Clinical experience of plasmapheresis for neuromyelitis optica patients in Mexico.

BACKGROUND: Neuromyelitis optica spectrum disorders (NMOSDs) are a group of chronic immune-mediated demyelinating diseases of the central nervous system. Their pathophysiology dependent on humoral mediated responses caused by autoreactive IgG antibodies against aquaporin-4 water channels (AQP4-IgG) or myelin oligodendrocyte glycoprotein (MOG-IgG). Plasma exchange (PLEX) has proved to be a beneficial therapy in patients with severe relapses. We present the largest series of Latin American patients treated with PLEX for acute NMOSDs relapses. METHODS: A retrospective study was conducted. Selection included patients diagnosed with NMOSDs who received PLEX between 2010-2019, irrespective of their AQP4-IgG serostatus. All patients received 5 grams of IV methylprednisolone. PLEX therapy could be initiated simultaneously or after IV steroids. Baseline and post-PLEX therapy Expanded Disability Status Scale (EDSS) was measured to identify acute response to therapy. Comparison between responders and non-responders was also conducted. Subgroup analysis stratified response by serostatus, type of clinical relapse and time to PLEX. RESULTS: A total of 89 patients were included. Mean age at onset was 38 ± 12.97 years. 49 (55.1%) patients were AQP4-IgG seropositive. Most patients had unilateral optic neuritis (34.8%) or longitudinally extensive transverse myelitis (33.7%). Mean time from onset to PLEX initiation was 20.9 ± 18.1 days. Response rate was 39.3% and mean decline in EDSS was 0.7 ± 0.9 (p <0.001). Decline in EDSS and response rate were independent of serostatus, type of clinical relapse or time to PLEX initiation. CONCLUSION: PLEX appears to be an effective therapy for NMOSDs relapses even in limited resources setting where treatment initiation may be delayed. The benefit seems to be independent of the type of clinical relapse and AQP4 IgG serostatus.

CSF neurofilament light chain testing as an aid to determine treatment strategies in MS.

OBJECTIVE: To evaluate the use of CSF neurofilament light chain (NfL) measurements in clinical practice as well as their effect on treatment strategies and outcomes in patients with MS. METHODS: This was an observational cohort study of patients with MS who had a CSF NfL measurement between December 2015 and July 2018 as part of their routine clinical care. Treatment strategies were classified as "No Treatment/No Escalation" (no treatment or no escalation of treatment) or "Treatment/Escalation" (first-line injectable/oral disease-modifying therapies (DMTs), highly active DMTs, or treatment escalation). Change in Expanded Disability Status Scale (EDSS) scores was evaluated after 1-year follow-up. RESULTS: Of 203 patients with MS, 117 (58%) had relapsing-remitting MS. Disease activity was most frequently indicated by elevated CSF NfL (n = 85), followed by clinical (n = 81) and MRI activity (n = 65). CSF NfL measurements were independently associated with clinical (p = 0.02) and MRI activity (p < 0.001). Of those with elevated CSF NfL as the only evidence of disease activity (n = 22), 77% had progressive MS (PMS). In patients with PMS, 17 (20%) had elevated CSF NfL as the sole indicator of disease activity. Elevated CSF NfL resulted more frequently in Treatment/Escalation than normal CSF NfL (p < 0.001). Median EDSS change at follow-up was similar between patients receiving No Treatment/No Escalation and Treatment/Escalation decisions (p = 0.81). CONCLUSIONS: CSF NfL measurements informed treatment strategies, alongside clinical and MRI measures. CSF NfL levels were the only indicator of disease activity in a subset of patients, which was more pronounced in patients with PMS. Elevated CSF NfL was associated with more Treatment/Escalation strategies, which had an impact on EDSS outcomes at 1 year.

Guillain-Barré Syndrome Associated With Zika Virus Infection: A Prospective Case Series From Mexico.

Background: On May 2016, anticipating the rainy season from June to October in Mexico, we expected an increase in cases of Zika virus (ZIKV) infections. With the goal of identifying cases of GBS associated with ZIKV infection, a prospective joint study was conducted by a reference center for neurological patients and the Secretary of Health in Mexico City from July 2016 to November 2016. Methods: Serum, cerebrospinal fluid, urine, and saliva were tested by RT-PCR for ZIKV, dengue virus, and chikungunya virus in patients referred from states with reported transmissions of ZIKV infection, and with clinical symptoms of GBS according to the Brighton Collaboration criteria. Clinical, electrophysiological, and long-term disability data were collected. Results: In the year 2016 twenty-eight patients with GBS were diagnosed at our institute. In five hospitalized patients with GBS, RT-PCR was positive to ZIKV in any collected specimen. Dengue and chikungunya RT-PCR results were negative. All five patients had areflexic flaccid weakness, and cranial nerves affected in three. Electrophysiological patterns were demyelinating in two patients and axonal in three. Three patients were discharged improved in 10 days or less, and two patients required intensive care unit admission, and completely recovered during follow-up. Conclusion: Our results are similar to those reported from the state of Veracruz, Mexico, in which out of 33 samples of urine of patients with GBS two had a positive RT-PCR for ZIKV. Simultaneous processing of serum, CSF, urine, and saliva by RT-PCR may increase the success of diagnosis of GBS associated to ZIKV.

Hypertensive thalamic hemorrhage: analysis of short-term outcome.

BACKGROUND: Hypertension is the main cause of intracerebral hemorrhage with a thalamic location frequency that varies from 6% to 26.5%. OBJECTIVE: We aimed to identify clinical and radiological features that could impact the short-term prognosis in patients with hypertensive thalamic hemorrhage (HTH). METHODS: Consecutive patients presenting to a tertiary referral hospital with HTH were analyzed from 2010 to 2014. Clinical features at emergency department and a 30-day outcome using the modified Rankin Scale (mRS) were obtained. RESULTS: A total of 104 patients were studied (53 women, mean age 68.2 years, range 27-91 years), 91 (87.5%) of them with hypertension history. Mean hemorrhage volume was 12.2 mL (range 2-45 mL), without significant differences according to gender or age group. Irruption into the ventricular system occurred in 79 (76%) cases. Thirty-day mortality was 38.5% and occurred with a higher frequency in men, in patients with GCS <8, intraventricular irruption, ventriculostomy, and intracerebral hemorrhage volumes >15 mL. CONCLUSIONS: Although HTH is associated with relatively small hemorrhage volume, it had a higher frequency of ventricular irruption and bad prognosis at short-term.

Evaluation of blood pressure measurements in first ambulatory neurological consultations: A missed part of the physical examination? / Evaluación de la medición de la presión arterial en primeras consultas neurológicas ambulatorias: ¿una parte olvidada del examen físico?

Objective: To obtain a blood pressure reading is mandatory during either the general or specialized physical examination. This study describes factors associated with the accomplishment of blood pressure measurement in the first neurological consultation. Methods: We studied first ambulatory neurology consultations in a Mexican referral hospital. Demographic characteristics, diagnostic category of referral, final diagnosis and data on physical examination were collected to establish a logistic regression analysis in order to identify factors associated with the accomplishment of blood pressure measurement. Results: Over 8 months 778 outpatients were studied. The most frequent diagnoses for first consultation were headache (26%), epilepsy (14%) and stroke (13%). Only in 39% (n = 301) of the outpatients blood pressure was registered, among them, 30% had normal blood pressure, 43% had 121-139/81-89mmHg, 20% had 140-159/90-99mmHg and 7% had ≥ 160/100mmHg. The independent factors that favored the practice of BP determination in multivariable analysis were >65 years of age (odds ratio: 2.26; 95% confidence interval: 1.52-3.36) and headache complaint (odds ratio: 1.81, 95% confidence interval: 1.30-2.53). Notably, only 43% of patients with stroke had blood pressure registration, even when these stroke patients had blood pressure readings, they had higher blood pressure than with other diagnoses (p< 0.05). Conclusion: Blood pressure registration was frequently omitted from the first neurological consultation, particularly in outpatients who might need it the most.

Objetivo: La medición de la presión arterial es mandatoria durante el examen físico general o especializado. Este estudio describe factores asociados al cumplimiento de la medición de la presión arterial en la primera consulta neurológica. Métodos: Realizamos un estudio sobre consultas neurológicas ambulatorias en un hospital de referencia mexicano. Se recolectaron características demográficas, categoría diagnóstica de referencia, diagnóstico final y datos sobre el examen físico para construir un análisis de regresión logística con el objetivo de identificar factores asociados con el cumplimiento de la medición de la presión arterial. Resultados: Durante 8 meses estudiamos a 778 pacientes. Los diagnósticos de envío más frecuentes fueron cefalea (26%), epilepsia (14%) y enfermedad cerebrovascular (13%). Solo en el 39% (n = 301) de los pacientes se midió la presión arterial y, de entre ellos, el 30% presentaron presión arterial normal, el 43% 121-139/81-89mmHg, el 20% 140-159/90-99mmHg y el 7% ≥ 160/100 mmHg. En un análisis multivariable, la edad > 65 años (razón de momios: 2.26, intervalo de confianza del 95%: 1.52-3.36) y cefalea como motivo de consulta (razón de momios: 1.81, intervalo de confianza del 95%: 1.30-2.53) fueron los factores independientes asociados al registro de la presión arterial. De manera notable, solo al 43% de los pacientes con enfermedad cerebrovascular se les había registrado la presión sanguínea; estos pacientes la tenían más elevada que los pacientes con otros diagnósticos (p <0.05). Conclusión: En este estudio con frecuencia se omitió el registro de la presión arterial en la primera consulta neurológica, especialmente en pacientes que podrían necesitarlo más.

Evaluation of blood pressure measurements in first ambulatory neurological consultations: a missed part of the physical examination?

OBJECTIVE: To obtain a blood pressure reading is mandatory during either the general or specialized physical examination. This study describes factors associated with the accomplishment of blood pressure measurement in the first neurological consultation. METHODS: We studied first ambulatory neurology consultations in a Mexican referral hospital. Demographic characteristics, diagnostic category of referral, final diagnosis and data on physical examination were collected to establish a logistic regression analysis in order to identify factors associated with the accomplishment of blood pressure measurement. RESULTS: Over 8 months 778 outpatients were studied. The most frequent diagnoses for first consultation were headache (26%), epilepsy (14%) and stroke (13%). Only in 39% (n=301) of the outpatients blood pressure was registered, among them, 30% had normal blood pressure, 43% had 121-139/81-89 mmHg, 20% had 140-159/90-99 mmHg and 7% had ≥ 160/100 mmHg. The independent factors that favored the practice of BP determination in multivariable analysis were >65 years of age (odds ratio: 2.26; 95% confidence interval: 1.52-3.36) and headache complaint (odds ratio: 1.81, 95% confidence interval: 1.30-2.53). Notably, only 43% of patients with stroke had blood pressure registration, even when these stroke patients had blood pressure readings, they had higher blood pressure than with other diagnoses (p<0.05). CONCLUSION: Blood pressure registration was frequently omitted from the first neurological consultation, particularly in outpatients who might need it the most.

Spontaneous intracerebral hemorrhage in Mexico: results from a Multicenter Nationwide Hospital-based Registry on Cerebrovascular Disease (RENAMEVASC).

INTRODUCTION: Scarce information exists on intracerebral hemorrhage (ICH) in Latin America, and the existent is derived from single-center registries with non-generalizable conclusions. The aim of this study is to describe the frequency, etiology, management and outcome of ICH in Mexico. PATIENTS AND METHODS: We studied consecutive patients with ICH pertaining to the National Multicenter Registry on Cerebro-vascular Disease (RENAMEVASC), conducted in 25 centers from 14 states of Mexico. The Intracerebral Hemorrhage Grading Scale (ICH-GS) at admission was used to assess prognosis at 30 days follow-up. RESULTS: Of 2,000 patients with acute cerebrovascular disease registered in RENAMEVASC, 564 (28%) had primary ICH (53% women; median age: 63 years; interquartile range: 50-75 years). Hypertension (70%), vascular malformations (7%) and amyloid angiopathy (4%) were the main etiologies. In 10% of cases etiology could not be determined. Main ICH locations were basal ganglia (50%), lobar (35%) and cerebellum (5%). Irruption into the ventricular system occurred in 43%. Median score of ICH-GS was 8 points: 49% had 5-7 points, 37% had 8-10 points and 15% had 11-13 points. The 30-day case fatality rate was 30%, and 31% presented severe disability. The 30-day survival was 92% for patients with ICH-GS 5-7 points, whereas it decreased to 27% in patients with ICH-GS 11-13 points. CONCLUSIONS: In Mexico, ICH represents about a third of the forms of acute cerebrovascular disease, and the majority of patients present severe disability or death at 30 days of follow-up. Hypertension is the main cause; hence, control of this important cardiovascular risk factor should reduce the health burden of ICH.