[Filter content after carotid angioplasty and stenting: relation to ischemic lesions in diffusion-weighted imaging]. / Contenido en filtros tras angioplastia y colocación de stent carotídeo: relación con lesiones isquémicas en la resonancia magnética de difusión.

OBJECTIVES: To evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting and the development of ischemic brain lesions in diffusion-weighted imaging (DWI). To determine the influence of demographic, clinical, and procedural variables in the pathogenesis of emboli and in ischemia after carotid angioplasty and stenting. MATERIAL AND METHODS: We submitted the contents of the filters of 76 patients (60 men; mean age, 68.39 years; range, 46-82) who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery for histologic analysis evaluating volume (< 1 λ = 0.001 ml = 1 µl; 1-10 λ; and > 10 λ) and the composition of the particles. All patients underwent DWI before and 24 hours after the procedure; we recorded whether lesions appeared and their number, size, and distribution. We correlated the findings with demographic, clinical, and procedural variables. RESULTS: Symptoms were present before the procedure in 58 (76.3%) patients. Particles were present in 49 (64.5%) of the filters; most particles (77.5%) were 1 λ with a predominance of fibrin-platelet aggregates, cell remnants, and cholesterol crystals. DWI after the procedure detected lesions in 12 (15.8%) patients. We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables. CONCLUSIONS: Ischemia after carotid angioplasty and stenting does not depend solely on the embolic load and its nature. We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development.

Health care resources for stroke patients in Spain, 2010: analysis of a national survey by the Cerebrovascular Diseases Study Group.

INTRODUCTION: Stroke is currently a major social health problem. For this reason, the Spanish Ministry of Health approved the Stroke National Strategy (SNS) in 2008 to improve the prevention, treatment and rehabilitation of stroke patients. This plan intends to guarantee 24-hour, 365-days neurological assistance in the whole country by the end of 2010. Our aim was to analyse the situation of stroke assistance in Spain in 2009. MATERIAL AND METHODS: A committee of neurologists practicing in the different autonomous communities (AC), and who had not participated in the preparation of the SNS, was created. A national survey was performed including the number of stroke units (SU) and their characteristics (monitoring, 24-h/7-day on-call neurology service, nursing staff ratio and the use of protocols), bed ratio of SU/100,000 people, availability of intravenous thrombolysis therapy, neurovascular intervention (NI) and telemedicine. RESULTS: We included data from 145 hospitals. There are 39 SU in Spain, unevenly distributed. The ratio between SU bed/number of people/AC varied from 1/75,000 to 1/1,037,000 inhabitants; Navarra and Cantabria met the goal. Intravenous thrombolysis therapy is used in 80 hospitals; the number of treatments per AC was between 7 and 536 in 2008. NI was performed in the 63% of the AC, with a total of 28 qualified hospitals (although only 1 hospital performed it 24h, 7 days a week in 2009). There were 3 hospitals offering clinical telemedicine services. CONCLUSIONS: Assistance for stroke patients has improved in Spain compared to previous years, but there are still some important differences between the AC that must be eliminated to achieve the objectives of the SNS.

Cerebral hemodynamic changes after carotid angioplasty and stenting.

BACKGROUND AND PURPOSE: Carotid angioplasty stent placement (CAS) is an accepted alternative to endarterectomy. However, little is known about its effect on cerebral hemodynamics. We prospectively studied the early and delayed hemodynamic changes after CAS. MATERIALS AND METHODS: Sixty patients underwent CAS for >or=70% internal carotid artery stenosis. Transcranial Doppler (TCD) was done before, 6 hours, and 30 days after CAS. Cerebrovascular reserve to apnea (CVR) was measured. RESULTS: On the ipsilateral side, basal middle cerebral artery (MCA) middle flow velocity (MFV) and pulsatility index (PI) increased from 49.7 cm/s and 0.85, respectively, to 62.5 cm/s and 1.09 immediately after CAS (P < .05); anterior cerebral artery (ACA) MFV and PI increased from 50.7 cm/s and 0.90, to 58.9 cm/s and 1.08 (P < .05); and posterior cerebral artery (PCA) MFV decreased from 47.5 to 36.5 cm/s, with no change in PI (P < .05). On the contralateral side, nonsignificant changes were seen on MCA, immediately after CAS; ACA and PCA MFV decreased from 63.7 and 45.3 cm/s to 50.3 and 38.6 cm/s, respectively (P < .05); ACA and PCA PI increased from 0.96 and 1.00, respectively, to 1.04 and 1.04 (P < .05). At 30 days, ipsilateral MCA MFV and PI were 52.8 cm/s and 1.12, respectively (P < .05), and contralateral values were 49.6 cm/s (P < .05) and 1.02 (nonsignificant), respectively. Basal ipsilateral and contralateral CVR improved from 26.0% to 37.0% (P < .05), and from 30.1% to 33.5% (nonsignificant), respectively, at 30 days. CONCLUSIONS: CAS produces an early significant increase of MFV and PI in the ipsilateral anterior circulation. This effect is maintained, though minor, 30 days later. In addition, CAS results in an improvement of CVR at 30 days.

Silent ischemia after neuroprotected percutaneous carotid stenting: a diffusion-weighted MRI study.

BACKGROUND AND PURPOSE: To assess by diffusion-weighted MR imaging (DWI) the efficacy of cerebral protection devices in avoiding embolization and new ischemic lesions in patients with severe internal carotid artery (ICA) stenosis undergoing carotid artery stent placement (CAS). METHODS: One hundred sixty-two CASs in the extracranial ICA were performed with the use of distal filters. Mean age of the patients was 68.5 years (range, 33-86) and 122 patients (75.3%) were symptomatic. MR imaging was performed in all patients during the 3-day period before CAS, and DWI was obtained within 24 hours after the procedure. Ninety-five patients (58.6%) were monitored by transcranial Doppler ultrasonography for microemboli detection in the territory of the middle cerebral artery (MCA), ipsilateral to the vessel being treated. RESULTS: Twenty-eight patients (17.3%) showed 58 new ischemic foci in DWI, and 13 patients (46.4%) had multiple foci. Location of new lesions was mainly in the vascular territory supplied by the treated vessel (19 patients; 67.9%), but also in the contralateral MCA (1 patient; 3.6%), and the posterior fossa (4 patients; 14.3%). A significant relationship (P < .03) was found between occurrence of transient ischemic attack (TIA) and appearance of new lesions. Microembolic signals (MES) were detected in 88 patients (92.6%), with no relationship between number of MES and the appearance of new ischemic foci. CONCLUSION: New ischemic foci were observed in 17.3% of the patients undergoing neuroprotected CAS. Appearance of new ischemic lesions were only significantly related to the occurrence of TIA but not to the number of MES registered or other variables. Despite the encouraging results, the incidence of new ischemic lesions should promote research for safer techniques and devices.

Mitochondrial disease and stroke.

BACKGROUND AND PURPOSE: It is well known that some mitochondrial disorders are responsible for ischemic cerebral infarction in young patients. Our purpose was to determine, in this prospective ongoing study, whether ischemic stroke is the only manifestation of a mitochondrial disorder in young patients. METHODS: Patients aged

Anti-Ri antibodies associated with opsoclonus and progressive encephalomyelitis with rigidity.

A 57-year-old woman without a known neoplasia developed opsoclonus, myoclonus, and ataxia. Positive anti-Ri antibodies were present in both serum and CSF. The patient also had progressive encephalomyelitis with rigidity, an association not previously described.

Stroke in the Lehigh Valley: racial/ethnic differences.

We investigated black/white differences in stroke rate (standardized morbidity), severity, and subtype, and the relative frequencies of 5 primary risk factors (hypertension, diabetes, myocardial infarction, other heart diseases, and transient ischemic attack [TIA]) using the Lehigh Valley Stroke Register. Blacks had a statistically significant higher, age-adjusted rate of stroke than whites. We found no differences in stroke severity using our measures but blacks had a statistically higher proportion of lacunar stroke, while whites had a higher proportion of embolic stroke. There were no differences in proportions of thrombotic stroke or intracerebral hemorrhage. The relative frequencies of hypertension, myocardial infarction, other heart diseases, and diabetes were higher for blacks, while the relative frequency of TIA was higher for whites. These observations are consistent with other reports that blacks have a higher frequency of stroke and tend to have more small-vessel cerebrovascular pathology than whites.

Morvan's fibrillary chorea: remission after plasmapheresis.

We evaluated the effects of plasmapheresis in two patients with Morvan's fibrillary chorea, one of whom had sigmoid carcinoma, with oligoclonal bands in the cerebrospinal fluid, and modifications of the lipid-oxidative muscle pattern. The use of plasmapheresis in the treatment of Morvan's fibrillary chorea has not been reported previously and in our patients improved the symptoms markedly.

Hereditary amyotrophic lateral sclerosis.

A Spanish family transmits, as an autosomal dominant trait, a form of amyotrophic lateral sclerosis characterized by an unusually prolonged evolution of the disease in all affected members. Precocity and persistence of muscle cramps, presence of unilateral proximal segmental myoclonus and early abolition of ankle jerks are other clinical features conspicuous in this family. This type of hereditary ALS of non-chamorro origin and prolonged evolution is rare.

[Spontaneous cerebral calcium embolism]. / Embolismo cálcico cerebral espontáneo.

INTRODUCTION: Calcium embolism is an uncommon cause of stroke which may not be diagnosed in cases which do not involve cardiac surgery or catheterization. The emboli may come from cardiac valves or calcified atheroma of the aortic or carotid arteries. CASE REPORTS: Two patients with cerebral infarcts secondary to spontaneous calcium embolism confirmed by neuro imaging. In both cases on CT scans there were dense points corresponding to calcified material within the middle cerebral artery or one of its branches. In the first case migration of the calcified point following the course of the artery was observed. CONCLUSIONS: Cranial CAT scans are essential for diagnosis of calcium embolism. Migration of the calcified point confirms the diagnosis. It is still not clear whether valve replacement is necessary in these patients and treatment with antiaggregants and/or anticoagulants is controversial.

[Increased level of Gerstmann's syndrome secondary to thalamic hematoma]. / Sindrome de Gerstmann ampliado secundario a hematoma talámico.

A patient developed enlarged Gerstmann syndrome after left thalamic haematoma. Single photon emission computerised tomography (SPECT) showed left parietal-temporal cortical hypocapture. These findings would lead us to believe that the clinical picture of our patient was due to a thalamic-cortical diaschitic phenomenon.

[The effect of angioplasty on cerebral vasomotor reactivity in patients with important stenosis of the internal carotid artery]. / Efecto de la angioplastia en la reactividad vasomotora cerebral de pacientes con estenosis significativa de la arteria carótida interna.

INTRODUCTION: We present the preliminary results of the effects on percutaneous translumenal angioplasty (PTA) cerebral haemodynamics in thirty patients with important stenosis of the internal carotidal artery. MATERIALS AND METHODS: Using transcranial doppler (TCD) with acetazolamide (ACZ) as a vasodilatory stimulus, we assessed vasomotor reactivity (VR and pulsatility index (Pl) both before and three months after angioplasty. We also carried out single photon emission computerized tomography (SPECT) and cartography and frequency measurement by electroencephalogram (EEG) again both before and after PTA. RESULTS: Of the first twelve patients who completed the study, VR was maintained in nine and PI increased after PTA in seven. In three patients VR was exhausted and in two recovered after PTA. CONCLUSIONS: PTA improved cerebral haemodynamics. Similar more exhaustive studies are needed if revascularization techniques are to be useful in treating patients with this level of stenosis but who are asymptomatic as to the risk of haemodynamic cerebral vasomotor angioplasty.

[A validity study of continuous Doppler]. / Estudio de validez del Doppler continuo.

INTRODUCTION: Ultrasound is regularly used for the detection of carotid stenosis which can be treated surgically. This technique includes continuous Doppler, which together with study of blood flow in the orbit is very useful and should be used systematically, not only in certain cases. We present a study of the usefulness of this technique in our Cerebral Vascular Pathology Laboratory. PATIENTS AND METHODS: We selected 708 patients studied sequentially over 10 years with continuous Doppler and conventional angiography (gold standard). The data obtained independently with each technique were compared in order to establish the degree of concordance between them and the corresponding indicators of validity. Contingency tables were drawn up for different cut-off points corresponding to the different degrees of stenosis (50, 70 and 100%). The parameters for validity (sensitivity, specificity, predictive value and precision) were calculated in each case. RESULTS: The percentage coincidence of the two techniques was 91.95%. At the cut-off points there was a high degree of precision (> 94.35%). The specificity and negative predictive value of Doppler compared with angiography was over 95% and 96% respectively. CONCLUSIONS: The validity markers obtained in our laboratory support the technique using continuous Doppler as the ideal non-invasive diagnostic method for carotid stenosis and this means that its systematic use is to be recommended in patients with suspected extracranial carotid disease. Moreover, the low cost of the equipment used as compared with other more sophisticated techniques should lead to its more widespread use as a first-line diagnostic method in all Neurology departments.

[Compression of the internal carotid artery due to elongated styloid process]. / Compresión de la arteria carótida interna por una apófisis estiloides alargada.

INTRODUCTION: Elongation of the styloid process has been reported as a source of pain in the head and neck region. However, transient ischemic attack (TIA) due to mechanical compression of the internal carotid artery (ICA) by an elongated styloid process has never been mentioned in the literature. CASE REPORT: Male aged 36 years, with a ten-year history of dull intermittent pain in the left side of the neck that worsened on turning the head, suffered a TIA in the silvian territory, ten days after a minor neck trauma. The eco-Doppler exploration demonstrated a compression of the ICA after rotation of the head. The arteriography revealed an stenosis of the cervical ICA by an external compression. The length of the elongated process in the orthopantomogram and the computed tomography was 35 mm. Angiotomography showed a closed relationship between the tip of the left elongated process and the stenosis of the ICA. Surgical styloidectomy was performed via an extraoral approach under general anaesthesia. The excised specimen measured 30 mm long. All symptoms were relieved with no recurrence during a three-year follow up period. CONCLUSION: TIA should be taken into account in the clinical feature associated to an elongated styloid process. Angiotomography is very reliable to define the anatomic relationship between the styloid process and the ICA. The treatment of choice is surgical shortening trough an external approach which provides an adequate control of the carotid artery.

[Complete recovery from transient coma in bilateral paramedian thalamic infarctions]. / Recuperación completa tras un coma transitorio en infartos talámicos paramedianos bilaterales.

Bilateral paramedian thalamic infarcts (BPTI) can begin clinically with transient coma, after which symptoms of fluctuating hypersomnolence, irrational behaviour, or amnesic states may be observed. We present two patients with BPTI who began with coma, recovering spontaneously in under eight hours, with no accompanying symptoms.

[Subacute combined degeneration of the spinal cord: manifestations of esophageal epidermoid carcinoma]. / Degeneración combinada subaguda espinal: manifestación de un carcinoma epidermoide esofágico.

INTRODUCTION: Subacute combined degeneration of the spinal cord associated with vitamin B12 deficit is well known. However a paraneoplastic induced cyanocobalamin malabsorption responsible for either subacute combined degeneration of the spinal cord, has not been reported. Moreover, the possibility of either subacute combined degeneration of the spinal cord may be manifestation of a cancer, it's unknown. CLINICAL CASE: We present the case of a 73-year-old woman with cutaneous paleness and clinical manifestations of a subacute combined degeneration of the spinal cord. Laboratory analysis showed a megaloblastic anemia and Schilling test showed cyanocobalamin malabsorption corrected by intrinsic factor. Anti-intrinsic factor antibodies were positive. Chronic atrophic gastritis and immunological diseases associated with pernicious anemia or with anti-intrinsic factor positive, were excluded. A hidden esophageal squamous cell carcinoma was discovered. Necropsy confirmed both, subacute combined degeneration of the spinal cord and esophageal carcinoma in the absence of chronic atrophic gastritis. CONCLUSIONS: Anti-intrinsic factor antibodies were the only found factor which could explain cyanocobalamin malabsorption. A esophageal squamous cel carcinoma was discovered. In our case, vitamin B12 malabsorption had a paraneoplastic origin mediated by anti-intrinsic factor antibodies. Subacute combined degeneration of the spinal cord may be the manifestation of a hidden esophageal squamous cell carcinoma.

[Transcranial Doppler velocimeter in pregnant and later normotensive puerperal women]. / Velocimetría Doppler transcraneal en gestantes y posteriormente puérperas normotensas.

INTRODUCTION: The physiological changes that take place in blood flow in the brain during pregnancy and the puerperium are still only poorly understood. The harmlessness of transcranial Doppler (TCD) makes it a suitable method of study. AIMS: The purpose of this study was to determine the TCD velocimeter reading at the end of pregnancy and in the early puerperium of healthy expectant mothers. SUBJECTS AND METHODS: TCD was used to perform a bilateral study of the anterior (ACA), middle (MCA) and posterior cerebral arteries (PCA). Arterial blood pressure and haematocrit were also measured. Mean velocity (MV), the pulsatility index (PI), mean arterial blood pressure and haematocrit were employed as variables in the statistical analysis. Results from 44 normotensive pregnant women in the latter stages of gestation (week 33 to term) were compared with those of a control group made up of 58 women of a similar age, who were normotensive and not pregnant. The study was repeated in the group of pregnant women during the early puerperium (the first five days after labour) and the two different results were compared. RESULTS: Age and MAP were similar in the gestating and non-gestating groups. Haematocrit was significantly lower in the former (p < 0.001) and MV were significantly lower in the pregnant women in all the arteries (p < 0.001), whereas the PI were also significantly lower in four of the six territories that were studied (p < 0.005). During the puerperium, a significant rise in MV was observed in all the arteries (p < 0.001) and the PI increased in three of them (p < 0.05). In this phase, the mean arterial pressure rose (p < 0.05), although haematocrit levels dropped (p < 0.001). CONCLUSIONS: The low MV and PI seen at the end of pregnancy are compatible with cerebral vasodilatation. MV increase during the early puerperium and is probably linked to a relative hyperperfusion.

[Restenosis and remodeling after percutaneous transluminal carotid angioplasty]. / Reestenosis y remodelado tras angioplastia transluminal percutánea carotídea.

INTRODUCTION: The characteristics of restenosis and remodeling after carotid percutaneous transluminal angioplasty (PTA) were badly known. OBJECTIVE: To describe these characteristics in our series of carotid PTA. PATIENTS AND METHODS: A total of 78 cases of PTA for symptomatic > 70% atherosclerotic stenosis of the extracranial internal carotid artery, were selected from our series of PTA if follow-up was > 12 months. All of them were followed with extracranial continuous-wave Doppler. RESULTS: Restenosis of any degree was found in 17 cases (21.79%) and always asymptomatic. A restenosis > or = 70% was found in 5 cases (6.4%). Restenosis was mainly found in cases without residual stenosis nor dissection after PTA (p = 0.002). Restenosis was found in 16 cases (94.11%) in the first 6-months, with no progression thereafter. Remodeling of residual stenosis was frequent (17 cases; 53.11%) and found mainly during the first month after PTA. Its incidence was highest in patients with dissection treated with heparin. In cases with restenosis, remodeling was infrequent, incomplete and occurred after 18-24 months. CONCLUSIONS: 1. Significant restenosis after PTA due to myointimal proliferation, was infrequent. All cases were asymptomatic, under antiplatelet treatment. A new interventional procedure might not be necessary. 2. Complete remodeling was frequently found after 1-month control, mainly in arteries with some residual stenosis and dissection after PTA.

[Vascular risk factors in patients with infratentorial vertebrobasilar ischemia]. / Factores de riesgo vascular en pacientes con isquemia en el territorio vertebrobasilar infratentorial.

INTRODUCTION: Arteriosclerosis is the commonest aetiology of vertebro-basilar ischemia (VBI). In the literature few studies mention the risk profile of cerebrovascular accidents at this site. MATERIAL AND METHODS: In order to establish whether this profile has specific characteristics, we carried out a transversal study of 70 patients with VBI of artherothrombotic origin situated in the brain stem or cerebellum, determining the prevalence of the main risk factors (RF). The results were compared with a control group of individuals who had no cerebral vascular pathology and also with another group who had arteriosclerotic obstructive lesions of the carotid artery as an example of involvement of another vascular territory. RESULTS: In the the group of patients with VBI we found greater prevalence of hypertension, smoking, ischaemic cardiopathy, peripheral vascular disease and excessive alcohol consumption together with raised levels of arterial hypertension, haematocrit, haemoglobin and total cholesterol as compared with the control group and within a similar range to the group of patients with ischemia of the carotid territory. We underline the high prevalence of diabetes in patients with VBI (45.7%), considerably greater than that of the control group (12.5%), than those with carotid pathology (20.4%) and that described in the literature (17-25%). CONCLUSIONS: According to our results, the prevalence of RF in VBI and in carotid pathology is similar, except in the case of diabetes. This may play a more decisive role in territory such as the vertebro-basilar, where vascularization is basically by small calibre vessels.

[Hyperperfusion syndrome as a complication of percutaneous transluminal angioplasty of the internal carotid artery]. / Síndrome de hiperperfusión como complicación de la angioplastia transluminal percutánea de la arteria carótida interna.

INTRODUCTION: The hyperperfusion syndrome (HS) is described as an infrequent complication of carotid endarterectomy. It may also occur in percutaneous transluminal carotid angioplasty with a similar causal mechanism and clinical features to those seen in HS related to carotid endarterectomy. CLINICAL CASE: We describe the case of a 69 year old man who developed HS at the time of transluminal carotid angioplasty and 'stenting' of symptomatic, pre-occlusive stenosis of the left internal carotid artery. This complication was not detected on the postoperative arteriography. On CT the presence of a hemispheric hematoma was confirmed. It is thought that HS is caused by a fault in autoregulation of the cerebral blood flow following correction of vascular stenosis in previously ischemic territory. CONCLUSIONS: Most of the early complications of transluminal carotid angioplasty are ischemic. HS is rare but is a possible complication of transluminal carotid angioplasty and therefore meticulous control of the blood pressure is necessary. A CT scan after any atypical complication of angioplasty may be considered to be essential.