MRI predicts intracranial hemorrhage in patients who receive long-term oral anticoagulation.

OBJECTIVE: We tested the hypothesis that the risk of intracranial hemorrhage (ICH) in patients with cardioembolic ischemic stroke who are treated with oral anticoagulants (OAs) can be predicted by evaluating surrogate markers of hemorrhagic-prone cerebral angiopathies using a baseline MRI. METHODS: Patients were participants in a multicenter and prospective observational study. They were older than 64 years, had a recent cardioembolic ischemic stroke, and were new users of OAs. They underwent a baseline MRI analysis to evaluate microbleeds, white matter hyperintensities, and cortical superficial siderosis. We collected demographic variables, clinical characteristics, risk scores, and therapeutic data. The primary endpoint was ICH that occurred during follow-up. We performed bivariate and multivariate Cox regression analyses. RESULTS: We recruited 937 patients (aged 77.6 ± 6.5 years; 47.9% were men). Microbleeds were detected in 207 patients (22.5%), moderate/severe white matter hyperintensities in 419 (45.1%), and superficial siderosis in 28 patients (3%). After a mean follow-up of 23.1 ± 6.8 months, 18 patients (1.9%) experienced an ICH. In multivariable analysis, microbleeds (hazard ratio 2.7, 95% confidence interval [CI] 1.1-7, p = 0.034) and moderate/severe white matter hyperintensities (hazard ratio 5.7, 95% CI 1.6-20, p = 0.006) were associated with ICH (C index 0.76, 95% CI 0.66-0.85). Rate of ICH was highest in patients with both microbleed and moderate/severe WMH (3.76 per 100 patient-years, 95% CI 1.62-7.4). CONCLUSION: Patients taking OAs who have advanced cerebral small vessel disease, evidenced by microbleeds and moderate to severe white matter hyperintensities, had an increased risk of ICH. Our results should help to determine the risk of prescribing OA for a patient with cardioembolic stroke. CLINICALTRIALSGOV IDENTIFIER: NCT02238470.

Sudden hemichorea and frontal lobe syndrome: a rare presentation of unbalanced polycythaemia vera.

Polycythaemia vera (PV) is an haematological neoplasm that frequently presents neurological symptoms. However, chorea is a rare complication of this disease, occurring in less than 5% of the patients. Cognitive impairment related to PV unbalanced is also a rare complication, and it can improve with proper treatment. We present a 96-year-old-man with acute-onset hemichorea and frontal lobe syndrome with no vascular pathology in the basal ganglia or frontal region. A clear relationship was observed between the onset of involuntary movements and the cognitive impairment and worsening of haematological parameters in the patient. After causal and symptomatic treatment, the patient's clinical status improved. In the elderly, PV must be considered as a cause of acute chorea and sudden cognitive impairment, as early diagnosis leads to effective treatment and prevention of complications.

Statins do not increase Markers of Cerebral Angiopathies in patients with Cardioembolic Stroke.

We investigated whether pre-treatment with statins is associated with surrogate markers of amyloid and hypertensive angiopathies in patients who need to start long-term oral anticoagulation therapy. A prospective multicenter study of patients naive for oral anticoagulants, who had an acute cardioembolic stroke. MRI was performed at admission to evaluate microbleeds, leukoaraiosis and superficial siderosis. We collected data on the specific statin compound, the dose and the statin intensity. We performed bivariate analyses and a logistic regression to investigate variables associated with microbleeds. We studied 470 patients (age 77.5 ± 6.4 years, 43.7% were men), and 193 (41.1%) of them received prior treatment with a statin. Microbleeds were detected in 140 (29.8%), leukoaraiosis in 388 (82.5%) and superficial siderosis in 20 (4.3%) patients. The presence of microbleeds, leukoaraiosis or superficial siderosis was not related to pre-treatment with statins. Microbleeds were more frequent in patients with prior intracerebral hemorrhage (OR 9.7, 95% CI 1.06-90.9) and in those pre-treated antiplatelets (OR 1.66, 95% CI 1.09-2.53). Prior treatment with statins was not associated with markers of bleeding-prone cerebral angiopathies in patients with cardioembolic stroke. Therefore, previous statin treatment should not influence the decision to initiate or withhold oral anticoagulation if these neuroimaging markers are detected.

Neuromielitis recidivante sin neuritis óptica: a propósito de un caso / Recurring neuromyelitis without optic neuritis: a case report

Introducción. La neuromielitis óptica o enfermedad de Devic es una enfermedad inflamatoria y desmielinizante del sistema nervioso central que afecta selectivamente a los nervios ópticos y a la médula espinal, con alta frecuencia de recidivas. Los anticuerpos antiacuaporina 4 (AQP4) son un marcador altamente específico de esta entidad. Caso clínico. Mujer de 66 años de edad con una mielitis transversa longitudinalmente extensa dorsal con remisión completa tras tratamiento esteroideo y recidiva aguda posterior, con plejía de una extremidad. Entre los diagnósticos diferenciales se consideraron los de tumoración espinal y malformación arteriovenosa medular. La positividad de AQP4 fue el factor determinante en el diagnóstico final. Conclusión. La detección precoz de los anticuerpos anti-AQP4 junto con una inmunoterapia apropiada puede representar la clave de un mejor pronóstico. Es muy importante un diagnóstico precoz de cara a un inicio temprano del tratamiento y así evitar recurrencias y secuelas graves (AU)

Introduction. Neuromyelitis optica, or Devic’s disease, is an inflammatory, demyelinating disease of the central nervous system that selectively affects the optic nerves and the spinal cord, with a high rate of relapses. Anti-aquaporin-4 (AQP4) antibodies are a highly specific marker for this condition. Case report. A 66-year-old female with longitudinally extensive dorsal transverse myelitis with complete remission following steroidal treatment and later acute relapse, with palsy in one limb. The differential diagnoses considered included a spinal tumour and arteriovenous malformation of the spinal cord. Being positive for AQP4 was the decisive factor in the final diagnosis. Conclusions. Early detection of anti-AQP4 antibodies together with appropriate immunotherapy can be the key to a better prognosis. An early diagnosis is essential to be able to start treatment at an early stage and thus prevent relapses and severe sequelae (AU)

[Transorbital echography for assessment of optical nerve atrophy in demyelinating diseases: a pilot study]. / Utilidad del dúplex orbitario para la valoración de atrofia del nervio óptico en enfermedades desmielinizantes: estudio piloto.

INTRODUCTION. Demielinating diseases are a group of heterogenic diseases in whom mieline is attacked. The optic nerve (ON) is one of the most commonly affected. SUBJECTS AND METHODS. An observational prospective case-control study with ON orbital echography was developed. The case group was formed by 31 demielinating diseases patients and the control group was formed by 24 healthy people. Mean age of cases: 48.3 ± 11.8 years old, controls 48.7 ± 9.9 years old. 46% of controls and 35% of cases were males. RESULTS. We found statistical significance differences between cases and controls regarding the diameter of right (controls 3.64 ± 0.58 mm vs patients 2.84 ± 0.56 mm; p < 0.001) and left ON (controls 3.95 ± 0.84 mm vs patients 2.74 ± 0.54 mm; p < 0.001). We found no differences between maximum systolic and median velocities regarding ophthalmic arteries in both groups, neither for previous acute optical neuritis history or visual evocated potentials. CONCLUSIONS. ON evaluation with transorbital echography is an easy, feasible, non invasive, useful and costless technique for the evaluation of the ON atrophy. As for visual evocated potentials are abnormal in a huge number of patients without previous optical neuritis evidence, the diameter of ON measured by transorbital Doppler could be a consistent paraclinic marker of these diseases.

Utilidad del dúplex orbitario para la valoración de atrofia del nervio óptico en enfermedades desmielinizantes: estudio piloto / Transorbital echography for assessment of optical nerve atrophy in demyelinating diseases: a pilot study

Introducción. Las enfermedades desmielinizantes son un grupo heterogéneo de procesos en los que se daña la mielina. Es bien conocida la predilección de estas patologías por el nervio óptico (NO).Sujetos y métodos. Estudio observacional prospectivo de casos y controles mediante ecografía del NO de pacientes diagnosticadosde enfermedad desmielinizante (n = 31) y de controles sanos (n = 24). La edad media de los casos es de 48,3 ±11,8 años, y de los controles, de 48,7 ± 9,9 años. El 46% de los controles y el 35% de los casos eran varones.Resultados. Se encontraron diferencias estadísticamente significativas entre casos y controles en cuanto al diámetro delNO tanto derecho (3,64 ± 0,58 mm en controles frente a 2,84 ± 0,56 mm en los pacientes; p < 0,001) como izquierdo (3,95 ± 0,84 mm en controles frente a 2,74 ± 0,54 mm en pacientes; p < 0,001). No se encontraron diferencias significativasen la velocidad pico sistólica de la arteria oftálmica entre ambos grupos, ni tampoco en el diámetro del NO de los casos con antecedentes de neuritis óptica y los que no presentaban dicho antecedente.Conclusiones. El dúplex del nervio óptico es una herramienta útil, accesible y no invasiva para la valoración de la existenciade atrofia óptica. De la misma forma que los potenciales evocados visuales están alterados en un número importante de pacientes sin antecedentes claros de haber sufrido neuritis óptica, el estudio del grosor del NO mediante Dopplertranscraneal también podría utilizarse como marcador paraclínico de enfermedad desmielinizante (AU)

Introduction. Demielinating diseases are a group of heterogenic diseases in whom mieline is attacked. The optic nerve(ON) is one of the most commonly affected.Subjects and methods. An observational prospective case-control study with ON orbital echography was developed. Thecase group was formed by 31 demielinating diseases patients and the control group was formed by 24 healthy people. Mean age of cases: 48.3 ± 11.8 years old, controls 48.7 ± 9.9 years old. 46% of controls and 35% of cases were males.Results. We found statistical significance differences between cases and controls regarding the diameter of right (controls3.64 ± 0.58 mm vs patients 2.84 ± 0.56 mm; p < 0.001) and left ON (controls 3.95 ± 0.84 mm vs patients 2.74 ± 0.54 mm; p < 0.001). We found no differences between maximum systolic and median velocities regarding ophthalmic arteries in both groups, neither for previous acute optical neuritis history or visual evocated potentials.Conclusions. ON evaluation with transorbital echography is an easy, feasible, non invasive, useful and costless technique for the evaluation of the ON atrophy. As for visual evocated potentials are abnormal in a huge number of patients withoutprevious optical neuritis evidence, the diameter of ON measured by transorbital Doppler could be a consistent paraclinic marker of these diseases (AU)

Changes in carotid plaque echogenicity with time since the stroke onset: an early marker of plaque remodeling?

Carotid plaques undergo histologic changes early after an ischemic stroke. However, the evolution of carotid plaques echolucency after a recent brain ischemia is not well known. A prospective observational study that included consecutive stroke patients and asymptomatic individuals with plaques showing ≥50% stenosis on duplex ultrasound was conducted. Plaque echogenicity was measured with the standardized gray-scale median (GSM) and compared with respect to symptoms presence and time from stroke onset. One hundred twenty-six carotid plaques in 124 patients were studied and four groups of plaques were analyzed: (1) plaques seen within 24 h of stroke onset (32); (2) between 1-7 days (50); (3) more than 7 days after stroke onset (22) and; (4) plaques without associated symptoms (22). Plaques of group 1 had less echogenicity than those of groups 2-4: median GSM (interquartile range) 14 (16), 19.5 (19), 22.5 (21), 26.5 (16) respectively (p = 0.001). In conclusion, carotid plaque echogenicity is increased with time from stroke onset and could be an early marker of plaque remodeling.

Cambio del patrón del dolor en un paciente migrañoso / Change in the pattern of pain in a patient with migraine

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Young women have poorer outcomes than men after stroke.

BACKGROUND AND PURPOSE: Gender differences in stroke outcome have not been fully assessed in young patients. METHODS: We conducted an observational study of consecutive young ischemic stroke patients (≤ 50 years of age) admitted to a stroke unit (January 1999 to December 2009). Basal data, subtype of ischemic stroke, stroke severity [Canadian Neurological Scale (CNS)], length of hospital stay, inhospital complications, mortality and functional outcome at discharge [modified Rankin Scale (mRS) score] were analyzed. For stroke severity and outcome analyses, 2 age groups were established: 15-30 (very young group) and 31-50 years old (middle-aged young group). RESULTS: A total of 310 patients were enrolled; 128 females and 182 males. The mean age was similar in women and men (41.07 ± 8.6 vs. 42.12 ± 8.2, NS). Migraine was more frequent in women, whereas arterial hypertension, hyperlipidemia, alcohol abuse, current smoking and atherothrombotic infarction were more frequent in men (p < 0.05). Females presented greater stroke severity than men [median CNS (IQR) = 8 (3.5) vs. 9 (2.5), p = 0.014] except in the very young group [median CNS (IQR) = 9 (1.8) vs. 8 (5), p = 0.022]. Female sex was a predictor of unfavorable outcomes (mRS >2) at discharge in the total sample (OR = 3.33; 95% CI = 1.41-7.84) and in the middle-aged young group (OR = 2.62; 95% CI = 1.05-6.53), adjusted by baseline data, stroke subtype, inhospital complications, length of stay and stroke severity. CONCLUSIONS: Female gender is associated with worse outcomes in adult ischemic stroke patients up to 50 years old. However, this effect is not observed in younger patients (15-30 years).

Treatment with angiotensin receptor blockers before stroke could exert a favourable effect in acute cerebral infarction.

INTRODUCTION: Evidence from experimental and clinical studies is accumulating about the possible cerebral protective properties of antihypertensive drugs, mainly angiotensin receptor blockers (ARB) or angiotensin-converting enzyme inhibitors (ACEI). Our aim was to analyse the impact of prestroke use of antihypertensive drugs on stroke severity and outcome. METHODS: We analysed 1968 consecutive patients with first-ever acute cerebral infarction admitted to an acute stroke unit. Stroke severity was evaluated using the Canadian Neurological Scale and the modified Rankin Score (mRS) was used to evaluate the outcome at discharge. RESULTS: Previous diagnosis of arterial hypertension was reported in 1212 patients and 73% were on antihypertensive treatment. No significant differences in stroke severity were found between patients with or without previous arterial hypertension, either in patients with or without antihypertensive treatment. Patients taking antihypertensive drugs at stroke onset had lower rates of poor outcome than those not on antihypertensive treatment (47 vs. 53%; P = 0.047) and those taking ARB had better outcomes than those without ARB (mRS

Update on ultrasound techniques for the diagnosis of cerebral ischemia.

Ultrasound (US) techniques increase the ability of neurologists specializing in stroke to rapidly evaluate stroke patients, determine likely mechanisms of brain ischemia, determine arterial patency, quantify stenosis severity, and determine the most appropriate clinical management. Furthermore, the development of new US techniques based on the detection of US contrast agents may permit the evaluation of cerebral microcirculation and the identification of regions of angiogenesis, inflammation and thrombus during brain ischemia.