Large vessel stroke in six patients following SARS-CoV-2 infection: a retrospective case study series of acute thrombotic complications on stable underlying atherosclerotic disease.

BACKGROUND AND PURPOSE: Ischaemic stroke has been described in association with COVID-19. Several pathophysiological mechanisms have been suggested, i.e. prothrombotic state, cardiac injury etc. It was sought to assess the potential association between ischaemic stroke associated with SARS-CoV-2 infection and underlying atherosclerotic lesions. METHODS: A retrospective analysis of stroke related to large vessel occlusion was conducted amongst patients with SARS-CoV-2 infection and underlying mild atherosclerotic disease, between 19 March and 19 April 2020 in six different stroke centers in the Île-de France area, France. RESULTS: The median age was 52 years, median body mass index was 29.5 kg/m2 . All patients displayed previous vascular risk factors such as high blood pressure, diabetes, dyslipidemia or body mass index > 25. The delay between the first respiratory symptoms of COVID-19 and stroke was 11.5 days. At baseline, all had tandem occlusions, i.e. intracerebral and extracerebral thrombus assessed with computed tomography or magnetic resonance imaging. Cases displayed a large thrombus in the cervical carotid artery with underlying mild non-stenosing atheroma, after an etiological workup based on angio-computed tomography or magnetic resonance imaging and/or cervical echography. CONCLUSION: Our study should alert clinicians to scrutinize any new onset of ischaemic stroke during COVID-19 infection, mainly in patients with vascular risk factors or underlying atherosclerotic lesions.

Endothelial markers are associated with thrombolysis resistance in acute stroke patients.

BACKGROUND AND PURPOSE: The endothelium is crucial in maintaining the haemostatic balance between pro- and anti-thrombotic factors. In this pilot study, the association of endothelial biomarkers with arterial recanalization and clinical outcome in the setting of acute ischaemic stroke (AIS) was evaluated amongst patients treated with recombinant tissue plasminogen activator (rt-PA). METHODS: Sixty-four AIS patients treated with rt-PA were prospectively recruited. Blood was collected before thrombolysis and analysed for von Willebrand factor (vWF), soluble thrombomodulin (sTM) and soluble endothelial protein C receptor (sEPCR). Complete recanalization was defined by a Thrombolysis in Myocardial Infarction Score of 3. Favourable clinical outcome was defined by a modified Rankin Score of 0-2 at 90 days. RESULTS: Amongst the 64 patients, 31 had no documented occlusion, 19 had persistent occlusion and 14 had complete recanalization. After adjustment for confounding factors, these patients presented lower sTM and sEPCR levels than patients with persistent occlusion (median sTM, 21 vs. 48 ng/ml, P = 0.008; median sEPCR, 78 vs. 114 ng/ml, P = 0.018), but similar levels compared with patients without occlusion. vWF levels did not differ between groups. None of these biomarkers was significantly associated with favourable outcome. CONCLUSIONS: Recanalization after thrombolytic therapy is associated with low sTM and sEPCR levels but not with vWF levels. If corroborated in further larger studies, these findings could be helpful in the identification of patients resistant to rt-PA thrombolysis who could benefit from a modified recanalization therapy.

Minimally invasive surgical treatment options for osteoporotic vertebral fractures OF4. / Opciones de tratamiento quirúrgico mínimamente invasivo en las fracturas vertebrales osteoporóticas OF4.

INTRODUCTION AND OBJECTIVE: The incidence of osteoporotic vertebral fractures (OVF) is increasing. The importance of their diagnosis and treatment lies in their frequency and the morbidity they cause in patients. The classification proposed for OVFs by the German Society of Orthopaedics and Traumatology (DGOU) recommends surgical treatment for vertebral fractures classified as OF4. Most of these fractures will require anterior bracing as an adjunct to posterior fixation because of the significant loss of vertebral body structure. In elderly patients, minimally invasive surgery (MIS) allows their treatment given the lesser tissue aggression and systemic repercussions. We present the results of the treatment of OF4 vertebral fractures using minimally invasive techniques in the Spine Unit of our hospital. MATERIAL AND METHODS: Retrospective study of 21 patients with OF4 osteoporotic fractures in the thoracolumbar transition treated in our centre. Six patients who underwent open posterolateral fusion or isolated vertebroplasty were excluded. The series consists of 15 cases (13 females and 2 males), with a mean age of 72.2, studied by computed tomography and magnetic resonance imaging. Clinical and analytical data were collected to decide the most appropriate surgical technique. In six cases a retropleural/retroperitoneal MIS approach was performed for partial corpectomy with expandable vertebral substitute plus long posterior percutaneous fixation (technique 1). In the remaining nine cases long posterior percutaneous fixation + vertebroplasty of the fractured vertebra (technique 2). Radiological measurements were taken pre-surgically, post-surgically, at 6 weeks and 3 months, determining the fracture angle, kyphotic deformity, compression and wedging percentage and deformation angle. To assess functional outcome, patients completed the Oswentry Disability Index before surgery and at 3 months. RESULTS: There were no intraoperative complications of note. In the corpectomy group the mean hospital stay was 9.4 days, with a mean operative time of 250 min, a postoperative haemoglobin loss of 3.3 g/dL and two patients were transfused. In the percutaneous fixation and vertebroplasty group the mean was 5.55 days, surgery time 71 min and loss of 1.6 g/dL haemoglobin. There was one post-surgical haematoma requiring transfusion. None of the patients had to be reoperated during follow-up. Radiological measurements showed adequate correction with both techniques which was maintained over time with minimal loss. In functional outcomes assessed with the Oswentry, patients following technique 1 suffered greater worsening (15%) than those treated with technique 2 (10%). CONCLUSIONS: In OWF classified as OF4, percutaneous fixation associated with vertebroplasty could be an alternative to corpectomy in older patients with comorbidities, in whom functional recovery is more important than radiological correction. The use of MIS surgery together with improvements in the prevention and treatment of osteoporosis may improve clinical outcomes in the treatment of this type of fracture.

Syndromic clubfoot beyond arthrogryposis and myelomeningocele: orthopedic treatment with Ponseti method. / Pie zambo sindrómico más allá de la artrogriposis y el mielomeningocele: tratamiento ortopédico con el método de Ponseti.

INTRODUCTION: Talipes equinovarus or clubfoot is a congenital deformity of the foot with bone, muscle, and tendon involvement. It's one of the most frequent foot malformations in pediatric orthopedics. Although generally idiopathic, it may have a syndromic cause and be associated with musculoskeletal, neurological, or connective tissue conditions. The treatment of choice in idiopathic clubfoot is the Ponseti method based on manipulation and fixation with serial casts that seek progressive correction of the deformity. The Ponseti method effectiveness has been demonstrated in arthrogryposis and myelomeningocele clubfoot. There are few clinical studies demonstrating the efficacy of this therapeutic option in patients with syndromic clubfoot. MATERIAL AND METHODS: Retrospective study with 6 patients (9 feet) with syndromic clubfoot treated in a tertiary center with the Ponseti method with a minimum follow up of two years (2-18). The results were evaluated with the Pirani classification, assessing clubfoot severity before and after treatment. RESULTS: Of the six patients treated were used an average of 6.5 casts. The Pirani scale obtained a mean score of 5.2 before treatment, with a decrease to 1.27 after treatment, with a mean improvement of 3.93 points. In more than half of the cases it was necessary to lengthen the Achilles tendon to correct the equine deformity. In addition, an ankle-foot orthosis was used to reduce recurrences in patients with dysmetria or psychomotor retardation. The most frequently observed residual deformity was the adduct. A patient relapsed twice. CONCLUSIONS: The Ponseti method obtains effective results in the correction of syndromic clubfoot, although it requires a greater number of corrective casts than other pediatric foot pathologies.

[Diagnostic and treatment of necrotizing cervical fascitis. Clinical course after a Ludwig angina]. / Diagnóstico y tratamiento de la fascitis necrotizante cervical. Evolución tras una angina de Ludwig.

The Ludwig angina is an infection of the base of the mouth and submandibular region, frecuently after a dental extraction or a piece in bad state. When it surpassees the milohioid muscle it extends dissecting the superficial aponeurotic planes, and can evolve to a necrotisant fascitis. We present the case of a 67 years old man with a painful tumefaction of the mouth base and submandibular region. The CT reflected an heterogenous submaxilar lesion that extended by the deep cervical fascia introducing itself in the thorax. Under antibiotic treatment the pus was drained by cervicotomy, with daily cures during 3 weeks.

[Progression of botulinum toxin type A dosage in craniocervical dystonias. An eight year comparative study]. / Evolucion de la dosis de toxina botulinica tipo A en distonias craneocervicales. Estudio comparativo a lo largo de ocho años.

INTRODUCTION: Botulinum toxin type A (BTA) is currently the choice treatment for focal dystonias; yet long term response to therapy is still not known with total accuracy. PATIENTS AND METHODS: In this study we analysed the dose of BTA used in the first eight years' treatment of 17 patients with cervical dystonia and 16 patients with blepharospasm who received treatment at our hospital. RESULTS: It was found that in the patients with cervical dystonia there was a significant increase in the dosage of BTA (41%) which rose in a linear fashion from the fourth year onwards. On the other hand, in the group of patients with blepharospasm, the dosage of BTA tended to drop with time and this reduction (16%) occurred essentially during the first four years of treatment. CONCLUSIONS: These findings clearly highlight the clinical and functional differences between the two types of craniocervical dystonia.

[Paraganglioma of the vagus. A case report and review of literature]. / Paraganglioma del nervio vago. Presentación de un caso y revisión de la literatura.

The vagal nerve paraganglioma is a rare tumor over all the head and neck tumours. It presents with a insidious clinic, appearing usually as a asymptomatic laterocervical mass of low growth pattern. We present a case of a 53 years old woman with a left of painless laterocervical mass that produced cough with the palpation. We pretend to review the most relevant aspects of the diagnosis and treatment of the paraganglioma and therefore include this pathology in the differential diagnosis of laterocervical tumor.

[A retrospective study of 250 diagnostic and therapeutic microlaryngoscopies]. / Estudio retrospectivo de 250 microlaringoscopias diagnósticas y terapéuticas.

Perusal of 250 microlaryngoscopies done with either diagnostic or therapeutic aim and statistical analysis of all them. Bibliographic review checking own results with those of similar studies.

[Treatment of malignant otitis externa]. / Tratamiento de la otitis externa maligna.

Though rare the malignant otitis externa must be borne in mind because in its precocious diagnosis is based the success of the management. Elderly people, diabetics and immunodepressed are especially exposed. The CAT is basic in order to detect the spreading of the process. The patient being admitted at a Medical center, the antibiotherapy started at once with Ceftazidine, 2 g every 12 hours via i.v. The exeresis of the e.e.ca proves sometimes necessary after control of the infection. This procedure assures the healing and prevent the recurrences some times seen. But when infection disappears owing to the success of the antibiotherapy in 2-3 weeks; the culture for Pseudomonas is negative 3 weeks later; and the previous CAT showed no spreading to the tympanal bone, the surgery must be discarded. The process is considered over when the culture for Pseudomonas aeruginosa is negative, but review of the patients is compulsory at least during half a year.

[Laryngeal neurofibroma. A case report and literature review]. / Neurofibroma laríngeo. Presentación de un caso y revisión bibliográfica.

Neurofibroma is a rare pathology on the larynx. We distinguish two types of neurofibromas: plexiform and not plexiform in which the difference is at the cytoarchitectural level. The plexiform type is usually associated to the Von Recklinhausen disease, also know as neurofibromatosis type 1. They usually affect the supraglottic structure, and more frequently they are described in aritenoids, ariepiglottic folds, and posterior commissure. We present a case located at the glottic level of plexiform type, with a postsurgical follow-up of five years. We make a revision of the aethiopathogenesis, evolution and prognostic of these pathology in the bibliography.

[Dysphonia caused by idiopathic skeletal hyperostosis. Apropos of a case]. / Disfonía por hiperostosis esquelética idiopática. A propósito de un caso.

The Forestier's disease is an skeletal idiopathy described by this A. and Rotés Querol, in 1950, characterized by the systemic ossification in variable degree of the vertebral column. The neck localization can produce pharyngeal or laryngeal symptoms, due to the compression of the structures of the neighbourhood. So was the case recorded which being symptomless remain untreated. Survey of today's literature on the subject so as diagnosis, pathophysiology and its management.

[Bilateral carotid chemodectoma on the external carotid arteries. A case report]. / Quemodectoma carotídeo bilateral dependiente de la arteria carótida externa. A propósito de un caso.

Tumors of the carotid body are rare neoplasms that arise from neuroectodermic tissues. They are located in the fork of the primitive carotid artery. They are benign, slow-growing, and asymptomatic, and predominate in women. We present a case of bilateral carotid chemodectoma on the external carotids. These tumors were diagnosed by CT, MRI and superselective angiography. The treatment of choice is surgical after arteriographic embolization. Exeresis is curative in most cases, but some cases require radiotherapy.

[Surgery and radiotherapy in esthesioneuroblastoma of the nose, apropos of 2 cases]. / Cirugía y radioterapia en el estesioneuroblastoma olfatorio, a propósito de dos casos.

The esthesioneuroblastoma is a rare tumor localized in nose and sinus with difficult diagnosis (aspect like undifferentiated carcinoma and lymphosarcoma) local malignant. We have 2 cases in our hospital whose treatment and evolution is good. We have revised the diagnosis and treatment in these diseases.

Prevalence of subdiaphragmatic visceral infarction in cardioembolic stroke.

BACKGROUND: A substantial proportion of ischemic strokes have an embolic mechanism, but the source of embolism is not detected. Coexistence of subdiaphragmatic visceral infarction (SDVI; e.g., renal, splenic, hepatic, bowel infarction) may be a suggestion of a common source of embolism. One large autopsy study found SDVI in 21.5% of patients with fatal stroke. METHOD: We performed diffusion-weighted magnetic resonance abdominal imaging and subsequently performed it in consecutive patients with stroke or TIA and a history of nonvalvular atrial fibrillation. RESULTS: Among 27 patients, 6 had SDVI (3 recent renal, 1 recent splenic, and 3 old splenic infarction). The median time between onset of ischemic stroke and abdominal MRI was 8 days (interquartile range 3-15 days). No predictive factor of SDVI was found in this study population with respect to demographic or ultrasound characteristics. CONCLUSIONS: One in 5 patients with nonfatal cardioembolic stroke or TIA may be associated with subdiaphragmatic visceral infarction (SDVI). Further study should evaluate the frequency of SDVI in patients with stroke of unknown cause.

[Vascular risk factors in patients with ischaemic stroke. Distribution according to age, sex and stroke subtype]. / Factores de riesgo vascular en pacientes con ictus isquémico. Distribución según edad, sexo y subtipo de ictus.

INTRODUCTION: Cardiovascular diseases are one of the leading health problems in developed countries. This term covers conditions such as coronary vascular disease, cerebrovascular diseases and peripheral vascular disease. Ischaemic cerebrovascular disease accounts for 80% of all cerebrovascular diseases. From a clinical point of view it is interesting to distinguish between modifiable and non-modifiable vascular risk factors. AIM: To analyse the prevalence of modifiable vascular risk factors and their different combinations in a case-control study on ischaemic cerebrovascular disease in the Spanish population, and also the differences in the distribution of the risk factors according to the type of stroke (TOAST classification), age and sex. SUBJECTS AND METHODS: The study was conducted on 308 patients with ischaemic stroke who were paired by age (+/- 5 years) and sex, with 307 controls with no prior history of thrombosis. The statistical analysis was performed using the software application SAS v. 9.1. RESULTS: The results suggest that the risk factors are subject to an adding effect, as well as pointing to the presence of a specific profile of these factors depending on the subtype of stroke that is developed. CONCLUSION: The addition of cardiovascular risk factors is associated with an increased risk of vascular events. The distribution of the modifiable vascular risk factors differs according to the type of stroke and the patient's sex and age.

Nasal septal perforation in a patient with subclinical celiac disease: a possible new association.

A female patient presented with nasal septal perforation that did not respond to conventional therapeutic management. Later, because of a malabsorption problem in one of her children, she underwent analytic tests and distal duodenal biopsy, which revealed that she was suffering from subclinical/silent celiac disease. The treatment, a gluten-free diet, unexpectedly resulted in the cessation of the destructive nasal process. Four years later, the patient remains asymptomatic. Nasal septal perforation might constitute a new entity associated with celiac disease hitherto not described in the literature.

[Short history of L-Dopa]. / Breve historia de la L-Dopa.

The introduction of L-Dopa has been a landmark in Neuroscience. Before the use of L-Dopa, Parkinson's disease (PD) was considered a disabling disease with no effective treatment. The development of L-Dopa followed a rationale approach: first, the discovery of dopamine deficiency in the striatum of patients with PD; and then the use of precursor of dopamine. Overall, the whole process took less than 12 years; this is a remarkable short time taking into account that the development of a similar crucial drug such as insulin took 50 years. In addition, the success of L-Dopa stimulated the neurochemistry research for all neurodegenerative diseases.

Inferences about predictable events: eye movements during reading.

Eye fixations were recorded to assess whether, how, and when readers draw inferences about predictable events. Predicting context sentences, or non-predicting control sentences, were presented, followed by continuation sentences in which a target word referred to a predictable event (inferential word) or an unlikely event (non-predictable word). There were no effects on initial target word processing measures, such as launch and landing sites, fixation probability, first-fixation duration, or first-pass reading time. However, relative to the control condition, the predicting context (1) speeded up reanalysis of the inferential word, as revealed by a reduction in second-pass reading time and regressions, and (2) interfered with processing of the non-predictable word, as shown by an increase in regressions. These results indicate that predictive inferences are active at late text integration processes, rather than at early lexical-access processes. The pattern of findings suggests that these inferences involve initial activation of rather general concepts following the inducing context, and that they are completed or refined with delay, after the inferential target word is read.

[Prothrombotic factors in stroke]. / Factores protrombóticos en la enfermedad cerebrovascular isquémica.

INTRODUCTION: Factor V Leiden and prothrombin 20210A polymorphisms are the most common mutations related to deep vein thrombosis, however their relationship with stroke is debated. This paper studies the possible relationship between both entities. MATERIAL AND METHODS: A case-control study was conducted during 27 months to study their association. A total of 312 stroke cases were included, 73 were under 60 years. Control group was obtained from blood donors. Factor V Leiden and prothrombin 20210A polymorphism prevalence was studied. Results were analyzed according to the age and the type of stroke (TOAST classification, 1993). RESULTS: Factor V Leiden was not related to stroke in the general population (OR: 0.65; 95 % CI: 0.18-2.27). The study according to age did not show any association (younger than 60 years: OR: 1.12; 95 % CI: 0.21-5.90; older than 60 years: OR: 0.50; 95 % CI: 0.11-2.14). However, prothrombin 20210A polymorphism OR in cases under 60 was OR: 2.92; 95 % CI: 0.71-11.92 suggesting a possible association between this mutation and stroke. There was no association in the general population (OR: 2.0; 95 % CI: 0.63-6.29) or in people over 60 (OR: 1.73; 95 % CI: 0.51- 5.83). The analysis according to stroke subtype did not show any association in the distribution of any of the polymorphisms studied. CONCLUSION: This study suggests that prothrombin 20210A polymorphism may play a role in stroke under 60 years of age. Factor V Leiden does not seem to be related to stroke.