COVID-19 Lockdown Effects on Acute Stroke Care in Latin America.

OBJECTIVES: COVID-19 pandemic has forced important changes in health care worldwide. Stroke care networks have been affected, especially during peak periods. We assessed the impact of the pandemic and lockdowns in stroke admissions and care in Latin America. MATERIALS AND METHODS: A multinational study (7 countries, 18 centers) of patients admitted during the pandemic outbreak (March-June 2020). Comparisons were made with the same period in 2019. Numbers of cases, stroke etiology and severity, acute care and hospitalization outcomes were assessed. RESULTS: Most countries reported mild decreases in stroke admissions compared to the same period of 2019 (1187 vs. 1166, p = 0.03). Among stroke subtypes, there was a reduction in ischemic strokes (IS) admissions (78.3% vs. 73.9%, p = 0.01) compared with 2019, especially in IS with NIHSS 0-5 (50.1% vs. 44.9%, p = 0.03). A substantial increase in the proportion of stroke admissions beyond 48 h from symptoms onset was observed (13.8% vs. 20.5%, p < 0.001). Nevertheless, no differences in total reperfusion treatment rates were observed, with similar door-to-needle, door-to-CT, and door-to-groin times in both periods. Other stroke outcomes, as all-type mortality during hospitalization (4.9% vs. 9.7%, p < 0.001), length of stay (IQR 1-5 days vs. 0-9 days, p < 0.001), and likelihood to be discharged home (91.6% vs. 83.0%, p < 0.001), were compromised during COVID-19 lockdown period. CONCLUSIONS: In this Latin America survey, there was a mild decrease in admissions of IS during the COVID-19 lockdown period, with a significant delay in time to consultations and worse hospitalization outcomes.

Cerebral venous thrombosis in Argentina: clinical presentation, predisposing factors, outcomes and literature review.

BACKGROUND: Cerebral venous thrombosis (CVT) is a rare medical condition that primarily affects young adults. The clinical spectrum is broad and its recognition remains a challenge for clinicians. Limited information is available on CVT in Argentina. Our goal was to report the results of the first National registry on CVT in Argentina and to compare clinical presentation, predisposing factors and outcomes with other international registries. MATERIAL AND METHOD: The Argentinian National Registry on CVT (ANR-CVT) is a multicenter retrospective cohort study comprising patients aged 18 and older with a diagnosis of CVT from January 2015 to January 2019. We evaluated demographics, predisposing factors, clinical presentation, and radiological characteristics (e.g. number of involved sinuses, venous infarction or hemorrhage on CT and MRI scans at admission), therapeutic interventions and functional outcomes at discharge and at 90 days. Our results were compared to a literature review of CVT registries. RESULTS: Overall, one hundred and sixty-two patients met the inclusion criteria. The mean age was 42 (±17) years; 72% were women. Seventy percent of patients were younger than 50 years. The most common presenting symptom was headache (82%). The transverse sinus was the most common site of thrombosis (70%) followed by the sigmoid sinus (46%). The main predisposing factor in women was contraceptive use (44%), 3% of the events occurred during pregnancy and 9% during the puerperium. Participants 50 years and older had a higher frequency on malignancy related (7.5% vs. 30%, p = 0.0001) and infections (2% vs. 11%, p = 0.001). The modified Rankin Scale (mRS) ≤2 at discharge was 81% and the rate of mortality at discharge was 4%. At 90 days, the mRS≤2 was 93%. When the ANR-CVT was compared with larger registries from Europe and Asia, the prevalence of cancer among patients with CVT was two to five-fold higher (15% vs. 7% and 3%, respectively; p = 0.002 and p < 0.001). Anticoagulation rates at discharge were also higher (94%) compared to registries from Asia (ASCVT - 68%) or Turkey (VENOST - 67%). CONCLUSION: Participants in the first ANR-CVT had a low mortality and disability at 90 days. Clinical and radiological characteristics were similar to CVT from other international registries with a higher prevalence of cancer. There was a high variability in treatment adherence to guidelines as reflected by anticoagulation rates (range 54.5%-100%) at discharge.

Stroke Care Trends During COVID-19 Pandemic in Zanjan Province, Iran. From the CASCADE Initiative: Statistical Analysis Plan and Preliminary Results.

BACKGROUND: The emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran. METHODS: This study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model. RESULTS: During the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE = 0.24, p < 0.0001). Furthermore, we observed lower admission rates for patients with mild (NIHSS < 5) ischemic stroke (p < 0.0001). Although, the presentation time and door-to-needle time did not change during the pandemic, a lower proportion of patients received thrombolysis (-10.1%; p = 0.004). We did not see significant changes in admission rate to the stroke unit and in-hospital mortality rate; however, disability at discharge increased (p < 0.0001). CONCLUSION: In Zanjan, Iran, the COVID-19 pandemic has significantly impacted stroke outcomes and altered the delivery of stroke care. Observed lower admission rates for milder stroke may possibly be due to fear of exposure related to COVID-19. The decrease in patients treated with thrombolysis and the increased disability at discharge may indicate changes in the delivery of stroke care and increased pressure on existing stroke acute and subacute services. The results of this research will contribute to a similar analysis of the larger CASCADE dataset in order to confirm findings at a global scale and improve measures to ensure the best quality of care for stroke patients during the COVID-19 pandemic.

[Neurologic complications of infective endocarditis: do they have an impact on prognosis?] / Endocarditis infecciosa: ¿Afectan su pronóstico las complicaciones neurológicas?

Neurologic complications of infective endocarditis have been observed in 20-40% of cases. Our aim was to determine the frequency of neurologic involvement, clinical manifestations, lesional patterns and evolution in patients with infective endocarditis. This was a prospective cohort study. We included 98 patients with left-sided infective endocarditis. Forty seven percent presented neurologic involvement at some time of the disease. The frequency of symptoms was: focal deficit 61%, sensory disturbance 17% and seizures 2%, while 20% remain asymptomatic. The most prevailing lesion was cerebral ischemia (76%). Vegetations larger than 1 cm were associated to neurologic involvement (57% vs. 31%, p = 0.01). Valvular replacement was more common among patients with neurologic involvement (70% vs. 44%, p = 0.01). Hospital mortality was 20% in patients with neurologic manifestation versus 15% of those without it (p = 0.5). The length of stay was significantly prolonged in patients with neurologic affection (32 ± 27 vs. 21 ± 15 days, p = 0.01) and a favorable Rankin assessment at the discharge was less likely in patients with neurologic involvement (36% vs. 74%, p = 0.0001). In this cohort, the most frequent clinical manifestation was focal deficit and the most prevalent pattern of lesion was cerebral ischemia. Those with neurologic involvement presented an increased length of stay and more disability at the discharge but not statistical significant difference in hospital mortality.

[Pachymeningitis associated with IgG4 disease]. / Paquimeningitis asociada a enfermedad por IgG4.

Hypertrophic pachymeningitis is an infrequent disorder. It can be idiopathic or secondary to infectious, autoimmune or neoplastic disease. The recently described 〈IgG4-related disease〉 could be the origin of many cases considered cryptogenic. We present the case of a 60-year-old man, with a history of headache and episcleritis in both eyes, with partial response to corticoid therapy. The brain MR study with gadolinium showed enhancement and thickening of the dura mater, extending from lateral wall of left temporal and occipital lobes to ipsilateral tentorium. Meningeal biopsy showed fibrosis and lymphoplasmacytic infiltrate, with more than 10 IgG4+ plasma cells per high power field. After treatment with rituximab there was clinical improvement accompanied by the virtual disappearance of the alterations detected in neuroimaging. Hypertrophic pachymeningitis as a manifestation of IgG4-related disease can be based on MRI findings if plasma IgG4 are elevated.

[Clinical predictors of hemorrhagic transformation in non lacunar ischemic stroke]. / Predictores clínicos de transformación hemorrágica en accidente cerebrovascular isquémico no lacunar.

Hemorrhagic transformation is a complex phenomenon where brain tissue bleeds, which could be associated or not to an increase in the neurological deficit after the acute ischemic stroke. The aim of our study was to evaluate clinical predictors of hemorrhagic transformation in patients with non-lacunar ischemic stroke. We performed a prospective analysis of the clinical records and images of patients with non-lacunar ischemic stroke. Demographics, vascular risk factors, previous medications and the information of the event in patients with and without hemorrhagic transformation were here compared. We included in this study 747 patients with non-lacunar stroke, the mean age was 77 ± 11 years and 61% were females. In the univariate analysis, the age, a history of hypertension, atrial fibrillation, chronic kidney disease and the previous use of oral anticoagulation resulted statistically significant. In the multivariate analysis of logistic regression adjusted by age and vascular risk factors: the age > 80 years (OR 3.6, CI 95% 1.8-7.6), the pulse pressure > 60 mmHg at admission (OR 5.3, CI 95% 3.2-9.1), the chronic kidney disease (OR 3, CI 95% 2.5-3.8) and the presence of previous atrial fibrillation (OR 3.5, CI 95% 2.1-6.1) were associated with and increased risk of hemorrhagic transformation. The predictors of hemorrhagic transformation in our cohort showed a relationship with severe vascular illness. The identification of these patients could influence therapeutic decisions that could increase the risk of hemorrhagic transformation.

Recent respiratory infection predicts atherothrombotic stroke: case-control study in a Buenos Aires healthcare system.

BACKGROUND AND PURPOSE: Increasing evidence links infections to atherosclerosis. Case-control and cohort studies have found that infections, especially respiratory and dental, are associated with coronary heart disease. However, data on the association of infections with cerebrovascular disease are limited, especially beyond Europe and the United States. We assessed the relationship between recent infections and atherothrombotic disease in a South American cohort. METHODS: We conducted a case-control study of 105 cases and 354 control subjects in a Buenos Aires healthcare system matched by age (mean age, 73.2+/-12.3 and 72.9+/-12.8 years), sex, and major cardiovascular risk factors. Cases were patients hospitalized with atherothrombotic ischemic stroke from December 2006 to October 2007. Control subjects were randomly assigned from an electronic outpatient database. Data from the preceding year on inpatient and ambulatory respiratory, urinary and abdominal infections as well as peripheral white blood cell count were collected. RESULTS: Infections were more frequent in cases than control subjects (29% versus 13%; OR, 2.6; 95% CI, 1.4 to 4.5; P=0.0004); however, this was driven by community-acquired respiratory tract infections (19% versus 6%; OR, 3.9; 95% CI, 1.9 to 8; P<0.001) because there were no differences between cases and control subjects for other types of infection. Respiratory tract infections were the most prevalent type of infection during the 3 months before an atherothrombotic ischemic event, occurring more in cases compared with control subjects (17% versus 4%; OR, 5; 95% CI, 2.2 to 11.3; P<0.001). In multivariable analysis adjusting for major vascular risk factors, history of respiratory infection in the prior year was associated more with cases than control subjects (OR, 4.9; 95% CI, 2.3 to 10.2;P<0.001). White blood cell count was slightly higher in cases versus control subjects (7602+/-2058 versus 7121.6+/-1947, P=0.01). CONCLUSIONS: In this South American cohort, recent respiratory tract infections were significantly associated with atherothrombotic stroke, suggesting that prompt identification and treatment of individuals with or at risk for these infections may mitigate the burden from this type of stroke.

Embolic stroke secondary to cardiac papillary fibroelastoma.

INTRODUCTION: Papillary fibroelastoma is the most common primary cardiac valvular tumor. Historically, papillary fibroelastoma was an incidental autopsy finding, deemed to have no clinical significance. More recently, reports of symptomatic cases of papillary fibroelastoma with complications such as myocardial infarction and stroke suggest it should be considered a potentially dangerous lesion. In this report, we describe the clinical and echocardiographic findings of 3 patients with cardiac papillary fibroelastoma who presented with cerebral vascular events. OBJECTIVE: To describe the clinical and echocardiographic findings of 3 patients with cardiac papillary fibroelastoma (CPF) who presented cerebral vascular events. METHODS: Describe the findings of 3 patients and review of the literature. RESULTS: We report 3 cases with cerebral ischemic events associated with the presence of CPF that were confirmed by histopathological examination. CONCLUSIONS: Cardiogenic embolism is recognized increasingly as an important cause of stroke, accounting of 20% of ischemic strokes. Cardioembolic stroke is largely preventable. The likelihood of recurrence is relatively high for most cardioembolic sources and therefore secondary stroke prevention is fundamental. TEE allowed to characterize well-established sources of embolism, and it was the best diagnostic approach in our patients. Magnetic resonance imaging was used in 1 of these patients, while it confirmed the presumptive diagnosis of cardiac tumor. The first-choice treatment of symptomatic CPF is surgical excision which must be performed as early as possible to reduce the risk of early recurrences of embolic events. The use of TEE in the evaluation of cerebral vascular events is not routinely performed, this method must be considered in patients for whom the cause of cerebrovascular ischemia is unclear, after noninvasive neurovascular studies.

Transesophageal echocardiography findings in lacunar stroke.

BACKGROUND: Transesophageal echocardiography (TEE) constitutes a valuable tool in patients with stroke and cardiac embolization, but its indication is controversial in lacunar stroke. The purpose of this study was to assess the findings of TEE in lacunar stroke. METHODS: Initial symptoms, brain computed tomography or magnetic resonance imaging, and TEE were performed for all patients with ischemic stroke admitted consecutively to our department of neurology. The subtype of ischemic stroke (lacunar v large-vessel stroke) was also reviewed. RESULTS: In all, 124 patients with ischemic stroke were identified and lacunar syndrome occurred in 46. Major risk factor of embolization in patients with lacunar stroke and indication for anticoagulation were detected in 20% (9 of 46). We compared findings in both groups (lacunar v nonlacunar stroke) to evaluate the differences in the presence of major risk factor for embolization, Chi square = 0.07, P = .8 (odds ratio 95% CI = 0.35-2.18). Characteristics of the 9 patients with lacunar stroke and major risk of embolization show that history of lacunar ischemic stroke was present in all the patients of this group. DISCUSSION: The results of the study suggest that TEE may be necessary to obtain a complete evaluation to optimize preventive treatment in patients with clinical and radiologic presentation that suggest lacunar infarct, particularly in cases with a history of ischemic stroke, in which a potential cardiac source of embolization may be detected.

[Spinocerebellar ataxia 7. Clinical and genetic investigation in an Argentine family]. / Ataxia espinocerebelosa 7. Investigacion clinica y genetica en una familia Argentina.

Spino cerebellar ataxia (SCA) are a complex group of hereditary neurodegenerative disturbances of autosomal dominant pattern. They are largely characterized by the clinical presence of cerebellar ataxia related to ophtalmoplegia, dysarthria, pyramidal and extra-pyramidal signs and loss of deep sensitivity. SCA 7 belongs to the SCA group in which the disturbance is a result of the expansion of CAG triplet repetition located in the 3p12-p21 chromosome. The characteristic clinical feature of SCA7 is the loss of visual acuity and blindness. We present here three cases of ataxia, from the same family, with loss of visual acuity and other neurological disorders. The diagnosis was confirmed by a genetic analysis of the index case in whom the characteristic genetic abnormality of SCA7 was discovered. To our knowledge, this is the first case of SCA7 confirmed by genetic study in Argentina. Only two other reports on family cases were found in a review of the literature of Latin America up to January 2006. The purpose of our report is to draw attention to the diagnosis of this degenerative disease in patients with progressive cerebellar ataxia associated with loss of visual acuity symptoms, where a positive family history is found.

Recomendaciones en el abordaje del hematoma intracerebral espontáneo durante la internación / Recommendations for the management of spontaneous intracerebral hemorrhage during hospitalization

Resumen El accidente cerebrovascular (ACV) constituye la principal causa de discapacidad de origen neuro- lógico en los adultos mayores a 40 años y la cuarta causa de muerte en Argentina. En los últimos diez años las publicaciones indexadas relacionadas al tratamiento del ACV isquémico fueron más numerosas que las de ACV hemorrágico. El objetivo de este material es proporcionar recomendaciones locales y actualiza- das del abordaje de pacientes con hematoma intraparenquimatoso espontáneo durante la internación. Para la redacción de este manuscrito se convocó a especialistas en esta enfermedad que conformaron grupos de trabajo. Se plantearon 10 tópicos centrales expresados como epidemiologia, atención inicial, imágenes, tratamiento de la presión arterial, reversión de antitrombóticos, indicación de cirugía, profilaxis anticonvulsivante, pronóstico, prevención de complicaciones y reinicio de antitrombóticos. De cada tópico se plantearon mediante preguntas PICO los interrogantes más frecuentes de la práctica diaria. Luego de una revisión sistemática de la literatura, se generaron recomendaciones evaluadas mediante sistema GRADE y consensuadas entre autores y pacientes.

Abstract Stroke is the leading cause of neurological disability in people over 40 years of age and the fourth leading cause of death in Argentina. In the last ten years, the indexed publications related to the treatment of ischemic stroke were more numerous than those of hemorrhagic stroke. The objective of this material is to provide local and updated recommendations for the management of patients with spontaneous intracere- bral hemorrhage during hospitalization. For the writing of this manuscript, diferent specialists were convened to form working groups. Ten central topics expressed as epidemiology, initial care, imaging, blood pressure treatment, reversal of antithrombotics, indication for surgery, seizure prophylaxis, prognosis, prevention of complications and resumption of antithrombotics were raised. For each topic, the most frequent questions of daily practice were raised through PICO questions. After a systematic review of the literature, recommendations were generated, evaluated using the GRADE system and agreed between authors and patients.

[Ischemic stroke registry]. / Registro de enfermedad cerebrovascular isquemica.

Current knowledge of stroke risk factors and epidemiology is based mostly on USA or European studies; scarce data have been published from developing countries. Because epidemiological and clinical characteristics in stroke vary according to regional factors, we need to know the peculiarities of stroke on this subcontinent. The purpose is to describe the clinical subtypes and risk factors in patients with ischemic stroke. We analyzed all consecutive ischemic stroke in patients admitted at Hospital Italiano of Buenos Aires, between June 1, 2003 and June 1, 2005. Among 395 ischemic stroke patients, the mean age was 71.36 years (+/- 13.82) and 55% were male. Ischemic stroke subtypes were as follows: 40% patients had lacunar, 20% atherosclerotic stroke, 10% cardioembolic infarction, and 5% other causes of stroke. Hypertension (76%), hyperlipemia (50%) and prior stroke (34%) were the most frequent risk factors. Most patients with cortical symptoms had significant large-artery atherosclerosis (> 70%). Stroke informations in developing countries is difficult to obtain. This could be the reason for the very few stroke registries in South America. Hypertension was the most frequent risk factor in our registry. The pattern of stroke subtypes seems to be different from that reported in other regions of the world, with a higher frequency of small-vessel disease.

Edema perianeurismático cerebral. Reporte de dos casos / Cerebral perianeurysmal edema. Report of two cases

La hemorragia subaracnoidea (HSA) secundaria a ruptura aneurismática es una causa importante de morbimortalidad. Hay muchos factores que aumentan la probabilidad de ruptura, como el tamaño, forma, localización, exclusión endovascular incompleta del aneurisma, entre otros. Existen reportes sobre el edema cerebral perianeurismático como factor de riesgo de ruptura aneurismática. Se presentan en el siguiente artículo dos casos, ambos con aneurisma silviano del lado derecho, asociado a edema "perianeurismático".

Subarachnoid hemorrhage (SAH) secondary to aneurysmal rupture is an important cause of morbidity and mortality. There are many factors that increase the probability of rupture, the size, shape, location, incomplete endovascular exclusion of the aneurysm, among others. There are reports on perianeurysmal cerebral edema as a risk factor for aneurysmal rupture. Two cases are presented in the following article, both with right-sided sylvian aneurysm, associated with "perianeursmatic" edema.

Paquimeningitis asociada a enfermedad por IgG4 / Pachymeningitis associated with IgG4 disease

La paquimeningitis hipertrófica es una enfermedad infrecuente. Puede ser idiopática, secundaria a infección o enfermedad oncológica. Recientemente se la describió asociada a la enfermedad por IgG4, pudiendo ser esta la causa de muchas clasificadas como idiopáticas. Se presenta el caso de un hombre de 60 años de edad con historia de cefalea y epiescleritis, con respuesta parcial a corticoides. La resonancia magnética con contraste evidenciaba refuerzo meníngeo a nivel temporal y occipital izquierdo con extensión a la tienda del cerebelo. La biopsia meníngea demostró fibrosis e infiltrado linfoplasmocitario con más de 10 células plasmáticas IgG4 positivas por campo de gran aumento. El tratamiento con rituximab provocó mejoría clínica y radiológica. La paquimeningitis hipertrófica es una manifestación de la enfermedad por IgG4 y debe ser sospechada con la resonancia magnética y niveles plasmáticos altos de IgG4.

Hypertrophic pachymeningitis is an infrequent disorder. It can be idiopathic or secondary to infectious, autoimmune or neoplastic disease. The recently described ‹IgG4-related disease› could be the origin of many cases considered cryptogenic. We present the case of a 60-year-old man, with a history of headache and episcleritis in both eyes, with partial response to corticoid therapy. The brain MR study with gadolinium showed enhancement and thickening of the dura mater, extending from lateral wall of left temporal and occipital lobes to ipsilateral tentorium. Meningeal biopsy showed fibrosis and lymphoplasmacytic infiltrate, with more than 10 IgG4+ plasma cells per high power field. After treatment with rituximab there was clinical improvement accompanied by the virtual disappearance of the alterations detected in neuroimaging. Hypertrophic pachymeningitis as a manifestation of IgG4-related disease can be based on MRI findings if plasma IgG4 are elevated.

Endocarditis infecciosa: ¿afectan su pronóstico las complicaciones neurológicas? / Neurologic complications of infective endocarditis: do they have an impact on prognosis?

De acuerdo a la literatura, en un 20 a 40% de las endocarditis infecciosas se producen complicaciones neurológicas. Nuestro objetivo fue determinar la frecuencia de compromiso neurológico en pacientes con endocarditis infecciosa de válvulas izquierdas, considerando la presentación clínica, tipo de lesión en las imágenes y su influencia en la evolución. Se incluyeron en forma prospectiva 98 pacientes con endocarditis infecciosa de válvulas izquierdas. El 47% (46 casos) presentó compromiso neurológico. En 28 casos (61%) el síntoma fue el déficit focal, en 9 (20%) la alteración de estado de conciencia; el 17% (8) fue asintomático y 2% (1 caso) presentó convulsiones. En las imágenes, la isquemia cerebral (76%) fue la lesión más frecuente. El tamaño de la vegetación mayor a 1 cm se asoció a compromiso neurológico (57% vs. 31%, p = 0.01). Aquellos pacientes con compromiso neurológico tuvieron mayor frecuencia de reemplazo valvular (70% vs. 44%, p = 0.01) y la mortalidad hospitalaria también fue mayor (20% vs. 15%, p = 0.5). El tiempo total de internación fue significativamente más prolongado en sujetos con compromiso neurológico (32 ± 27 vs. 21 ± 15 días, p = 0.01) y la discapacidad fue mayor en los que tenían manifestaciones neurológicas (74% vs. 36% p = 0.0001). En nuestra serie, el síntoma más frecuente fue el déficit focal, y en las imágenes la isquemia cerebral fue el patrón más común. Los casos con lesión neurológica presentaron mayor tiempo de internación y grado de discapacidad al alta, pero no mayor mortalidad hospitalaria.

Neurologic complications of infective endocarditis have been observed in 20-40% of cases. Our aim was to determine the frequency of neurologic involvement, clinical manifestations, lesional patterns and evolution in patients with infective endocarditis. This was a prospective cohort study. We included 98 patients with left-sided infective endocarditis. Forty seven percent presented neurologic involvement at some time of the disease. The frequency of symptoms was: focal deficit 61%, sensory disturbance 17% and seizures 2%, while 20% remain asymptomatic. The most prevailing lesion was cerebral ischemia (76%). Vegetations larger than 1 cm were associated to neurologic involvement (57% vs. 31%, p = 0.01). Valvular replacement was more common among patients with neurologic involvement (70% vs. 44%, p = 0.01). Hospital mortality was 20% in patients with neurologic manifestation versus 15% of those without it (p = 0.5). The length of stay was significantly prolonged in patients with neurologic affection (32 ± 27 vs. 21 ± 15 days, p = 0.01) and a favorable Rankin assessment at the discharge was less likely in patients with neurologic involvement (36% vs. 74%, p = 0.0001). In this cohort, the most frequent clinical manifestation was focal deficit and the most prevalent pattern of lesion was cerebral ischemia. Those with neurologic involvement presented an increased length of stay and more disability at the discharge but not statistical significant difference in hospital mortality.

Predictores clínicos de transformación hemorrágica en accidente cerebrovascular isquémico no lacunar / Clinical predictors of hemorrhagic transformation in non lacunar ischemic stroke

La transformación hemorrágica es un fenómeno complejo en el que el tejido cerebral isquémico sangra; este proceso puede asociarse o no a un deterioro del estado neurológico inicial. El objetivo de nuestro estudio fue evaluar los predictores clínicos de trasformación hemorrágica en los pacientes con accidente cerebrovascular isquémico no lacunar. Se analizaron las historias clínicas y las imágenes de pacientes con infarto cerebral no lacunar incluidos prospectivamente en un programa de prevención secundaria. Se compararon datos demográficos, factores de riesgo vascular, medicación previa y datos del evento de los pacientes con transformación hemorrágica y sin ella. Se incluyeron 747 pacientes, la edad promedio fue de 77 ± 11 años, 61% mujeres. En el análisis univariado, la edad, el antecedente de hipertensión arterial, la fibrilación auricular, la insuficiencia renal crónica y la anticoagulación oral previa se relacionaron significativamente con la presencia de transformación hemorrágica. En el análisis multivariado de regresión logística ajustado por edad y factores de riesgo vascular, resultaron predictores de transformación hemorrágica: la edad > 80 años (OR 3.6; IC 95% 1.8-7.6), la presión de pulso > 60 mmHg al ingreso (OR 5.3; IC 95% 3.2-9.1), la insuficiencia renal crónica (OR 3; IC 95% 2.5-3.8) y el antecedente de fibrilación auricular (OR 3.5; IC 95% 2.1-6.1). En nuestra cohorte los predictores clínicos de conversión hemorrágica del infarto cerebral muestran una relación con la gravedad de la enfermedad vascular. La identificación de estos pacientes influenciaría en la toma de decisiones terapéuticas que pudieran incrementar el riesgo de transformación hemorrágica.

Hemorrhagic transformation is a complex phenomenon where brain tissue bleeds, which could be associated or not to an increase in the neurological deficit after the acute ischemic stroke. The aim of our study was to evaluate clinical predictors of hemorrhagic transformation in patients with non-lacunar ischemic stroke. We performed a prospective analysis of the clinical records and images of patients with non-lacunar ischemic stroke. Demographics, vascular risk factors, previous medications and the information of the event in patients with and without hemorrhagic transformation were here compared. We included in this study 747 patients with non-lacunar stroke, the mean age was 77 ± 11 years and 61% were females. In the univariate analysis, the age, a history of hypertension, atrial fibrillation, chronic kidney disease and the previous use of oral anticoagulation resulted statistically significant. In the multivariate analysis of logistic regression adjusted by age and vascular risk factors: the age > 80 years (OR 3.6, CI 95% 1.8-7.6), the pulse pressure > 60 mmHg at admission (OR 5.3, CI 95% 3.2-9.1), the chronic kidney disease (OR 3, CI 95% 2.5-3.8) and the presence of previous atrial fibrillation (OR 3.5, CI 95% 2.1-6.1) were associated with and increased risk of hemorrhagic transformation. The predictors of hemorrhagic transformation in our cohort showed a relationship with severe vascular illness. The identification of these patients could influence therapeutic decisions that could increase the risk of hemorrhagic transformation.

Accidente cerebrovascular de causa hemodinámica / Hemodynamic causes in cerebrovascular ischemic event

El accidente cerebrovascular hemodinámico es una entidad pobremente descripta. Puede ser causada por enfermedades sistémicas tales como insuficiencia cardíaca o hipotensión y también por la obstrucción grave de las arterias carótidas o vertebrales. Los pacientes con accidente cerebrovascular hemodinámico pueden mostrar características clínicas específicas que los distinguen de los pacientes con embolia o enfermedad de pequeños vasos. Los estudios complementarios de perfusión cerebral pueden mostrar si el flujo de sangre al cerebro se ve comprometido y proporcionar información de valor pronóstico. El tratamiento dirigido a incrementar el flujo sanguíneo cerebral podría ser considerado en pacientes con estenosis graves de las arterias extracraneanas sobre la base de la información proveniente de series de casos. (AU)

Hemodynamic stroke is a poorly described entity. It can be caused by systemic diseases such as heart failure or hypotension, but also by severe obstruction of the carotid or vertebral arteries. Patients with hemodynamic cerebrovascular event might show specific clinical features that distinguish them from patients with embolism or local small-vessel disease. Complementary studies of cerebral perfusion can show whether blood flow to the brain is compromised and provide important prognostic information. Treatment aimed at increasing cerebral blood flow might be considered in patients with severa extracraneal artery stenosis on the basis of information from case series. (AU)