Nontraumatic convexity subarachnoid hemorrhage: different etiologies and outcomes.

BACKGROUND: Nontraumatic convexity subarachnoid hemorrhage (cSAH) is a rarely reported condition with multiple etiologies. We report the clinical presentation, imaging findings, etiologies, and long-term outcomes of a case series of cSAH. METHODS: We retrospectively analyzed consecutive cases of cSAH, admitted at a Stroke Unit of a tertiary hospital (January 2006 to March 2012). Recorded variables were demographics, clinical presentation, complementary investigation, etiology, and outcome. RESULTS: We included 15 patients (9 men, median age of 65 years), 7% of the 210 nontraumatic SAH patients in this period. The most common clinical manifestation was a focal neurologic deficit. Predominant location of the cSAH was frontal. In 5 cases, there was a clinical significant internal carotid artery (ICA) atheromatous stenosis, ipsilateral to cSAH. Two patients had a possible cerebral amyloid angiopathy (CAA) at presentation. There were 2 cases of reversible cerebral vasoconstriction syndrome, 1 cerebral venous thrombosis, 2 dural fistulae, and 3 undetermined. Short-term outcomes were good in most patients. At follow-up (24.3 months), 2 of the patients with undetermined etiology had a lobar hematoma conferring a severe disability, and the diagnosis of CAA was made. There were no other relevant events or added disability in the other patients. CONCLUSIONS: Significant ICA atherosclerotic stenosis was the most frequent cause of cSAH in our series, reinforcing that cSAH should prompt vascular imagiological evaluation including cervical vessels. Outcomes in cSAH seem to be related to etiology. Patients with undetermined etiology should be followed up because cSAH may be the first manifestation of CAA.

Feline oral cavity lesions diagnosed by histopathology: a 6-year retrospective study in Portugal.

OBJECTIVES: The aim of this study was to analyse the frequency of oral cavity lesions in cats, their anatomical location and histological diagnosis, and the effect of life stage, breed and sex on different diagnoses. METHODS: For this purpose, a retrospective study comprising 297 feline oral cavity lesions was performed over a 6-year period between 2010 and 2015. Histopathological records from the DNAtech Pathology Laboratory (Lisbon, Portugal) were analysed. RESULTS: The incidence of oral disease was higher in male cats (n = 173; 58.4%), mature adults (ranging from 7 to 10 years old [n = 88; 33.0%]) and in the European Shorthair breed (n = 206; 73.6%). The gingiva was the site where oral lesions were most commonly found, with 128 samples (43.1%). Incisional biopsies were used to obtain the majority of samples (n = 256; 86.2%), while excisional biopsies and punch biopsies were performed in 36 (12.1%) and five (1.7%) cases, respectively. Inflammatory and neoplastic lesions accounted for 187 (63%) and 110 (37%) of the studied cases, respectively. Malignancies were found in >80% of neoplastic cases. Feline chronic gingivostomatitis was the most common histological diagnosis (n = 116; 39.1%), followed by squamous cell carcinoma (n = 49; 16.5%) and eosinophilic granuloma complex (n = 33; 11.1%). CONCLUSIONS AND RELEVANCE: The present work, involving a large series of samples of feline oral cavity lesions, from numerous geographically scattered practices and all examined at a reference veterinary pathology laboratory, adds important new understanding of the epidemiology of feline oral disease.

Study of cerebral cavernous malformation in Spain and Portugal: high prevalence of a 14 bp deletion in exon 5 of MGC4607 (CCM2 gene).

OBJECTIVE: We aimed to study clinical, radiological and molecular genetic features of patients with cerebral cavernous malformations (CCMs) from the Iberian Peninsula. METHODS: We screened Krit1(CCM1), MGC4607(CCM2), and PDCD10(CCM3) by systematic SSCP and direct sequencing of coding exons in 48 nuclear families and 30 sporadic cases of CCM from Spain and Portugal. RESULTS: Screening of CCM patients detected nine different mutations in 19 families. We found four new mutations in Krit1. Three of them were caused by either a small insertion or deletion, which lead to frameshift and premature termination codons. We also found a missense L308H mutation located in a highly conserved sequence within the ankyrin domain of Krit1. In CCM2, we found a redundant 14 bp deletion in exon 5 of MGC4607 which predicts a truncated protein at residue 230. We did not find mutations in CCM3. CONCLUSIONS: Finding that the 14 bp deletion was present in eleven families from the Iberian Peninsula indicates a high prevalence of this mutation. This redundant CCM2 mutation is worth considering in molecular diagnosis and genetic counselling of cerebral cavernous malformations.

Chiropractic manipulation: reasons for concern?

Chiropractic's popularity is rising among the general population. Moreover, few studies have been conducted to properly evaluate its safety. We report three cases of serious neurological adverse events in patients treated with chiropractic manipulation. The first case is a 41 years old woman who developed a vertebro-basilar stroke 48 h after cervical manipulation. The second case represents a 68 years old woman who presented a neuropraxic injury of both radial nerves after three sessions of spinal manipulation. The last case is a 34 years old man who developed a cervical epidural haematoma after a chiropractic treatment for neck pain. In all three cases there were criteria to consider a causality relation between the neurological adverse events and the chiropractic manipulation. The described serious adverse events promptly recommend the implementation of a risk alert system.

Improvement of sleep architecture in the follow up of a patient with bilateral paramedian thalamic stroke.

Normal sleep architecture and arousal require an intact thalamus. Thalamic vascular lesions, particularly in the paramedian region may cause arousal disturbances and hypersomnolence. Although hypersomnolence is one of the main characteristics of acute bilateral paramedian thalamic infarcts, there are only scarce reports in literature concerning polysomnographic follow-up of these patients. The few reported cases in literature show that sleep stages do not significantly change from the acute to chronic phase. We present a case report of a patient with a bilateral paramedian thalamic infarct in which a polysomnographic evaluation of sleep was performed four days and five months after stroke. In the acute phase, polysomnography showed an impairment of phase 2 NREM and absence of phase 3 and 4 NREM with absent sleep spindles. After the acute stroke phase, hypersomnolence improved and sleep spindles reappeared as well as phase 3 and 4 of NREM sleep. Our patient clear clinical and polysomnographic improvement makes us suppose that in this case the initial impairment could have been essentially due to a functional transitory impairment of the thalamocortical and corticothalamic connections. This case report is peculiar because it discloses a marked improvement of sleep architecture which to the best of our knowledge has not been clearly described before.

N-terminal probrain natriuretic peptide as a biomarker of cardioembolic stroke.

BACKGROUND: and purpose N-terminal probrain natriuretic peptide, which is mainly produced by the heart, is increased in acute stroke. We aimed to determine if N-terminal probrain natriuretic peptide could be a biomarker for ischemic stroke with a cardioembolic cause. METHODS: Consecutive sample of acute stroke patients admitted to a Stroke Unit. Ischemic stroke subtype was classified using the TOAST classification. Blood samples were drawn within 72 h after stroke onset. Serum N-terminal probrain natriuretic peptide concentration was measured using an electrochemiluminescence immunoassay. Mean values of N-terminal probrain natriuretic peptide were compared between patients with hemorrhagic stroke vs. ischemic stroke, cardioembolic stroke vs. noncardioembolic stroke, cardioembolic stroke with atrial fibrillation vs. noncardioembolic stroke using t-test. Receiver operating characteristic curves were used to test the ability of N-terminal probrain natriuretic peptide values to identify cardioembolic stroke and cardioembolic stroke with atrial fibrillation. RESULTS: Ninety-two patients were included (66 with ischemic stroke) with a mean age of 58·6 years. Twenty-eight (42·4%) ischemic strokes had a cardioembolic cause. Mean N-terminal probrain natriuretic peptide values for cardioembolic stroke were significantly higher (P<0·001) (491·6; 95% confidence interval 283·7-852·0 pg/ml) than for noncardioembolic ischemic stroke (124·7; 86·3-180·2 pg/ml). The area under the receiver operating characteristic curve for N-terminal probrain natriuretic peptide in cardioembolic stroke was 0·77. The cut-off point with the highest sensitivity and specificity was set at 265·5 pg/ml (71·4% and 73·7% respectively). The area under the curve of N-terminal probrain natriuretic peptide for cardioembolic stroke related to atrial fibrillation was 0·92, cut-off was set at 265·5 pg/ml (sensitivity 94·4%, specificity 72·9%). CONCLUSION: N-terminal probrain natriuretic peptide is a biomarker with a good accuracy to predict ischemic stroke of cardioembolic cause, namely associated with atrial fibrillation.

Lumbar puncture and dural sinus thrombosis--a causal or casual association?

BACKGROUND: A few cases of cerebral venous thrombosis (CVT) were reported after a lumbar puncture (LP), suggesting a causal association. The purpose of our study was to document that LP might predispose to CVT by decreasing blood flow velocities (BFV) in veins or dural sinus. METHODS: We performed a transcranial Doppler ultrasound study to register the mean BFV of the straight sinus (SS) before, during and after LP. RESULTS: Thirteen patients were studied. LP induced a decrease of 47% of mean BFV in the SS. The mean decrease of BFV was significant immediately at the end (p = 0.003), 30 min after (p = 0.015) and more than 6 h after LP (p = 0.008). CONCLUSIONS: LP induced a sustained decrease of mean BFV in the SS. The decrease of venous blood flow is a possible mechanism contributing to the occurrence of CVT.

Thrombolytics for cerebral sinus thrombosis: a systematic review.

BACKGROUND AND PURPOSE: The use of thrombolytics is frequently mentioned in patients with cerebral venous or dural sinus thrombosis (CVDST) who deteriorate despite anticoagulant therapy. The aim of this review was to collect all the published information about their use in CVDST and to assess their efficacy and safety. METHODS: To find cases of CVDST treated with thrombolytics, we performed a MEDLINE search from 1966 to July 2001, checked all reference lists of studies found and hand searched volumes of 11 journals. Data was extracted by means of a standardised data extraction form. Proportions and 95% confidence intervals (CI) were calculated for outcomes and complications of thrombolytics. Cases were stratified according to variables that may influence the outcome and subgroups were compared by odds ratios and 95% CI. RESULTS: No randomised clinical trial (RCT) was found. Seventy-two studies (169 patients) were included. Urokinase was the thrombolytic most frequently administered (76%). In the majority of cases the thrombolytic was locally infused in the occluded sinus (88%). At discharge, 10 cases (7%; 95% CI 3-12%) were dependent and 9 cases (5%; 95% CI 2-9%) died. Intracranial haemorrhages occurred in 17% of cases. In 5% they were associated with clinical deterioration. Extracranial haemorrhages occurred in 21%, but only 2% required blood transfusion. CONCLUSIONS: Thrombolytics appeared to be reasonably safe in CVDST, but its efficacy cannot be assessed from the published data. Considering that CVDST is an uncommon disease, a randomised controlled trial to assess effectiveness and safety of local thrombolytics in cases of CVDST with poor prognosis is difficult but not impossible to undertake, on a multicentre international collaboration trial.