The relation between echocardiographic epicardial fat thickness and cha2ds2-vasc score in patients with sinus rhythm

Abstract Objective: To evaluate the predictive value of epicardial fat thickness (EFT) in CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) score risk groups. Methods: A total of 158 consecutive patients (75 females, 83 males, mean age 70.8±6.3 years) admitted routinely for cardiologic control were divided into two groups according to their CHA2DS2-VASc scores (scores 0 and 1 were regarded as low risk, and score ≥2 as high risk). One hundred twenty-five of 158 patients had a high-risk score. Results: Mean EFT was significantly higher in the high-risk group than in the low-risk group (4.34±0.62 vs. 5.37±1.0; P<0.001). EFT was positively correlated with CHA2DS2-VASc score (r=0.577, P<0.001). According to receiver operating characteristics (ROC) analysis, EFT value of 4.4 mm was found to be predictive of high risk in CHA2DS2-VASc score with 80% of sensitivity and 79% of specificity (C-statistic = 0.875, P<0.001, 95% confidence interval [CI] = 0.76-0.90). And according to multivariate logistic regression analysis, EFT was an independent predictor of high thromboembolic risk in terms of CHA2DS2-VASc score. Conclusion: Our findings suggest that echocardiographic EFT measurement could provide additional information on assessing cardiovascular risks, such as thromboembolic events, and individuals with increased EFT should receive more attention to reduce unfavorable cardiovascular risk factors and the development of future cardiovascular events.

Pérdida transitoria de la visión / Transient vision loss

La pérdida transitoria de la visión monocular (PTVM), es un síntoma alarmante relacionado frecuentemente con alteraciones vasculares retinales y puede tener consecuencias importantes desde el punto de vista ocular y vital. Es por ello, que se requiere de un manejo precoz y adecuado. El presente artículo tiene por objeto revisar las principales causas, su presentación, diagnóstico y manejo, como enfermedades oclusivas vasculares y alteraciones el nervio óptico entre otras

Transient monocular vision loss (TMVL) is an alarming symptom often in relation with retinal vascular anomalies that may have severe consequences for vision and life, so it should be evaluated urgently and a prompt approach is needed. This article will review the main causes, its presentation, diagnosis and management such as vascular occlusive diseases and optic nerve abnormalities among others

Subarachnoid hemorrhage with transient ischemic attack: Another masquerader in cerebral venous thrombosis.

Cerebral venous thrombosis has a wide spectrum of clinical manifestations that may mimic many other neurological disorders and lead to frequent misdiagnoses or delay in diagnosis. The most frequent symptoms and signs are headache, seizures, focal deficits, and papilledema. A number of rare atypical manifestations have been described. Cerebral venous thrombosis may present with an isolated intracranial hypertension type picture, thunderclap headache, attacks of migraine with aura, isolated psychiatric disturbances, pulsatile tinnitus, isolated or multiple cranial nerve involvement, and occasionally as subarachnoid hemorrhage (SAH) or transient ischemic attack. Our patient presented with thunderclap headache and transient ischemic attack like episode with obvious SAH on CT scan. Acute SAH suggests the presence of a vascular lesion, such as ruptured aneurysm, and CVT is not generally considered in the diagnostic workup of SAH. The case emphasizes the importance of cerebral venous study in nonaneurysmal cases of SAH. It is important to have a high index of suspicion in such atypical cases to avoid delay in diagnosis.

Evaluación y manejo del paciente con accidente isquémico transitorio / Evaluation and management of patients with transitory ischemic accident

El manejo de los pacientes con accidente isquémico transitorio (AIT) en los servicios de urgencia es muy variable, en algunas instituciones todos los pacientes son admitidos al hospital para su evaluación y tratamiento, y en otras se recomienda efectuar la evaluación en el ámbito ambulatorio. Definir el pronóstico a corto plazo y los factores de riesgo para desarrollar un accidente vascular encefálico después de un episodio de AIT nos permite identificar a los grupos de riesgo que necesitan ser admitidos al hospital porque requieren monitorización y evaluación inmediata. En la última década, el manejo de los pacientes con AIT ha sufrido cambios significativos que los médicos de los servicios de urgencia deben conocer e incorporar en sus protocolos de atención. En esta revisión se han actualizado algunos conceptos sobre tópicos específicos relacionados con el manejo de urgencia de pacientes con AIT: 1) La definición de AIT ha sido modificada, 2) Criterios diagnósticos de AIT, 3) Evaluación diagnóstica y tratamiento recomendado para el paciente con AIT, 4) Evaluación de los factores de riesgo que permiten orientar el lugar de manejo y el estudio de los enfermos. Para ilustrar el problema, se presenta el caso clínico de un paciente que consultó en el servicio de urgencia por síntomas neurológicos transitorios que no estaban presentes en el momento de la consulta.

Management of patients with acute transient ischemic attack (TIA) varies widely, with some institutions admitting all patients and others proceeding with outpatient evaluations. Defining the short-term prognosis and risk factors for stroke after TIA may provide guidance in determining which patients need rapid evaluation. In the past few years, the approach to patients with transient ischemic attacks has undergone a transformation. To care for these patients, emergency physicians must understand these changes. They must be comfortable with the diagnosis and treatment of transient ischemic attacks in their emergency department. To this end, we ask and answer the following important questions in this up-to-date review of transient ischemic attacks: 1) How is a transient ischemic attack defined?, 2) Does this patient have a transient ischemic attack?, 3) Once diagnosed, what diagnostic evaluation should be done (and when)?, 4) What treatment should be instituted (and when)? and 5) What is the correct disposition? We submit a case report of a patient who presented to the emergency physician completely asymptomatic with complaints of transient neurologic symptoms.

Carotid transient ischemic attacks presenting as limb-shaking syndrome: report of two cases

A síndrome do membro tremulante, inicialmente descrita há 40 anos, é apresentação rara de ataques isquêmicos transitórios, sendo usualmente secundária a estenose carotídea crítica comprometendo a circulação intracraniana. Dois novos casos são aqui descritos, visando ilustrar e discutir esta condição incomum e com alto potencial de morbidade.

Circadian pattern in cerebro vascular disorders.

Over the last decade, various studies have been reported to evaluate the circadian pattern of cardiovascular and cerebro-vascular diseases. The data from Indian population is lacking. We undertook this prospective observational study to evaluate the circadian variation in disorders like cerebro-vascular accidents and transient ischemic attacks. Total of 146 patients (events) were studied. Only 10 patients had TIA's. 55% had hemorrhage and 45% had infarction. The 24 hours period was divided into 6 equal portions of 4 hours each. The maximum events were seen between 4 am to 8 am and 12 noon to 4 pm (23.28%) each. Minimum events were seen between 12 midnight to 4 am 14/146 - 9.58%). The circadian variation in occurrence of cerebro-vascular disorders was present with two equal peaks.

Micro embolic signals in patients with cerebral ischaemic events.

The aim of this study was to evaluate the occurrence of micro embolic signals (MES) in patients with a cerebral ischaemia using transcranial doppler monitoring and to find out its diagnostic relevance. We prospectively performed bilateral multigated transcranial doppler monitoring from both middle cerebral arteries in 359 patients with an acute or recent (<4 weeks) cerebral ischaemic event, and in 182 control subjects without a cerebral ischaemic event. MES were analysed according to the standardised protocol. Patients with cerebral ischaemic events had a significantly higher (p<0.00001) rate of MES occurrence (31.8%) than control subjects (5.5%). MES were detected significantly higher in patients with partial or total anterior circulation infarcts (39.1%) than in those with lacunar infarcts (26.0%) or transient ischaemic attacks (27.3%). A correlation of MES and neuroimaging finding was also tried. TCD was found to have a predictive role in microemboli monitoring, predominantly in patients with large vessel territory infarction.

Aneurisma apical e hipertrofia ventricular esquerda / Apical aneurysm and left ventricular hypertrophy

A 59-year-old woman presented with an embolic transient ischemic attack and a history of controlled hypertension for 16 years. Both echocardiogram and MRI showed severe biventricular hypertrophy and an apical aneurysm with a thrombus. The occurrence of an apical aneurysm in the presence of cardiac hypertrophy is a rare finding and has been described in patients with hypertrophic cardiomyopathy. However, it has not been reported in patients with systemic arterial hypertension. In this patient the lack of a relationship between the severity of the hypertrophy and the levels of blood pressure, together with the presence of histologic disorganization of myocardial cardiac muscle cells by endomyocardial biopsy suggested the diagnosis of hypertrophic cardiomyopathy.

Ataques isquêmicos transitórios em pacientes com síndrome da veia cava superior / Transient ischemic attacks in apatient with superio vena cava obstruction: case report

A síndrome da veia cava superior (SVCS) é condiçao relativamente rara. Relatamos o caso de um paciente de 42 anos, masculino, hipertenso há 15 anos, que evoluiu com dor cervical e torácica há um ano, sendo evidenciada oclusao de 95 por cento da coronária direita. Submetido a angioplastia, porém com persistência de dor torácica. Posteriormente evoluiu com episódios recorrentes de hemiplegia à direita associados a crises hipertensivas, que melhoravam com medicamentos anti-hipertensivos. Pela presença de coloraçao vinhosa na face e acentuaçao durante os períodos de ataques isquêmicos transitórios, foi feita a suspeita diagnóstica de provável acometimento do sistema de drenagem venosa, confirmada à venografia pelo achado de dilataçao da veia jugular direita e imagem de estreitamento importante na junçao com a veia cava superior. Em conclusao, nao foi possível definir com certeza a relaçao entre as duas patologias no caso aqui apresentado, porém chamou a atençao a melhora dos sintomas neurológicos após o controle da SVCS com o tratamento instituído.

On the pathogenesis of headache following TIA

Twelve out of 49 patients with single or multiple transient ischemic attacks (TIAs) had TIA-related headaches, mostly in close temporal relation to the ischemic onset. Headache predominated in patients taking vasodilators when TIA occurred or with orthostatic hypotension at the first clinical examination, but arterial hypertension or a personal history of migraine were not more frequent in patients with headache. The site of the pain did not correlate with the presumed territory of cerebral ischemia. Pain during TIA is conceivably due to an interaction between cerebral vessels and the surrounding nervous system. Blood vessels have a sturdy physiological role corcerning blood flow regulation, with receptors and signaling molecules potentialy involved with pain production. Reflex mechanisms should justify pain in other areas.

Crisis isquémicas transitorias en Chile y su relación con el patrón de enfermedad cerebrovascular chileno / Transient ischemic attacks in Chile and it relation with chilean cerebrovascular disease standard

Patients and methods: One hundred forty nine patientes admitted to a Neurology service of a public hospital in Santiago, with an acute stroke, were studied. Patients and close relatives were interrogated about previous symptoms of TIA using a structured questionnaire. Results: One hundred nine patients had an ischemic and 40 patients a hemorrhagic stroke. Twenty patients with ischemic stroke had a history of TIA (18 percent). Fifteen out of 74 patients without a cardiac source of emboli (20 percent) and five out of 354 cases with an embolic source (14 percent) had a TIA preceding their stroke. Three out of 40 patients (8 percent) with hemorrhagic stroke had a history of TIA. Conclusions: This study does not support nor reject the hypothesis of a Chilean pattern of cerebrovascular disease unlike that found in Northern Caucasians

Síndrome do "coto" da carótida interna: relato de caso / Internal carotid stump syndrome: report of a case

Os autores relatam o caso de um paciente com ataques isquêmicos transitórios (AITs) cuja fonte de êmbolos originou-se ipsilateralmente ao fundo de saco de uma carótida interna ocluída (carotid stump syndrome). O paciente foi submetido a ressecçäo cirúrgica do "coto" (stump), com alívio total dos sintomas. O tromboembolismo decorrente do fundo de saco ou coto, documentado por arteriografia, se faz através das artérias anastomóticas, sendo agravado pela turbulência do fluxo sangüíneo a esse nível

Análisis de los resultados de la casuística de la hemorragias subaracnoideas de origen aneurismástico:Instituto de Neurocirugía "Costa Buero".Período 1980-1990 / Analysis results and casuistic of the subarachnoid hemorrhage by aneurysmatic origen:Neurosurgery Institute \"Costa Buero\" 1980-1990

Fueron revisadas retrospectivamente 210 casos de hemorragias subaracnoideas espontáneas entre 1980 y 1990.Los casos por malformaciones arteriovenosas fueron considerados.La angiografía de los 4 vasos demostró aneurisma cerebrales como causa de hemorragía en 160 de esos casos.Un análisis estadístico de la serie fue realizado en la búsqueda de antecedentes epidemiológicos,historia natural de la enfermedad,factores de riesgo y pronóstico,influjo del resangrado,vasoespasmo y seguimiento.Se concluye que el porcentaje de éxito terapéutico y fracaso, acorde al tipo de procedimiento y duración de la operación,coincide general con los resultados hallados en estudios cooperativos internacionales.Algunas dificultades técnicas por operaciones hechas en forma temprana en el curso de una hemorragia subaracnoidea son frecuentemente manejables.El "clipado" quirúrgica de los aneurismas previene el resangrado

Neuropéptidos Vasculares y Vasoespasmo Cerebral

A nivel de Sistema Nervioso Central coexisten múltiples neurotransmisores y neuromoduladores que a través de complejas interrelaciones participan en la regulación del flujo y perfusión cerebral tanto en condiciones normales como patológicas. A continuación se revisarán los principales neuropéptidos vasculares reconocidos hasta el momento, que participan en esta regulación

The effect of hyperglycemia on lipid peroxidation in the global cerebral ischemia of the rat

To investigate the influence of hyperglycemia on ischemic brain damage, we measured brain ATP, lactate and malondialdehyde (MDA) levels in global cerebral ischemic models of Wistar rats. We induced global cerebral ischemia by the 4-vessel occlusion method. After 30 or 60 min of occlusion, and after 30 min of reperfusion, we measured brain ATP, lactate and MDA levels. During the ischemic period, brain ATP levels decreased to 30-70% of sham groups both in normoglycemic and hyperglycemic groups. But during the reperfusion period, the recovery rate of ATP levels was significantly lower in the hyperglycemic than in the normoglycemic groups (p less than 0.05). After 60 min of global ischemia, brain lactate increased much more in the hyperglycemic than in the normoglycemic group, and, during reperfusion, was washed out slowly in the hyperglycemic group. The MDA level, a parameter of lipid peroxidation, increased more in the hyperglycemic group than in the normoglycemic group during reperfusion periods (p less than 0.05). We conclude that hyperglycemia increases lactate accumulation, delays the recovery of energy metabolism, and enhances the lipid peroxidation in the transient global ischemia of rat brain. These findings may suggest the harmfulness of hyperglycemia in clinical cerebral ischemia.

Primary intracerebral and subarachnoid hemorrhage: an approach to diagnosis and therapy

O diagnóstico da hemorragia intracerebral primária (HIP), bem como o da hemorragia subaracnóidea (HSA), ficou mais fácil com o advento das modernas técnicas de imagem. A incidência da HIC tem declinado, ao passo que a da HSA tem permanecido relativamente constante. O prognóstico de ambas ainda é desanimador e a taxa de mortalidade substancialmente maior que a observada nas afecçöes isquêmicas. A indicaçäo precoce da TC ou da RNM do crânio é importante para um diagnóstico rápido e preciso. Pacientes que näo estejam morimbundos devem receber cuidados médicos gerais em instalçöes com equipes de enfermagem especializada. O tratamento da HIC é predominantemente de apoio e intervençöes médicas e cirúrgicas continuam indefinidas. Quanto a HSA, bloqueadores dos canais de cálcio podem reduzir as complicaçöes cerebrais isquêmicas relacionadas ao vasoespasmo, mas näo se estabeleceram tratamentos médicos eficazes para prevenir novos sangramentos. Naqueles pacientes clinicamente estáveis, deve-se considerar a antecipaçäo da cirurgia. Muitos desafios permanecem no tocante à prevençäo e ao tratamento desses dois subtipos de hemorragia cerebral