Time to recanalization and risk of symptomatic intracerebral haemorrhage in patients treated with intravenous thrombolysis.

BACKGROUND AND PURPOSE: To test whether time to recanalization is associated with a progressive risk of symptomatic intracerebral haemorrhage (SICH) after intravenous alteplase (IVT), we conducted a serial transcranial duplex monitoring study up to 24 h after IVT in a cohort of 140 patients with acute ischaemic stroke attributed to large artery occlusion in the anterior circulation. METHODS: Patients were classified in four groups according to the time to complete recanalization (Thrombolysis in Brain Ischaemia, TIBI grades 4 or 5) after alteplase bolus: <2 h (n = 53), 2-6 h (n = 9), 6-24 h (n = 32) and no recanalization (NR) at 24 h (n = 46). SICH was defined as any haemorrhagic transformation with National Institute of Health Stroke Scale (NIHSS) score worsening ≥ 4 points (European Australian Acute Stroke Study II, ECASS II criteria) or parenchymal haematoma type 2 with neurological worsening (SITS-MOST criteria) in the 24-36 h CT. Favourable outcome was defined as modified Rankin score ≤ 2 at 3 months. RESULTS: There were no differences between the groups of patients who recanalized at each time frame regarding localization of the occlusion (P = 0.29), stroke severity at baseline (P = 0.22) and age (P = 0.06). SICH (ECASS/SITS-MOST) was observed in 5.7%/5.7% of the patients who recanalized in <2 h, in 0%/0% of the patients who recanalized between 2-6 h, in 3.1%/3.1% of the patients who recanalized within 6-24 h and in 2.2%/0% of those patients who did not recanalize at 24 h. The rate of favourable outcome according to the time of recanalization was 79.2%, 50%, 46.9% and 34.1% (P < 0.001). CONCLUSIONS: Our findings are in line with the literature showing a relationship between time to recanalization and functional outcome after IVT in acute stroke, but they do not confirm a progressive increase in the rate of SICH.

Hyperintensity of distal vessels on FLAIR is associated with slow progression of the infarction in acute ischemic stroke.

BACKGROUND: Hyperintensity of distal vessels on FLAIR-MRI has been associated with a higher grade of arterial collaterals and a smaller infarct volume in acute stroke patients. No studies analyze the influence of the hyperintense vessel (HV) sign on the speed of the ischemia progression during the first hours. Our aim was to study the association of the HV sign with progression of infarction in acute stroke patients. METHODS: From a prospectively derived stroke database, we retrospectively selected acute stroke patients with a large artery occlusion of the anterior circulation admitted to our comprehensive stroke center with available baseline CT scan and a multimodal MRI carried out thereafter to make a decision about endovascular treatment. Progression of the ischemic area was calculated as the difference in the Alberta Stroke Program Early CT Scan (ASPECTS) score between CT scan and diffusion-weighted imaging (DWI). Slow progression was considered as no change or 1 point decrease on the ASPECTS score between both exams. The presence of HV on FLAIR sequence was graded as absent, subtle or prominent by two readers. RESULTS: A total of 70 patients were included in the study. Mean time between baseline CT and MRI was 124 ± 82 min. ASPECTS score on baseline CT was 10 in 34% of patients, 9 in 49% and 8 or less in 17%. ASPECTS score was 2 (1-3) points lower in the DWI and this decrease did not correlate with the time elapsed between the two exams. Distal HV sign was observed in 57/70 (81%) patients (subtle in 33 and prominent in 24). HV was more frequently observed in patients with proximal artery occlusion. There were no differences regarding stroke severity, stroke subtype and ASPECTS score on baseline CT between groups. Patients with prominent HV showed a lower progression of the ischemic area [median ASPECTS score decrease, 1 (1-0)] compared with patients with subtle HV [median ASPECTS score decrease, 2 (2-1)] and patients with absence of HV [median ASPECTS score decrease, 3 (4-3)] (p < 0.001). Prominent HV was independently associated with slow progression of ischemia in a multivariate logistic regression analysis adjusted by systolic blood pressure on admission, site of occlusion and time elapsed between both neuroimaging exams compared to the absence of HV (OR, 16.2; 95% CI, 2.1-123.1) and to subtle HV sign (OR, 6.1; 95% CI, 1.5-23.9). CONCLUSION: HV sign on FLAIR, especially if prominent, is associated with a slow progression of the ischemic area in acute stroke patients with cerebral artery occlusion of the anterior circulation. This radiological sign may predict the speed of the ischemia progression, opening an opportunity for reperfusion therapies in longer time windows.

Ischaemic stroke as a complication of cardiac catheterisation. Clinical and radiological characteristics, progression, and therapeutic implications.

INTRODUCTION: Ischaemic stroke is the most common neurological complication of cardiac catheterisation. This study aims to analyse the clinical and prognostic differences between post-catheterisation stroke code (SC) and all other in-hospital and prehospital SC. METHODS: We prospectively recorded SC activation at our centre between March 2011 and April 2016. Patients were grouped according to whether SC was activated post-catheterisation, in-hospital but not post-catheterisation, or before arrival at hospital; groups were compared in terms of clinical and radiological characteristics, therapeutic approach, functional status, and three-month mortality. RESULTS: The sample included 2224 patients, of whom 31 presented stroke post-catheterisation. Baseline National Institutes of Health Stroke Scale score was lower for post-catheterisation SC than for other in-hospital SC and pre-hospital SC (5, 10, and 7, respectively; P=.02), and SC was activated sooner (50, 100, and 125minutes, respectively; P<.001). Furthermore, post-catheterisation SC were more frequently due to transient ischaemic attack (38%, 8%, and 9%, respectively; P<.001) and less frequently to proximal artery occlusion (17.9%, 31.4%, and 39.2%, respectively; P=.023). The majority of patients with post-catheterisation strokes (89.7%) did not receive reperfusion therapy; 60% of the patients with proximal artery occlusion received endovascular treatment. The mortality rate was 12.95% for post-catheterisation strokes and 25% for all other in-hospital strokes. Although patients with post-catheterisation stroke had a better functional prognosis, the adjusted analysis showed that this effect was determined by their lower initial severity. CONCLUSIONS: Post-catheterisation stroke is initially less severe, and presents more often as transient ischaemic attack and less frequently as proximal artery occlusion. Most post-catheterisation strokes are not treated with reperfusion; in case of artery occlusion, mechanical thrombectomy is the preferred treatment.

Ischaemic stroke as a complication of cardiac catheterisation. Clinical and radiological characteristics, progression, and therapeutic implications. / Ictus isquémico como complicación del cateterismo cardíaco. Características clínicas, radiológicas y evolutivas e implicaciones terapéuticas.

INTRODUCTION: Ischaemic stroke is the most common neurological complication of cardiac catheterisation. This study aims to analyse the clinical and prognostic differences between post-catheterisation stroke code (SC) and all other in-hospital and prehospital SC. METHODS: We prospectively recorded SC activation at our centre between March 2011 and April 2016. Patients were grouped according to whether SC was activated post-catheterisation, in-hospital but not post-catheterisation, or before arrival at hospital; groups were compared in terms of clinical and radiological characteristics, therapeutic approach, functional status, and three-month mortality. RESULTS: The sample included 2224 patients, of whom 31 presented stroke post-catheterisation. Baseline National Institutes of Health Stroke Scale score was lower for post-catheterisation SC than for other in-hospital SC and pre-hospital SC (5, 10, and 7, respectively; P=.02), and SC was activated sooner (50, 100, and 125minutes, respectively; P<.001). Furthermore, post-catheterisation SC were more frequently due to transient ischaemic attack (38%, 8%, and 9%, respectively; P<.001) and less frequently to proximal artery occlusion (17.9%, 31.4%, and 39.2%, respectively; P=.023). The majority of patients with post-catheterisation strokes (89.7%) did not receive reperfusion therapy; 60% of the patients with proximal artery occlusion received endovascular treatment. The mortality rate was 12.95% for post-catheterisation strokes and 25% for all other in-hospital strokes. Although patients with post-catheterisation stroke had a better functional prognosis, the adjusted analysis showed that this effect was determined by their lower initial severity. CONCLUSIONS: Post-catheterisation stroke is initially less severe, and presents more often as transient ischaemic attack and less frequently as proximal artery occlusion. Most post-catheterisation strokes are not treated with reperfusion; in case of artery occlusion, mechanical thrombectomy is the preferred treatment.

Posttreatment Infarct Volumes when Compared with 24-Hour and 90-Day Clinical Outcomes: Insights from the REVASCAT Randomized Controlled Trial.

BACKGROUND AND PURPOSE: Endovascular therapy has become the standard of care for patients with disabling anterior circulation ischemic stroke due to proximal intracranial thrombi. Our aim was to determine whether the beneficial effect of endovascular treatment on functional outcome could be explained by a reduction in posttreatment infarct volume in the Endovascular Revascularization With Solitaire Device Versus Best Medical Therapy in Anterior Circulation Stroke Within 8 Hours (REVASCAT) trial. MATERIALS AND METHODS: The REVASCAT trial was a multicenter randomized open-label trial with blinded outcome evaluation. Among 206 enrolled subjects (endovascular treatment, n = 103; control, n = 103), posttreatment infarct volume was measured in 204 subjects. Posttreatment infarct volumes were compared with treatment assignment and recanalization status. Appropriate statistical models were used to assess the relationship among baseline clinical and imaging variables, posttreatment infarct volume, the 24-hour NIHSS score, and functional status with the 90-day modified Rankin Scale score. RESULTS: The median posttreatment infarct volume in all subjects was 23.7 mL (interquartile range = 68.9 mL) and 16.3 mL (interquartile range = 50.2 mL) in the endovascular treatment arm and 38.6 mL (interquartile range = 74.9 mL) in the control arm (P = .02 for endovascular treatment versus control subjects). Baseline NIHSS (P < .01), site of occlusion (P < .03), baseline NCCT ASPECTS (P < .01), and recanalization status (P = .02) were independently associated with posttreatment infarct volume. Baseline NIHSS (P < .01), time from symptom onset to randomization (P = .02), treatment type (P = .04), and recanalization status (P < .01) were independently associated with the 24-hour NIHSS scores. The 24-hour NIHSS score strongly mediated the relationship between treatment type and 90-day mRS (P < .01 for indirect effect when adjusted for age), while posttreatment infarct volume did not (P = .26). CONCLUSIONS: Endovascular treatment saves brain and improves 90-day clinical outcomes primarily through a beneficial effect on the 24-hour stroke severity.

Medulloblastoma in young adults. Must we give adjuvant chemotherapy?

Medulloblastoma is a rare entity in adult patients. All data about treatment are from children, where this disease is the most common cerebral tumour. Reports of medulloblastoma in adults are scarce but in all of them the prognosis seems similar to the prognosis of children. We present our experience in five cases of medulloblastoma in young adults, treated at the University Hospital "Germans Trias i Pujol" from June 1994 to October 2003. This has not been a good experience as more than 50% of the patients had a recurrence in spite of the standard treatment. We have reviewed the literature, concluding that we have to adapt the findings in children to our adult patients, offering them adjuvant chemotherapy after surgery.

The tuberculosis program of Catalonia's Central Health Region (1986-1993).

SETTING: Catalonia's Central Health Region antituberculosis program, which began in 1985. OBJECTIVE: To evaluate the cooperation of health staff and the program's effectiveness after 8 years. METHOD: The following data from the nominal notifications and the expanded case reports were processed: epidemiological, clinical and treatment data, each patient's end results and the outcome of the contact investigation. The implementation of the program was evaluated by means of the number of notifications and contact investigations received, and its effectiveness was assessed by the percentage of sputum smear positive cases having completed treatment. RESULTS: There was an increase in the number of patients with an expanded case report (from 74% to 100%), with a final notification (from 61% to 99%) and with contact investigation (from 29% to 79%). The sputum smear positive cases who completed the treatment after 1990 exceeded 85%. CONCLUSION: The implementation of the program in the Region's health system is good and is improving in parallel with the control of the disease.

[The tuberculin skin test in BCG-vaccinated individualse]. / La prueba de la tuberculina en los vacunados con BCG.

The aim of this study was to evaluate the tuberculin skin test in individuals vaccinated with bacillus Calmette-Guérin (BCG) using 2 IU of RT-23. One hundred ninety-six individuals aged 22-40 years-old who had been vaccinated with BCG between 1965 and 1974 were enrolled along with 375 non-vaccinated individuals of the same age and with similar level of risk of infection. The positive predictive value of the test was assessed for three levels of response as indicated by areas of thickening in three diameters: 5, 10 and 15 mm. Vaccinated individuals with negative results were given a second skin test 7 days later to detect a booster effect. Positive diameters 5 mm were observed in 66% of the vaccinated individuals and 24% of the non-vaccinated subjects. Positive diameters 10 mm were observed in 51% of the vaccinated individuals and 19% of the non vaccinated ones. Positive diameters 15 mm were observed in 29% of the vaccinated subjects and in 13% of the non vaccinated ones. The differences were significant for all diameters. The positive predictive value of the test was 36.4% for a diameter 5 mm, 37.6% for diameter 10 mm and 44.8% for diameter 15 mm. The booster effect was detected in 25.8% of the vaccinated individuals who had tested negative at first. In vaccinated individuals, no guidelines can be established to guarantee that a positive reaction is due to infection by Mycobacterium tuberculosis infection, although the likelihood of infection (increased positive predictive value) increases with diameter. It is also impossible to fix a time limit. A second skin test is needed to detect a booster effect in all vaccinated individuals whose first test is negative.

[Tuberculosis control in the Central Health Region of Catalonia during the period 1986-2000]. / El control de la tuberculosis en la Región Sanitaria Centro de Cataluña durante el período 1986-2000.

OBJECTIVE: To assess tuberculosis control in the Central Health Region, Catalonia, Spain, from the implementation of the area's Tuberculosis Control Program in 1986 until the year 2000. METHOD: To study the epidemiological profile of tuberculosis and the outcome of the following control measures in sputum smear-positive patients: final outcome of treatment and monitoring, and the percentage of patients for whom a contact investigation (CI) was carried out. Tuberculosis control is considered effective if the sum of noncompliant patients, plus the cases in which treatment failed, plus the patients transferred out remains below 10% of the cohort of patients studied, and if a CI has been conducted in at least 80% of this cohort. RESULTS: The number of cases reported was 6326, of which 7% were retreatments. A total of 5865 new cases was detected. Of these, 5652 (96%) were patients born in Spain. The number of cases reported annually peaked in 1990 (474) and then declined continuously until 2000, when it was 54% lower (220). Foreign-born patients numbered 213 (4%), and 95% of them came from countries with a high prevalence of tuberculosis. In the cohort of patients studied between 1997 and 2000, the sum of noncompliant patients, plus cases in which treatment failed, plus the patients transferred out came to 11%. Since 1994, a CI has been carried out for over 80% of patients, and this figure reached 92% in 2000. CONCLUSIONS: We consider that a substantial degree of tuberculosis control has been achieved given the decline in tuberculosis morbidity among people born in Spain, the fact that the percentage of noncompliant patients, treatment failures and transfers was only slightly over 10%, and that a CI has been conducted for over 80% of patients since 1994 (92% in 2000).

[Thyroid dysfunction after haematopoietic stem cell transplantation during childhood]. / Complications thyroïdiennes après greffes de cellules souches hématopoïétiques dans l'enfance.

UNLABELLED: To evaluate the percentage and risk factors of thyroid dysfunction in 79 children who underwent bone marrow transplantation in a single centre. PATIENTS AND METHODS: The mean age of the cohort was 6.8 and mean follow-up 5.5 years. The 79 patients were divided in two groups according to the pretransplant conditioning regimen: fractionated total body irradiation (TBI)(N=54), chemotherapy with Busulphan (N=25). Thyroid function was evaluated by thyroid-stimulating hormone (TSH) and free thyroxine (fT4) tests. Overt hypothyroidism was defined by low fT4 blood levels and TSH > 4 mU/l, and compensated hypothyroidism by normal fT4 index and TSH >4 mU/L. RESULTS: The six-year probability of hypothyroidism was 36 +/-6% for the whole group of 79 patients, 49 +/-8% after TBI and 9 +/-6% in the Busulphan group (P <0.001). Neither gender, nor primary disease, nor presence of graft versus host disease were found to be statistically significant for occurrence of hypothyroidism in the TBI group. However, a younger age seemed to influence statistically the 6-year probability of hypothyroidism in the TBI group: 59 +/-9% if age <7.7 years versus 34 +/-13% if age >7.7 years (P =0.02). CONCLUSION: A careful follow-up of thyroid function is recommended even without TBI conditioning regimen. Young age as a potential risk factor of hypothyroidism has never been described and needs to be studied in a larger cohort.

Chronic traumatic pseudoaneurysm of right subclavian artery.

A right subclavian artery pseudoaneurysm caused by blunt trauma is described. CT and digital subtraction angiography helped us to establish a correct diagnosis. Radiologic features of subclavian artery aneurysms and relevant literature are briefly discussed.

Tuberculin reactivity in Bacillus Calmette-Guérin vaccinated subjects.

SETTING: The Centre for Prevention and Control of Tuberculosis in Barcelona, Spain, where the staff appointed to Training Centers are examined. AIMS: To check for tuberculin sensitivity due to Bacillus Calmette-Guérin (BCG) vaccine and ascertain its duration. METHOD: We compared the results of a tuberculin test (TT) on vaccinated and non-vaccinated subjects. The induration diameter and the time elapsed between BCG vaccination and the TT were determined. RESULTS: Of the 2424 vaccinated subjects, 1489 (61.4%) reacted to TT (> or = 5 mm) and of the 3135 non-vaccinated, 905 (28.9%) reacted, a significant difference. Of 1978 subjects vaccinated between 6 and 14 years of age, 63.3% were TT reactors, compared to 23.9% of the 1948 non-vaccinated. Induration diameters > or = 15 mm amounted to 11% for vaccinated subjects and 8% for those not vaccinated, a significant difference. The time from vaccination to TT was 13-25 years. Of the 446 subjects vaccinated at birth, 237 were reactors (53.1%); of the 887 non-vaccinated subjects of the same age, 154 (17.4%) reacted. Reactors > or = 15 mm amounted to 40 (9%) for vaccinated subjects and 46 for non-vaccinated (5.2%), a significant difference. The time elapsed between vaccination and TT was 20-25 years. For 124 vaccinated subjects with a previous negative TT, a second test was positive for 87 (70.2%), and for 257 non-vaccinated it was positive for 64 (24.9%). The difference is due to a booster effect. CONCLUSIONS: BCG vaccination at birth and for school age children causes a reactivity to tuberculin which persists for 20 to 25 years. An induration diameter of > or = 15 mm does not exclude a vaccinal origin. For vaccinated subjects with a previous negative TT, it is necessary to exclude the booster effect.

Xanthogranulomatous cholecystitis: a radiological study of 12 cases and a review of the literature.

BACKGROUND: Twelve cases of xanthogranulomatous cholecystitis (XGC) are presented, and their radiologic appearance is described. METHODS: Four men and eight women, aged 31-82 years old, with XGC were reviewed. Abdominal ultrasound (US) was performed in all patients. Computed tomography (CT) was performed in five patients, barium enema examination in two, and percutaneously CT-guided fine-needle aspirative biopsy of the gallbladder in one. RESULTS: Barium enema examination showed an indentation of the hepatic flexure. Cholelithiasis was present in all patients, and sludge was present in six. The gallbladder wall was thickened in all patients, irregular in nine, and could not be properly differentiated from surrounding liver parenchyma or from other adjacent structures in most patients. A curvilinear halo, hypoechoic on US and with low attenuation on CT, within the gallbladder wall was found in three patients and pericholecystic fluid in two others. On CT, the pericholecystic fat had streaky soft tissue densities in three cases. Percutaneously CT-guided fine-needle aspirative biopsy of the gallbladder was nondiagnostic. The diagnosis of gallbladder carcinoma was considered preoperatively in three patients. CONCLUSION: Despite the characteristic histologic appearance of XCG, radiologic findings are nonspecific, varying from signs observed in other forms of cholecystitis to the appearance of a gallbladder neoplasm.

Use of 201Tl SPECT imaging to assess the response to therapy in patients with high grade gliomas.

PURPOSE: To assess the potential role of 201Tl single photon emission tomography (201-Thallium SPECT) when compared to other imaging modalities in the evaluation of the response to therapy in high grade gliomas. MATERIALS AND METHODS: Twenty patients with histologically proved high grade glioma have been included: 15 with glioblastoma (GBM), 3 with anaplastic astrocytoma (AA) and 2 with anaplastic oligoastrocytoma (AOA). Patients were assessed by 201Tl SPECT, computed tomography (CT) and magnetic resonance imaging (MRI) at (a) either at the moment of maximum response to first line chemotherapy, or after the completion of radiotherapy and chemotherapy if post-surgical residual disease was present, and (b) after the completion of second line chemotherapy if disease persisted, or either a relapse or disease progression was confirmed. Final response was evaluated according to the McDonald criteria, and by comparing SPECT, CT and MRI results. RESULTS: According to the McDonald criteria, clinical response after first line chemotherapy was 5 partial response, 7 stable disease and 8 progressive disease. Evaluation by 201Tl SPECT was in agreement with such criteria in nearly all patients (90%). MRI findings closely agreed with the clinical follow-up. CT findings clearly differed from those observed by SPECT and MRI. After second line therapy, 10 patients progressed, 3 had stable disease and 7 had partial response. 201Tl SPECT agreed with the clinical status in 89% cases, whereas MRI and, specially CT, fared significantly lower. CONCLUSION: Compared to conventional neuroimaging, 201Tl SPECT added valuable information in the assessment of the response to therapy in our patient population; whenever findings were not conclusive and in the case of disagreement between CT and MRI findings.

Medulloblastoma in young adults. Must we give adjuvant chemotherapy?

Medulloblastoma is a rare entity in adult patients. All data about treatment are from children, where this disease is the most common cerebral tumour. Reports of medulloblastoma in adults are scarce but in all of them the prognosis seems similar to the prognosis of children. We present our experience in five cases of medulloblastoma in young adults, treated at the University Hospital "Germans Trias i Pujol" from June 1994 to October 2003. This has not been a good experience as more than 50% of the patients had a recurrence in spite of the standard treatment. We have reviewed the literature, concluding that we have to adapt the findings in children to our adult patients, offering them adjuvant chemotherapy after surgery (AU)

El control de la tuberculosis en la Región Sanitaria Centro de Cataluña durante el período 1986-2000 / Tuberculosis control in the central Health Region of Catalonia during the period 1986-2000

OBJETIVO: Valorar el control de la tuberculosis en la Región Sanitaria Centro de Cataluña desde el inicio de su Programa de la Tuberculosis en 1986 hasta 2000. MÉTODO: Estudio de la evolución epidemiológica de la tuberculosis y el resultado de las siguientes medidas de control en los enfermos con baciloscopia de esputo positiva: resultado final de su seguimiento y tratamiento y porcentaje de enfermos con estudio de contactos (EC).Se considera que el control de la tuberculosis es correcto cuando la suma de no cumplidores del tratamiento, fracasos terapéuticos y traslados no supera el 10 por ciento de la cohorte de enfermos estudiados y si se ha realizado el EC en, al menos, el 80 por ciento de estos enfermos. RESULTADOS: El número de enfermos declarados fue de 6.326, y el porcentaje de retratamientos, del 7 por ciento. Se encontraron 5.865 casos nuevos. La cifra de los pacientes nacidos en España fue de 5.652 (96 por ciento) y el año 1990 fue en el que se presentaron más notificaciones (474) con descenso continuado del 54 por ciento hasta 2000 (220). La cifra de los pacientes nacidos fuera de España fue de 213 (4 por ciento), de los que el 95 por ciento procedía de países de alta prevalencia tuberculosa. En la cohorte de enfermos de 1997-2000, la tasa de no cumplidores, traslados y fracasos fue del 11 por ciento. En cuanto a los enfermos con EC, desde 1994 se venía superando el 80 por ciento hasta alcanzar el 92 por ciento en 2000. CONCLUSIONES: Dada la tendencia descendente de la morbilidad tuberculosa en los nacidos en España, la muy discreta elevación por encima del 10 por ciento de no cumplidores, traslados y fracasos y haber superado el 80 por ciento de enfermos con EC desde 1994 hasta alcanzar el 92 por ciento en 2000, consideramos que se ha logrado un notable grado de control de la tuberculosis (AU)