healthy controls. NVC was significantly impaired in HFrEF patients with reduced augmentation of CBFV during stimulation (overshoot systolic CBFV 19.11 ± 6.92 vs. 22.61 ± 7.78 vs. 27.92 ± 6.84, p = 0.04), slower upright of CBFV (rate time to overshoot: 1.19 ± 3.0 vs. 3.06 (4.30) vs. 2.90 ± 3.84, p = 0.02); p = 0.023) and reduced arterial oscillatory properties (natural frequency 0.17 ± 0.06 vs. 0.20 ± 0.09 vs. 0.24 ± 0.07, p = 0.03; attenuation 0.34 ±0.24vs 0.48 ± 0.35 vs. 0.50 ± 0.23, p = 0.05). Cerebral autoregulation was preserved. The neurovascular unit of subjects with chronically reduced heart pumping capability is severely dysfunctional. Dynamic testing with transcranial Doppler could be useful in these patients, but whether it helps in predicting cognitive impairment must be addressed in future prospective studies.
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Periodic limb movements (PLMs) may occur as a primary condition or be associated with other pathologies, such as sleep disorders. However, PLMs have not been described in comatose patients. We report the case of a 66-year-old man, with no history of sleep disorders, who presented PLMs during coma caused by an extensive right hemispheric abscess inducing midline shift. These movements were further characterized by video and electromyographic recordings, which displayed bilateral periodic bursts of the tibialis anterior muscles, occurring every 7 to 15 seconds, with no concomitant electroencephalographic correlate. After a long period of hospitalization, the patient eventually regained consciousness and PLMs seem to persist, only in sleep. To the best of our knowledge, this is the first report showing that PLMs may be observed in a setting where the networks supporting consciousness are lost, namely in a coma of structural etiology.
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Coma/fisiopatologia , Síndrome da Mioclonia Noturna/fisiopatologia , Idoso , Humanos , MasculinoRESUMO
BACKGROUND: Cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most frequent monogenic cause of cerebral ischemia, but reliable biomarkers to monitor the disease are lacking. AIMS AND OBJECTIVES: To evaluate cerebral autoregulation (CA), vasoreactivity (VR), and neurovascular coupling (NVC) in CADASIL patients through a battery of dynamic transcranial Doppler tests. METHODS: We screened our database for all pre-dementia CADASIL cases. We monitored cerebral blood flow velocity (CBFV) with transcranial Doppler, blood pressure, and expiratory carbon dioxide (CO2) non-invasively. CA was assessed by transfer function from the spontaneous oscillations of blood pressure to CBFV, VR with inhalation of CO2 at 5%, and hyperventilation and NVC by the CBFV response to visual stimulation. RESULTS: We included 27 CADASIL patients and 20 healthy controls with similar age and sexes. CA and VR were similar between groups. However, NVC was significantly affected in CADASIL patients, with lower magnitudes of CBFV upsurge (overshoot 19 ± 5 vs 26 ± 6%, p = 0.013; gain 12 ± 7 vs 17 ± 5%, p = 0.003) and altered time behavior during visual stimulation (natural frequency 0.18 ± 0.06 vs 0.24 ± 0.06 Hz, p = 0.005; rate time 0.7 ± 1.7 vs 2.7 ± 3.5 s, p = 0.025). CONCLUSION: Our results express a primary and selective involvement of the neurovascular unit in CADASIL rather than a generalized cerebral vasomotor disturbance. Functional cerebrovascular testing could be useful in patient evaluation and monitoring.
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CADASIL/diagnóstico por imagem , Infarto Cerebral/diagnóstico por imagem , Leucoencefalopatias/diagnóstico por imagem , Acoplamento Neurovascular/fisiologia , Adulto , Idoso , Velocidade do Fluxo Sanguíneo/fisiologia , CADASIL/fisiopatologia , Infarto Cerebral/fisiopatologia , Feminino , Humanos , Leucoencefalopatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Ultrassonografia Doppler Transcraniana/métodosRESUMO
INTRODUCTION: Multiple sclerosis is a chronic inflammatory disease, in which a diagnostic delay could reduce the available therapeutic options. Therefore, it is important to monitor the time to diagnosis and understand factors that may potentially reduce it. The objective of this study was to determine the time between the first symptoms and the diagnosis of multiple sclerosis and which factors may contribute to a diagnostic delay. MATERIAL AND METHODS: Cross-sectional multicenter study, with retrospective data analysis, conducted in five tertiary Portuguese hospitals. Patients were consecutively selected from each local multiple sclerosis patients´ database. Sociodemographic and initial clinical data were collected through a questionnaire. Date of final diagnosis and multiple sclerosis classification was obtained from clinical files. RESULTS: A total of 285 patients were included with mean age at diagnosis of 36 years. The median time between first clinical manifestation and multiple sclerosis diagnosis was nine months (IQR 2 - 38). Diagnostic delay was associated with an older age (p < 0.001; r = 0.35), motor deficit at onset [26.5 months (IQR 4.5 - 56.5); p = 0.0005], higher number of relapses before diagnosis (p < 0.001; r = 0,626), first observation by other medical specialty [11 months (IQR 2 - 48); p < 0.001], prior alternative diagnosis [20 months (IQR 4 - 67.5); p < 0.001] and primary progressive subtype [37 months (IQR 25 - 64.5); p < 0.001]. The most significant delay occurred between the initial symptom and neurological observation. DISCUSSION: A significant delay occurred between initial symptoms and the diagnosis of multiple sclerosis, reflecting the need toincrease awareness of this entity and its diverse symptom presentation.
Introdução: A esclerose múltipla é uma doença inflamatória crónica na qual um atraso no diagnóstico poderá reduzir as opções terapêuticas, sendo importante monitorizar o tempo até ao diagnóstico e compreender os fatores que potencialmente o reduzam. Foi objetivo deste estudo determinar o tempo entre os primeiros sintomas e o diagnóstico de esclerose múltipla e quais os fatores que podem contribuir para o atraso no diagnóstico. Material e Métodos: Estudo multicêntrico transversal retrospetivo, realizado em cinco hospitais portugueses. Os doentes foram selecionados, consecutivamente, a partir de bases de dados locais. Os dados sociodemográficos e clínicos iniciais foram adquiridos através de questionário individual. A data do diagnóstico final e a classificação da esclerose múltipla foram obtidas por consulta do processo clínico. Resultados: Foram incluídos 285 doentes com média de idade ao diagnóstico de 36 anos. A mediana do tempo entre a primeira manifestação clínica e o diagnóstico foi de nove meses (IQR 2 - 38). O atraso no diagnóstico foi associado a idade avançada (p < 0,001; r = 0,35), défice motor inicial [26,5 meses (IQR 4,5 - 56,5), p = 0,0005], maior número de surtos previamente ao diagnóstico (p < 0,001; r = 0,626), primeira observação por outra especialidade médica [11 meses (IQR 2 - 48); p < 0,001], diagnóstico prévio alternativo [20 meses (IQR 4 - 67,5); p < 0,001] e esclerose múltipla primária progressiva [37 meses (IQR 25 - 64,5), p < 0,001]. O atraso mais significativo ocorreu entre o primeiro sintoma e a observação por neurologista. Discussão: Ocorreu um atraso significativo entre o primeiro sintoma e o diagnóstico de esclerose múltipla, refletindo uma necessidade de maior acuidade na identificação dos seus principais sintomas.
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Diagnóstico Tardio , Esclerose Múltipla/diagnóstico , Adulto , Fatores Etários , Idoso , Estudos Transversais , Progressão da Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Motores , Esclerose Múltipla/complicações , Exame Neurológico , Portugal , Recidiva , Estudos Retrospectivos , Fatores de TempoRESUMO
Meige Syndrome (MS) is a disabling movement disorder which impairs daily routines such as eating and speaking and, when not responsive to best medical treatment, deep brain stimulation (DBS) of the globus pallidus interna (GPi) has been considered. Previous evidence has shown a significant improvement in motor dysfunction with DBS, however its benefit on disease-specific disability and quality of life has not been thoroughly studied. We describe two patients with severe MS submitted to GPi-DBS. Patient improvement was assessed preoperatively and 24 months after the surgery by applying the movement subscore of the Burke-Fahn-Marsden Dystonia Rating Scale (BFMRS) and Jankovic Rating Scale (JRS) for motor function and the BFMRS disability subscore and Blepharospasm Disability Scale (BDS) for disability. At 24-month follow-up, dystonia improved 68% in Patient 1 and 96% in Patient 2, while disability improved 77%-92% respectively. No major adverse effects were observed. Improvement in motor function is in agreement with previous findings, but we emphasise the important improvement in disability and consequently in quality of life. Therefore, we suggest that DBS should be a therapeutic tool in refractory cases of MS.
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Estimulação Encefálica Profunda , Globo Pálido/cirurgia , Síndrome de Meige/cirurgia , Qualidade de Vida , Idoso , Pessoas com Deficiência , Feminino , Globo Pálido/fisiopatologia , Humanos , Movimento/fisiologia , Resultado do TratamentoRESUMO
BACKGROUND: Immunophenotypic analysis of the bone marrow (BM) cells has proven to be helpful in the diagnosis of Myelodysplastic Syndromes (MDS). However, the usefulness of flow cytometry (FCM) for the detection of myelodysplasia in the peripheral blood (PB) still needs to be investigated. The aim of this pilot study was to evaluate the value of FCM-based PB neutrophil and monocyte immunophenotyping for the diagnosis of lower risk MDS (LR-MDS). METHODS: We evaluated by 8-color FCM the expression of multiple cell surface molecules (CD10, CD11b, CD11c, CD13, CD14, CD15, CD16, CD34, CD45, CD56, CD64 and HLA-DR) in PB neutrophils and monocytes from a series of 14 adult LR-MDS patients versus 14 normal individuals. RESULTS: Peripheral blood neutrophils from patients with LR-MDS frequently had low forward scatter (FSC) and side scatter (SSC) values and low levels of CD11b, CD11c, CD10, CD16, CD13 and CD45 expression, in that order, as compared to normal neutrophils. In addition, patients with LR-MDS commonly display a higher fraction of CD14+CD56+ and a lower fraction of CD14+CD16+ monocytes in the PB. Based on these results, we proposed an immunophenotyping score based on which PB samples from patients with LR-MDS could be distinguished from normal PB samples with a sensitivity 93% and a specificity of 100%. In addition, we used this score to construct the MDS Thermometer, a screening tool for detection and monitoring of MDS in the PB in clinical practice. CONCLUSIONS: Peripheral blood neutrophil and monocyte immunophenotyping provide useful information for the diagnosis of LR-MDS, as a complement to cytomorphology. If validated by subsequent studies in larger series of MDS patients and extended to non-MDS patients with cytopenias, our findings may improve the diagnostic assessment and avoid invasive procedures in selected groups of MDS patients.
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BACKGROUND: Determining the size of infarct extent is crucial to elect patients for reperfusion therapies. Computed tomography perfusion (CTP) based on cerebral blood volume may overestimate infarct core on admission and consequently include ghost infarct core (GIC) in a definitive lesional area. PURPOSE: Our goal was to confirm and better characterize the GIC phenomenon using CTP cerebral blood flow (CBF) as the reference parameter to determine infarct core. METHODS: We performed a retrospective, single-center analysis of consecutive thrombectomies of middle cerebral or intracranial internal carotid artery occlusions considering noncontrast CT Alberta Stroke Program Early CT Score ≥6 in patients with pretreatment CTP. We used the RAPID® software to measure admission infarct core based on initial CBF. The final infarct was extracted from follow-up CT. GIC was defined as initial core minus final infarct > 10 mL. RESULTS: A total of 123 patients were included. The median National Institutes of Health Stroke Scale score was 18 (13-20), the median time from symptoms to CTP was 188 (67-288) min, and the recanalization rate (Thrombolysis in Cerebral Infarction score 2b, 2c, or 3) was 83%. Twenty patients (16%) presented with GIC. GIC was associated with shorter time to recanalization (150 [105-291] vs. 255 [163-367] min, p = 0.05) and larger initial CBF core volume (38 [26-59] vs. 6 [0-27] mL, p < 0.001). An adjusted logistic regression model identified time to recanalization < 302 min (OR 4.598, 95% CI 1.143-18.495, p = 0.032) and initial infarct volume (OR 1.01, 95% CI 1.001-1.019, p = 0.032) as independent predictors of GIC. At 24 h, clinical improvement was more frequent in patients with GIC (80 vs. 49%, p = 0.01). CONCLUSIONS: CTP CBF < 30% may overestimate infarct core volume, especially in patients imaged in the very early time window and with fast complete reperfusion. Therefore, the CTP CBF technique may exclude patients who would benefit from endovascular treatment.