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1.
World Neurosurg ; 92: 95-107, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27163552

RESUMO

OBJECTIVE: Moyamoya disease is a cerebral vasculopathy characterized by stenosis of the terminal internal carotid artery, proximal middle cerebral artery, and anterior cerebral artery. There is an association between moyamoya vasculopathy and Graves disease, primarily in Asian populations. Here, we present the largest series of non-Asian, predominantly Latino patients with moyamoya vasculopathy in the setting of Graves thyrotoxicosis, as well as the largest review of the literature to date. METHODS: We retrospectively analyzed patients presenting with stroke in the setting of clinical Graves disease to our institution from 2004 to 2014. Moyamoya vasculopathy was diagnosed by magnetic resonance angiography in all patients. RESULTS: Eight patients with Graves disease thyrotoxicosis and moyamoya vasculopathy were identified. Six patients were effectively managed with aggressive medical management using antithyroid and antiplatelet medications. No recurrent strokes were noted once thyrotoxicosis was controlled. Intracranial bypass was necessary in 2 patients who failed medical management. Seventy-nine additional cases were reported from the literature. There was no significant difference in clinical improvement between medical therapy alone and medical therapy with neurosurgical prophylaxis (87.0% vs. 88.0%, respectively; P = 0.94). CONCLUSIONS: Moyamoya vasculopathy associated with Graves disease thyrotoxicosis in non-Asian women may be more common than previously thought. In addition, our series suggests that thyrotoxicosis promotes the progression of vasculopathy. Based on our review, there is no significant difference in clinical improvement between proper medical and surgical therapies. Aggressive medical therapy should be considered first-line treatment for moyamoya vasculopathy with Graves thyrotoxicosis, with neurosurgical rescue reserved for medically refractory cases.


Assuntos
Doença de Graves/complicações , Doença de Moyamoya/complicações , Acidente Vascular Cerebral/complicações , Tireotoxicose/etiologia , Feminino , Humanos , América Latina/epidemiologia , Estudos Retrospectivos , Saúde da Mulher
2.
J Stroke Cerebrovasc Dis ; 21(6): 487-92, 2012 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21334223

RESUMO

The influence of statin therapy on cerebral vasomotor function has not been fully characterized. We report the effects of high-dose atorvastatin therapy on cerebral vasomotor reactivity (VMR) in patients with controlled hypertension and dyslipidemia. We prospectively enrolled 36 patients with controlled hypertension and a low-density lipoprotein (LDL) cholesterol concentration >100 mg/dL. Atorvastatin 80 mg was given daily for 6 months and then discontinued. VMR was assessed by hypercapnic and hypocapnic transcranial Doppler challenge in both the right and left middle cerebral artery (MCA) at baseline, and after 3 and 6 months of therapy. Forty-five days after statin cessation, a repeat VMR was performed. VMR impairment was defined as ≤70%. Blood pressure, lipid levels, liver function, and creatine kinase level were monitored. Mean patient age was 60 years, 16 were men, and 13 had a previous history of subcortical infarction. Mean LDL cholesterol level before treatment was 154 ± 30 mg/dL. Atorvastatin lowered LDL by 53% at 3 months and by 46% at 6 months. Baseline VMR was 71% ± 21% in the right MCA and 70% ± 19% in the left MCA. No significant effect of atorvastatin on VMR was seen at 3 months and 6 months in the study population as a whole. In the subgroup of patients with baseline VMR impairment, atorvastatin therapy was associated with significantly improved VMR at both 3 and 6 months. This effect persisted for at least 45 days after discontinuation of therapy. Our findings indicate that high-dose atorvastatin therapy can significantly improve impaired cerebral VMR, and that the effects of atorvastatin on VMR persist for 1.5 months after discontinuation of therapy. We found no benefit of atorvastatin therapy in patients with preserved baseline vasoreactivity.


Assuntos
Circulação Cerebrovascular/efeitos dos fármacos , Hemodinâmica/efeitos dos fármacos , Ácidos Heptanoicos/administração & dosagem , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Hipercolesterolemia/tratamento farmacológico , Artéria Cerebral Média/efeitos dos fármacos , Pirróis/administração & dosagem , Idoso , Anti-Hipertensivos/uso terapêutico , Atorvastatina , Biomarcadores/sangue , Velocidade do Fluxo Sanguíneo/efeitos dos fármacos , Pressão Sanguínea/efeitos dos fármacos , Infarto Encefálico/etnologia , Infarto Encefálico/fisiopatologia , Distribuição de Qui-Quadrado , LDL-Colesterol/sangue , Feminino , Florida , Hispânico ou Latino , Humanos , Hipercolesterolemia/diagnóstico por imagem , Hipercolesterolemia/etnologia , Hipercolesterolemia/fisiopatologia , Hipertensão/tratamento farmacológico , Hipertensão/etnologia , Hipertensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/diagnóstico por imagem , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Transcraniana
3.
Circulation ; 123(18): 1947-52, 2011 May 10.
Artigo em Inglês | MEDLINE | ID: mdl-21518982

RESUMO

BACKGROUND: The fat embolism syndrome is clinically characterized by dyspnea, skin petechiae, and neurological dysfunction. It is associated mainly with long bone fracture and bone marrow fat passage to the systemic circulation. An intracardiac right-to-left shunt (RLS) could allow larger fat particles to reach the systemic circulation. Transcranial Doppler can be a useful tool to detect both RLS and the fat particles reaching the brain. METHODS AND RESULTS: We prospectively studied patients with femur shaft fracture with RLS evaluation, daily transcranial Doppler with embolus detection studies, and neurological examinations to evaluate the relation of RLS and microembolic signals to the development of fat embolism syndrome. Forty-two patients were included; 14 had an RLS detected. Seven patients developed neurological symptoms; all of them had a positive RLS (P=<0.001). The patients with an RLS showed higher counts and higher intensities of microembolic signals (P=<0.05 and P=<0.01, respectively) compared with those who did not have an RLS identified. The presence of high microembolic signal counts and intensities in patients with RLS was strongly predictive of the occurrence of neurological symptoms (odds ratio, 204; 95% confidence interval, 11 to 3724; P<0.001) with a positive predictive value of 86% and negative predictive value of 97%. CONCLUSIONS: In patients with long bone fractures, the presence of an RLS is associated with larger and more frequent microembolic signals to the brain detected by transcranial Doppler study and can predict the development of neurological symptoms.


Assuntos
Embolia Gordurosa/diagnóstico por imagem , Embolia Paradoxal/diagnóstico por imagem , Embolia Intracraniana/diagnóstico por imagem , Ultrassonografia Doppler Transcraniana/métodos , Adolescente , Adulto , Embolia Gordurosa/etiologia , Embolia Paradoxal/etiologia , Feminino , Fraturas do Fêmur/complicações , Fraturas do Fêmur/cirurgia , Forame Oval Patente/complicações , Humanos , Embolia Intracraniana/etiologia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Valor Preditivo dos Testes , Estudos Prospectivos , Adulto Jovem
5.
J Neuroimaging ; 19(3): 242-5, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-18681927

RESUMO

BACKGROUND: Despite remaining an important cause of posterior circulation stroke, the non-invasive diagnosis of vertebral artery origin (VAo) stenosis is problematic. We here examine peak systolic velocity (PSV) criteria for the diagnosis of VAo stenosis and assess if the PSV ratio at the origin to the distal segments improves diagnostic accuracy. METHODS: We performed a retrospective analysis of patients studied by catheter cerebral angiography and extracranial Duplex ultrasonography. The angiographic degree of stenosis, PSV at the VAo, proximal vertebral artery (VA1), and intra-foraminal (VA2) segment were recorded. We calculated the VAo/VA1 and VAo/VA2 PSV ratio. A receiver operator curve was obtained (ROC) and the area under the curve (AUC) was compared for three different diagnostic criteria: PSV VAo, VAo/VA1, and VAo/VA2 PSV ratio. RESULTS: A total of 386 vertebral arteries were angiographically examined and VAo stenosis 50-99% was found in 36 (9%) vessels. The PSV VAo was the most accurate diagnostic parameter with an AUC .821 +/- .052 (SE) (CI: .72, .92). A PSV of 114 cm/second maximized sensitivity (71%) and specificity (90%). CONCLUSION: Our results support the use of PSV as a diagnostic criterion for VAo stenosis compared to a PSV ratio of VAo/V1 and VAo/V2.


Assuntos
Insuficiência Vertebrobasilar/diagnóstico por imagem , Insuficiência Vertebrobasilar/diagnóstico , Área Sob a Curva , Angiografia Cerebral , Humanos , Curva ROC , Estudos Retrospectivos , Sensibilidade e Especificidade , Ultrassonografia Doppler Transcraniana , Artéria Vertebral/diagnóstico por imagem
6.
J Neuroimaging ; 18(4): 396-401, 2008 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-18494776

RESUMO

BACKGROUND AND PURPOSE: The determinants of ischemic complications in subarachnoid hemorrhage (SAH) are not well defined. The objective of this study is to evaluate the role of microemboli in SAH-related cerebral ischemia. METHODS: Forty patients with aneurysmal SAH were monitored with transcranial Doppler (TCD) for the presence of embolic signals (ES) and vasospasm, and followed clinically for the development of cerebral ischemic symptoms, from the time the aneurysm was secured until day 14 posthemorrhage or discharge. RESULTS: Microembolic signals were detected in 15/40 patients, appeared at a mean of 6.7 days after hemorrhage, and were often noted bilaterally. There was a close association between ES and cerebral ischemic symptoms (P= .003), and ES were commonly present in the distribution of the vessel with ischemic symptoms. Ultrasonographic vasospasm did not correlate with ischemia and there was no relationship between microembolic signals and vasospasm. CONCLUSIONS: In this study, ES detected in over a third of SAH victims, were associated with the development of cerebral ischemic symptoms, and were not related to vasospasm, but rather appeared to be an independent risk factor for the development of ischemic symptoms in SAH.


Assuntos
Aneurisma Roto/diagnóstico por imagem , Processamento de Imagem Assistida por Computador , Aneurisma Intracraniano/diagnóstico por imagem , Embolia Intracraniana/diagnóstico por imagem , Hemorragia Subaracnóidea/diagnóstico por imagem , Ultrassonografia Doppler Transcraniana , Vasoespasmo Intracraniano/diagnóstico por imagem , Aneurisma Roto/terapia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/terapia , Embolização Terapêutica , Feminino , Seguimentos , Escala de Resultado de Glasgow , Humanos , Aneurisma Intracraniano/terapia , Embolia Intracraniana/terapia , Masculino , Pessoa de Meia-Idade , Sensibilidade e Especificidade , Hemorragia Subaracnóidea/terapia , Instrumentos Cirúrgicos , Vasoespasmo Intracraniano/terapia
7.
Transfusion ; 48(7): 1383-9, 2008 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-18422844

RESUMO

BACKGROUND: Visceral leishmaniasis (VL) caused by Leishmania infantum is a zoonotic disease endemic throughout the Mediterranean basin. The existence of asymptomatic human infection entails the risk of transmission by blood transfusion. STUDY DESIGN AND METHODS: The prevalence of Leishmania infection was studied in 1437 blood donors from the Balearic Islands (Majorca, Formentera, and Minorca) using immunologic (Western blot [WB] and delayed-type hypersensitivity [DTH]), parasitologic (culture), and molecular (nested polymerase chain reaction [PCR]) methods. In addition, the efficiency of leukoreduction by filtration to remove the parasite was tested by nested PCR in the red blood cell (RBC) units. RESULTS: Leishmania antibodies were detected in 44 of the 1437 blood donors tested (3.1%). A sample of 304 donors from Majorca was selected at random. L. infantum DNA was amplified in peripheral blood mononuclear cells (PBMNCs) in 18 of the 304 (5.9%), and cultures were positive in 2 of the 304 (0.6%). DTH was performed on 73 of the 304 donors and was positive for 8 of them (11%). Of the 18 donors with positive L. infantum nested PCR, only 2 were seropositive. All the RBC samples tested (13 of 18) from donors with a positive PBMNC nested PCR yielded negative nested PCR results after leukodepletion. CONCLUSIONS: Cryptic Leishmania infection is highly prevalent in blood donors from the Balearic Islands. DTH and L. infantum nested PCR appear to be more sensitive to detect asymptomatic infection than the serology. The use of leukodepletion filters appears to remove parasites from RBC units efficiently.


Assuntos
Doadores de Sangue , Leishmania infantum/isolamento & purificação , Leishmaniose Visceral/virologia , Animais , Eritrócitos/citologia , Eritrócitos/parasitologia , Humanos , Leishmania infantum/genética , Leishmaniose Visceral/sangue , Leishmaniose Visceral/epidemiologia , Reação em Cadeia da Polimerase , Prevalência , Espanha/epidemiologia
8.
Neurology ; 70(13): 1049-51, 2008 Mar 25.
Artigo em Inglês | MEDLINE | ID: mdl-18362285
9.
Neurocrit Care ; 8(3): 316-21, 2008.
Artigo em Inglês | MEDLINE | ID: mdl-18360781

RESUMO

BACKGROUND: The optimal blood pressure (BP) for treating acute intracerebral hemorrhage remains (ICH) uncertain. High BP may contribute to hematoma growth while excessive BP reduction might precipitate peri-hemorrhage ischemia. We examine here the feasibility and safety of reducing BP to lower than presently recommended levels in patients with acute ICH. METHODS: Patients with ICH were prospectively randomized to standard BP treatment (mean arterial BP [MAP] 110-130 mmHg) or aggressive BP lowering (MAP < 110 mmHg) within 8 h of symptom onset. MAP was managed during the 48 h treatment period. NIHSS was obtained at baseline, 24, and 48 h. Brain CT was done 24 h after symptoms. A modified Rankin Scale (mRs) was obtained at 90 days. A clinical decline (NIHSS drop > or = 2 points) within the first 48 h was the primary endpoint. Hematoma enlargement at 24 h was a secondary endpoint. RESULTS: We enrolled 21 patients into each group. Mean age was 60.6 +/- 12.3 years and MAP on presentation was 147.6 +/- 18.2 mmHg. Treatment was started on average 3.2 +/- 2.2 h after symptom onset. Baseline clinical variables were identical between the 2 treatment groups. Target blood pressure was achieved within 87.1 +/- 59.6 min in the standard group and 163.5 +/- 163.8 min in the aggressive BP treatment group. There were no significant differences in early neurological deterioration, hematoma and edema growth, and clinical outcome at 90 days. CONCLUSION: A more aggressive reduction of acute hypertension after ICH does not increase the rate of neurological deterioration even when treatment is initiated within hours of symptom onset. Lowering BP aggressively did not affect hematoma and edema expansion but this possibility deserves further study.


Assuntos
Anti-Hipertensivos/administração & dosagem , Hemorragia Intracraniana Hipertensiva/tratamento farmacológico , Labetalol/administração & dosagem , Doença Aguda , Idoso , Anti-Hipertensivos/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Edema Encefálico/tratamento farmacológico , Estudos de Viabilidade , Feminino , Hematoma/tratamento farmacológico , Humanos , Labetalol/efeitos adversos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
10.
J Neuroimaging ; 17(4): 332-5, 2007 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-17894622

RESUMO

BACKGROUND: Diffusion-weighted (DW) imaging abnormalities often develop in patients after invasive procedures associated with cerebral microembolism. Cerebral microembolism has recently been shown during orthopedic surgery. We here examine the effects of intraoperative microembolism on acute magnetic resonance(MR) imaging in patients undergoing hip and knee replacement. METHODS: We enrolled 24 patients, at least 65 years old, requiring elective knee or hip replacement surgery. MR with DW and axial fluid-attenuated inversion recovery (FLAIR) imaging was performed pre- and postoperatively. All patients were monitored intraoperatively for microemboli. RESULTS: The mean age of patients was 74 years. All patients had intraoperative microemboli. The mean number of emboli detected was 9.9 +/- 18 per surgery. MR imaging was obtained a mean of 3.5 days postoperatively. No DW imaging abnormalities were found after surgery. One patient had new findings on postoperative FLAIR imaging. CONCLUSION: Intraoperative microembolism occurred universally, but did not lead to acute DW imaging abnormalities following knee and hip replacement. Acute imaging abnormalities on FLAIR imaging are rare but may occasionally occur after joint surgery.


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Imagem de Difusão por Ressonância Magnética , Embolia Intracraniana/diagnóstico , Embolia Intracraniana/etiologia , Idoso , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Estatísticas não Paramétricas
11.
J Stroke Cerebrovasc Dis ; 16(3): 114-8, 2007.
Artigo em Inglês | MEDLINE | ID: mdl-17689405

RESUMO

BACKGROUND: In animal models, brief periods of hypoxemia render the brain tolerant to subsequent ischemic insults. Sleep apnea leads to frequent episodes of nocturnal hypoxemia and may induce ischemic tolerance. Snoring and daytime sleepiness are cardinal symptoms of sleep apnea. We undertook this study to determine differences in stroke severity and early neurologic course in patients at risk for sleep apnea as determined by a sleep questionnaire. METHODS: Patients admitted with acute ischemic stroke completed the Berlin questionnaire. The Berlin questionnaire examines habitual snoring, daytime sleepiness, presence of hypertension, and body mass index (BMI) and classifies patients into a high or low risk for sleep apnea group. National Institutes of Health Stroke Scale (NIHSS) score was determined on admission and day 5 of hospitalization. Age, sex, cardiovascular risk factors, BMI, and stroke mechanism were determined prospectively. RESULTS: We enrolled 190 patients with a mean age of 60 years and 53% were men. The Berlin questionnaire classified 103 patients (54%) at high risk for sleep apnea. The median NIHSS score on admission and day 5 of hospitalization did not differ between the two groups after multivariate analysis. Examined separately, we found no effect of snoring, daytime sleepiness, or BMI on acute stroke severity and outcome. CONCLUSION: We found that a large number of patients admitted with acute ischemic stroke were at high risk for having sleep apnea. We were not able to show that a constellation of symptoms and features highly suggestive of sleep apnea influenced stroke severity or early neurologic course after acute ischemic stroke.


Assuntos
Isquemia Encefálica/complicações , Síndromes da Apneia do Sono/complicações , Acidente Vascular Cerebral/diagnóstico , Doença Aguda , Idoso , Índice de Massa Corporal , Isquemia Encefálica/fisiopatologia , Complicações do Diabetes/fisiopatologia , Distúrbios do Sono por Sonolência Excessiva/etiologia , Dislipidemias/complicações , Feminino , Humanos , Hipertensão/complicações , Embolia Intracraniana/complicações , Embolia Intracraniana/fisiopatologia , Precondicionamento Isquêmico , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Risco , Índice de Gravidade de Doença , Síndromes da Apneia do Sono/diagnóstico , Síndromes da Apneia do Sono/fisiopatologia , Ronco/etiologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/fisiopatologia , Inquéritos e Questionários
13.
Stroke ; 38(3): 1079-81, 2007 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-17255544

RESUMO

BACKGROUND AND PURPOSE: Intra-operative cerebral microembolism may be a factor in the etiology of cognitive decline after orthopedic surgery. We here examine the impact of intra-operative microembolism on cognitive dysfunction after hip and knee replacement surgery. METHODS: We enrolled 24 patients, at least 65 years old, requiring elective knee or hip replacement surgery. A transcranial Doppler shunt study was done to determine study eligibility so that the final study population consisted of 12 consecutive patients with and 12 consecutive patients without a venous-arterial shunt. A standard neuropsychological test battery was administered before surgery, at hospital discharge and 3 months after surgery. All patients were monitored intra-operatively for microemboli. Quality of life data were assessed at 1 year. RESULTS: The mean age of patients was 74 years. All patients had intra-operative microemboli. The mean number of emboli was 9.9+/-18. Cognitive decline was present in 18/22 (75%) at discharge and in 10/22 (45%) at 3 months, despite improved quality of life measures. There was no correlation between cognitive decline and intra-operative microembolism. CONCLUSIONS: Cognitive decline was seen frequently after hip and knee surgery. Intra-operative microembolism occurred universally but did not significantly influence postoperative cognition. Quality of life and functional outcome demonstrated improvement in all cases in spite of cognitive dysfunction.


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Transtornos Cognitivos/psicologia , Embolia Gordurosa/psicologia , Embolia Intracraniana/psicologia , Idoso , Idoso de 80 Anos ou mais , Transtornos Cognitivos/etiologia , Embolia Gordurosa/etiologia , Feminino , Humanos , Embolia Intracraniana/etiologia , Complicações Intraoperatórias/psicologia , Masculino
14.
Neurol Res ; 29(7): 664-6, 2007 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-18173904

RESUMO

OBJECTIVE: To determine the causes of in-hospital delays for thrombolysis. METHODS: We performed a 4 year retrospective chart analysis of i.v. tPA-treated patients at an academic medical center. Data collected included age, stroke severity by the National Institutes of Health Stroke Scale (NIHSS) and the following time points: symptom onset, hospital arrival, computed tomography (CT), i.v. tPA order and i.v. tPA initiation of infusion. RESULTS: Thirty-one cases with sufficient information for analysis were identified. Mean time from onset to arrival was 58 minutes, from arrival to brain CT was 32 minutes, and from onset to i.v. rtPA infusion was 169 minutes. The mean delay between i.v. tPA order and infusion was 32 minutes. Delay between order and administration of i.v. tPA resulted in treatment after 3 hours in 9/31 cases. An inverse relationship between early hospital arrival and delayed thrombolysis was noted. Age and stroke severity did not impact treatment times. CONCLUSION: An unexpected delay between order and actual initiation of i.v. tPA infusion resulted in almost one-third of patients receiving thrombolytics after 3 hours from symptom onset. The cause of this delay could not be discerned by this study. The paradoxical effect between early arrival to hospital and delayed treatment may be related to a sense of urgency in those arriving close to 3 hours after onset. Critical reviews such as this permit identification of hospital delays in stroke treatment, thus allowing institution of appropriate strategies to ensure prompt treatment.


Assuntos
Centros Médicos Acadêmicos/normas , Revisão de Uso de Medicamentos , Serviço Hospitalar de Emergência/normas , Tratamento de Emergência/normas , Fibrinolíticos/administração & dosagem , Auditoria Médica , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/estatística & dados numéricos , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Infusões Intravenosas , Pessoa de Meia-Idade , Qualidade da Assistência à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo , Estudos de Tempo e Movimento , Transporte de Pacientes/normas , Triagem/normas
15.
Med Clin (Barc) ; 127 Suppl 1: 3-20, 2006 Jul 18.
Artigo em Espanhol | MEDLINE | ID: mdl-17020674

RESUMO

The Consensus Document on Alternatives to Allogenic Blood Transfusion (AABT) has been drawn up by a panel of experts from 5 scientific societies. The Spanish Societies of Anesthesiology (SEDAR), Critical Care Medicine and Coronary Units (SEMICYUC), Hematology and Hemotherapy (AEHH), Blood Transfusion (SETS) and Thrombosis and Hemostasis (SETH) have sponsored and participated in this Consensus Document. Alternatives to blood transfusion have been divided into pharmacological and non-pharmacological, with 4 modules and 12 topics. The main objective variable was the reduction of allogenic blood transfusions and/or the number of transfused patients. The extent to which this objective was achieved by each AABT was evaluated using the Delphi method, which classifies the grade of recommendation from A (supported by controlled studies) to E (non-controlled studies and expert opinion). The experts concluded that most of the indications for AABT were based on middle or low grades of recommendation, "C", "D", or "E", thus indicating the need for further controlled studies.


Assuntos
Hemorragia/terapia , Ácido Aminocaproico/administração & dosagem , Ácido Aminocaproico/efeitos adversos , Ácido Aminocaproico/uso terapêutico , Antifibrinolíticos/administração & dosagem , Antifibrinolíticos/efeitos adversos , Antifibrinolíticos/uso terapêutico , Aprotinina/administração & dosagem , Aprotinina/efeitos adversos , Aprotinina/uso terapêutico , Perda Sanguínea Cirúrgica/prevenção & controle , Substitutos Sanguíneos/administração & dosagem , Substitutos Sanguíneos/efeitos adversos , Substitutos Sanguíneos/uso terapêutico , Transfusão de Sangue Autóloga , Coloides/administração & dosagem , Coloides/efeitos adversos , Coloides/uso terapêutico , Soluções Cristaloides , Desamino Arginina Vasopressina/administração & dosagem , Desamino Arginina Vasopressina/efeitos adversos , Desamino Arginina Vasopressina/uso terapêutico , Medicina Baseada em Evidências , Fator VIIa/administração & dosagem , Fator VIIa/efeitos adversos , Fator VIIa/uso terapêutico , Hematínicos/administração & dosagem , Hematínicos/efeitos adversos , Hematínicos/uso terapêutico , Hemodiluição , Hemorragia/tratamento farmacológico , Hemostáticos/administração & dosagem , Hemostáticos/efeitos adversos , Hemostáticos/uso terapêutico , Humanos , Ferro/administração & dosagem , Ferro/efeitos adversos , Ferro/uso terapêutico , Soluções Isotônicas/administração & dosagem , Soluções Isotônicas/efeitos adversos , Soluções Isotônicas/uso terapêutico , Recuperação de Sangue Operatório , Hemorragia Pós-Operatória/tratamento farmacológico , Pré-Medicação , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Proteínas Recombinantes/uso terapêutico , Ácido Tranexâmico/administração & dosagem , Ácido Tranexâmico/efeitos adversos , Ácido Tranexâmico/uso terapêutico
17.
Neuroepidemiology ; 25(4): 192-5, 2005.
Artigo em Inglês | MEDLINE | ID: mdl-16103730

RESUMO

The black Caribbean population continues to grow in the US and little is known about stroke etiologies in that community. We examined stroke subtypes in 175 consecutive Haitian-born patients living in Miami, admitted for acute stroke. Ischemic stroke was diagnosed in 72%. Small vessel occlusion was the most frequent stroke subtype. There was a high prevalence of hypertension, medication noncompliance and intracranial atherosclerosis. Hypertension was the only cardiovascular risk factor significantly associated with small vessel infarction when compared with non-small vessel infarcts.


Assuntos
Acidente Vascular Cerebral/etiologia , Fatores Etários , Idoso , População Negra , Doenças Cardiovasculares/epidemiologia , Hemorragia Cerebral/complicações , Hemorragia Cerebral/epidemiologia , Infarto Cerebral/complicações , Infarto Cerebral/epidemiologia , Circulação Cerebrovascular/fisiologia , Feminino , Florida/epidemiologia , Haiti/etnologia , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Acidente Vascular Cerebral/epidemiologia
18.
Arch Neurol ; 62(8): 1228-31, 2005 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-16087763

RESUMO

BACKGROUND: Acute multiple brain infarction (AMBI) pattern on diffusion-weighted imaging (DWI) is associated with arterial and cardiac sources of embolism. The DWI characteristics of patients with stroke due to vertebrobasilar arterial dissection and atherosclerotic disease have not been reported in detail. OBJECTIVE: To describe the DWI stroke patterns in patients with posterior circulation occlusive disease to determine mechanisms of ischemia. DESIGN: Retrospective analysis of infarct patterns in patients with symptomatic vertebrobasilar disease. SETTING: Large community-based teaching hospital. PATIENTS: Patients admitted with stroke due to vertebrobasilar disease were identified retrospectively. Patients were included if DWI was obtained within 7 days of symptom onset. MAIN OUTCOME MEASURE: Infarct patterns were analyzed according to established templates of vascular territories. RESULTS: Eleven patients with vertebral dissection and 39 patients with atherothrombosis were identified. An AMBI pattern was present in 8 (72%) of 11 patients with arterial dissections and 25 (64%) of 39 patients with atherosclerotic disease (P = .48). Distal embolism to the terminal branches of the basilar artery occurred with equal frequency in both groups and was found in half of all cases. Isolated thalamic infarction did not occur. Pontine infarction was noted in 2 (18%) of 11 patients with dissections and 18 (46%) of 39 patients with atherosclerosis (P = .09). Cerebellar border zone involvement was found in 14 (36%) of 39 patients with atherosclerosis and 4 (37%) of 11 patients with dissections (P = .6). CONCLUSIONS: Large arterial disease is frequently associated with AMBI in the posterior circulation. The incidence of AMBI was comparable to that reported in the anterior circulation. This DWI study supports the importance of embolism as the main mechanism of infarction in patients with vertebrobasilar occlusive disease. On the basis of our experience, large-vessel vertebrobasilar disease rarely causes isolated small-vessel thalamic infarction.


Assuntos
Artéria Basilar/patologia , Infarto Encefálico/patologia , Arteriosclerose Intracraniana/patologia , Dissecação da Artéria Vertebral/patologia , Artéria Vertebral/patologia , Insuficiência Vertebrobasilar/patologia , Adulto , Idoso , Artéria Basilar/fisiopatologia , Infarto Encefálico/etiologia , Infarto Encefálico/fisiopatologia , Tronco Encefálico/irrigação sanguínea , Tronco Encefálico/patologia , Tronco Encefálico/fisiopatologia , Cerebelo/irrigação sanguínea , Cerebelo/patologia , Cerebelo/fisiopatologia , Córtex Cerebral/irrigação sanguínea , Córtex Cerebral/patologia , Córtex Cerebral/fisiopatologia , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Arteriosclerose Intracraniana/complicações , Arteriosclerose Intracraniana/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tálamo/irrigação sanguínea , Tálamo/patologia , Tálamo/fisiopatologia , Artéria Vertebral/fisiopatologia , Dissecação da Artéria Vertebral/complicações , Dissecação da Artéria Vertebral/fisiopatologia , Insuficiência Vertebrobasilar/fisiopatologia
19.
Arch Neurol ; 61(4): 510-2, 2004 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-15096398

RESUMO

BACKGROUND: Acute multiple brain infarction pattern on diffusion-weighted imaging is associated with arterial or cardiac sources of embolism. OBJECTIVES: To review the diffusion-weighted imaging characteristics of patients with strokes secondary to internal carotid artery (ICA) dissection and to gain further insights into the mechanisms of cerebral ischemia. DESIGN: Patients with ICA dissection and ischemic stroke were identified by review of an angiographic database and hospital discharge codes. Patients were included if the diagnosis of ICA dissection was confirmed and diffusion-weighted imaging was obtained within 10 days of symptom onset. Infarct patterns were analyzed according to established templates of vascular territories. RESULTS: Inclusion criteria were met by 14 patients. Internal carotid artery occlusion was present in 10. Acute multiple brain infarction was found in 10 (71%) of the 14 patients. Cortical involvement was found in 8 patients, while the infarct was restricted to the subcortical region in 6. In 9 (64%) of the 14 patients, ischemic lesions were located in 1 of the 3 border zones. CONCLUSIONS: Acute multiple brain infarction pattern with border zone involvement is frequently found in ICA dissection-related strokes. This finding may further support an interaction of hemodynamic and embolic mechanisms as a cause of cerebral ischemia in this condition.


Assuntos
Isquemia Encefálica/etiologia , Dissecação da Artéria Carótida Interna/diagnóstico , Infarto Cerebral/etiologia , Imagem de Difusão por Ressonância Magnética , Aumento da Imagem , Processamento de Imagem Assistida por Computador , Doença Aguda , Adulto , Encéfalo/patologia , Isquemia Encefálica/diagnóstico , Artéria Carótida Interna/patologia , Dissecação da Artéria Carótida Interna/complicações , Estenose das Carótidas/diagnóstico , Angiografia Cerebral , Córtex Cerebral/patologia , Infarto Cerebral/diagnóstico , Feminino , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Exame Neurológico , Estudos Retrospectivos
20.
J Neuroimaging ; 14(2): 176-9, 2004 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-15095565

RESUMO

The authors report a patient with rapidly progressive cognitive decline due to bilateral internal carotid artery occlusion (ICAO) resulting in multiple pathologically proven cerebral infarctions including the entire length of the corpus callosum. The gradual evolution of the deficits was suggestive of hemodynamic ischemia. Bilateral ICAO should be considered in the differential diagnosis of patients with rapidly cognitive decline. Although ICAO commonly spares the splenium, complete callosal infarction is possible in the presence of bilateral ICAO.


Assuntos
Estenose das Carótidas/diagnóstico , Corpo Caloso/irrigação sanguínea , Demência por Múltiplos Infartos/diagnóstico , Dominância Cerebral/fisiologia , Aumento da Imagem , Processamento de Imagem Assistida por Computador , Infarto da Artéria Cerebral Média/diagnóstico , Imageamento por Ressonância Magnética , Estenose das Carótidas/patologia , Angiografia Cerebral , Circulação Colateral/fisiologia , Corpo Caloso/patologia , Demência por Múltiplos Infartos/patologia , Progressão da Doença , Eletroencefalografia , Evolução Fatal , Lobo Frontal/irrigação sanguínea , Lobo Frontal/patologia , Humanos , Infarto da Artéria Cerebral Média/patologia , Masculino , Pessoa de Meia-Idade
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