High-flow carotid cavernous fistula and 'white eye': A rare and easily misdiagnosed presentation - A case report and literature review.

The three classic symptoms of carotid cavernous fistula (CCF) are pulsating exophthalmos, bruit and conjunctival chemosis. Here, we present a clinical case of isolated abducens nerve palsy due to a high-flow CCF in an 84-year-old woman, without the typical congestive orbito-ocular features. It was a diagnostic challenge because, for patients older than 50 years with cardiovascular risk factors, ischaemic mononeuropathy is the most frequent aetiology. This case illustrates the least common type of CCF that can be easily misdiagnosed. Physicians should consider fistula as a possible diagnosis in a patient with isolated abducens nerve palsy even without the classic triad.

[Cerebral infarction in young patients: clinical characteristics and evolution in an Argentine cohort]. / Infarto cerebral en pacientes jóvenes: características clínicas y evolución en una cohorte argentina.

INTRODUCTION: Stroke (CVA) in young adults comprises approximately 10% of all cerebrovascular events. The information available on the recurrence of a new event in this population and particularly in Latin America is limited. Our objective was to examine the presence of stroke recurrence after having presented a stroke. METHODS: A retrospective cohort study was carried out, including patients with arterial cerebral infarctions between the ages of 18 and 55, between January 2005 and May 2020. The main outcome was the recurrence of a cerebrovascular attack. RESULTS: 138 patients were included during a median follow-up of 24 months. The 52.2% (n = 72) were male patients and 73.4% (n = 94) had an initial NIHSS score of less than 4. The 38% (n = 52) had a history of arterial hypertension and 13, 1% (n = 18) history of previous stroke / TIA. 13% (n = 18) presented recurrence during their follow-up. DISCUSSION: The recurrence of neurovascular events occurs predominantly in patients with a history of previous stroke/TIA, probably secondary to diseases that are difficult to diagnose.

Introducción: El ataque cerebral (ACV) en adultos jóvenes comprende aproximadamente el 10% de todos los eventos cerebrovasculares. La información disponible sobre la recurrencia de un nuevo evento en esta población y particularmente en Latinoamérica es limitada. Nuestro objetivo fue examinar la presencia de recurrencia de ACV luego de haber presentado un infarto cerebral. Métodos: Se realizó un estudio de cohorte retrospectivo, incluyendo pacientes con infartos cerebrales arteriales en edades comprendidas entre 18 y 55 años, entre enero de 2005 a mayo de 2020. El resultado principal fue la recurrencia de un ataque cerebrovascular. Resultados: Se incluyeron 138 pacientes durante una mediana de seguimiento de 24 meses. El 52.2% (n = 72) de sexo masculino y el 73,4% (n = 94) tuvo un NIHSS inicial menor a 4. El 38% (n = 52) tenía antecedentes de hipertensión arterial y 13,1% (n = 18) antecedentes de ACV / ataque isquémico transitorio (AIT) previo. El 13% (n = 18) presento recurrencia durante su seguimiento. Discusión: La recurrencia de los eventos neurovasculares ocurren predominantemente en pacientes con antecedentes de ACV/AIT previo, probablemente secundario a enfermedades de difícil diagnóstico.

Infarto cerebral en pacientes jóvenes: características clínicas y evolución en una cohorte Argentina / Cerebral infarction in young patients: clinical character istics and evolution in an Argentine cohort

Resumen Introducción : El ataque cerebral (ACV) en adultos jó venes comprende aproximadamente el 10% de todos los eventos cerebrovasculares. La información disponible so bre la recurrencia de un nuevo evento en esta población y particularmente en Latinoamérica es limitada. Nuestro objetivo fue examinar la presencia de recurrencia de ACV luego de haber presentado un infarto cerebral. Métodos : Se realizó un estudio de cohorte retros pectivo, incluyendo pacientes con infartos cerebrales arteriales en edades comprendidas entre 18 y 55 años, entre enero de 2005 a mayo de 2020. El resultado principal fue la recurrencia de un ataque cerebro vascular. Resultados: Se incluyeron 138 pacientes durante una mediana de seguimiento de 24 meses. El 52.2% (n = 72) de sexo masculino y el 73,4% (n = 94) tuvo un NIHSS inicial menor a 4. El 38% (n = 52) tenía antecedentes de hipertensión arterial y 13,1% (n = 18) antecedentes de ACV / ataque isquémico transitorio (AIT) previo. El 13% (n = 18) presento recurrencia durante su seguimiento. Discusión : La recurrencia de los eventos neurovas culares ocurren predominantemente en pacientes con antecedentes de ACV/AIT previo, probablemente secun dario a enfermedades de difícil diagnóstico.

Abstract Introduction : Stroke (CVA) in young adults comprises approximately 10% of all cerebrovascular events. The information available on the recurrence of a new event in this population and particularly in Latin America is limited. Our objective was to examine the presence of stroke recurrence after having presented a stroke. Methods : A retrospective cohort study was carried out, including patients with arterial cerebral infarctions between the ages of 18 and 55, between January 2005 and May 2020. The main outcome was the recurrence of a cerebrovascular attack. Results : 138 patients were included during a median follow-up of 24 months. The 52.2% (n = 72) were male patients and 73.4% (n = 94) had an initial NIHSS score of less than 4. The 38% (n = 52) had a history of arterial hypertension and 13, 1% (n = 18) history of previous stroke / TIA. 13% (n = 18) presented recurrence during their follow-up. Discussion : The recurrence of neurovascular events occurs predominantly in patients with a history of previ ous stroke/TIA, probably secondary to diseases that are difficult to diagnose.

AISYF: first national, prospective, multicenter study of young patients with stroke in Argentina.

Up to 15% of all strokes affect young patients and the incidence of ischemic stroke in this population is rising. Nevertheless, there is limited information of cerebrovascular events in this population both in our country and in Latin America. The aim of our study was to evaluate the clinical characteristics and risk factors of young adults with stroke in Argentina. This is a prospective, multicenter study of stroke in young adults (18 - 55 years) in Argentina. Patients presenting with a cerebrovascular event within 180 days were included. Stroke subtypes were classified according to TOAST criteria. A total number of 311 patients were enrolled (men 53.9%, mean age: 43.3 years). Ischemic strokes occurred in 91.8% (brain infarcts 82.6%, transient ischemic attack 9.2%) and hemorrhagic strokes in 8.2%. The most frequent vascular risk factors (including ischemic and hemorrhagic strokes) were: hypertension 120 (41%), smoking 92 (31.4%), dyslipidemia 81 (27.6%) and, overweight/obesity: 74 (25.3%). Stroke subtypes were: large artery disease 12.3%, cardioembolism 7.5%, small artery occlusion 11.5%, other defined etiology 27.1%, and undetermined etiology 41.6%. Our study demonstrates that vascular risk factors are very frequent in young adults with stroke. Our findings underline that urgent strategies are required for primary and secondary stroke prevention in this group of patients.

Aproximadamente un 15% de todos los ataques cerebrovasculares afectan a pacientes jóvenes y su incidencia estaría en aumento. Existe escasa información sobre el ataque cerebral en esta población tanto en nuestro país como en Latinoamérica. El objetivo de nuestro estudio fue evaluar las características clínicas y los factores de riesgo de los adultos jóvenes con ictus en Argentina. Realizamos un estudio prospectivo y multicéntrico en adultos jóvenes (18-55 años) en Argentina, que presentaron un evento cerebrovascular dentro de los 180 días previos. Los subtipos de ictus se clasificaron según los criterios de TOAST. Se incluyeron un total de 311 pacientes (hombres 53.9%, edad media: 43,3 años). Los ataques cerebrovasculares isquémicos ocurrieron en el 91.8% (infartos cerebrales 82.6%, ataque isquémico transitorio 9.2%) y los eventos hemorrágicos correspondieron al 8.2%. Los factores de riesgo vascular más frecuentes (incluyendo los eventos isquémicos y hemorrágicos) fueron: hipertensión 120 (41%), tabaquismo 92 (31.4%), dislipidemia 81 (27.6%) y sobrepeso/obesidad: 74 (25.3%). Los subtipos de ictus isquémicos fueron: arteriopatía de gran vaso 12.3%, cardioembolismo 7.5%, oclusión de pequeña arteria 11.5%, otra etiología definida 27.1% y etiología indeterminada 41.6%. Los factores de riesgo vascular son muy frecuentes en los adultos jóvenes con ictus. Nuestros hallazgos subrayan que se requieren estrategias urgentes para la prevención primaria y secundaria del ictus en este grupo particular de pacientes en nuestro país.

AISYF: first national, prospective, multicenter study of young patients with stroke in Argentina / AISYF: primer estudio nacional, prospectivo y multicéntrico de pacientes jóvenes con ataque cerebral en Argentina

Abstract Up to 15% of all strokes affect young patients and the incidence of ischemic stroke in this population is rising. Nevertheless, there is limited information of cerebrovascular events in this population both in our country and in Latin America. The aim of our study was to evaluate the clinical characteristics and risk factors of young adults with stroke in Argentina. This is a prospective, multicenter study of stroke in young adults (18 - 55 years) in Argentina. Patients presenting with a cerebrovascular event within 180 days were included. Stroke subtypes were classified according to TOAST criteria. A total number of 311 patients were enrolled (men 53.9%, mean age: 43.3 years). Ischemic strokes occurred in 91.8% (brain infarcts 82.6%, transient ischemic attack 9.2%) and hemorrhagic strokes in 8.2%. The most frequent vascular risk factors (including ischemic and hemorrhagic strokes) were: hypertension 120 (41%), smoking 92 (31.4%), dyslipidemia 81 (27.6%) and, over weight/obesity: 74 (25.3%). Stroke subtypes were: large artery disease 12.3%, cardioembolism 7.5, small artery occlusion 11.5%, other defined etiology 27.1%, and undetermined etiology 41.6%. Our study demonstrates that vascular risk factors are very frequent in young adults with stroke. Our findings underline that urgent strategies are required for primary and secondary stroke prevention in this group of patients.

Resumen Aproximadamente un 15% de todos los ataques cerebrovasculares afectan a pacientes jóvenes y su incidencia estaría en aumento. Existe escasa información sobre el ataque cerebral en esta población tanto en nuestro país como en Latinoamérica. El objetivo de nuestro estudio fue evaluar las características clínicas y los factores de riesgo de los adultos jóvenes con ictus en Argentina. Realizamos un estudio prospectivo y multicéntrico en adultos jóvenes (18-55 años) en Argentina, que presentaron un evento cerebrovascular dentro de los 180 días previos. Los subtipos de ictus se clasificaron según los criterios de TOAST. Se incluyeron un total de 311 pacientes (hombres 53.9%, edad media: 43,3 años). Los ataques cerebrovasculares isquémicos ocurrieron en el 91.8% (infartos cerebrales 82.6%, ataque isquémico transitorio 9.2%) y los eventos hemorrágicos correspondieron al 8.2%. Los factores de riesgo vascular más frecuentes (incluyendo los eventos isquémicos y hemorrágicos) fueron: hipertensión 120 (41%), tabaquismo 92 (31.4%), dislipidemia 81 (27.6%) y sobrepeso/obesidad: 74 (25.3%). Los subtipos de ictus isquémicos fueron: arteriopatía de gran vaso 12.3%, cardioembolismo 7.5%, oclusión de pequeña arteria 11.5%, otra etiología definida 27.1% y etiología indeterminada 41.6%. Los factores de riesgo vascular son muy frecuentes en los adultos jóvenes con ictus. Nuestros hallazgos subrayan que se requieren estrategias urgentes para la prevención primaria y secundaria del ictus en este grupo particular de pacientes en nuestro país.

[Long-term psychosocial impact in young stroke survivors: a frequent but often under diagnosed complication]. / Impacto psicosocial del ataque cerebral en pacientes jóvenes: una complicación frecuente y habitualmente sub-diagnosticada.

INTRODUCTION: Approximately 15% of all strokes occur in young patients, affecting them in the most productive years of their lives. Currently, there is limited information (particularly in Latin America) regarding the long-term psychosocial consequences of stroke in young patients. Therefore, the objective of our study was to analyze the functional impact of stroke in this group of patients, regarding both cognitive and psychosocial aspects. MATERIAL AND METHODS: A Beck Depression Inventory (BDI) was administered to outpatients with ischemic stroke between 16 and 55 years of age in two centers of Argentina. The following variables were compared in depressed and non-depressed individuals: NIHSS, modified Rankin Score, Mini-Mental State Examination, Barthel Index, as well as clinical-demographic variables. A BDI score greater than 10 was considered as marker of depression. RESULTS: Thirty-four patients with cerebral infarction were included, 67% (n = 23) were women, mean age: 45.53 ± 9.78 years (range: 21-59). Eleven patients (33%) had depression; 50% of the population was unable to continue with their previous job and 15% divorced or separated from their partner after the vascular event. The stroke recurrence rate was 0.03%. CONCLUSIONS: A high proportion of patients with depressive symptoms was observed. It should be noted that, in the majority, symptoms of depression had not been recognized and the patients were under-treated. Likewise, depression spread persistently after several years of the cerebrovascular event. Likewise, a significant proportion of patients were not able to re-insert themselves into their usual work activity. Moreover, stroke also had an important impact on their affective relationships. Treatment of depression after stroke should be particularly considered in these individuals due to their long-term survival, and should be offered to achieve the highest possible quality of recovery after stroke.

Misdiagnosis of acute ischemic stroke in young patients.

Misdiagnosis is a challenging risk in young patients with ischemic stroke that leads to delayed recognition, prevents thrombolytic therapy and increases morbidity and mortality. To assess the frequency and reasons for misdiagnosis of ischemic stroke in young adults in the emergency department, we retrospectively evaluated 101 consecutive patients. The diagnosis required both the presence of an ischemic lesion in diffusion-weighted MRI as well as neurological symptoms. Twenty-three individuals were misdiagnosed (15 females, mean age 43 years [range 26-55 years]). The most common diagnostic errors included headache/neck pain n = 11 (48%) and peripheral vertigo n = 4 (17.3%), and the most common missed etiology was arterial dissection (AD) n = 15 (65.2%). The initial diagnosis was made by emergency physicians in 22 persons. The group with misdiagnosis had a significantly higher frequency of AD at 15 vs. 8 (p < 0.01), posterior territory involvement at 12 vs. 6 (p < 0.01), and female predominance. Misdiagnosis occurred in a third of young patients with an ischemic stroke and was more frequent in those with arterial dissection involving the posterior circulation and presenting with non-specific symptoms.

El error diagnóstico es una situación riesgosa en pacientes jóvenes con infarto cerebral, ya que conduce a demora en el reconocimiento, previene la administración de terapia trombolítica e incrementa la morbimortalidad. Para valorar la frecuencia y las razones de errores en esta población, evaluamos retrospectivamente 101 pacientes consecutivos. El diagnóstico de infarto cerebral requirió tanto la presencia de lesión isquémica aguda en resonancia magnética como también la presencia de síntomas neurológicos. Veintitrés pacientes fueron mal diagnosticados (15 mujeres, edad media 43 años, [rango 26-55 años]). El error más frecuente incluyó cefalea/cervicalgia n = 11 (48%) y vértigo periférico n = 4 (17.3%). La etiología menos sospechada fue disección arterial n = 15 (62.2%). La evaluación inicial en 22 pacientes fue realizada por emergentólogos. El grupo con errores tuvo significativamente mayor frecuencia de disección arterial 15 vs. 8 (p < 0.01), afectación del territorio posterior 12 vs. 6 (p < 0.01) y sexo femenino. En conclusión, los errores diagnósticos ocurrieron en un tercio de los pacientes jóvenes con infarto cerebral, y fueron más frecuentes en aquellos con disección arterial, compromiso del territorio posterior y síntomas de presentación inespecífica.

Misdiagnosis of acute ischemic stroke in young patients

Misdiagnosis is a challenging risk in young patients with ischemic stroke that leads to delayed recognition, prevents thrombolytic therapy and increases morbidity and mortality. To assess the frequency and reasons for misdiagnosis of ischemic stroke in young adults in the emergency department, we retrospectively evaluated 101 consecutive patients. The diagnosis required both the presence of an ischemic lesion in diffusion-weighted MRI as well as neurological symptoms. Twenty-three individuals were misdiagnosed (15 females, mean age 43 years [range 26-55 years]). The most common diagnostic errors included headache/ neck pain n = 11 (48%) and peripheral vertigo n = 4 (17.3%), and the most common missed etiology was arterial dissection (AD) n = 15 (65.2%). The initial diagnosis was made by emergency physicians in 22 persons. The group with misdiagnosis had a significantly higher frequency of AD at 15 vs. 8 (p < 0.01), posterior territory involvement at 12 vs. 6 (p < 0.01), and female predominance. Misdiagnosis occurred in a third of young patients with an ischemic stroke and was more frequent in those with arterial dissection involving the posterior circulation and presenting with non-specific symptoms.

El error diagnóstico es una situación riesgosa en pacientes jóvenes con infarto cerebral, ya que conduce a demora en el reconocimiento, previene la administración de terapia trombolítica e incrementa la morbimortalidad. Para valorar la frecuencia y las razones de errores en esta población, evaluamos retrospectivamente 101 pacientes consecutivos. El diagnóstico de infarto cerebral requirió tanto la presencia de lesión isquémica aguda en resonancia magnética como también la presencia de síntomas neurológicos. Veintitrés pacientes fueron mal diagnosticados (15 mujeres, edad media 43 años, [rango 26-55 años]). El error más frecuente incluyó cefalea/cervicalgia n = 11 (48%) y vértigo periférico n = 4 (17.3%). La etiología menos sospechada fue disección arterial n = 15 (62.2%). La evaluación inicial en 22 pacientes fue realizada por emergentólogos. El grupo con errores tuvo significativamente mayor frecuencia de disección arterial 15 vs. 8 (p < 0.01), afectación del territorio posterior 12 vs. 6 (p < 0.01) y sexo femenino. En conclusión, los errores diagnósticos ocurrieron en un tercio de los pacientes jóvenes con infarto cerebral, y fueron más frecuentes en aquellos con disección arterial, compromiso del territorio posterior y síntomas de presentación inespecífica.

Ischemic stroke of the "hand knob area": A case series and literature review.

Isolated hand paresis may reflect an infarction of the "hand knob area", which represents less than 1% of all ischemic strokes. In this type of stroke, a potential source of embolism is often identified. There are no large case series regarding this topic in Latin America. Herein we present the largest cohort of this entity in the region and we compare our results with those previously published. We analyzed all stroke patients admitted to our hospital between May 2015 - June 2018. Only patients with motor +/- sensory deficits restricted to the hand and ischemic stroke confirmed by MRI were included. We assessed stroke mechanism, clinical characteristics and outcome. From 339 patients admitted with ischemic stroke, 12 (3.53%) were included (9 men, 75%). Mean age: 60.4 years-old (range:24-79). Localization of stroke: 8 patients (66%) precentral gyrus, 3 (25%) postcentral; in 1 both gyri were affected. Stroke mechanism according to TOAST classification was as follows: two patients (16%) large artery atherosclerosis, two cardioembolic, one other determined etiology (thrombophilia), seven (58%) undetermined etiology (SUE). Nine patients (75%) received antiplatelets and statins, and three (25%) anticoagulants. The mean follow-up period was 11 months (range 1-26). Stroke recurrence was observed in one patient. At follow up, eight patients (66%) had a modified Rankin Score (mRS) of 0 and one a mRS of 1. In conclusion, in this series the most prevalent stroke mechanism was SUE, mainly embolic stroke of undetermined source. The outcome was excellent regardless of stroke mechanism.

Blood pressure evolution in young patients with acute ischemic stroke: a new model for understanding the natural course of spontaneous hypertension?

BACKGROUND: Approximately 80% of patients suffering an acute ischemic stroke develop transient hypertension. The physiopathological mechanism remains unclear. Due to the lack of vascular risk factors, young adults could be a useful model for understanding blood pressure (BP) evolution in this setting. METHODS: Patients between 18 and 55 years old admitted with an acute ischemic stroke were included. BP was evaluated during the following 48 h. Hypertension was defined as: systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. Patients were divided into two groups: RF group included those who had a previous vascular risk factor and/or other medical condition known to affect the autonomic function; noRF group included patients without any of the previously stated conditions. RESULTS: Thirty-nine patients were included: mean age: 44.26 years old, 21 were males (53.8%). Mean SBP and DBP at admission were 139.77 ± 5.35 mmHg (range: 90-243) and 84.44 ± 3.02 mmHg (range: 60-128), respectively; 43.58% patients were hypertensive at admission. SBP decreased significantly during the first 48 h (p = 0.044) for the entire population. RF group has higher SBP (p = 0.009) and DBP (p = 0.011) at admission than the noRF group. CONCLUSION: Most patients were normotensive at admission and BP fell spontaneously despite BP at admission. Young patients without medical conditions that could alter the autonomic system function could be a useful model for understanding acute hypertension in ischemic stroke.

Holmes tremor: Clinical description, lesion localization, and treatment in a series of 29 cases.

OBJECTIVE: To describe the clinical features, etiology, findings from neuroimaging, and treatment results in a series of 29 patients with Holmes tremor (HT). METHODS: A retrospective study was performed based on review of medical records and videos of patients with HT diagnosis. RESULTS: A total of 16 women and 13 men were included. The mean age at the moment of CNS insult was 33.9 ± 20.1 years (range 8-76 years). The most common causes were vascular (48.3%), ischemic, or hemorrhagic. Traumatic brain injury only represented 17.24%; other causes represented 34.5%. The median latency from lesion to tremor onset was 2 months (range 7 days-228 months). The most common symptoms/signs associated with HT were hemiparesis (62%), ataxia (51.7%), hypoesthesia (27.58%), dystonia (24.1%), cranial nerve involvement (24.1%), and dysarthria (24.1%). Other symptoms/signs were vertical gaze disorders (6.8%), bradykinesia/rigidity (6.8%), myoclonus (3.4%), and seizures (3.4%). Most of the patients had lesions involving more than one area. MRI showed lesions in thalamus or midbrain or cerebellum in 82.7% of the patients. Levodopa treatment was effective in 13 out of 24 treated patients (54.16%) and in 3 patients unilateral thalamotomy provided excellent results. CONCLUSIONS: The most common causes of HT in our series were vascular lesions. The most common lesion topography was mesencephalic, thalamic, or both. Treatment with levodopa and thalamic stereotactic lesional surgery seems to be effective.

Fluoxetina y Parkinson / Fluoxetine and Parkinson's disease

Diversas drogas han sido señaladas como capaces de inducir o exacerbar los síntomas de parkinsonianos, presentamos un paciente con enfermedad de parkinson que incrementó su déficit motor luego de la administración de fluoxetina. La supresión del fármaco produjo reversión de los síntomas

Blefaroespasmo. Distonía oromandibular / Blepharospasm. Distonia oromandibular

El blefaroespasmo es una distonía focal que compromete el orbicularis oculi, que en casos severos produce una ceguera funcional. Hemos evaluado las características clínicas y perfil neurofarmacológico en 100 casos consecutivos estudiados en los últimos 9 años en el Hospital Universitario de Buenos Aires, Argentina. La población estuvo compuesta por 69 mujeres y 39 hombres cuyas edades oscilaron entre 29 y 78 años. El 61 por ciento presentó blefaroespasmo mientras que el resto tenía una distonía oromandibular asociada. La gran mayoría comenzó en la 5ta. década y el comienzo fue unilateral en el 12 por ciento pero en todos los casos evolucionó a una forma bilateral. Sólo el 60 por ciento había sido previamente diagnosticado en forma correcta, mientras que en el 40 por ciento restante el diagnóstico se difirió hasta varios años el tratamiento más efectivo fue la infiltración del orbicular de los párpados con toxina botulínica (88 por ciento) seguido por el lisuride en dosis bajas que benefició al 56 por ciento y el trihexifenidilo en el 54.5 por ciento de los tratados. Nuestros resultados sugieren que el cuadro puede ser manejado con éxito luego de hacer un correcto diagnóstico. Las infiltraciones con toxina botulínica debieran ser efectuadas por neurólogos con experiencia en movimientos anormales.