Outcomes and Experiences of Patients and Their Caregivers After Severe Stroke Requiring Tube Feeding in Peru.

OBJECTIVES: Evaluate clinical outcomes of stroke survivors in Peru discharged with artificial nutrition via a feeding tube (FT), and explore perspectives and experiences of these patients and their caregivers. METHODS: Retrospective chart review to describe the prevalence of FT placement and characteristics of patients admitted with stroke to the Instituto Nacional de Ciencias Neurológicas in Lima, Peru between January 2019 and 2021. Follow-up calls to stroke survivors discharged home with FTs or their caregivers included quantitative and qualitative questions to assess long-term outcome and explore perspectives around poststroke care and FT management. We analyzed quantitative data descriptively and applied thematic analysis to qualitative data using a consensus-driven codebook. RESULTS: Of 812 hospitalized patients with stroke, 146 (18%) were discharged home with FT, all with nasogastric tubes (NGTs). Follow-up calls were performed a median of 18 months after stroke with 96 caregivers and three patients. Twenty-five patients (25%) had died, and 82% of survivors (n = 61) remained dependent for some care. Four themes emerged from interviews: (1) perceived suffering (physical, emotional, existential) associated with the NGT and stroke-related disability, often exacerbated by lack of preparedness or prognostic awareness; (2) concerns around compromised personhood and value-discordant care; (3) coping with their loved-one's illness and the caregiving role; and (4) barriers to NGT care and skill acquisition. CONCLUSION: We identified a high burden of palliative and supportive needs among severe stroke survivors with NGTs and their caregivers suggesting opportunities to improve poststroke care through education, communication, and support.

Importance of multiplanar reformation angiographic images for the detection of carotid web: A case series.

Carotid web (CW) is considered a variant of intimal fibromuscular dysplasia. CW represents between 9.4% and 37% of ischemic strokes that were initially misclassified as "cryptogenic." However, in Latin America, there is a lack of detection. We present 5 cases of ischemic stroke due to CW and discuss the usefulness of multiplanar reformatting (MPR) imaging in computed tomography angiography. The identification of CW with the use of tridimensional (3D) reconstructions and maximum intensity projection was 20%, the rest was misdiagnosed as atherosclerotic plaque. With the MPR, the identification of typical CW findings was improved, such as a thin septum, a shelf-like image, and a mountain shadow-like image. However, one must be alert to changes in the 3D disposition of the carotid bifurcation, as they may mask the typical CW findings. A good practice is to align the internal carotid artery exactly posterior to the external carotid artery in the sagittal plane.

Bilateral Ischemic Strokes Secondary to Moyamoya Syndrome Associated With Graves Thyrotoxicosis in a Patient of Amerindian Descent From Peru: A Case Report.

Moyamoya disease (MMD) is characterized by progressive stenosis of the distal portion of the internal carotid artery and its two main branches, the middle cerebral artery, and the anterior cerebral artery. Clinically, MMD can present with ischemic or hemorrhagic cerebrovascular events. The term Moyamoya syndrome (MMS) is used when the characteristic Moyamoya vasculopathy presents in association with other conditions such as Graves' disease (GD). We report a case of a 34-year-old, right-handed male patient of Amerindian descent. He presented to the emergency room with a two-month history of palpitation, fatigue, and weight loss associated with sudden-onset left hemiparesis, facial asymmetry, and dysarthria. His workup was remarkable for elevated levels of thyroid hormones with the presence of autoantibodies and radiological findings typical of MMS. Moyamoya syndrome in association with Graves' disease has increasingly been noted in Latin American patients and should be considered in the differential diagnosis in the appropriate clinical context.

Spinal Dural Arteriovenous Fistula: A Mimic of Demyelinating Disease and Radiculopathy.

Spinal dural arteriovenous fistula (SDAVF) is characterized by an abnormal connection between a radicular artery and the venous plexus producing spinal cord venous congestion. It manifests with nonspecific sensory and motor symptoms. We present three cases of SDAVF with different forms of presentation; in two cases, an autoimmune etiology was considered, and in the third case, the initial diagnosis was chronic radiculopathy. In all three cases, a serpentine enhancement was observed after the gadolinium in the dorsal region of the spinal cord corresponded to flow voids in T2-weighted images, which guided the diagnosis. SDAVF should be considered in atypical clinical presentations of radiculopathies or spinal cord syndromes, especially spinal conus or epicone syndrome. Likewise, it should be part of the differential diagnosis of spinal cord presentations of demyelinating diseases such as multiple sclerosis or neuromyelitis optica spectrum disorders.

Carotid Web Diagnosed by Ultrasound Carotid Duplex in a Patient With Ischemic Stroke.

Carotid web (CW) is an atypical form of intimal fibromuscular dysplasia that occurs at the level of the carotid bulb. It is associated with ischemic strokes. The first report of this association was in 1967 and it is currently known to represent a significant percentage of cryptogenic stroke. We report the case of a young female patient with a history of transient ischemic attack who presented a cerebral infarction of the territory of the left middle cerebral artery. The diagnosis of CW was suggested by the findings of the ultrasound carotid duplex and was confirmed by digital subtraction angiography. Likewise, brain magnetic resonance angiography showed an incipient alteration in the morphology of the wall of the left internal carotid artery in its intracranial segment. Aspirin treatment was started and there was no recurrence up to two years of follow-up. CW represents a diagnostic challenge; it should be suspected in young adults with ischemic stroke. In them, studies of the supra-aortic vessels should be performed. Ultrasound carotid duplex can be a useful diagnostic tool.

Diagnostic Value of Thunderclap Headache and Convexal Subarachnoid Hemorrhage for Reversible Cerebral Vasoconstriction Syndrome: A Case Report.

Reversible cerebral vasoconstriction syndrome (RCVS) is an underdiagnosed cause of convexal subarachnoid hemorrhage, characterized by thunderclap headache associated with focal and segmental intracranial vasoconstriction. It can appear complications such as intracerebral hemorrhage, seizures, posterior reversible leukoencephalopathy, or ischemic stroke. Our objective is to present the case of a 51-year-old woman with an RCVS diagnosis, who had a normal digital subtraction angiography at the illness onset. We highlight the high diagnostic value of thunderclap headache and convexal subarachnoid hemorrhage. We also highlight the importance of repeating the angiographic studies in the second week when there is strong diagnostic suspicion.

Infarto cerebral limítrofe secundario a enfermedad inflamatoria orbitaria idiopática / Watershed cerebral infarction secondary to idiopathic orbital inflammatory disease

Los infartos limítrofes son aquellos ubicados en regiones entre dos territorios vasculares contiguos y la enfermedad inflamatoria orbitaria idiopática es un proceso inflamatorio orbitario inespecífico. Presentamos el caso de un varón de 60 años con exoftalmos, ptosis palpebral, disminución de agudeza visual derecha y afección de los nervios oculomotores derechos. Los estudios de imágenes mostraron una masa retro ocular derecha con invasión de los senos cavernosos y esfenoidal. Durante la hospitalización, el paciente sufrió un infarto cerebral limítrofe por compresión de la arteria carótida interna derecha en su segmento intracavernoso. La exéresis y la anatomía patológica de la lesión orbitaria fueron compatibles con la enfermedad inflamatoria orbitaria idiopática. Nuestro caso muestra a la enfermedad inflamatoria orbitaria idiopática como una causa inhabitual de infarto cerebral limítrofe.

Watershed cerebral infarctions are those located in regions between two adjacent vascular territories and Idiopathic orbital inflammatory disease is a nonspecific inflammatory process of the orbit. We report the case of a 60-year-old man who presented suddenly in the right eye: exophthalmos, ptosis, reduced visual acuity and paresis of the extraocular muscles innervated by the III, IV and VI cranial nerves. Imaging studies showed a right retro-ocular mass with invasion of the ipsilateral cavernous and sphenoid sinus. During hospitalization, suddenly he presented a watershed infarction with narrowing of the right internal carotid artery in its intracavernous portion. Surgical excision of the lesion was performed and pathology showed a characteristic infiltration of idiopathic orbital inflammatory disease. Our case shows idiopathic orbital inflammatory disease as an uncommon cause of watershed cerebral infarction.

Fistula carótido-cavernosa unilateral con síntomas neuro-oftalmológicos bilaterales e infarto cerebral venoso: Reporte de un caso / Carotid-cavernous fistula with bilateral neuro-ophthalmologic symptoms and venous ischemia: A case report

La fistula carótido-cavernosa es una comunicación anómala entre la arteria carótida y el seno cavernoso que provoca un shunt arteriovenoso patológico y cuyo origen es traumático o espontáneo. Las manifestaciones clínicas están relacionadas con el cambio de dirección del drenaje venoso y del flujo sanguíneo a través de la fístula e incluyen síntomas oculares tales como quemosis, exoftalmos y soplo orbitario, además de manifestaciones neurológicas como infartos venosos y hemorragias intracerebrales. Su presencia se confirma mediante la angiografía por sustracción digital (ASD) y la clasificación generalmente aceptada se basa en la propuesta por Barrow. El tratamiento endovascular ha sido el enfoque terapéutico preferido durante las últimas dos décadas; sin embargo, el tratamiento quirúrgico sigue siendo una opción cuando aquél falla o no está disponible. Se reporta el caso de una paciente de 71 años de edad, con antecedente de traumatismo cráneo-encefálico en la que se diagnósticó fístula carótido-cavernosa izquierda y síntomas neuro-oftalmológicos bilaterales asociados a un infarto venoso a nivel temporal izquierdo. La paciente fue intervenida quirúrgicamente y presentó una evolución clínica favorable.

The carotid-cavernous fistula is an abnormal communication between the carotid artery and the cavernous sinus that induces a pathological arterio-venous shunt, and whose origin may be traumatic or spontaneous. Its clinical symptoms are related to changes in the direction of the venous drainage and blood flow through the fistula, and include ocular symptoms as chemosis, exophthalmos and orbital murmur besides neurological manifestations such as venous infarctions and intracerebral hemorrhage. Its presence is confirmed by digital subtraction angiography and the generally accepted classification is based on Barrow'se proposal. Endovascular treatment has been the preferred treatment approach for the past two decades; however, surgical treatment remains an option when the former fails or is not possible. The case of a 71 year-old woman with a history of traumatic brain injury is reported: the patient was diagnosed with carotid-cavernous fistula and bilateral neuro-ophthalmic symptoms associated with left temporal venous infarction, and underwent surgical treatment with a favorable clinical outcome.

Enfermedad de Moyamoya: reporte de un caso / Moyamoya disease: a case report

La enfermedad de Moyamoya es una patología caracterizada por la estenosis progresiva de la arteria carótida interna y sus ramas principales. Es de etiología desconocida, tiene como forma de presentación a la enfermedad cerebrovascular isquémica o hemorrágica, siendo la primera más frecuente, y afecta en mayor proporción a niños y adultos jóvenes constituyendo un reto diagnóstico. Su presencia se confirma mediante la angiografía por sustracción digital (ASD) y el manejo es médico y/o quirúrgico, siendo el último el que se asocia a un mejor pronóstico. Comunicamos el caso de un paciente peruano de ascendencia japonesa, sin factores de riesgo, con una hemorragia intracraneal cuyo diagnóstico final fue enfermedad de Moyamoya...

Moyamoya disease is characterized by progressive stenosis of the internal carotid artery and its main branches. The cause of the disease is unknown, ischemic or hemorrhagic stroke are the main manifestations (the former is more common) that disproportionately affect children and young adults, and is consider a diagnostic challenge. Its presence is confirmed by digital subtraction angiography (DSA) and the management may be medical or surgical, being the latter associated with a better prognosis. We report the case of a Peruvian male of Japanese ancestry without risk factors, with an intracranial hemorrhage who was finally diagnosed with Moyamoya disease...

[Creutzfeldt-Jakob disease in Peru: report of eleven cases]. / Enfermedad de Creutzfeldt-Jakob en el Perú: reporte de once casos.

Creutzfeldt-Jakob disease (CJD) is a fatal neurological disease caused by pathological isoform of the human prion protein. Clinical features of six cases of the sporadic form of CJD with definitive diagnosis by histopathology, and five cases with probable diagnosis were reported in patients treated at the Peruvian National Institute of Neurological Sciences. The average age of onset in definite cases was 55.8 years and in probable cases was 59.6, mostly males. The average disease duration was 8.8 months. A typical EEG was found in 50% of definite cases and in 80% of probable. The 14-3-3 protein in cerebrospinal fluid was positive in a probable case, and typical MRI findings were observed in two probable cases. All cases studied had a typical clinical course of the disease, and it is considered as the first report of CJD in Peru.

Enfermedad de creutzfeldt-jakob en el Perú: reporte de once casos / Creutzfeldt-jakob disease in Peru: report of eleven cases

La enfermedad de Creutzfeldt-Jakob (ECJ) es una enfermedad neurológica fatal producida por la isoforma patológica de la proteína priónica humana. Se reporta las características clínicas de seis casos de la forma esporádica de ECJ con diagnóstico definitivo por histopatología, y cinco casos con diagnóstico probable, en pacientes atendidos en el Instituto Nacional de Ciencias Neurológicas del Perú. La edad de inicio en los casos definitivos fue de 55,8 años y, en los probables, de 59,6 años, con predominio del sexo masculino. El tiempo de enfermedad fue de 8,8 meses. Se encontró un EEG típico en 50% de los casos definitivos y 80% de los probables. La proteína 14-3-3 en líquido cefalorraquídeo fue positiva en un caso probable y los hallazgos típicos en resonancia magnética se observaron en dos casos probables. Todos los casos cursaron con una evolución clínica típica de la enfermedad, y se considera el primer reporte de ECJ en el Perú.

Creutzfeldt-Jakob disease (CJD) is a fatal neurological disease caused by pathological isoform of the human prion protein. Clinical features of six cases of the sporadic form of CJD with definitive diagnosis by histopathology, and five cases with probable diagnosis were reported in patients treated at the Peruvian National Institute of Neurological Sciences. The average age of onset in definite cases was 55.8 years and in probable cases was 59.6, mostly males. The average disease duration was 8.8 months. A typical EEG was found in 50% of definite cases and in 80% of probable. The 14-3-3 protein in cerebrospinal fluid was positive in a probable case, and typical MRI findings were observed in two probable cases. All cases studied had a typical clinical course of the disease, and it is considered as the first report of CJD in Peru.

Arteria trigeminal persistente: reporte de tres casos / Persistent trigeminal artery: three case reports

La persistencia de la arteria trigeminal es una alteración vascular infrecuente y representa la permanencia, después del nacimiento, de la comunicación entre el sistema carotideo y el sistema vertebro-basilar. Esta persistencia se ha asociado a la existencia de otras alteraciones de la morfología vascular cerebral y a condiciones clínicas variadas. Reportamos tres casos de persistencia de la arteria trigeminal, dos como hallazgo incidental en pacientes con sintomatología transitoria y uno en un cuadro de hemorragia subaracnoidea, identificados mediante reconstrucción tridimensional de imágenes obtenidas por angiotomografía.

Persistent trigeminal artery is a rare vascular disorder and represents the permanence of the communication between the carotid system and vertebrobasilar system after birth. This persistence has been associated with the existence of other alterations of brain vascular morphology and different clinical conditions. We report three cases of persistent trigeminal artery, two incidental findings in patients with transient symptoms and one in a patient with subarachnoid hemorrhage, identified by three-dimensional reconstruction of images obtained by angiotomography.

Absceso cerebral complicado con ruptura intraventricular: reporte de dos casos y revisión de la literatura / Intraventricular rupture of brain abscess: report of two cases and review of the literature

El absceso cerebral es una patología infecciosa infrecuente cuyo diagnóstico oportuno y tratamiento adecuado conducen a un buen pronóstico en la mayoría de los casos. La ruptura intraventricular es una complicación rara del absceso cerebral con elevada mortalidad; se caracteriza por compromiso brusco de la conciencia, con aparición de signos de irritación meníngea y hallazgos radiológicos compatibles con un drenaje de secreción purulenta hacia los ventrículos. El tratamiento incluye la administración de antibióticos intravenosos e intratecales asociados a una rápida intervención quirúrgica para drenaje del absceso y del contenido intraventricular. Presentamos dos casos de absceso cerebral complicado con ruptura intraventricular, que mostraron características clínicas y radiológicas propias de esta condición, con evolución favorable solo con tratamiento antibiótico endovenoso durante seis a diez semanas, respectivamente...

Brain abscess is an infrequent infectious disease that has a good prognosis in most of the cases with timely diagnosis and suitable treatment. Intraventricular rupture is a rare complication of the brain abscess with high mortality. It is characterized by a sudden consciousness compromise with signs of meningeal irritation and radiological findings compatible with purulent drainage into the ventricles. Treatment includes administration of intravenous and intrathecal antibiotics associated to prompt surgical intervention to drain the abscess and intraventricular content. Two cases of brain abscess complicated with intraventricular rupture showing clinical and radiological features typical of this condition and favorable outcome with intravenous antibiotic treatment during six and ten weeks respectively are reported...

Mielinolisis Central Pontina: a proposito de un caso / Central Pontine Myelinolysis: a case report

La Mielinolisis central pontina es una lesión desmielinizante en la base de la protuberancia que en la mayoría de los casos se produce por una rápida correción de la hiponatremia. Comunicamos el caso de un paciente varón de 29 años con cuadriparesia, ataxia disartria y parálisis bilateral del sexto nervio craneal de presentación siete días después de la correción hidroelectrlítica por un estado de deshidratación secundario a un cuadro emético. Los estudios de resonancia magnética mostraron un patrón compatible con la enfermedad y su evolución en el tiempo. Este caso resalta la importancia de plantear el diagnostico de mielinolisis central pontina en pacientes con comprmiso corticoespinal, corticobulbar y otras vías nerviosas, en quienes exista el antecedente de corrección hidroelectrolítica.

Central pontine myelinolysis is a demyelinating lesion in the basis pontis which in most cases is caused by a rapid correction of hyponatremia. we report the case of a 29 years old male patient presented with quadriparesis, ataxia, dysarthria and bilateral sixth nerve palsy appeared seven days after correction of fluid and electrolyte imbalance by a state of dehydration secondary to an emetic event. MRI studies showed a pattern consistent with the disease and its evolution over time. This case highlights the importance of addressing the diagnosis of central pontine myelinolysis in patients with commitment corticospinal, corticobulbar and other neural pathways, where there is a history of fluid and electroyte management.

Corea y eritrocitosis de altura: reporte de caso / Chorea and high altitude erythrocytosis: a case report

La corea es un trastorno del movimiento que tiene a la eritrocitosis como causa poco frecuente. La eritrocitosis o poliglobulia es el aumento de la masa eritrocitaria absoluta y su causa primaria más frecuente es la policitemia vera. Entre las causas secundarias adquiridas figura la eritrocitosis por hipoxia central, como la que ocurre en los habitantes de grandes alturas. La corea es una manifestación neurológica rara de la eritrocitosis, se presenta en 0,5 a 2% de estos pacientes. Se reporta el caso de un paciente de sexo masculino de 71 años de edad que presentó corea generalizada, de inicio súbito, a predominio orolinguofacial y de extremidades inferiores, secundario a eritrocitosis adquirida, que mejoró tras la disminución del hematocrito mediante sesiones sucesivas de flebotomías.

Chorea is a movement disorder which is rarely caused by erythrocytosis. Erithrocytosis or polycythemia is the augmentation of the absolute erythrocytic mass and its most common primary cause is polycythemia vera. Some of the secondary causes are erythrocytosis by central hipoxia occurring in people who live in the highlands. Chore is a rare neurological manifestation of erythrocytosis occurring in 0.5 to 2% of these patients. There was a report of a 71 year-old male patient with generalized chorea of sudden onset predominant in mouth, tongue and face and lower limbs, secondary to acquired erythrocytosis, which improved after the number of erythrocytes decreased through successive sessions of phlebotomy.

[Chorea and high altitude erythrocytosis: a case report]. / Corea y eritrocitosis de altura: reporte de caso.

Chorea is a movement disorder which is rarely caused by erythrocytosis. Erithrocytosis or polycythemia is the augmentation of the absolute erythrocytic mass and its most common primary cause is polycythemia vera. Some of the secondary causes are erythrocytosis by central hipoxia occurring in people who live in the highlands. Chore is a rare neurological manifestation of erythrocytosis occurring in 0.5 to 2% of these patients. There was a report of a 71 year-old male patient with generalized chorea of sudden onset predominant in mouth, tongue and face and lower limbs, secondary to acquired erythrocytosis, which improved after the number of erythrocytes decreased through successive sessions of phlebotomy.