Assessment of visuospatial functions in post-Covid 19 patients: Beyond the traditional paradigm.

Several studies indicate that some cognitive changes occur after COVID-19. Visuospatial alterations have been reported in 24-40 %. These alterations may be useful as early biomarkers of neurodegenerative disease. Thus, we can emphasize the importance of visuospatial processes in cognition through quantitative and qualitative analysis of performance on the Clock Test (CDT) and the Rey-Osterrieth Complex Figure (FCRO). Our objective was to describe the performance of post COVID 19 patients in visuospatial tests, with different degrees of respiratory impairment and to perform a qualitative analysis of the performance to check its relationship with alterations in attention and executive functions. This will allow highlighting the executive component of the performance of the CDT and ROCF and differentiate patients with possible cognitive impairment. 77 patients with SARS-CoV-2 infection were evaluated (3 months post-infection) with a complete neuropsychological battery and MRI. Overall, there is a significant difference between FCRO and CDT, with FCRO having only 9 % change and CDT having 51.9 % change. Regarding the correlations observed between groups (VM Inv, VM non I and non hospitalized) the highest correlations were observed between Boston with FCRO copy (r=0.497; p=0.001) and with FCRO memory (r=0.429; p=0.001). Comparing the performance between groups by severity, significant differences were observed only in the TMT A (13.706 p=0.001) and B (9.583 p=0.008) tests and in the phonological fluency letter A (13.445 p=0.001), we observed that the group of non-hospitalized patients had a better performance. Neuropsychological deficits often have a direct impact on daily life by affecting the ability to learn and adapt. Thus, a useful strategy for the neuropsychological characterization of post-COVID-19 patients is the qualitative analysis of visuospatial abilities in conjunction with executive functions that cannot be analyzed in isolation.

SARS-CoV-2's brain impact: revealing cortical and cerebellar differences via cluster analysis in COVID-19 recovered patients.

BACKGROUND: COVID-19 is a disease known for its neurological involvement. SARS-CoV-2 infection triggers neuroinflammation, which could significantly contribute to the development of long-term neurological symptoms and structural alterations in the gray matter. However, the existence of a consistent pattern of cerebral atrophy remains uncertain. OBJECTIVE: Our study aimed to identify patterns of brain involvement in recovered COVID-19 patients and explore potential relationships with clinical variables during hospitalization. METHODOLOGY: In this study, we included 39 recovered patients and 39 controls from a pre-pandemic database to ensure their non-exposure to the virus. We obtained clinical data of the patients during hospitalization, and 3 months later; in addition we obtained T1-weighted magnetic resonance images and performed standard screening cognitive tests. RESULTS: We identified two groups of recovered patients based on a cluster analysis of the significant cortical thickness differences between patients and controls. Group 1 displayed significant cortical thickness differences in specific cerebral regions, while Group 2 exhibited significant differences in the cerebellum, though neither group showed cognitive deterioration at the group level. Notably, Group 1 showed a tendency of higher D-dimer values during hospitalization compared to Group 2, prior to p-value correction. CONCLUSION: This data-driven division into two groups based on the brain structural differences, and the possible link to D-dimer values may provide insights into the underlying mechanisms of SARS-COV-2 neurological disruption and its impact on the brain during and after recovery from the disease.

Hospital Arrival and Functional Outcome after Intracerebral Hemorrhage.

BACKGROUND: Intracerebral hemorrhage (ICH) is associated with an ominous outcome influenced by the time to hospital presentation. OBJECTIVE: This study aims to identify the factors that influence an early hospital arrival after ICH and the relationship with outcome. METHODS: In this multicenter registry, patients with confirmed ICH on CT scan and well-known time of symptoms onset were studied. Clinical data, arrival conditions, and prognostic scores were analyzed. Multivariate models were built to find independent predictors of < 6 h arrival (logistic regression) and in-hospital death (Cox proportional-hazards model). RESULTS: Among the 473 patients analyzed (51% women, median age 63 years), the median delay since onset to admission was 6.25 h (interquartile range: 2.5-24 h); 7.8% arrived in < 1 h, 26.3% in < 3 h, 45.3% in < 6 h, and 62.3% in < 12 h. The in-hospital, 30-day and 90-day case fatality rates were 28.8%, 30.0%, and 32.6%, respectively. Predictors of arrival in < 6 h were hypertension treatment (odds ratios [OR]: 1.675, 95% confidence intervals [CI]: 1.030-2.724), ≥ 3 years of schooling (OR: 1.804, 95% CI: 1.055-3.084), and seizures at ICH onset (OR: 2.416, 95% CI: 1.068-5.465). Predictors of death (56.9% neurological) were systolic blood pressure > 180 mmHg (hazards ratios [HR]: 1.839, 95% CI: 1.031-3.281), ICH score ≥ 3 (HR: 2.302, 95% CI: 1.300-4.074), and admission Glasgow Coma Scale < 8 (HR: 4.497, 95% CI: 2.466-8.199). Early arrival was not associated with outcome at discharge, 30 or 90 days. CONCLUSIONS: In this study, less than half of patients with ICH arrived to the hospital in < 6 h. However, early arrival was not associated with the short-term outcome in this data set.

Stroke Care and Application of Thrombolysis in Ibero-America: Report From the SITS-SIECV Ibero-American Stroke Register

Background and Purpose: Standardized registries may provide valuable data to further improve stroke care. Our aim was to obtain updated information about characteristics of stroke patients and management of stroke across the Ibero-American countries, using a common in-hospital registry (Safe Implementation of Treatments in Stroke­Sociedad Iberoamericana de Enfermedades Cerebrovasculares) as a basis for further quality improvement. Methods: Data for this study were entered into the Safe Implementation of Treatments in Stroke registry from September 2009 to December 2013 by 58 centers in 14 countries. Data included demographics, risk factors, onset-to-door time, National Institutes of Health Stroke Scale score, stroke subtype, ischemic stroke etiology, treatments, 3-month mortality, and modified Rankin Scale score. Time to treatment was also recorded for patients treated with thrombolysis. Results: Five thousand four hundred one patients were registered; median age, 65 years; 46% women; 3915 (72.5%) ischemic strokes; 686 (13.7%) hemorrhagic strokes; 213 (4.3%) subarachnoid hemorrhages; 414 (8.3%) transient ischemic attacks; and 31 (0.6%) cerebral vein thrombosis. The most prevalent risk factors were hypertension (71.3%), dyslipidemia (35.2%), and diabetes mellitus (23.6%). Atrial fibrillation was present in 15.1%. Three hundred one ischemic strokes were treated with intravenous thrombolysis (IVT; 7.7%). Patients undergoing IVT were more severely affected (median baseline National Institutes of Health Stroke Scale score, 11 versus 6). The rate of symptomatic intracerebral hemorrhages after IVT was 5.7%. At 3 months, 60.3% of IVT-treated patients and 59.1% of untreated patients were independent (modified Rankin Scale score, 0­2). Mortality was 11.4% in treated and 12.8% in untreated patients. Conclusions: Safe Implementation of Treatments in Stroke­Sociedad Iberoamericana de Enfermedades Cerebrovasculares is the largest registry of a general stroke population and the first study to evaluate the level of IVT use in Ibero-America. It provides valuable information that may help to improve the quality of stroke care in the Ibero-American region.

Public and Private Hospital Care Disparities of Ischemic Stroke in Mexico: Results from the Primer Registro Mexicano de Isquemia Cerebral (PREMIER) Study.

BACKGROUND AND AIMS: Mortality and bad outcome by stroke are higher in developing countries than in industrialized countries. Health-care system efficiency could explain these disparities. Our objective was to identify the impact on short- and middle-term outcomes of patients with acute ischemic stroke (AIS) among public and private Mexican medical care. METHODS: We analyzed data from patients with AIS included in the Primer Registro Mexicano de Isquemia Cerebral (PREMIER) study. Transient ischemic attacks (TIAs) and ambulatory patients were excluded. Mortality and good outcome were assessed by the modified Rankin Scale (mRS) and analyzed at 1, 3, and 12 months of follow-up. RESULTS: From 1246 patients with AIS included in the registry, 1123 were hospitalized, either in public (n = 881) or in private (n = 242) hospitals. There were no significant differences regarding age and gender. In private settings, patients had a higher educational level, a major frequency of dyslipidemia, a previous stroke and TIA, less overweight and obesity, a sedentary lifestyle, and diabetes; stroke severity, the rate of systemic complications, the length of stay, and in-hospital mortality were also lower; a major frequency of thrombolysis was observed when compared with public hospitals. Our study showed a better outcome (mRS score ≤2) in private scenarios and a higher mortality in patients treated in public hospitals at short- and middle-term follow-ups. CONCLUSIONS: A polarized medical practice was observed in the AIS care in this large multicenter cohort of Mexico. There is evidence of an advantage for private scenarios, possibly related with an optimal infrastructure or with a strong patient's economic status.

Reunión multidisciplinaria sobre el uso de los anticoagulantes orales directos en la fibrilación auricular no valvular / Multidisciplinary meeting about the use of direct oral anticoagulants in nonvalvular atrial fibrillation

Resumen: Conociendo el impacto real de la fibrilación auricular en el evento vascular cerebral, la Sociedad Mexicana de Electrofisiología y Estimulación Cardiaca (SOMEEC) contempló la iniciativa de desarrollar una reunión multidisciplinaria de expertos con la finalidad de actualizar la evidencia científica disponible a partir de guías de práctica clínica, metaanálisis y ensayos clínicos controlados, y complementarla con la experiencia y los puntos de vista de un grupo de expertos. Para cumplir con este objetivo, se reunió a un grupo de especialistas en el área de cardiología, electrofisiología, neurología y hematología que, dada su experiencia en ciertas áreas, compartieron la evidencia científica disponible ante el panel de expertos para dejar abierta una discusión sobre la información que se presentaría en el presente artículo. Este documento reúne la mejor evidencia científica disponible y pretende ser una herramienta útil que agilice la toma de decisiones para uso de los nuevos anticoagulantes orales en fibrilación auricular no valvular y cardiopatía isquémica, o referente al manejo de pacientes que presentan evento vascular cerebral, o insuficiencia renal, e incluso en aquellos que serán sometidos a procedimientos invasivos y cirugía electiva. En la misma se manejan esquemas comparativos de seguimiento y tratamiento que simplifica la toma de decisión por los especialistas participantes.

Abstract: Knowing the real impact of atrial fibrillation in the stroke, the Sociedad Mexicana of Electrofisiología y Estimulación Cardiaca (SOMEEC) had the initiative to develop a multidisciplinary meeting of experts the with the purpose to update the available scientific evidence from clinical practice guidelines, meta-analyses, controlled clinical trials, and complementing with the experience and views of a group of experts. To meet this goal, SOMEEC gathered a group of specialists in the area of cardiology, electrophysiology, neurology and hematology that given their experience in certain areas, they share the scientific evidence with the panel of experts to leave open a discussion about the information presented in this article. This document brings together the best scientific evidence available and aims to be a useful tool in the decision to use of new oral anticoagulants in nonvalvular atrial fibrillation and ischemic heart disease, or relating to the management of patients with stroke or renal failure, and even those that will be submitted to elective surgery and invasive procedures. In the same, they handled comparative schemes of follow-up and treatment which simplifies the decision making by the specialists participants.

[Multidisciplinary meeting about the use of direct oral anticoagulants in nonvalvular atrial fibrillation]. / Reunión multidisciplinaria sobre el uso de los anticoagulantes orales directos en la fibrilación auricular no valvular.

Knowing the real impact of atrial fibrillation in the stroke, the Sociedad Mexicana of Electrofisiología y Estimulación Cardiaca (SOMEEC) had the initiative to develop a multidisciplinary meeting of experts the with the purpose to update the available scientific evidence from clinical practice guidelines, meta-analyses, controlled clinical trials, and complementing with the experience and views of a group of experts. To meet this goal, SOMEEC gathered a group of specialists in the area of cardiology, electrophysiology, neurology and hematology that given their experience in certain areas, they share the scientific evidence with the panel of experts to leave open a discussion about the information presented in this article. This document brings together the best scientific evidence available and aims to be a useful tool in the decision to use of new oral anticoagulants in nonvalvular atrial fibrillation and ischemic heart disease, or relating to the management of patients with stroke or renal failure, and even those that will be submitted to elective surgery and invasive procedures. In the same, they handled comparative schemes of follow-up and treatment which simplifies the decision making by the specialists participants.

Isolated vein thrombosis of the posterior fossa presenting as localized cerebellar venous infarctions or hemorrhages.

BACKGROUND AND PURPOSE: Cerebellar venous infarction or hemorrhage due to isolated venous thrombosis of the posterior fossa is a rare form of intracranial vein thrombosis that can be unsuspected in clinical practice. METHODS: We studied 230 patients with intracranial vein thrombosis, identifying 9 (3.9%: 7 women, mean age 34 years) with neuroimaging or histopathologic evidence of localized posterior fossa vein thrombosis causing parenchymal injury limited exclusively to the cerebellum. RESULTS: All patients had an insidious presentation suggesting other diagnoses. Intracranial hypertension (n=6) and cerebellar (n=4) syndromes were the main clinical presentations. Intracranial vein thrombosis was idiopathic in 3 patients; associated with puerperium in 3; and with contraceptives, protein C deficiency, and dehydration in 1 case each. CT was abnormal but not diagnostic in 5 patients, showing a cerebellar hypodensity with fourth ventricle compression and variable hydrocephalus in 5 patients, and cerebellar hemorrhage in 2. Conventional MRI provided diagnosis in 6 cases, showing the causal thrombosis and cerebellar involvement; angiography was practiced in 2 of them, confirming the findings identified by MRI. In the other 3 patients, diagnosis was reached by histopathology. Thromboses were localized at the straight sinus (n=4), lateral sinuses (n=3), and superior petrosal vein (n=2). The acute case fatality rate was 22.2% (n=2), 1 (11.1%) patient was discharged in a vegetative state, 1 (11.1%) was severely disabled, and 5 (55.6%) were moderately disabled. CONCLUSIONS: Isolated venous thrombosis of the posterior fossa is infrequent and implies a challenging diagnosis. Risk factors for intracranial vein thrombosis and atypical cerebellar findings on CT should lead to further MRI assessment.

[Cavernous angioma. Clinical observations and prognosis of 133 patients]. / Angiomas cavernosos. Observaciones clínicas y pronóstico de 133 pacientes.

BACKGROUND: Cavernous angiomas represent 9% of the vascular malformations that affect nervous system. The principal mode of onset is cerebral hemorrhage and epilepsy, and can be sporadic of multiple. In the last, there is a familiar factor specially found in Mexician-American. In our Country there is no data of the clinical or demographic characteristics of the disease. The aim of this study is to describe the clinical characteristics and prognosis of 133 patients with cavernous angiomas consecutively attended in the National Institute of Neurology of Mexico City. PATIENTS AND METHODS: Since 1988 we evaluated a total of 146 cases of cavernous angiomas, 133 were confirmed by MRI and included in the analysis of this study. In every case we registered the demographic characteristic, neurological manifestations, and prognosis divided in good o bad outcome, according to the Glasgow outcome scale (1 and > or = 2 respectively). Data were analyzed with descriptive statistics with the Chi square test, and p was set at 0.05 level. RESULTS: The mean age was 34.3 +/- 14.6 years; 50.4% in male. Eighty seven percent were unique, and the principal manifestation was supratentorial in 65%, infratentorial in 24.8%, supra-infratentorial in 6.8%, and spinal in 3.8%. The clinical manifestations were intracerebral hemorrhage in 58.7%, epilepsy in 48.1%, headache in 37.6%, neurological focalization not secondary to hemorrhage in 8.3%, and incidental in 2.3%. The 6 month outcome was good in 80% of patient assessed by the Glasgow outcome scale. CONCLUSIONS: In our serie the mean age or presentation was 34 years old, the mean neurological manifestations were cerebral hemorrhage and epilepsy, and the outcome was good in the majority of the cases.

Hallazgos ecocardiográficos transesofágicos en pacientes menores de 40 años con evento vascular cerebral / Transesophageal echocardiographic changes in patients younger than 40 years with embolic stroke

Las anomalías cardiovasculares con potencialidad embolígena causantes de eventos vasculares cerebrales (EVC) isquémicos en menores de 40 años son asintomáticas y asignológicas. La finalidad de este estudio es justificar la implementación del ecocardiograma transesofágico (ETE) en todo protocolo de estudio de paciente joven con EVC isquémico. Material y métodos: Se estudiaron con ETE 34 pacientes menores de 40 años con EVC isquémico. Se complementó con estudio contrastado en búsqueda de cortocircuitos intracavitarios. Resultados: 19 pacientes fueron del sexo masculino y 15 del femenino con edades de 18 a 40 años (media 31 años). Ninguno tuvo signos o síntomas cardiovasculares. Se detectaron 11 anomalías en 20 pacientes (58.8 por ciento). De éstas, 3 son consideradas como probablemente embolígenas: el foramen oval permeable (FOP), prolapso valvular mitral y dilatación ventricular y se encontraron en 12 pacientes (35.29 por ciento). En 8 pacientes con anomalías cardiovasculares se encontró como factor asociado un estado hipercoagulable; 4 con FOP, 2 con engrosamientos valvulares y 2 con nódulos valvulares. Conclusión: En pacientes menores de 40 años con EVC isquémico, el ETE detecta fuentes embolígenas directas e indirectas, aún en pacientes sin sospecha de enfermedad cardiaca.

Uso de anticoagulantes en la fase aguda del infarto cerebral / Antithrombotic therapies in acute cerebral stroke

El uso óptimo de antitrombóticos en la fase aguda del infarto cerebral puede prevenir la recurrencia y progresión de la isquemia. En el caso de anticoagulación, su uso continua siendo controvertido debido a que hasta ahora no se ha establecido la seguridad y/o efectividad. Investigaciones recientes en cuanto a otras alternativas terapéuticas con similares características antitrombóticas, pero con menor propensión a sangrados o trombocitopenia, han llevado al desarrollo de heparinas de bajo peso molecular y de heparinoides. Se revisan las implicaciones terapéuticas de estos estudios, las potenciales indicaciones de anticoagulación en la fase aguda del infarto cerebral y la nueva información disponible en relación con el tema

Patrones sonográficos por Doppler transcraneal en el infarto cerebral agudo / Sonographic patterns by transcranial Doppler in acute cerebral infarction

Objetivo. Evaluar los patrones sonográficos obtenidos por Doppler transcraneal y su asociación con el sitio de oclusión arterial, extensión del infarto cerebral, mecanismo de la isquemia y pronóstico en pacientes con infarto cerebral agudo. Material y métodos. Treinta y siete pacientes consecutivos con isquemia cerebral en el territorio carotídeo en las primeras 24 horas de evolución se evaluaron con Doppler transcraneal (DTC), estudios de neuroimagen, y gravedad clínica a su ingreso y egreso. Los hallazgos sonográficos registrados en la arteria cerebral media afectada fueron divididos en 4 patrones: normal, estenosante, de asimetría interhemisférica y oclusión troncal de arteria cerebral media; se correlacionaron con la extensión, mecanismo de producción y pronóstico del infarto. Resultados. El grupo normal se asoció a infartos cerebrales predominantemente profundos por enfermedad de pequeño vaso (p=0.01) con evolución clínica favorable (p<0.02). Los grupos con patrón estenosante y de asimetria interhemisférica se asociaron a infartos superficiales (p<0.05) y con tendencia a mecanismo de producción cardioembólico (17 por ciento). El grupo con patrón de oclusión trocal se caracterizó por la presencia de infartos cerebrales extensos (p<0.01=, con diferentes mecanismos de producción y con mayor morbimortalidad (p=0.004=. Conclusiones. Nuestros resultados muestran que el DTC permite detectar diferentes patrones sonográficos que orientan al mecanismo de producción, extensión y pronóstico de la zona de isquemia