Ischaemic stroke in patients treated with oral anticoagulants. / Ictus isquémico en pacientes en tratamiento anticoagulante por vía oral.

INTRODUCTION: Cardioembolic stroke is associated with poorer outcomes. Prevention is based on oral anticoagulant (OAC) therapy. Haemorrhage is the main complication of OACs, which are sometimes ineffective. PATIENTS AND METHODS: We retrospectively reviewed 1014 consecutive patients who suffered an ischaemic stroke between 2011 and 2013, analysing those who were receiving OAC treatment at stroke onset (107 patients in total) with special attention to aetiology, outcomes, and INR value in the acute phase. RESULTS: The mean age (SD) was 71.9 (10) years. Patients had been treated with OACs for 5.9 (5.5) years; 98.1% of them were being treated for heart disease. INR was <2 in 77 patients (72%), and 30 patients (28%) had an INR≥2. Nine patients (8.4%) had INR values within the therapeutic range. According to TOAST classification criteria, 88.8% of strokes were cardioembolic and 1.9% were atherothrombotic. Anticoagulation therapy was discontinued in 48 patients (44.9%) due to haemorrhagic transformation (24 patients), extensive infarction (23), or endarterectomy (1). Therapy was resumed in 24 patients (50%) after a mean lapse of 36 days. This was not possible in the remaining patients because of death or severe sequelae. New OACs (NOACs) were prescribed to 9 patients (18.7% of all potential candidates). At 3 months, patients with INR>1.7 in the acute phase exhibited better outcomes than patients with INR≤1.7 (mRS 0-2 in 62% vs 30.8%; death in 10% vs 38.4%; P=.0004). CONCLUSIONS: Some patients taking OACs suffer ischaemic strokes that are usually cardioembolic, especially if INR is below the therapeutic range. OACs can be resumed without complications, and NOACs are still underused. Despite cases in which treatment is ineffective, outcomes are better when INR is above 1.7 at stroke onset.

Infarto cerebeloso: pronóstico y complicaciones de sus territorios vasculares / Cerebellar infarction: prognosis and complications of vascular territories

Introducción: Los infartos cerebelosos (IC) son infrecuentes pero pueden presentar complicaciones graves. Nuestro objetivo ha sido estudiar las características de los pacientes con IC, así como su evolución, en función del territorio afectado. Pacientes y métodos: Se han recogido datos de 124 pacientes ingresados en nuestro servicio durante un periodo de 5 años, con diagnóstico radiológico de IC, con y sin afectación de otras regiones cerebrales. Resultados: La edad media de nuestra serie es de 65,2 años, con predominio masculino (68,5%). El territorio más afectado fue la arteria cerebelosa posteroinferior (PICA) en el 49,2%, seguido de la arteria cerebelosa superior (ACS) en el 17,7% y cerebelosa anteroinferior (AICA) en el 10,5%. Se afectaron territorios supra-infratentoriales en el 13,7% y dos/tres territorios cerebelosos en el 8,9%. La etiología aterotrombótica fue más prevalente en PICA (p=0,02) y la cardioembólica en la afectación de múltiples territorios (p = 0,04), siendo similares en ACS y AICA. Se produjo transformación hemorrágica en 29 pacientes (23,4%), sobretodo en la afectación de múltiples territorios y en PICA. Se asoció hidrocefalia en 15 pacientes (12,1%, 12 de ellos PICA; p = 0,02), apareciendo de media a los 2,9±1,5 días del inicio del ictus. Al alta, la dependencia funcional (Rankin≥3) era mayor si la afectación territorial era múltiple (64% vs 31-36%; p = 0,05). Se contabilizaron 4 defunciones (3,2%).Conclusiones: Los IC tienen gran heterogeneidad. Sin embargo, cabe destacar que los infartos de PICA son los más prevalentes, su etiología suele ser aterotrombótica y son los más asociados a complicaciones graves, que ocurren durante la primera semana del ictus (AU)

Introduction: Cerebellar infarction (CI) is uncommon, but may result in severe complications. The aim of our study was to determine the characteristics of patients with CI, as well as their outcomes as regards the territories affected. Patients and methods:Data were collected from 124 patients admitted to our department during a five-year period, with a radiological diagnosis of CI, and with or without involvement of other brain territories. Results: The mean age in our series was 65.2 years, with most being male (68.5%). The posterior inferior cerebellar artery (PICA) was the most commonly affected territory at 49.2%, followed by superior cerebellar artery (SCA) at 17.7%, and anterior inferior cerebellar artery (AICA) at 10.5%. There was simultaneous supratentorial involvement in 13.7%, and two or three cerebellar arteries involved in 8.9%. The main aetiology in PICA was atherothrombosis (P=.02). On the other hand, cardio-embolism was the main origin in cases with more than one affected territory (P=.04). No particular aetiology could be found in SCA and AICA. There was haemorrhagic transformation in 29 patients (23.4%), particularly in the PICA and when other territories were involved. There was hydrocephalus in 15 patients (12.1%, 12 of them PICA; P=.02) in 2.9±1.5 days from stroke onset. At discharge, the degree of disability was worse if more than one arterial territory was involved (Rankin≥3, 64% versus 31-36%; P=.05). Four (3.2%) patients died. Conclusions: CI is very heterogeneous. Nevertheless, it is noteworthy that PICA infarction is the most frequent type and its aetiology is usually atherothrombotic. Moreover, it is the territory most frequently associated with severe complications, which take place during the first week of the stroke (AU)

[Cerebellar infarction: prognosis and complications of vascular territories]. / Infarto cerebeloso: pronóstico y complicaciones de sus territorios vasculares.

INTRODUCTION: Cerebellar infarction (CI) is uncommon, but may result in severe complications. The aim of our study was to determine the characteristics of patients with CI, as well as their outcomes as regards the territories affected. PATIENTS AND METHODS: Data were collected from 124 patients admitted to our department during a five-year period, with a radiological diagnosis of CI, and with or without involvement of other brain territories. RESULTS: The mean age in our series was 65.2 years, with most being male (68.5%). The posterior inferior cerebellar artery (PICA) was the most commonly affected territory at 49.2%, followed by superior cerebellar artery (SCA) at 17.7%, and anterior inferior cerebellar artery (AICA) at 10.5%. There was simultaneous supratentorial involvement in 13.7%, and two or three cerebellar arteries involved in 8.9%. The main aetiology in PICA was atherothrombosis (P=.02). On the other hand, cardio-embolism was the main origin in cases with more than one affected territory (P=.04). No particular aetiology could be found in SCA and AICA. There was haemorrhagic transformation in 29 patients (23.4%), particularly in the PICA and when other territories were involved. There was hydrocephalus in 15 patients (12.1%, 12 of them PICA; P=.02) in 2.9 ± 1.5 days from stroke onset. At discharge, the degree of disability was worse if more than one arterial territory was involved (Rankin ≥ 3, 64% versus 31-36%; P=.05). Four (3.2%) patients died. CONCLUSIONS: CI is very heterogeneous. Nevertheless, it is noteworthy that PICA infarction is the most frequent type and its aetiology is usually atherothrombotic. Moreover, it is the territory most frequently associated with severe complications, which take place during the first week of the stroke.

Training using short-time features for OSA discrimination.

Heart rate variability (HRV) is one of the promising directions for a simple and noninvasive way for obstructive sleep apnea syndrome detection (OSA). The interaction between the sympathetic and parasympathetic systems on the HRV recordings, gives rise to several non-stationary components added to the signal. Aiming to improve the classifier accuracy for obstructive sleep apnoea detection, the use of more appropriated techniques for leading with non-stationarity and mixed dynamics, are needed. This work aims at searching a convenient training strategy of combining the feature set to be further fed in to the classifier, which should take into consideration the different dynamics in the HRV signal. Therefore, a set of the short-time features, extracted from a given HRV time-varying decomposition, and selected by spectral splitting is considered. Additionally, three methods of projection are used: none, simple, and multivariate. Finally, the different approaches are tested and compared, using k-nn and support vector machines (SVM) classifiers. Attained results show that using continuous wavelet transform with short-time features and multivariate projection, followed by a SVM classifier, allow to obtain a suitable OSA detection.

On determining available stochastic features by spectral splitting in obstructive sleep apnea detection.

Heart rate variability (HRV) is one of the promising directions for a simple and noninvasive way for obstructive sleep apnea syndrome detection. The time-frequency representations has been proposed before to investigate the non-stationary properties of the HRV during either transient physiological or pathological episodes. Within the framework of the filter-banked feature extraction, estimation of the spectral splitting for stochastic features extraction is an open issue. Usually, this splitting is fixed empirically without taking into account the actual informative distribution of time-frequency representations. In the present work, a relevance-based approach that aims to find a priori a boundaries in the frequency domain for the spectral splitting upon t-f planes is proposed. Results show that the approach is able to find the most informative frequency bands, achieving accuracy rate over 75%.

Sleep apnoea detection in children using PPG envelope-based dynamic features.

Photopletysmography signal has been developed for monitoring of Obstructive Sleep Apnoea, in particular, whenever an apneic episode occurs, that is reflected by decreases in the photopletysmography signal amplitude fluctuation. However, other physiological events such as artifacts and deep inspiratory gasp produce sympathetic activation, being unrelated to apnea. Thus, its high sensitivity can produce misdetections and overestimate apneic episodes. In this regard, a methodology for selecting a set of relevant non-stationary features to increase the specificity of the obstructive sleep apnea detector is discussed. A time-evolving version of the standard linear multivariate decomposition is discussed to perform stochastic dimensionality reduction. As a result, performed outcomes of accuracy bring enough evidence that if using a subset of cepstral-based dynamic features, then patient classification accuracy is 83.3%. Therefore, photoplethysmography--based detection provides an adequate scheme for obstructive sleep apnea diagnosis.

On improvement of detection of Obstructive Sleep Apnea by partial least square-based extraction of dynamic features.

This paper presents a methodology for Obstructive Sleep Apnea (OSA) detection based on the HRV analysis, where as a measure of relevance PLS is used. Besides, two different combining approaches for the selection of the best set of contours are studied. Attained results can be oriented in research focused on finding alternative methods minimizing the HRV-derived parameters used for OSA diagnosing, with a diagnostic accuracy comparable to a polysomnogram. For two classes (normal, apnea) the results for PLS are: specificity 90%, sensibility 91% and accuracy 93.56%.

Síndrome de Eagle y disección carotídea / Eagle syndrome and carotid dissection

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18F-FDG PET/CT in the evaluation of POEMS syndrome.

In POEMS syndrome the identification and biopsy of an osteosclerotic lesion or a lymph node typical of Castleman's disease (CD) is essential to establish the diagnosis and plan appropriate treatment. We report four patients in whom the localisation and identification of diagnostic bone lesions or lymphadenopathies were guided by fluorodeoxyglucose positron emission tomography integrated with computerised tomography (FDG PET/CT). FDG PET/CT identified bone lesions not detected with other techniques in one patient, and revealed hypermetabolic characteristics in bone lesions or adenopathies in the others, thus guiding the diagnostic biopsy in those with hypermetabolism. In conclusion, FDG PET/CT may be useful in detecting and selecting bone lesions and lymph nodes for biopsy in patients with suspected POEMS syndrome.

Reversible acute leukoencephalopathy as a form of presentation in cerebral amyloid angiopathy.

BACKGROUND: Cerebral amyloid angiopathy (CAA) may present as cerebral haemorrhage, cerebral infarction and periventricular white matter lesions. Reversible leukoencephalopathy is a rare manifestation of CAA. AIMS OF THE STUDY: To describe two patients with reversible acute leukoencephalopathy as the first manifestation of CAA. PATIENTS: Two consecutive patients were admitted to our neurology department with transient focal neurological symptoms. They showed reversible focal leukoencephalopathy on magnetic resonance imaging (MRI). CAA was finally diagnosed in both, and pathologically confirmed in one. The latter patient showed multiple foci of petechial bleeding in the cortex and subcortex in T2-weighted GRE sequences, suggestive of CAA. CONCLUSION: Reversible acute focal leukoencephalopathy may be an infrequent clinical and radiological pattern of CAA.