Digital analyses of nuclear features can help discriminate among non-invasive follicular thyroid neoplasm with papillary-like nuclear features, papillary thyroid carcinoma follicular subtype, and follicular carcinoma in cytological specimens.

BACKGROUND: As it stands, the diagnosis of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) is primarily based on histological analysis. We hypothesised that computerised analysis of nuclear images of cytological specimens could be used to differentiate NIFTP from papillary thyroid carcinoma follicular subtype (PTCFS) and follicular carcinoma (FC), influencing patient management. METHODS: We employed a retrospective analytical observational study based on nuclear morphometric variables of cytological material from thyroid nodules classified as PTCFS, NIFTP, or FC. Five cases of each entity were analysed. Cytological slides were photographed, and 1170 cells for each entity were analysed digitally. The captured images were evaluated (blindly) using the ImageJ software package. The morphometric evaluation included area, perimeter, width, height, and circularity. Numerical variables were expressed as mean, median, minimum, and maximum (min; max) values. Kruskal-Wallis and Dunn's tests were used with a 5% significance level. RESULTS: Regarding nuclear analysis, all variables differed among the three groups (p < 0.001). Given the interdependence among the variables, these data indicated that nuclear size was greatest in the NIFTP group, followed by FC and PTCFS. DISCUSSION/CONCLUSION: Our analysis of the digital images, with a focus on nuclear parameters, found significantly difference among cytological specimens from cases of NIFTP, PTCFS and FC. Thus, this tool has the potential to provide additional information that may help in the diagnosis of NIFTP, even during the preoperative period. Additional studies are needed to create protocols, evaluate the applicability of nuclear morphological and morphometric parameters-focusing on digital pathology-and create algorithms and tools to assist cytopathologists with their diagnostic routines.

Thyroid FNA performed by cytopathologists accompanied by radiologists guiding the ultrasound provide high-level quality results: A retrospective observational study.

BACKGROUND: On thyroid cytology, false negative and false positive rates are considered parameters for quality control. Nevertheless, there are few studies about medical professional involved in this procedure. We conducted a 4-year cytohistological correlation of thyroid specimens in a single institution. To describe cytological and histological correlation where radiologists guide the ultrasound (US) and cytopathologists perform the thyroid fine needle aspiration (FNA). METHODS: Retrospective observational study of thyroid specimens in a Brazilian countryside setting. The ultrasound was performed by radiologists, and the FNA was performed by pathologists. All cases were reviewed by two pathologists following the Bethesda Reporting System for Reporting Thyroid Cytopathology and the World Health Organization's Classification of Tumours of Endocrine Organs. Clinical information, such as sex, age, location, and ultrasound data, was collected from our reports. RESULTS: From a total of 3265 patients, 3703 nodules (391 patients showed more than one nodule) were submitted to FNA. For correlation, there were 168 surgical thyroidectomy specimens. The risk of malignancy for the Bethesda system categories were: nondiagnostic/unsatisfactory = 0/4 (0%); benign = 1/38 (2.6%); atypia of undetermined significance or follicular lesion of undetermined significance = 2/20 (10.0%); follicular neoplasm or suspicious for follicular neoplasm = 3/16 (18.7%); suspicious for malignancy = 63/67 (94.0%); and malignant = 22/23 (95.6%). CONCLUSION: High-level quality results can be accomplished with cooperation between cytopathologists performing thyroid FNA accompanied by radiologists guiding the ultrasound.

Impact of Extent of Investigation on Causes of Ischemic Stroke in The Young: A Retrospective Evaluation.

Background: Despite enormous advances in the diagnosis and treatment of ischemic stroke over the past decades, the extent of "standard" investigation to define its causes is heterogeneous. Young patients often undergo a myriad of diagnostic tests in developed countries, but the cost-effectiveness of this approach is uncertain. Objectives: Our main goal was to compare the frequencies of ischemic stroke of undetermined and determined etiologies in young patients with "complete" or "incomplete" investigation according to either a stepwise or an extensive protocol. Methods: Data from 143 young patients with ischemic stroke were reviewed. For each patient, available data were assessed by means of a stepwise and an extensive protocol of investigation. We compared the frequencies of ischemic stroke of undetermined and determined etiology according to "complete" or "incomplete" investigation according to each protocol. Results: Completeness of investigation led to a significant increase in determination of stroke etiology when a stepwise approach but not an extensive protocol was applied. Conclusions: These results suggest that ordering an extensive workup to all young patients does not enhance the capability of determining causes of ischemic stroke. Evidence-based guidelines to define pathways of investigation and consensus about the interpretation of tests are deeply needed.

Interhemispheric asymmetry of corticomotor excitability after chronic cerebellar infarcts.

Early after stroke, there is loss of intracortical facilitation (ICF) and increase in short-interval intracortical inhibition (SICI) in the primary motor cortex (M1) contralateral to a cerebellar infarct. Our goal was to investigate intracortical M1 function in the chronic stage following cerebellar infarcts (>4 months). We measured resting motor threshold (rMT), SICI, ICF, and ratios between motor-evoked potential amplitudes (MEP) and supramaximal M response amplitudes (MEP/M; %), after transcranial magnetic stimulation was applied to the M1 contralateral (M1(contralesional)) and ipsilateral (M1(ipsilesional)) to the cerebellar infarct in patients and to both M1s of healthy age-matched volunteers. SICI was decreased in M1(contralesional) compared to M1(ipsilesional) in the patient group in the absence of side-to-side differences in controls. There were no significant interhemispheric or between-group differences in rMT, ICF, or MEP/M (%). Our results document disinhibition of M1(contralesional) in the chronic phase after cerebellar stroke.

[Stroke in a neurology ward: etiologies, complications and length of stay]. / Acidente vascular cerebral isquêmico em uma enfermaria de neurologia: complicações e tempo de internação.

INTRODUCTION: Purposes of this study were: evaluate complications and length of stay of patients admitted with diagnosis of ischemic stroke (IS) in the acute or subacute phase, in a general Neurology ward in São paulo, Brazil; investigate the influence of age, risk factors for vascular disease, arterial territory and etiology. METHODS: Data from 191 IS patients were collected prospectively. RESULTS: Fifty-one patients (26.7%) presented at least one clinical complication during stay. pneumonia was the most frequent complication. Mean length of stay was 16.8+-13.8 days. Multivariate analysis revealed a correlation between younger age and lower complication rates (OR=0.92-0.97, p < 0.001). presence of complications was the only factor that independently influenced length of stay (OR=4.20; CI=1.928.84; p<0.0001). CONCLUSION: These results should be considered in the planning and organization of IS care in Brazil.

Stroke management in a university hospital in the largest South American city.

OBJECTIVE: To describe characteristics and provision of care for patients admitted with cerebrovascular disorders (CVD), focusing on ischemic stroke (IS), in a large, public, academic hospital in São Paulo, Brazil. METHOD: We retrieved information about 357 patients with CVD admitted to the Neurology Emergency Department (NED) and Neurology Ward (NW) of our institution. We described patient characteristics and management of IS in NED and in NW. RESULTS: IS was diagnosed in 79.6% of CVD patients admitted to NED; 2.7% were submitted to thrombolysis. Extent of IS investigation and management were significantly different in NED and NW. CONCLUSION: IS patients in our center were younger than in developed countries. IS management was significantly influenced by patient characteristics. This information can aid in planning strategies to decrease stroke burden.

"Salt and pepper" in the eye and face: a prelude to brainstem ischemia.

PURPOSE: To report the "salt and pepper"(SP) eye pain as a herald symptom of pontine ischemia. DESIGN: Observational case series. METHODS: We reviewed clinical and neuroimaging findings of four patients who presented initially with the sensation of SP in the eyes and then developed paramedian pontine infarcts confirmed by neuroimaging. RESULTS: All of the patients developed other neurologic symptoms or signs, either in association with the sensation of SP in the eyes, from hours to days later. Magnetic resonance imaging (MRI) showed paramedian pontine infarcts in all of the patients and angiography showed basilar artery occlusive disease in three of them. CONCLUSION: Impending pontine ischemia is an important differential diagnosis in patients with acute ocular pain. Prompt neurovascular evaluation and treatment may avoid devastating brainstem infarcts that cause death or long-term disability, particularly in patients with basilar artery occlusive disease.

Bilateral occipital infarcts associated with carotid atherosclerosis and a persistent hypoglossal artery.

The persistent hypoglossal artery (PHA) is the second most common persistent embryological carotid-basilar connection and usually represents an incidental finding in cerebral arteriograms. The hypoglossal artery connects the primordial carotid artery with the longitudinal neural arteries, which later form the basilar artery. The PHA leaves the internal carotid artery as an extracranial branch, enters the skull through the anterior condyloid foramen, the hypoglossal canal and joins the caudal portion of the basilar artery. We report magnetic resonance and digital subtraction angiography findings in the first case of bilateral occipital infarctions associated with PHA and carotid atherosclerosis. The probable mechanism underlying bilateral occipital infarcts was embolism from the carotid territory to the posterior cerebral arteries. PHA may present a challenge in diagnosis and management of patients with carotid atherosclerosis and vertebrobasilar ischemia.

Methylenetetrahydrofolate reductase gene polymorphism is not related to the risk of ischemic cerebrovascular disease in a Brazilian population.

PURPOSE: Data are conflicting concerning the risk for ischemic stroke associated with a common polymorphism in the gene encoding 5,10-methylenetetrahydrofolate reductase C677T, which predisposes carriers to hyperhomocysteinemia. A meta-analysis study suggested that the 5,10-methylenetetrahydrofolate reductase 677TT genotype might have a small influence in determining susceptibility to ischemic stroke. METHODS: We analyzed the 5,10-methylenetetrahydrofolate reductase 677TT genotype polymorphism in Brazilian subjects with ischemic stroke, using a case-control design. RESULTS: We compared 5,10-methylenetetrahydrofolate reductase genotypes in groups of subjects presenting ischemic stroke (n = 127) and normal control (n = 126) and found an odds ratio of 1.97 (95% CI, 0.84-4.64) in a multivariate analysis in which results were adjusted to baseline clinical characteristics of study participants. CONCLUSION: We found that the homozygous 5,10-methylenetetrahydrofolate reductase C677T genotype was not a risk factor for ischemic stroke in these Brazilian subjects.

Screening for MELAS mutations in young patients with stroke of undetermined origin.

PURPOSE: It has been suggested that mitochondrial disease may be responsible for a substantial proportion of strokes of indetermined origin. We have preliminarily screened for MELAS (mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes) mutations in young patients with cryptogenic strokes. METHOD: The mitochondrial mutations A3243G and T3271C were investigated in 38 subjects aged less than 46 years. Group 1: 15 patients with cryptogenic strokes; Group 2: 3 patients with diagnosis of MELAS syndrome, including stroke-like episodes; Group 3: 20 healthy subjects. RESULTS: The A3243G mutation was absent in all subjects in Groups 1 and 3 but was present in all subjects in Group 2. CONCLUSION: Our results do not support screening for these mutations to diagnose oligosymptomatic forms of MELAS in cryptogenic strokes in the absence of other features of the syndrome. We suggest that clinical findings should guide mitochondrial genetic testing.

Endovascular treatment of a basilar artery dissecting aneurysm.

Basilar artery (BA) dissecting aneurysms pose difficulties to treatment because both bleeding and thrombosis can happen in the same patient, clinical course is unpredictable and high morbidity is usual. We report the case of a 37-year-old woman with a BA aneurysm probably caused by arterial dissection, presenting embolic and hemorrhagic complications. The aneurysm was submitted to endovascular treatment with stenting and coil embolization. Clinical and radiological results were excellent and no complications were observed, suggesting that BA stenting and coil embolization may be a safe and effective treatment for this condition.

Comparison between digital subtraction angiography and magnetic resonance angiography in investigation of nonlacunar ischemic stroke in young patients: preliminary results.

PURPOSE: We preliminarily investigated the relevance of performing digital subtraction angiography (DSA) in addition to magnetic resonance angiography (MRA) in definition of ischemic stroke etiology in young patients. METHOD: DSAs and MRAs from 17 young patients with nonlacunar ischemic stroke were blindly analyzed and their impact on stroke management was evaluated. RESULTS: Etiologies were the same considering results of either DSA or MRA in 12/17 cases. In 15/17 patients no changes would have been made in treatment, regardless of the modality of angiography considered. CONCLUSION: These preliminary results suggest that DSA may be redundant in two thirds of ischemic strokes in young patients. Further larger prospective studies are necessary to determine indications of DSA in this age group.

Cerebral microbleeds and intravenous thrombolysis: case report.

Intravenous thrombolysis is an important procedure that has significant impact on ischemic stroke prognosis. However, intracranial hemorrhage (ICH) is a feared complication of this procedure. It has been suggested that cerebral microbleeds (CMBs) may increase the risk of ICH after thrombolysis. We report on a 69 years-old woman with multiple CMBs submitted to intravenous thrombolysis without complications.

Facial sensory symptoms in medullary infarcts.

OBJECTIVE: To investigate the correlation between facial sensory abnormalities and lesional topography in eight patients with lateral medullary infarcts (LMIs). METHOD: We reviewed eight sequential cases of LMIs admitted to the Neurology Division of Hospital das Clínicas/São Paulo University between July, 2001 and August, 2002 except for one patient who had admitted in 1996 and was still followed in 2002. All patients were submitted to conventional brain MRI including axial T1-, T2-weighted and Fluid attenuated inversion-recovery (FLAIR) sequences. MRIs were evaluated blindly to clinical features to determine extension of the infarct to presumed topographies of the ventral trigeminothalamic (VTT), lateral spinothalamic, spinal trigeminal tracts and spinal trigeminal nucleus. RESULTS: Sensory symptoms or signs were ipsilateral to the bulbar infarct in 3 patients, contralateral in 4 and bilateral in 1. In all of our cases with exclusive contralateral facial sensory symptoms, infarcts had medial extensions that included the VTT topography. In cases with exclusive ipsilateral facial sensory abnormalities, infarcts affected lateral and posterior bulbar portions, with slight or no medial extension. The only patient who presented bilateral facial symptoms had an infarct that covered both medial and lateral, in addition to the posterior region of the medulla. CONCLUSION: Our results show a correlation between medial extension of LMIs and presence of contralateral facial sensory symptoms.

[Neuroprotective agents in stroke: national opinion]. / Neuroproteção no acidente vascular celebral: opinião nacional.

The Brazilian Stroke Society constituted a committee composed by specialists from different areas of Brazil that emitted a viewpoint called "National Opinion", written similar to the consensus pattern. The study purpose is to guide and offer subsidies for diagnosis and therapeutical plans for different situations in cerebrovascular diseases. The current article analyses "neuroprotective agents in stroke", discussing the level of evidence for the use of potential neuroprotective drugs and ongoing clinical trials.

The association of post-stroke anhedonia with salivary cortisol levels and stroke lesion in hippocampal/parahippocampal region.

BACKGROUND: Anhedonia constitutes a coherent construct, with neural correlates and negative clinical impact, independent of depression. However, little is known about the neural correlates of anhedonia in stroke patients. In this study, we investigated the association of post-stroke anhedonia with salivary cortisol levels and stroke location and volume. PATIENTS AND METHODS: A psychiatrist administered the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition to identify anhedonia in 36 inpatients, without previous depression, consecutively admitted in a neurology clinic in the first month after a first-ever ischemic stroke. Salivary cortisol levels were assessed in the morning, evening, and after a dexamethasone suppression test. We used magnetic resonance imaging and a semi-automated brain morphometry method to assess stroke location, and the MRIcro program according to the Brodmann Map to calculate the lesion volume. RESULTS: Patients with anhedonia had significantly larger diurnal variation (P-value =0.017) and higher morning levels of salivary cortisol (1,671.9±604.0 ng/dL versus 1,103.9±821.9 ng/dL; P-value =0.022), and greater stroke lesions in the parahippocampal gyrus (Brodmann area 36) compared to those without anhedonia (10.14 voxels; standard deviation ±17.72 versus 0.86 voxels; standard deviation ±4.64; P-value =0.027). The volume of lesion in the parahippocampal gyrus (Brodmann area 36) was associated with diurnal variation of salivary cortisol levels (rho=0.845; P-value =0.034) only in anhedonic patients. CONCLUSION: Our findings suggest that anhedonia in stroke patients is associated with the volume of stroke lesion in the parahippocampal gyrus and with dysfunction of the hypothalamic-pituitary-adrenal axis.

Progressive cervicocranial arteriopathy with dilatations and stenoses: case report.

We report the case of a 36 year-old woman who presented occlusion of a basilar artery fusiform aneurysm (FA) associated with pontine infarction, and two episodes of subarachnoid hemorrhage possibly due to arterial dissection. She also had asymptomatic FAs in the right middle cerebral and left internal carotid arteries. Over 5 years, lesions suggestive of fibromuscular dysplasia in the right vertebral artery and occlusion of the left vertebral artery were observed. This combination of lesions emphasizes the possibility of a common pathogenetic mechanism causing different degrees of media disruption in cervicocranial arteries.

[Spontaneous cervical carotid and vertebral arteries dissection: study of 48 patients]. / Dissecção espontânea cervical carotídea e vertebral: estudo de 48 pacientes.

OBJECTIVE: To report a Brazilian series of spontaneous cervical arterial dissections, risk factors, warning symptoms, clinical manifestations, diagnostic tests, treatment and prognosis. METHOD: We performed the retrospective analysis of clinical and neuroradiological records (MRI, A-MRI and Angiography) of patients with this diagnosis who were evaluated in a tertiary hospital for the period of 1997-2003. RESULTS: 48 patients (24 men) with median age 37.9 years: 26 patients with unilateral internal carotid dissection (ICAD), 15 with unilateral vertebral artery dissection (VAD) and 7 with multivessel dissections. All patients presented neurological deficits. Hypertension, smoking and dyslipidemia were the main risk factors. More than 80% of patients presented at least one initial symptom, most of them temporoparietal headache. 44% of patients with VAD and only 3.4% of patients with ICAD had neck pain. The median interval between the onset of symptom and the appearance of neurological deficit was 5.4 days for ICAD and 13.5 days for VAD. Five patients with ICAD presented preceding TIA. Angiography was performed in 93% of patients. In 42% of these patients, MRI and A-MRI were associated. In three patients the diagnosis was made just through cervical MRI. 75% of patients received anticoagulation. Two patients received intravenous thrombolytic therapy with no complications. Prognosis was good for all patients but two patients with bilateral ICAD died. CONCLUSION: Our results are similar to the literature, except for the low frequency of neck pain in ICAD patients and predominance of temporoparietal headache in cervical artery dissection patients. Vascular risk factors were commonly found.