Rate of atrial fibrillation by Holter-Stroke Risk Analysis in undetermined TIA/rapidly improving stroke symptoms patients.

Introduction: Holter-SRA (Stroke Risk Analysis) is an automated analysis of ECG monitoring for Atrial Fibrillation (AF) detection. The aim of this study was to evaluate the rate of AF in undetermined TIA/Rapidly improving stroke symptoms (RISS) patients. Methods: Prospective study of undetermined TIA/RISS patients who presented to the emergency department. Early vascular studies (angio CT, transthoracic echocardiography and ECG) were performed in emergency department. The Holter-SRA device was placed for 2 h and the patients were classified into: confirmed AF, high risk of AF or low risk of AF. Prolonged ambulatory monitoring (7 days) was carried out every month for patients with a high-risk pattern. The results were evaluated until definitive detection of AF or low-risk pattern. The endpoints were rate of AF and vascular recurrence at 90 days. Results: Over a period of 24 months, 83 undetermined TIA/RISS patients were enrolled. The mean age was 70 ± 10 years and 61% were men. The median ABCD2 score was 4 points (1-7). After 2 h of monitoring in the emergency department, AF was detected in one patient (1.2%), 51 patients with a low-risk pattern and 31 patients (37.3%) showed a high-risk pattern of AF. During the ambulatory monitoring, of the 31 patients high risk pattern patients, AF was diagnosed to 17 cases and of the 51 patients with a low-risk pattern, one case experienced a recurrent vascular due to undetected AF (1.9% false negative). Three patients (3.6%) suffered a vascular recurrence within the first 90 days, before AF diagnosis. Conclusions: In our study, AF was detected in 22.9% of the 83 patients with indeterminate TIA/RISS. Holter-SRA has allowed us to increase the detection of AF, especially those patients with a high-risk pattern in the first 3 months.

Riesgo de hemorragia cerebral en el traumatismo craneal leve y tratamiento antitrombótico / Risk of cerebral hemorrhage in mild traumatic brain injury and antithrombotic treatment

Objetivo El tiempo de observación en el traumatismo craneoencefálico leve (TCEL) es controvertido. Nuestro objetivo se basó en evaluar el riesgo de complicaciones neurológicas en el TCEL con y sin tratamiento antitrombótico. Método Evaluamos retrospectivamente los pacientes con TCEL atendidos en urgencias durante 3 años. Consideramos TCEL aquellos con Glasgow ≥13 al ingreso. Se realizó una TC craneal en todos los casos con >1 factor de riesgo al ingreso y a las 24h en aquellos con deterioro neurológico o TC craneal inicial patológica. Se revisó retrospectivamente las complicaciones en los siguientes 3 meses. Resultados Evaluamos 907 pacientes con una edad media de 73±19 años. El 91% presentaron factores de riesgo, con un 60% en tratamiento antitrombótico. Detectamos un 11% de hemorragia cerebral inicial, 0,4% a las 24h y ningún caso a los 3 meses. El tratamiento antitrombótico no se asoció con incremento de riesgo de hemorragia cerebral (9,9 con vs. 11,9% sin tratamiento; p=0,3). El 39% de las hemorragias presentaron síntomas neurológicos (18% amnesia postraumática, 12% cefalea, 8% vómitos, 1% convulsiones), siendo en un 78,4% síntomas leves. De las 4 hemorragias detectadas a las 24h, 3 fueron asintomáticas y un caso emporó la cefalea inicial. Ningún paciente asintomático sin lesión en la TC craneal inicial presentó clínica a las 24h. Conclusiones Nuestro estudio sugiere que los pacientes con TCEL asintomáticos, sin lesión en la TC craneal inicial no precisarían periodo de observación ni TC craneal de control, independientemente del tratamiento antitrombótico o nivel de INR (AU)

Introduction The observation time in mild traumatic brain injury (mTBI) is controversial. Our aim was to assess the risk of neurological complications in mTBI with and without antithrombotic treatment. Method We retrospectively evaluated patients with mTBI seen in the emergency room for 3 years. We considered MTBI those with Glasgow ≥13 at admission. A cranial CT was performed in all cases with >1 risk factor at admission and at 24h in those with neurological impairment or initial pathological cranial CT. Complications in the following 3 months were retrospectively reviewed. Results We evaluated 907 patients with a mean age of 73±19 years. Ninety-one percent presented risk factors, with 60% on antithrombotic treatment. We detected 11% of initial brain hemorrhage, 0.4% at 24h, and no cases at 3 months. Antithrombotic treatment was not associated with an increased risk of brain hemorrhage (9.9% with vs. 11.9% without treatment, P=.3). 39% of the hemorrhages presented neurological symptoms (18% post-traumatic amnesia, 12% headache, 8% vomiting, 1% seizures), with 78.4% having mild symptoms. Of the 4 hemorrhages detected at 24h, 3 were asymptomatic and one case that worsened the initial headache. No asymptomatic patient without lesion on initial clinical cranial CT presented at 24h. Conclusions Our study suggests that patients with asymptomatic mTBI, without a lesion on the initial cranial CT, would not require the observation period or CT control regardless of antithrombotic treatment or INR level (AU)

Risk of cerebral hemorrhage in mild traumatic brain injury and antithrombotic treatment.

INTRODUCTION: The observation time in mild traumatic brain injury (mTBI) is controversial. Our aim was to assess the risk of neurological complications in mTBI with and without antithrombotic treatment. METHOD: We retrospectively evaluated patients with mTBI seen in the emergency room for 3 years. We considered MTBI those with Glasgow ≥13 at admission. A cranial CT was performed in all cases with ≥1 risk factor at admission and at 24 h in those with neurological impairment or initial pathological cranial CT. Complications in the following 3 months were retrospectively reviewed. RESULTS: We evaluated 907 patients with a mean age of 73 ±â€¯19 years. Ninety-one percent presented risk factors, with 60% on antithrombotic treatment. We detected 11% of initial brain hemorrhage, 0.4% at 24 h, and no cases at 3 months. Antithrombotic treatment was not associated with an increased risk of brain hemorrhage (9.9% with vs 11.9% without treatment, p = 0.3). 39% of the hemorrhages presented neurological symptoms (18% post-traumatic amnesia, 12% headache, 8% vomiting, 1% seizures), with 78.4% having mild symptoms. Of the 4 hemorrhages detected at 24 h, 3 were asymptomatic and one case that worsened the initial headache. No asymptomatic patient without lesion on initial clinical cranial CT presented at 24 h. CONCLUSIONS: Our study suggests that patients with asymptomatic mTBI, without a lesion on the initial cranial CT, would not require the observation period or CT control regardless of antithrombotic treatment or INR level.

Influencia del tratamiento de los puntos gatillo miofasciales en pacientes con ictus isquémico agudo: estudio piloto aleatorizado, doble ciego / Influence of the treatment of miofascial trigger points in acute ischaemic stroke patients: Randomized pilot study, double blind

Objetivos Evaluar la influencia del tratamiento de los puntos gatillo miofasciales (PGM) en el balance motor y en la autonomía funcional en pacientes con ictus isquémico agudo. Participantes y métodos Se incluyeron 22 pacientes con ictus isquémico de menos de cinco días de evolución, con paresia braquial y/o crural en un estudio piloto, aleatorizado, a doble ciego, de tratamiento experimental vs. control. Durante la hospitalización, ambos grupos recibieron la fisioterapia. Adicionalmente, al grupo experimental (GE) se le trataron los PGM detectados en hombro y cadera paréticos y al grupo control (GC) se le aplicó un tratamiento sin efectos sobre los PGM. Fueron registrados al alta y a los 90 días postictus el grado fuerza de las extremidades paréticas mediante la National Institute of Health Stroke Scale, y el grado de autonomía funcional mediante la escala de Rankin modificada. Resultados Se detectó una mejoría tanto en la fuerza de las extremidades paréticas (probabilidad al alta de un mejor balance motor del 75,6% en la extremidad superior y del 69% en la extremidad inferior), como en la autonomía funcional (probabilidad de una mejor funcionalidad del 68%) en el GE comparado con el GC. Estos resultados no se mantuvieron a los 90 días de seguimiento. Conclusiones El tratamiento de los PGM como complemento al tratamiento de fisioterapia durante el ingreso hospitalario parece mejorar el balance motor y el grado de autonomía funcional al alta. Son necesarios futuros estudios que permitan confirmar nuestros resultados y evaluar el beneficio de una intervención más allá del ingreso hospitalario (AU)

Objectives To assess the influence of treatment of MTrPs on motor balance and functional autonomy in patients with acute ischaemic stroke. Patients and methods 22 patients with ischaemic stroke of less than 5 days’ evolution, with brachial and / or leg paresis were included in a randomized, double-blind, pilot study of experimental versus control treatment. During hospitalization, both groups received physiotherapy. In addition, the MTrPs detected in the paretic shoulder and hip were treated in the experimental group (EG). In contrast, the control group (CG) were given treatment without effects on the MTrPs. At the time of hospital discharge and 90 days post-stroke, we recorded the degree of strength of the paretic limbs using the National Institute of Health Stroke Scale, and the degree of functional autonomy using the modified Rankin Scale. Results We detected an improvement both in the strength of the paretic limbs (probability at discharge of a better motor balance of 75.6% in the upper limb and 69% in the lower limb) and in functional autonomy (68% probability of better functionality) in the EG compared to the CG. These results were not maintained at 90 days of follow-up. Conclusions Treatment of MTrPs as a complement to physiotherapy treatment during hospital admission seems to improve the degree of strength of paretic limbs and the degree of functional autonomy at hospital discharge. Future studies are necessary to confirm our results and evaluate the benefit of an intervention beyond hospital admission (AU)

Reducción de la tasa de broncoaspiración con el test 2 volúmenes/3 texturas con pulsioximetría en una unidad de ictus / Lowering bronchoaspiration rate in an acute stroke unit by means of a 2 volume/3 texture dysphagia screening test with pulsioximetry

Introducción: En la fase aguda del ictus el 30% de los pacientes presentan disfagia, y de ellos, el 50% experimentarán broncoaspiración. Nuestro objetivo fue evaluar los resultados de mortalidad y broncoaspiración del test del agua comparado con el test 2 volúmenes/3 texturas controlado con pulsioximetría (2v/3t-P) en una unidad de ictus. Pacientes y métodos: Durante 5 años se analizaron de forma prospectiva y consecutiva todos los pacientes con infarto cerebral en la Unidad de Ictus. Del año 2008 al 2010 se utilizó el test del agua (grupo 0 o G0), y del 2011 al 2012, el test 2v/3t-P (grupo 1 o G1). Se recogieron las siguientes variables: demográficas, factores de riesgo vascular, gravedad neurológica con la escala NIHSS, subtipo etiológico según criterios TOAST, subtipo clínico según la clasificación Oxfordshire, prevalencia de disfagia, broncoaspiración y exitus. Resultados: Se analizaron 418 pacientes con infarto cerebral agudo (G0 = 275, G1 = 143). Se detectaron diferencias significativas entre ambos grupos en el porcentaje de pacientes con TACI (17% en G0 vs. 29% en G1, p = 0,005) y en la mediana de NIHSS (4 puntos en G0 vs. 7 puntos en G1, p = 0,003). Con el test 2v/3t-P se detectó un aumento no significativo en el porcentaje de disfagia (22% en G0 vs. 25% en G1, p = 0,4), una menor tasa de mortalidad (1,7% en G0 vs. 0,7% en G1, p = 0,3) y una reducción significativa de broncoaspiración (6,2% en G0 vs. 2,1% en G1, p = 0,05). Conclusiones: El nuevo test 2v/3t-P, comparado con el test del agua, mejoró significativamente los resultados de broncoaspiración en los pacientes con infarto cerebral agudo

Introduction: During acute stroke, 30% of all patients present dysphagia and 50% of that subgroup will experience bronchoaspiration. Our aim was to compare mortality and bronchoaspiration rates associated with the water test compared to those associated with a 2 volume/3 texture test controlled with pulse oximetry (2v/3t-P test) in our stroke unit. Patients and methods. Over a 5-year period, we performed a prospective analysis of all consecutive acute ischaemic stroke patients hospitalised in the Stroke Unit. Dysphagia was evaluated using the water test between 2008 and 2010 (group 0 or G0), and the 2v/3t-P test (group 1 or G1) between 2011 and 2012. We analysed demographic data, vascular risk factors, neurological deficit on the NIHSS, aetiological subtype according to TOAST criteria, clinical subtype according to the Oxfordshire classification, prevalence of dysphagia, percentage of patients with bronchoaspiration, and mortality. Results: We examined 418 patients with acute stroke (G0 = 275, G1 = 143). There were significant differences between the 2 groups regarding the percentage of patients with TACI (17% in G0 vs. 29% in G1, P = .005) and median NIHSS score (4 points in G0 vs. 7 points in G1, P = .003). Since adopting the new swallowing test, we detected a non-significant increase in the percentage of dysphagia (22% in G0 vs. 25% in G1, P = .4), lower mortality (1.7% in G0 vs. 0.7% in G1, P = .3) and a significant decrease in the bronchoaspiration rate (6.2% in G0 vs. 2.1% in G1, P = .05). Conclusions: Compared to the water test used for dysphagia screening, the new 2v/3t-P test lowered bronchoaspiration rates in acute stroke patients

Lowering bronchoaspiration rate in an acute stroke unit by means of a 2 volume/3 texture dysphagia screening test with pulsioximetry. / Reducción de la tasa de broncoaspiración con el test 2 volúmenes/3 texturas con pulsioximetría en una unidad de ictus.

INTRODUCTION: During acute stroke, 30% of all patients present dysphagia and 50% of that subgroup will experience bronchoaspiration. Our aim was to compare mortality and bronchoaspiration rates associated with the water test compared to those associated with a 2 volume/3 texture test controlled with pulse oximetry (2v/3t-P test) in our stroke unit. PATIENTS AND METHODS: Over a 5-year period, we performed a prospective analysis of all consecutive acute ischaemic stroke patients hospitalised in the Stroke Unit. Dysphagia was evaluated using the water test between 2008 and 2010 (group 0 or G0), and the 2v/3t-P test (group 1 or G1) between 2011 and 2012. We analysed demographic data, vascular risk factors, neurological deficit on the NIHSS, aetiological subtype according to TOAST criteria, clinical subtype according to the Oxfordshire classification, prevalence of dysphagia, percentage of patients with bronchoaspiration, and mortality. RESULTS: We examined 418 patients with acute stroke (G0=275, G1=143). There were significant differences between the 2 groups regarding the percentage of patients with TACI (17% in G0 vs. 29% in G1, P=.005) and median NIHSS score (4 points in G0 vs. 7 points in G1, P=.003). Since adopting the new swallowing test, we detected a non-significant increase in the percentage of dysphagia (22% in G0 vs. 25% in G1, P=.4), lower mortality (1.7% in G0 vs. 0.7% in G1, P=.3) and a significant decrease in the bronchoaspiration rate (6.2% in G0 vs. 2.1% in G1, P=.05). CONCLUSIONS: Compared to the water test used for dysphagia screening, the new 2v/3t-P test lowered bronchoaspiration rates in acute stroke patients.

Frequency and outcome of total anterior circulation strokes without intracranial large-vessel occlusion.

BACKGROUND AND PURPOSE: The percentage of patients with clinical total anterior circulation infarct (TACI) syndrome treated with reperfusion therapies in the absence of intracranial large-vessel occlusion (ILVO) was determined and their characteristics and outcome are described. METHODS: Data from a population-based, prospective, externally audited registry of all stroke patients treated with intravenous thrombolysis (IVT) and endovascular therapies in Catalonia from January 2011 to December 2013 were used. Patients with a baseline TACI and initial stroke severity measured by the National Institute of Health Stroke Scale (NIHSS) ≥ 8, evaluated less than 4.5 h post-onset, for whom a vascular study prior to treatment was available (n = 1070) were selected. Clinical characteristics, outcome and radiological data for patients treated with IVT alone (n = 605) were compared between those with detected ILVO (n = 474) and non-ILVO patients (n = 131). RESULTS: A total of 1070 patients met study criteria; non-ILVO was found in 131 (12.2%). Analysing the 605 patients treated only with IVT, no significant differences were found between non-ILVO and ILVO patients in age, sex, risk factors, time-to-treatment and type of radiological studies performed. Although non-ILVO patients had lower initial stroke severity (P < 0.001) and a better prognosis (P = 0.001), 51.3% had a poor outcome and 16% were deceased at 90 days. In 66.4% of patients without ILVO, a recent anterior territorial infarct was detected. CONCLUSIONS: Intracranial artery patency was observed in 12.2% of TACI patients evaluated within 4.5 h. Although absence of ILVO was associated with slightly better prognosis, more than half had a poor outcome at 3 months.

Baja tasa de infarto cerebral, infarto de miocardio y muerte vascular con el diagnóstico y tratamiento etiológico rápido del ataque isquémico transitorio / Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death

Introducción: El riesgo de infarto cerebral dentro de los primeros 90 días tras un ataque isquémico transitorio (AIT) se estima entre un 8-20%. Existe escaso consenso sobre cuál es la estrategia diagnóstica más eficaz. Nuestro objetivo fue evaluar del beneficio del estudio precoz con ecocardiografía transtorácica (ETT) y ultrasonografía carotídea y transcraneal (DTSA/TC) en los pacientes con AIT. Métodos: Evaluamos de forma prospectiva todos los pacientes con AIT atendidos en urgencias durante 24 meses. Recogimos variables demográficas, factores de riesgo vascular y escala ABCD2. La etiología del AIT fue clasificada según criterios TOAST. En todos los pacientes se realizó el estudio vascular precoz (< 72 h) con ETT y DTSA/TC. Los objetivos primarios fueron la recurrencia vascular cerebral, infarto de miocardio (IAM) o muerte vascular durante el primer año. Resultados: Evaluamos 92 pacientes con una edad media de 68,3 ± 13 años y el 61% fueron hombres. La media de la escala ABCD2 fue de 3 puntos (≥ 5 en un 30%). La distribución etiológica fue la siguiente: aterotrombótico de gran vaso 12%; cardioembólico 30%; pequeño vaso 10%; indeterminado 40% e inhabitual 8%. Los hallazgos de la ETT cambiaron el tratamiento en 6 pacientes (6,5%) con exploración física y ECG normal. Al año de seguimiento 3 pacientes (3,2%) sufrieron un infarto cerebral, uno (1%) un IAM y no detectamos ninguna muerte vascular. Conclusiones: El estudio etiológico precoz en los pacientes con AIT y la detección de pacientes con cardiopatía silente puede haber contribuido a la baja tasa de recurrencia vascular

Introduction: The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. Methods: Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD2 score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (< 72 hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. Results: We evaluated 92 patients enrolled over 24 months. Mean age was 68.3 ± 13 years and 61% were male. The mean ABCD2 score was 3 points (≥ 5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. Conclusions: In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence

Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death.

INTRODUCTION: The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. METHODS: Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD(2) score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. RESULTS: We evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD(2) score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. CONCLUSIONS: In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.

Diagnóstico de la enfermedad de CADASIL en pacientes normotensos y no diabéticos con infarto lacunar / Diagnosis of CADASIL disease in normotensive and non-diabetics with lacunar infarct

Introducción: la enfermedad de CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) se caracteriza por isquemias cerebrales recurrentes de tipo lacunar, habitualmente en pacientes sin factores de riesgo vascular. Analizamos la frecuencia de enfermedad de CADASIL en pacientes con infarto lacunar sin factores de riesgo vascular clásicos. Métodos: estudiamos pacientes con un primer infarto lacunar menores de 65 años sin hipertensión, diabetes mellitus u otra causa que justificara la isquemia cerebral. Realizamos estudio inmunohistoquímico de 5μm de espesor sobre biopsia cutánea usando el anticuerpo monoclonal anti-Notch 3 (1E4). Además del estudio inmunohistoquímico se realizó en todos los casos el estudio genético del gen Notch 3 de los exones 3, 4, 5, 6, 11 y 19. Resultados: de 1.519 pacientes con infarto lacunar, sólo 57 (3,7%) cumplieron los criterios de selección, y 30 de ellos aceptaron participar en el estudio. Analizamos 30 pacientes con edad media de 53 años; el 50% fueron hombres y todos presentaron un primer infarto cerebral tipo lacunar. El estudio inmunohistoquímico y genético confirmó la enfermedad de CADASIL en dos pacientes (6,6%) en el exón 4 nt 622C/T (Arg 182 Cys) y 694 T/C (Cys206Arg) respectivamente (AU)

Background: CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is characterized by recurrent cerebral ischemic episodes of the lacunar subtype usually without traditional vascular risk factors. We investigated the frequency of CADASIL among selected patients with cerebral ischemia of the lacunar subtype. Methods: we studied patients under 65 years old who presented cerebral ischemia of the lacunar subtype without hypertension, diabetes mellitus or other causes that explained the cerebral ischemia. On the skin biopsies, we performed immunostaining analysis on 5μm frozen sections with monoclonal antibody anti-Notch 3 (1E4). We also performed a genetic analysis of the Notch 3 gene (exons 3,4,5,6,11 and 19). Results: of 1.519 patients analyzed, only 57 (3.7%) fulfilled the selection criteria, and 30 of them accepted to participated in the study. We studied 30 patients, mean age was 53 years (range 34 to 65), 50% were men and all patients suffered a lacunar stroke. Immunostaining analysis was positive in two patients (6.6%) and the genetic analysis confirmed a mutation characteristic of CADASIL in exon 4 nt 622C/T (Arg 182 Cys) and 694 T/C (Cys206Arg) respectively. Conclusions: CADASIL disease was present in 6.6% of patients younger than 65 years with a lacunar stroke and without hypertension or diabetes mellitus. Screening for CADASIL should be considered in these patients (AU)

Diagnosis of CADASIL disease in normotensive and non-diabetics with lacunar infarct.

BACKGROUND: CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is characterized by recurrent cerebral ischemic episodes of the lacunar subtype usually without traditional vascular risk factors. We investigated the frequency of CADASIL among selected patients with cerebral ischemia of the lacunar subtype. METHODS: we studied patients under 65 years old who presented cerebral ischemia of the lacunar subtype without hypertension, diabetes mellitus or other causes that explained the cerebral ischemia. On the skin biopsies, we performed immunostaining analysis on 5µm frozen sections with monoclonal antibody anti-Notch 3 (1E4). We also performed a genetic analysis of the Notch 3 gene (exons 3,4,5,6,11 and 19). RESULTS: of 1.519 patients analyzed, only 57 (3.7%) fulfilled the selection criteria, and 30 of them accepted to participated in the study. We studied 30 patients, mean age was 53 years (range 34 to 65), 50% were men and all patients suffered a lacunar stroke. Immunostaining analysis was positive in two patients (6.6%) and the genetic analysis confirmed a mutation characteristic of CADASIL in exon 4 nt 622C/T (Arg 182 Cys) and 694 T/C (Cys206Arg) respectively. CONCLUSIONS: CADASIL disease was present in 6.6% of patients younger than 65 years with a lacunar stroke and without hypertension or diabetes mellitus. Screening for CADASIL should be considered in these patients.

[Transthoracic echocardiography in stroke performed by neurologist: pilot study]. / Ecocardiografía transtorácica realizada por neurólogos en patología vascular: estudio piloto.

INTRODUCTION: The aim of this study is to assess concordance between transthoracic echocardiography (TTE) performed by neurologists and cardiologists for the screening of cardioembolic sources in patients with ischemic stroke. METHODS: We examined prospectively 27 consecutive patients with ischemic stroke. A potential source of embolism in all of the patients was sought by means of a TTE study. This study was performed by one neurologist after one-month full-time training on the technique and independently by one cardiologist whose results were considered as the reference standard. Regarding the risk of cardioembolism, findings from TTE studies were considered as normal, or indicative of either moderate or high risk, according to the TOAST criteria. Agreement between the two observers on the diagnosis of cardioembolic source was analyzed with the Cohen's Kappa Test (K). A K > 0,6 was considered as good agreement. RESULTS: The 27 patients studied had a mean age of 68,7 +/- 10,2 years and 70 % were men. A cardioembolic source was detected in 9 patients by the cardiologist and 8 of these were also identified by the neurologist: in 1 patient a mitral annulus calcification was not detected in the examination performed by the neurologist. In 2 patients with poor echocardiographic window, the neurologist underestimated the left ventricular function. Diagnostic agreement between both examinations was 88,9 % (K: 0,77; p = 0,001). CONCLUSION: Compared with cardiologists, trained neurologists show a fairly high degree of accuracy in the TTE screening of patients with stroke. Those cases with poor echocardiographic window or with abnormal findings should be confirmed by the cardiologists.

Ecocardiografía transtorácica realizada por neurólogos en patología vascular: estudio piloto / Transthoracic echocardiopraphy in stroke performed by neurologist: pilot study

El objetivo de nuestro estudio es comparar la concordancia entre la ecocardiografía transtorácica (ETT) realizada por neurólogos y cardiólogos en el cribado de fuentes cardioembólicas en pacientes con isquemia cerebral. Métodos. Evaluamos de forma prospectiva y consecutiva 27 pacientes con isquemia cerebral. A todos se les realizó una ETT por un neurólogo que había sido entrenado previamente durante un mes en la técnica, e independientemente, por un cardiólogo cuyos resultados fueron considerados como la referencia estándar. Según el riesgo de cardioembolismo, los hallazgos en la ETT fueron clasificados como normales, de moderado o alto riesgo según los criterios TOAST. La concordancia en el diagnóstico de fuente cardioembólica entre ambos exploradores fue evaluado con el test Kappa de Cohen (K). Una K>0,6 se consideró como buena concordancia. Resultados. De 27 pacientes con isquemia cerebral, la edad media fue de 68,7 ± 10,2 años y 70 % fueron hombres. En 9 pacientes el cardiólogo detectó una fuente cardioembólica, y de ellos, 8 pacientes también por el neurólogo (1 paciente con calcificación del anillo mitral no fue detectado). En 2 pacientes con mala ventana ecocardiográfica, el neurólogo infraestimó la función ventricular. El diagnóstico fue concordante entre ambas exploraciones en un 88,9 % de los pacientes (K: 0,77; p = 0,001). Conclusiones. Comparado con el cardiólogo, un neurólogo entrenado realiza la ETT con una buena fiabilidad. En los casos con mala ventana ecocardiográfica o con hallazgos patológicos, éstos deberían ser confirmados por el cardiólogo (AU)

Introduction. The aim of this study is to assess concordance between transthoracic echocardiography (TTE) performed by neurologists and cardiologists for the screening of cardioembolic sources in patients with ischemic stroke. Methods. We examined prospectively 27 consecutive patients with ischemic stroke. A potential source of embolism in all of the patients was sought by means of a TTE study. This study was performed by one neurologist after one-month full-time training on the technique and independently by one cardiologist whose results were considered as the reference standard. Regarding the risk of cardioembolism, findings from TTE studies were considered as normal, or indicative of either moderate or high risk, according to the TOAST criteria. Agreement between the two observers on the diagnosis of cardioembolic source was analyzed with the Cohen's Kappa Test (K). A K > 0,6 was considered as good agreement. Results. The 27 patients studied had a mean age of 68,7 ± 10,2 years and 70 % were men. A cardioembolic source was detected in 9 patients by the cardiologist and 8 of these were also identified by the neurologist: in 1 patient a mitral annulus calcification was not detected in the examination performed by the neurologist. In 2 patients with poor echocardiographic window, the neurologist underestimated the left ventricular function. Diagnostic agreement between both examinations was 88,9 % (K: 0,77; p = 0,001). Conclusion. Compared with cardiologists, trained neurologists show a fairly high degree of accuracy in the TTE screening of patients with stroke. Those cases with poor echocardiographic window or with abnormal findings should be confirmed by the cardiologists (AU)

Diagnostic yield of prothrombotic state studies in cryptogenic stroke.

OBJECTIVES: Around 30% of ischemic strokes are considered cryptogenic. We analyzed the diagnostic yield of prothrombotic state (PS) studies in patients with an initial cryptogenic stroke (CS). MATERIAL AND METHODS: We prospectively included consecutive CS patients according to the TOAST criteria. PS included plasmatic determinations of antiphospholipid (APL) antibodies and lupus anticoagulant (LA), S (SPd) and C (CPd) protein deficiencies, and genetic analysis of the prothrombin gene mutation (PT G20210A) and the factor V Leiden mutation (FV G1691A). We recorded age, sex and vascular risk factors. RESULTS: From a total of 89 patients (mean age 56.9 +/- 14.3 years, 53% men), we identified 16 PS in 15 patients (16.85%): APL-6, LA-2, SPd-2, CPd-1, PT G20210A -3 and FV G1691A -2. One patient presented an association (APL and PT G20210A). CONCLUSIONS: One of every six patients with initial CS present a PS. Age or sex and conventional cardiovascular risk factors were not related to PS study findings, supporting the relevance of such studies in all patients with an initial CS.

Aspirin or anticoagulants in stenosis of the middle cerebral artery: A randomized trial.

BACKGROUND: We report the results of an open, randomized, multicenter trial that compared the efficacy of aspirin to oral anticoagulants (OA) for the prevention of vascular events in patients with symptomatic stenosis of the middle cerebral artery (MCA). METHODS: Participants were randomly assigned to receive 300 mg/day of aspirin or a dose of OA (target INR 2-3). The MCA stenosis was demonstrated by conventional angiography or by at least two noninvasive examinations. Patients had either transient ischemic attack or cerebral infarct (CI) attributable to the MCA stenosis within 90 days before inclusion. The primary endpoint was: nonfatal CI, nonfatal acute myocardial infarct, vascular death and major hemorrhage. The patients were followed-up for a minimum of 1 year and a maximum of 3 years. RESULTS: The study included 28 patients (14 in each treatment group); the average age was 67 +/- 9.9 years. Men constituted 68% of the patients. After a mean follow-up of 23.1 +/- 10.9 months, there were no recurrences of CI in both groups. No endpoint was reported in the aspirin group, but 2 patients in the OA group (14.3%) exhibited vascular events: 1 acute myocardial infarct and 1 intracerebral hemorrhage). However, this difference was not statistically significant (p = 0.48). CONCLUSIONS: Our study suggests that aspirin is the treatment of choice for the prevention of vascular events in patients with symptomatic MCA stenosis.

[Percutaneous transluminal angioplasty of the subclavian artery in Takayasu disease: results of long-term follow-up]. / Angioplastia transluminal percutánea de arteria subclavia en la enfermedad de Takayasu: resultados a largo plazo.

Takayasu arteritis is a chronic inflammatory arteriopathy of unknown etiology affecting the aorta and proximal portion of its main branches. Although it was initially reported in young women of Oriental descent, its current worldwide distribution is known to affect both sexes. In the last decade, percutaneous transluminal angioplasty (PTA) has emerged as a viable alternative in its treatment. However, the percentage of restenosis is more common in Takayasu disease than atherosclerotic lesions (21% vs 10%), probably due to diffuse inflammatory vascular involvement. Since the introduction of stent, this technique has emerged as a viable alternative to treatment of atherosclerotic stenotic lesions, although its efficacy and safety in Takayasu disease is still unclear. Herein, we report our experience in a woman with subclavian steal syndrome in whom Takayasu disease was diagnosed and treated with subclavian artery angioplasty and stent, with a good outcome during four years of follow-up.

Angioplastia transluminal percutánea de arteria subclavia en la enfermedad de Takayasu: resultados a largo plazo / Percutaneous transluminal angioplasty of the subclavian artery in Takayasu disease: results of long-term follow-up

La arteritis de Takayasu es una arteriopatía inflamatoria crónica idiopática que afecta preferentemente a la arteria aorta y la porción proximal de sus grandes ramas. Aunque fue descrita inicialmente en mujeres jóvenes de origen oriental, en la actualidad se conoce su distribución mundial con afectación en ambos sexos. Durante la última década la angioplastia percutánea transluminal (APT) se ha demostrado eficaz en el tratamiento de esta enfermedad. Sin embargo, la proporción de reestenosis es mayor que la observada en la patología ateroesclerótica (21 frente a 100/0) posiblemente debido a la afectación difusa arterial y al proceso inflamatorio de base 1. Desde la introducción del stent esta técnica emerge como alternativa válida en el tratamiento de las estenosis arteriales ateromatosas, aunque su eficacia y seguridad en la patología inflamatoria permanece sin aclarar. Presentamos el caso de una mujer afecta de arteritis de Takayasu con síndrome de robo de la subclavia, tratada con angioplastia y colocación de stent, con un tiempo de seguimiento de 4 años, sin recurrencias durante este período

Takayasu arteritis is a chronic inflammatory arteriopathy of unknown etiology affecting the aorta and proximal portion of its main branches. Although it was initially reported in young women of Oriental descent, its current worldwide distribution is known to affect both sexes. In the last decade, percutaneous transluminal angioplasty (PTA) has emerged as a viable altemative in its treatment. However, the percentage of restenosis is more common in Takayasu disease than atherosclerotic lesions (21 % vs 10 %), probably due to diffuse inflammatory vascular involvement. Since the introduction of stent, this technique has emerged as a viable altemative to treatment of atherosclerotic stenotic lesions, although its efficacy and safety in Takayasu disease is still unclear. Herein, we report our experience in a woman with subclavian steal syndrome in whom Takayasu disease was diagnosed and treated with subclavian artery angioplasty and stent, with a good outcome during four years of follow-up

Stroke and pulmonary thromboembolism after a long flight.

In the economy class syndrome (ECS) the patient presents a deep venous thrombosis (DVT) with or without pulmonary thromboembolism (PTE) during or after a long trip as a result of prolonged immobilization. Economy class stroke syndrome is an infrequent ECS variant in which ischemic stroke is associated with a patent foramen ovale (PFO). Few cases have been published in the literature to date. We present a patient who suffered a PTE and an ischemic stroke immediately after a transoceanic flight. A 36-year-old woman with no significant medical or familial history flew economy class from Lima, Peru, to Madrid, Spain. On disembarkation she presented sudden dyspnea and a depressed level of consciousness, global aphasia, and right hemiparesis. A pulmonary scintigraphy showed a PTE and a cranial MRI revealed an ischemic infarct in the left middle cerebral artery territory. We simultaneously performed a transesophageal echocardiography and a transcranial Doppler and observed a massive right-to-left shunt through a PFO. The patient was a heterozygous carrier of the C46T mutation of coagulation factor XII. The appearance of a stroke following a long trip is suggestive of paradoxical embolism through a PFO, mainly if it is associated with a DVT and/or a PTE. The cause of the initial event, the DVT, could be a prothrombotic state.

Hemostatic markers of recanalization in patients with ischemic stroke treated with rt-PA.

OBJECTIVE: To determine whether pretreatment markers of coagulation and fibrinolysis are related to recanalization and functional outcome. METHODS: The authors included patients treated with IV rt-PA with occlusion on baseline transcranial Doppler (Thrombolysis in Brain Ischemia [TIBI] criteria) in whom recanalization within 6 hours was monitored. At baseline, the authors recorded data about demographics, vascular risk factors, the NIH Stroke Scale (NIHSS) score, early CT signs, etiology, blood glucose, and time to rt-PA. The authors also measured plasmatic markers of coagulation (fibrinogen, prothrombin fragments 1 + 2, Factor XIII, Factor VII) and fibrinolysis (alpha2-antiplasmin, Plasminogen Activator Inhibitor, Functional Thrombin Activatable Fibrinolysis Inhibitor [fTAFI]). A favorable outcome was defined as a modified Rankin score < 2 at 3 months. RESULTS: The authors studied 63 patients with a mean age of 67.3 +/- 12.5 years. The median NIHSS score was 16. Patients who recanalized had lower concentrations of alpha2-antiplasmin (87.5 +/- 18% vs 96.5 +/- 12.5%, p = 0.023) and fTAFI (91.7 +/- 26.7% vs 104.4 +/- 21%, p = 0.039). A multivariant logistic regression analysis showed that the level of alpha2-antiplasmin was the only predictive variable of recanalization (OR 0.95, 95% CI 0.91, 0.99, p = 0.038), while the NIHSS score was the only predictive variable of functional outcome (OR 0.81, 95% CI 0.72, 0.92, p = 0.001). CONCLUSION: Baseline levels of alpha2-antiplasmin were predictive of recanalization but were not related to the long-term outcome in patients treated with rt-PA within the first 3 hours.

Reasons for exclusion from thrombolytic therapy following acute ischemic stroke.

Despite evidence for the efficacy of thrombolytic therapy in acute ischemic stroke, only 1 to 7% of patients receive this therapy. The authors sought to determine the reasons for exclusion from tissue plasminogen activator (tPA) in an acute setting and found avoidable causes in 18% of patients. Improvements in intrahospital coordination would increase the number of patients who might benefit from tPA treatment at the authors' center.