Perspectiva neurológica en la elección del anticoagulante oral directo para la prevención del accidente cerebrovascular en fibrilación auricular / Neurological perspective in the choice of direct oral an ticoagulants for prevention of stroke in atrial fibrillation

Resumen La fibrilación auricular no valvular (FA) es la arritmia con potencial embolígeno más prevalente y una de las principales y crecientes causas de accidente cerebrovas cular isquémico (ACVi). El principal objetivo del uso de la anticoagulación en pacientes con FA es la prevención del ACVi. Hasta hace poco tiempo, la anticoagulación con antagonistas de la vitamina K (AVKs) era la única opción disponible. Los anticoagulantes orales directos (DOACs) como el inhibidor directo de la trombina, dabigatrán, o los inhibidores directos del factor Xa, rivaroxabán, apixa bán y edoxabán, tienen un perfil de efectividad/seguridad más favorable en comparación con los AVKs. No existen estudios que comparen la efectividad de los DOACs entre sí. La elección del DOAC depende de múltiples factores específicos del paciente, preferencias del médico, costos y accesibilidad. Entre 1-2% de los pacientes correctamente tratados con un DOAC intercurre con un ACVi cada año. La posibilidad de contar con un agente reversor debería ser tenida en cuenta al momento de la elección del DOAC, especialmente por el riesgo residual de ocurrencia de ACVi. En la actualidad, en nuestro país solo el dabigatrán cuenta con un agente reversor disponible y lo convierte en el único DOAC que no contraindica el uso de trombolisis intraveno sa con rtPA. Esta situación debería ser considerada en el momento de la elección del DOAC para la prevención de eventos tromboembólicos en pacientes con FA.

Abstract Non-valvular atrial fibrillation (AF) is the most preva lent arrhythmia with high embolic potential, and one of the main and growing causes of stroke. The main objec tive of anticoagulation in patients with AF is prevention of stroke. Until recently, anticoagulation with vitamin K antagonists (VKAs) was the only available option. Direct oral anticoagulants (DOACs), such as the direct thrombin inhibitor dabigatran, or the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban, have a more favor able effectiveness/safety profile compared to VKAs. There are no studies comparing the efficacy of DOACs with each other. The choice of a DOAC arose from patient car achterictis, physician preferences, cost, and accessibility. Between 1-2% of patients correctly treated with a DOAC experience a stroke each year. The possibility of having a reversal agent should be taken into account when choos ing a DOAC, especially due to the residual risk of stroke occurrences even under DOACs. Currently, in our country only dabigatran has a reversing agent available, making it the only DOAC that does not contraindicate the use of intravenous thrombolysis. This should be taken into account when choosing the DOAC for the prevention of thromboembolic events in patients with AF.

Evaluating Rates of Recurrent Ischemic Stroke Among Young Adults With Embolic Stroke of Undetermined Source: The Young ESUS Longitudinal Cohort Study.

Importance: Cryptogenic strokes constitute approximately 40% of ischemic strokes in young adults, and most meet criteria for the embolic stroke of undetermined source (ESUS). Two randomized clinical trials, NAVIGATE ESUS and RESPECT ESUS, showed a high rate of stroke recurrence in older adults with ESUS but the prognosis and prognostic factors among younger individuals with ESUS is uncertain. Objective: To determine rates of and factors associated with recurrent ischemic stroke and death and new-onset atrial fibrillation (AF) among young adults. Design, Setting, and Participants: This multicenter longitudinal cohort study with enrollment from October 2017 to October 2019 and a mean follow-up period of 12 months ending in October 2020 included 41 stroke research centers in 13 countries. Consecutive patients 50 years and younger with a diagnosis of ESUS were included. Of 576 screened, 535 participants were enrolled after 1 withdrew consent, 41 were found to be ineligible, and 2 were excluded for other reasons. The final follow-up visit was completed by 520 patients. Main Outcomes and Measures: Recurrent ischemic stroke and/or death, recurrent ischemic stroke, and prevalence of patent foramen ovale (PFO). Results: The mean (SD) age of participants was 40.4 (7.3) years, and 297 (56%) participants were male. The most frequent vascular risk factors were tobacco use (240 patients [45%]), hypertension (118 patients [22%]), and dyslipidemia (109 patients [20%]). PFO was detected in 177 participants (50%) who had transthoracic echocardiograms with bubble studies. Following initial ESUS, 468 participants (88%) were receiving antiplatelet therapy, and 52 (10%) received anticoagulation. The recurrent ischemic stroke and death rate was 2.19 per 100 patient-years, and the ischemic stroke recurrence rate was 1.9 per 100 patient-years. Of the recurrent strokes, 9 (64%) were ESUS, 2 (14%) were cardioembolic, and 3 (21%) were of other determined cause. AF was detected in 15 participants (2.8%; 95% CI, 1.6-4.6). In multivariate analysis, the following were associated with recurrent ischemic stroke: history of stroke or transient ischemic attack (hazard ratio, 5.3; 95% CI, 1.8-15), presence of diabetes (hazard ratio, 4.4; 95% CI, 1.5-13), and history of coronary artery disease (hazard ratio, 10; 95% CI, 4.8-22). Conclusions and Relevance: In this large cohort of young adult patients with ESUS, there was a relatively low rate of subsequent ischemic stroke and a low frequency of new-onset AF. Most recurrent strokes also met the criteria for ESUS, suggesting the need for future studies to improve our understanding of the underlying stroke mechanism in this population.

Frequency and Patterns of Brain Infarction in Patients With Embolic Stroke of Undetermined Source: NAVIGATE ESUS Trial.

BACKGROUND AND PURPOSE: The spectrum of brain infarction in patients with embolic stroke of undetermined source (ESUS) has not been well characterized. Our objective was to define the frequency and pattern of brain infarcts detected by magnetic resonance imaging (MRI) among patients with recent ESUS participating in a clinical trial. METHODS: In the NAVIGATE ESUS trial (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source), an MRI substudy was carried out at 87 sites in 15 countries. Participants underwent an MRI using a specified protocol near randomization. Images were interpreted centrally by those unaware of clinical characteristics. RESULTS: Among the 918 substudy cohort participants, the mean age was 67 years and 60% were men with a median (interquartile range) of 64 (26-115) days between the qualifying ischemic stroke and MRI. On MRI, 855 (93%) had recent or chronic brain infarcts that were multiple in 646 (70%) and involved multiple arterial territories in 62% (401/646). Multiple brain infarcts were present in 68% (510/755) of those without a history of stroke or transient ischemic attack before the qualifying ESUS. Prior stroke/transient ischemic attack (P<0.001), modified Rankin Scale score >0 (P<0.001), and current tobacco use (P=0.01) were associated with multiple infarcts. Topographically, large and/or cortical infarcts were present in 89% (757/855) of patients with infarcts, while in 11% (98/855) infarcts were exclusively small and subcortical. Among those with multiple large and/or cortical infarcts, 57% (251/437) had one or more involving a different vascular territory from the qualifying ESUS. CONCLUSIONS: Most patients with ESUS, including those without prior clinical stroke or transient ischemic attack, had multiple large and/or cortical brain infarcts detected by MRI, reflecting a substantial burden of clinical stroke and covert brain infarction. Infarcts most frequently involved multiple vascular territories. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02313909.

Uso y resultados de la fibrinolisis intravenosa en una unidad cerebrovascular / Use and results of intravenous fibrinolysis in a stroke unit

Resumen La fibrinólisis intravenosa con activador del plasminógeno tisular recombinante (rTPA) y la utilización de unidades cerradas, demostraron disminuir sustancialmente la morbimortalidad en pacientes con accidente cerebrovascular isquémico (ACVi). Sin embargo, los datos publicados en Argentina son escasos. Describimos la experiencia en la utilización de fibrinólisis en pacientes con ACVi agudo antes y después de la implementación de una unidad cerebrovascular (UCV) en un Centro Integral de Neurología Vascular de la Ciudad de Buenos Aires durante 17 años. Se realizó un análisis retrospectivo de pacientes consecutivos tratados con rTPA entre enero 2003 y diciembre 2019. Se evaluaron tiempos de tratamiento, de internación, complicaciones post tratamiento y discapacidad a 3 meses. Para su análisis se evaluaron los períodos pre y post apertura de la UCV, período 1 (P1 de 2003-2011) y P2 (2012 -2019). Se realizó fibrinolisis intravenosa en 182 pacientes. La apertura de UCV resultó en aumento del porcentaje de fibrinólisis sobre el total de los ACVi ingresados (4% en P1 vs. 10% en P2, p < 0.001), acortamiento del tiempo puerta-aguja (75 minutos en P1 vs. 53 minutos en P2, p < 0.00001) y mayor proporción de pacientes tratados dentro de los 60 minutos del ingreso hospitalario (36% en P1 vs. 76% en P2, p < 0.00001). Además, hubo reducción de la mediana de internación de 9 días en P1 a 5 días en P2 (p < 0.00001). En conclusión, la UCV parece optimizar la utilización de fibrinólisis en el ACVi agudo, aumentando el porcentaje de pacientes tratados, reduciendo el tiempo puerta-aguja y disminuyendo el de internación.

Abstract Intravenous fibrinolysis with recombinant tissue plasminogen activator (rTPA) and use of stroke units improve morbidity and mortality in patients with acute ischemic stroke (AIS). However, data published in Argentina are scarce. We describe the experience in the use of fibrinolysis in patients with acute ischemic stroke (AIS) before and after the implementation of a stroke unit in a Comprehensive Stroke Center in Buenos Aires during the last 17 years. Retrospective analysis of consecutive patients treated with rTPA between January 2003 and December 2019. Treatment times, hospitalization time, post-treatment complications and disability at 3 months were evaluated. For the analysis, the pre and post opening periods of the stroke unit were evaluated, Period 1 (P1, from 2003 to 2011) and Period 2 (P2, from 2012 to 2019). Intravenous fibrinolysis was performed in 182 patients. Opening of the stroke unit resulted in an increase in the percentage of fibrinolysis over the total number of admitted strokes (4% in P1 vs. 10% in P2, p < 0.001), shortening of the door-to-needle time (75 minutes in P1 vs. 53 minutes in P2, p < 0.00001) and higher proportion of patients treated within 60 minutes of hospital admission (36% in P1 vs. 76% in P2, p < 0.00001). In addition, there was a reduction in the median hospital stay from 9 days in P1 to 5 days in P2 (p < 0.00001). In conclusion, stroke units seem to optimize the use of fibrinolysis in acute stroke, increasing the percentage of patients treated, reducing door-to-needle time, and reducing hospitalization time.

Efecto de la pandemia COVID-19 y la cuarentena en el número de consultas, subtipos y tratamiento del accidente cerebrovascular en un centro neurológico de argentina / Effect of the COVID-19 pandemic and preventive social isolation measures on the number of outpatient visits, hospitalizations and treatment of cerebrovascular accident in a neurological center in Argentina

Resumen La pandemia por COVID-19 y el aislamiento social preventivo y obligatorio (ASPO) han generado cambios en la organización y utilización del sistema de salud en todo el mundo. Analizamos el impacto de la situación sanitaria en el número de consultas ambulatorias, internaciones y acceso a terapias de revascularización por enfermedad cerebrovascular. Se analizó el período desde el 1 marzo al 31 de julio de 2020. Se comparó con el mismo período de 2019. Se evaluaron total de consultas ambulatorias e internaciones, escala NIHSS (National Institute of Health Stroke Scale) al ingreso, tipo de enfermedad cerebrovascular y uso de terapias de revascularización. Ingresaron 197 pacientes con eventos cerebrovasculares agudos en 2019 y 150 pacientes en 2020. Hubo un descenso significativo en el número de internaciones por eventos isquémicos totales y accidentes isquémico transitorios en el comparativo de los 5 meses. Se vio además un aumento en trombosis venosas cerebrales y hemorragias cerebrales. El acceso a fibrinolisis intravenosa y trombectomía mecánica se mantuvo estable, pero con prolongación del tiempo puerta-aguja. Las consultas ambulatorias descendieron 67%, siendo mayor el descenso en abril y más marcado en consultas de seguimiento. El número de internaciones y de consultas ambulatorias durante el ASPO descendió sustancialmente. Esto pareciera obedecer al cumplimiento estricto de la cuarentena y no a mecanismos fisiopatológicos relacionados con el COVID-19. Debe educarse a la población sobre la necesidad del control de enfermedades crónicas y de eventos agudos y se deben garantizar medidas de seguridad en los centros de salud.

Abstract The COVID-19 pandemic and preventive and compulsory social isolation (PCSI) have generated changes in the organization and use of the health system around the world. We analyze the impact of the health situation on the number of outpatient visits, hospitalizations and access to revascularization therapy for cerebrovascular disease. The period from March 1 to July 31, 2020 was analyzed. It was compared with the same period in 2019. Total outpatient and hospital visits were evaluated, NIHSS scale (National Institute of Health Stroke Scale) upon admission, type of cerebrovascular disease and use of revascularization therapies; 197 patients with acute cerebrovascular events were admitted in 2019 and 150 patients in 2020. There was a significant decrease in the number of hospitalizations for total ischemic events and transient ischemic attacks in the comparison of 5 months. An increase in cerebral venous thrombosis and cerebral hemorrhages was also seen. Access to intravenous fibrinolysis and mechanical thrombectomy remained stable, but with prolonged door-to-needle time. Outpatient visits fell 67%, the decrease being greater in April and more marked in follow-up visits. The number of hospitalizations and outpatient visits during the PCSI dropped substantially. This seems to be due to strict compliance with quarantine and not to pathophysiological mechanisms related to COVID-19. The population should be educated about the need to control chronic diseases and acute events and safety measures should be guaranteed in health centers.

Rehabilitación multidisciplinaria para pacientes adultos con accidente cerebrovascular / Multidisciplinary rehabilitation for adult patients with stroke

Se estima que dos tercios de las personas que han sufrido un accidente cerebrovascular (ACV) tienen secuelas que condicionan su calidad de vida. La rehabilitación del ACV es un proceso complejo, que requiere de un equipo multidisciplinario de profesionales especializados (médicos, kinesiólogos, enfermeros, terapistas ocupacionales, fonoaudiólogos, neuropsicólogos y nutricionistas). Actualmente, las prácticas realizadas en rehabilitación son consecuencia de la combinación de evidencia y consenso, siendo la mayoría aportadas a través de guías internacionales de rehabilitación en ACV. El objetivo de esta revisión es ajustar las recomendaciones internacionales sobre rehabilitación a lo aplicado a la práctica diaria, a fin de unificar criterios en las recomendaciones y reducir la variabilidad de las prácticas empleadas. En este trabajo, se realizó una revisión de la literatura sobre las guías de rehabilitación en ACV realizadas en los últimos 10 años y cada apartado fue supervisado por distintos profesionales especializados en dichas áreas. Se analizaron los tiempos y organización necesaria para desarrollarla, las recomendaciones para la rehabilitación motora, cognitiva y visual, el tratamiento de la disfagia y nutrición, de las comorbilidades (trombosis venosa, úlceras cutáneas, dolor, trastornos psiquiátricos, osteoporosis) y las tareas necesarias para favorecer el retorno a las actividades de la vida diaria.

It is estimated that two thirds of people who have suffered a stroke have sequels that condition their quality of life. The rehabilitation of the stroke is a complex process, which requires the multidisciplinary approach of specialized professionals (doctors, kinesiologists, nurses, occupational therapists, phonoaudiologists, neuropsychologists and nutritionists). Currently, the practices carried out are a consequence of the combination of evidence and consensus, most of them through international stroke rehabilitation guides. The objective of this review is to adjust the international recommendations on stroke rehabilitation to what is applied to daily practice, in order to unify the criteria of the recommendations and to reduce the variability of the practices carried out. This work is a review of the literature on stroke rehabilitation guides developed in the last 10 years. Each section was supervised by different professionals specialized in these areas. We analyze the time and organization necessary to develop rehabilitation, recommendations for motor, cognitive and visual rehabilitation, the management of dysphagia and nutrition, the approach of comorbidities (venous thrombosis, skin ulcers, pain, psychiatric disorders and osteoporosis) and the necessary tasks to favor the return to the activities of daily life.

Predictors of Recurrent Ischemic Stroke in Patients with Embolic Strokes of Undetermined Source and Effects of Rivaroxaban Versus Aspirin According to Risk Status: The NAVIGATE ESUS Trial.

BACKGROUND: Embolic stroke of undetermined source (ESUS) identifies patients with cryptogenic ischemic stroke presumed due to embolism from several unidentified sources. Among patients with recent ESUS, we sought to determine independent predictors of recurrent ischemic stroke during treatment with aspirin or rivaroxaban and to assess the relative effects of these treatments according to risk. METHODS: Exploratory analyses of 7213 participants in the NAVIGATE ESUS international trial who were randomized to aspirin 100 mg/day or rivaroxaban 15 mg/day and followed for a median of 11 months, during which time there were 309 first recurrent ischemic strokes (4.6% per year). Baseline features were correlated with recurrent stroke by multivariate analysis. RESULTS: The 7 independent predictors of recurrent stroke were stroke or transient ischemic attack (TIA) prior to the qualifying stroke (hazard ratio [HR] 2.03 95% confidence internal [CI] 1.58-2.60), current tobacco user (HR 1.62, 95% CI 1.24-2.12), age (HR 1.02 per year increase, 95%CI 1.01-1.03), diabetes (HR 1.28, 95% CI 1.01-1.64), multiple acute infarcts on neuroimaging (HR 1.49, 95% CI 1.09-2.02), aspirin use prior to qualifying stroke (HR 1.34, 95% CI 1.02-1.70), and time from qualifying stroke to randomization (HR .98, 95% CI .97-.99). The rate of recurrent stroke rate was 2.6% per year for participants without any of these risk factors, and increased by an average of 45% for each independent predictor (P < .001). There were no significant interactions between treatment effects and independent stroke predictors or stroke risk status. CONCLUSIONS: In this large cohort of ESUS patients, several features including prior stroke or TIA, advanced age, current tobacco user, multiple acute infarcts on neuroimaging, and diabetes independently identified those with an increased risk of ischemic stroke recurrence. The relative effects of rivaroxaban and aspirin were similar across the spectrum of independent stroke predictors and recurrent stroke risk status.

Accidente cerebrovascular bulbar lateral con trayecto extracraneal de la arteria cerebelosa póstero-inferior / Lateral medullary stroke with extracranial course of the postero- inferior cerebellar artery

Presentamos dos casos de accidente cerebrovascular en sujetos con trayecto extracraneal de la arteria cerebeloso póstero-inferior. Caso 1: varón de 21 años, quien presentó ataxia y dismetría derecha luego de un traumatismo cervical en un partido de rugby. Caso 2: mujer de 56 años, quien inició con vértigo y hemiparesia izquierda luego de esfuerzo físico intenso. En ambos casos, los estudios angiográficos mostraron un trayecto extracraneal de la arteria cerebelosa póstero-inferior. Este vaso raramente se origina por debajo del foramen magno, en relación cercana con las primeras tres vértebras cervicales y la articulación atlanto-axial. En este nivel, está expuesta a daño mecánico causante de disección, como por ejemplo trauma directo, manipulación cervical abrupta o extensión cefálica prolongada. Por lo tanto, en pacientes con accidente cerebrovascular de región lateral de bulbo y trayecto extracraneal de la arteria cerebelosa póstero-inferior se debería considerar esta asociación.

We present two cases of lateral medullary stroke in subjects with extracranial trajectory of the postero-inferior cerebellar artery. Case 1: a 21-year-old male who presented ataxia and right dysmetria after cervical trauma in a rugby match. Case 2: 56-year-old woman, who started with vertigo and left hemiparesis after intense physical effort. In both cases, the angiographic studies showed an extracranial trajectory of the posterior inferior cerebellar artery. This vessel rarely originates below the foramen magnum, in close relationship with the first three cervical vertebrae and the atlanto-axial joint. At this level, it is exposed to mechanical damage causing dissection, such as direct trauma, abrupt cervical manipulation or prolonged cephalic extension. Therefore, this association should be considered in patients with stroke of the lateral region of the bulb and extracranial trajectory of the posterior-inferior cerebellar artery.

Epilepsia asociada al accidente cerebrovascular / Post-stroke epilepsy

El accidente cerebrovascular (ACV) es la causa más común de convulsiones y epilepsia observada en estudios poblacionales de adultos. Las convulsiones ocurren dentro de las 24 horas posteriores al ACV en un alto porcentaje de pacientes. La patogénesis de estas convulsiones de inicio temprano puede estar relacionada con cambios iónicos locales y liberación de altos niveles de neurotransmisores excito-tóxicos en el área lesionada. Una lesión permanente con cambios en la excitabilidad neuronal parece ser responsable de convulsiones de inicio tardío después del ACV. Los factores de riesgo más comúnmente identificados con el comienzo agudo o tardío de las convulsiones post ACV son la gravedad y la localización cortical. La mayoría de las convulsiones post ACV son focales al inicio pero pueden generalizarse secundariamente, el estatus epiléptico es poco frecuente. La eficacia de las drogas antiepilépticas para estas convulsiones no ha sido rigurosamente evaluada en estudios controlados, aunque la mayoría de las convulsiones pueden ser controladas con un solo agente. Dada la frecuencia relativamente baja de convulsiones recurrentes después del ACV y la ausencia de predictores absolutos de epilepsia post ACV, la decisión de cuándo tratar a los pacientes con una convulsión después de un ACV es difícil.

Stroke is the most common cause of seizures and epilepsy in population stuies of adults. Seizures occur within 24 hours of the stroke in a high percent of patients. The pathogenesis of these early-onset seizures may be related to local ion shifts and release of high levels of excitotoxic neurotransmitters in the area of ischemic injury. The risk of late-onset seizures may increase over time, an underlying permanent lesion that leads to persistent chnges in neuronal excitability appears to be responsible for late-onset seizures after stroke. The most consistently identified risk factors for acute and late post-stroke seizures are stroke severity and cortical location. Most seizures following stroke are focal at onset, but secondary generalization is common, particularly in patients with late-onset seizures. Status epilepticus is relatively uncommon. The efficacy of antiepileptic drugs for these post-stroke seizures has not been rigorously assessed in controlled trials, although most seizures can be controlled with a single agent. Given the relatively low frequency of recurrent seizures after stroke, and an absence of absolute predictors of poststroke epilepsy, the decision of when to treat patients for a post-stroke seizure is difficult.

Characterization of Patients with Embolic Strokes of Undetermined Source in the NAVIGATE ESUS Randomized Trial.

BACKGROUND: The New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial vs. ASA to Prevent Embolism in Embolic Stroke of Undetermined Source (NAVIGATE-ESUS) trial is a randomized phase-III trial comparing rivaroxaban versus aspirin in patients with recent ESUS. AIMS: We aimed to describe the baseline characteristics of this large ESUS cohort to explore relationships among key subgroups. METHODS: We enrolled 7213 patients at 459 sites in 31 countries. Prespecified subgroups for primary safety and efficacy analyses included age, sex, race, global region, stroke or transient ischemic attack prior to qualifying event, time to randomization, hypertension, and diabetes mellitus. RESULTS: Mean age was 66.9 ± 9.8 years; 24% were under 60 years. Older patients had more hypertension, coronary disease, and cancer. Strokes in older subjects were more frequently cortical and accompanied by radiographic evidence of prior infarction. Women comprised 38% of participants and were older than men. Patients from East Asia were oldest whereas those from Latin America were youngest. Patients in the Americas more frequently were on aspirin prior to the qualifying stroke. Acute cortical infarction was more common in the United States, Canada, and Western Europe, whereas prior radiographic infarctions were most common in East Asia. Approximately forty-five percent of subjects were enrolled within 30 days of the qualifying stroke, with earliest enrollments in Asia and Eastern Europe. CONCLUSIONS: NAVIGATE-ESUS is the largest randomized trial comparing antithrombotic strategies for secondary stroke prevention in patients with ESUS. The study population encompasses a broad array of patients across multiple continents and these subgroups provide ample opportunities for future research.

Spontaneous Cystic Arteriovenous Malformation-A Novel Treatment Alternative.

BACKGROUND: Brain arteriovenous malformation (BAVM) is a life-threatening vascular congenital malformation due to the risk of intracerebral hemorrhage. The formation of a spontaneous cyst within a BAVM, without history of hemorrhage or gamma knife surgery, is rare and has an unknown pathophysiology. We suggest a novel theory of spontaneous cystic BAVM formation, subsequently treated with endovascular embolization followed by surgery with a favorable long-term outcome. METHODS: Review of the literature using PUBMED database and comparison between clinical presentation, diagnostic imaging studies, and treatment options. RESULTS: The high flow causing a shear stress over the drainage vein may be responsible for venous ectasia and thus incrementing hydrostatic intranidal pressure causing a serous effusion that develops into a pseudocyst. We hypothesize that hemodynamic factors may be responsible for both origin and growth of such cystic lesions. CONCLUSIONS: Endovascular treatment allowed us to achieve cyst volume reduction by managing its unique flow characteristics. To our knowledge, this is the first case report of combined treatment with endovascular and surgical approach of a cystic BAVM.

Headache and Treatment of Unruptured Intracranial Aneurysms.

BACKGROUND AND PURPOSE: The relationship between unruptured intracranial aneurysms (UIAs) and chronic headache and the impact of aneurysm treatment on headache outcome are controversial. The aim of this study was to determine clinical features of a supposedly primary headache in patients with UIA. We also assessed changes in headache characteristics after UIA treatment. METHODS: We examined clinical and imaging data of patients in whom a UIA was diagnosed during diagnostic workup of a suspected primary headache. Medical records were reviewed and personal telephone follow-ups were performed after UIA treatment to assess changes in the frequency and intensity of the headache. RESULTS: Forty-two patients (76%) reported a substantial improvement in headache frequency and intensity after UIA treatment. Forty-five patients (81%) reported a decrease in headache frequency from a median of 8 days/month before treatment to 1 day/month after treatment (95% confidence interval [CI] 81-83, P < .001). The average intensity in an analog pain scale was 7.7 ± 1.6 before treatment and 5.6 ± 2.4 after treatment (P < .001). Higher headache frequency was associated with a greater odd of improvement after treatment (odds ratio 1.12, 95% CI 1.0-1.26, P = .03). No associations were found between the type of headache, type of treatment (endovascular versus surgical), number, size, or localization of the aneurysms and the response to treatment. CONCLUSIONS: The treatment of UIA had a robust beneficial effect on previous headache. Although a "placebo" effect of aneurysm treatment cannot be ruled out, these results suggest a potential association between UIA and certain chronic headaches usually considered to be primary.

Perception of stroke symptoms and utilization of emergency medical services / Percepción de los síntomas del accidente cerebrovascular y utilización de los servicios de emergencias médicos

ABSTRACT Lack of stroke awareness and slow activation of emergency medical services (EMS) are frequently reported reasons for delayed arrival to the hospital. We evaluated these variables in our population. Methods Review of hospital records and structured telephone interviews of 100 consecutive stroke patients. Forward stepwise logistic regression was used for the statistical analysis. Results Seventy patients (75%) arrived at the hospital 4.5 hours after stroke symptoms onset. The use of EMS did not improve arrival times. Most patients who recognized their symptoms did not use EMS (p < 0.02). Nineteen patients (20%) were initially misdiagnosed. Eighteen of them were first assessed by non-neurologist physicians (p < 0.001). Conclusions Our population showed a low level of stroke awareness. The use of EMS did not improve arrival times at the hospital and the non-utilization of the EMS was associated with the recognition of stroke symptoms. There was a concerning rate of misdiagnosis, mostly by non-neurologist medical providers.

RESUMO La falta de reconocimiento de los síntomas del accidente cerebrovascular (ACV) y la lenta activación de los servicios de emergencias médicos (SEM) son causas frecuentes de demoras en el arribo hospitalario. Nuestro objetivo fue evaluar ambas variables en nuestra población. Métodos Revisión de registros hospitalarios y entrevista telefónica estructurada de 100 pacientes consecutivos internados por ACV. El análisis estadístico se realizó mediante un modelo de regresión logística multivariada por pasos. Resultados Setenta pacientes (75%) arribaron al hospital luego de 4.5 horas del comienzo de los síntomas. El uso de los SEM no mejoró los tiempos de arribo al hospital (p < 0.02). Inicialmente, 19 pacientes (20%) recibieron un diagnóstico erróneo. Dieciocho de ellos fueron evaluados por médicos no neurólogos. (p < 0.001). Conclusiones El reconocimiento de los síntomas de ACV en nuestra población fue bajo. El uso de los SEM no mejoró los tiempos de arribo hospitalario y la no utilización de los mismos se asoció con el correcto reconocimiento de los síntomas por parte de los pacientes. La proporción de diagnósticos erróneos fue preocupante, fundamentalmente entre médicos no neurólogos.

Left atrial appendage occlusion with Amplatzer Cardio Plug is an acceptable therapeutic option for prevention of stroke recurrence in patients with non-valvular atrial fibrillation and contraindication or failure of oral anticoagulation with acenocumarol / La oclusión de la orejuela izquierda con Amplatzer Cardio Plug es una terapia aceptable para prevención del ACV isquémico en pacientes con fibrilación auricular y contraidicación o falla terapéutica con acenocumarol

ABSTRACT Left atrial appendage occlusion (LAAO) appears as a therapeutic option for some atrial fibrillation patients not suitable for oral anticoagulation because an increased hemorrhagic risk or recurrent ischemic events despite anticoagulant treatment. Methods Report of consecutive atrial fibrillation patients treated with LAAO with Amplatzer Cardio Plug because contraindication or failure of oral anticoagulation with acenocumarol. CHA2DS2VASC, HAS-BLED, NIHSS, mRS, procedural complications and outcome were assessed. Seven patients (73 ± 6 year-old) were treated after intracerebral (n = 5) and gastrointestinal (n = 1) hemorrhages or ischemic stroke recurrence while on acenocumarol (n = 1). Results Mean follow up was 18 months. Baseline CHA2DS2Vasc y HAS-BLED scores were 5.6 ± 0.7 and 4.1 ± 0.3 respectively. There were no strokes or deaths. There was only one non-serious adverse event. Conclusion LAAO with ACP appears as a feasible therapeutic option for stroke prevention in patients with atrial fibrillation and failure or contraindication to acenocumarol.

RESUMEN La oclusión de la orejuela auricular izquierda (OOAI) es una opción terapéutica en pacientes con fibrilación auricular y alto riesgo hemorrágico o recurrencia de accidente cerebrovascular isquémico (ACVi) a pesar del tratamiento anticoagulante. Métodos Reporte de pacientes con fibrilación auricular y contraindicación o fallo terapéutico con acenocumarol tratados con OOAI. Se evaluaron escalas CHA2DS2VASC, HAS-BLED, NIHSS y mRS, complicaciones procedurales y resultados. Resultados Siete pacientes (73 ± 6 años) fueron tratados luego de sufrir hemorragia cerebral (n = 5), gastrointestinal (n = 1) o ACVi recurrente a pesar del tratamiento con acenocumarol. Las escalas CHADS2VASC y HAS-BLED fueron 5.6 ± 0.7 y 4.1 ± 0.3 respectivamente. Luego de un seguimeinto promedio fue de 18 meses (3-50) no se registraron ACVi o muertes. Se registró sólo un evento adverso no serio. Conclusión La OOAI es una opción terapéutica factible para prevenir ACVi en pacientes con fibrilación auricular y fallo o contraindicación para recibir acenocumarol.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) in Argentina.

CADASIL is the most common cause of hereditary stroke and vascular dementia. Published information about this disease in South America is scant. We describe clinical and demographic characteristics of 13 patients (10 families) with CADASIL from Argentina.Methods Medical records, diagnostic tests and family history of patients with CADASIL were reviewed.Results Thirteen patients with CADASIL (10 families) were included. All patients had European ancestry. Initial presentation was stroke in most patients (n = 11). Stroke patients later developed cognitive complaints (n = 9), migraine with aura (n = 1), apathy (n = 4) and depression (n = 6). External capsule and temporal lobe involvement on MRI were characteristic imaging findings. Two patients died after intracerebral hemorrhage.Conclusion This is the first report of non-related patients with CADASIL in South America addressing ancestry. Since European ancestry is not highly prevalent in all South American countries, there may be variable incidence of CADASIL within this region.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) in Argentina / Arteropatia cerebral autosomal dominante com infartos subcorticais e leucoencefalopatia (CADASIL) na Argentina

CADASIL is the most common cause of hereditary stroke and vascular dementia. Published information about this disease in South America is scant. We describe clinical and demographic characteristics of 13 patients (10 families) with CADASIL from Argentina.Methods Medical records, diagnostic tests and family history of patients with CADASIL were reviewed.Results Thirteen patients with CADASIL (10 families) were included. All patients had European ancestry. Initial presentation was stroke in most patients (n = 11). Stroke patients later developed cognitive complaints (n = 9), migraine with aura (n = 1), apathy (n = 4) and depression (n = 6). External capsule and temporal lobe involvement on MRI were characteristic imaging findings. Two patients died after intracerebral hemorrhage.Conclusion This is the first report of non-related patients with CADASIL in South America addressing ancestry. Since European ancestry is not highly prevalent in all South American countries, there may be variable incidence of CADASIL within this region.

CADASIL é a causa mais frequente de acidente vascular cerebral e demência hereditários. São poucas as publicações sobre esta doença na América do Sul. Aqui descrevemos dados clínicos e demográficos de 13 pacientes (10 famílias) da Argentina com CADASIL.Métodos Prontuários médicos testes diagnósticos e história familiar de pacientes com CADASIL foram revisados.Resultados Treze pacientes com CADASIL (10 famílias) foram incluídos. Todos os pacientes tinha ancestralidade europeia. A apresentação inicial foi acidente vascular cerebral na maioria dos pacientes (n = 11). Pacientes com acidente vascular cerebral depois desenvolveram alterações cognitivas (n = 9), enxaqueca com aura (n = 1), apatia (n = 4) e depressão (n = 6). Os achados de imagem característicos da RM foram na cápsula externa e no lobo temporal. Dois pacientes morreram por hemorragia intracerebral.Conclusão Este é o primeiro relato de série de casos de pessoas não relacionadas entre si que apresentavam CADASIL na América do Sul, discutindo ancestralidade. Uma vez que a ascendência europeia tem prevalência variada em diferentes países da América do Sul, é possível que esta seja uma variável de incidência de CADASIL nesta região.

Control moderado de hiperglucemia luego de infarto cerebral agudo en unidad de cuidados intensivos / Moderate control of hyperglycemia after acute stroke in the intensive care unit

La hiperglucemia después de un accidente cerebrovascular isquémico (ACVi) se asocia con peor pronóstico. Se compararon retrospectivamente los efectos entre el control de la glucemia moderado (corrección a partir de 135 mg/dl) y el conservador (a partir de 200 mg/dl) en evolución neurológica, tiempo de internación y complicaciones asociadas al tratamiento de pacientes con ACVi internados en unidad de cuidados intensivos, al alta y 30 días post-egreso. Se estudiaron 208 pacientes, 103 (24% diabéticos) con tratamiento moderado y 105 (23% diabéticos) con tratamiento conservador. La glucemia media a lo largo de la internación tendió a ser menor con el tratamiento moderado sin significancia estadística (129 ± 30 vs. 138 ± 31 mg/dl; p = 0.06). La diferencia fue significativa en los no diabéticos (119 ± 24 vs. 128 ± 24 mg/dl; p < 0.05), siendo más pronunciada en aquellos no diabéticos con déficit neurológico moderado a grave al ingreso (116 ± 23 vs. 130 ± 23 mg/dl; p < 0.01). Los pacientes que ingresaron con déficit neurológico moderado a grave tuvieron mejor evolución al alta y a 30 días bajo tratamiento moderado (variación de NIHSS: alta 2.1 ± 2.6 vs. 3.4 ± 3; 30 días: 3.2 ± 3 vs. 4.8 ± 3; p < 0.01). La duración de la internación fue menor con tratamiento moderado (6 ± 5 vs. 9 ± 5 días; p < 0.05). No hubo diferencias significativas en la incidencia de hipoglucemias. En conclusión, el control moderado de la glucemia en pacientes con ACVi se asoció con mejor evolución neurológica en aquellos que ingresaban con déficit neurológico moderado a grave (escala de NIH = 4), y una hospitalización más corta, sin un aumento sustancial de episodios de hipoglucemia.

Hyperglycemia following an ischemic stroke has been associated with poor clinical outcome. We retrospectively assessed the effect of moderately controlled plasma glucose (correction from 135mg/dl) compared to conservative treatment (correction from 200 mg/dl), as regards neurological evolution, duration of hospitalization, at discharge and at 30 days post-discharge, also complications associated with the treatment in patients admitted to the intensive care unit. We studied 208 patients, 103 (24% diabetics) with moderate therapy and 105 (23% diabetics) with conservative treatment. The average blood glucose during hospitalization tended to be lower with the moderate treatment with no statistic significance (129 ± 30 vs. 138 ± 31 mg/dl; p = 0.06). The difference was significant in non-diabetics (119 ± 24 vs. 128 ± 24 mg/dl; p < 0.05), being even more pronounced in those non-diabetics with moderate to severe neurological deficit on admission (116 ± 23 vs. 130±23 mg/dl; p < 0.01). Patients admitted with moderate to severe neurological deficit and treated with moderate regime had a better outcome at discharge and at 30 days (NIHSS variation: high 2.1 ± 2.6 vs. 3.4 ± 3; 30 days: 3.2 ± 3 vs. 4.8 ± 3; p < 0.01). The duration of hospitalization was lower in the moderate treatment group (5.7 vs. 9.2 days, p < 0.05), with no significant difference showing in the incidence of hypoglycemia in either group. In conclusion, moderate control of blood glucose in ACVi patients relates to an improved neurological outcome in those admitted with moderate to severe neurological deficits (NIH scale = 4), with a reduced hospital stay, and no substantial increase of hypoglycemia episodes.