Central Venous Reflux, a Rare Cause of Neurological Manifestations in Hemodialysis Patients: A Case Report and Literature Review.

Central venous disease (CVD) is a serious complication in hemodialysis patients. Neurological manifestations are rare. We describe a female with end-stage renal disease with throbbing headache accompanied by paresthesia, weakness, and abnormal posture of her right hand during dialysis sessions. Motor symptoms completely resolved after each dialysis session, although the headaches persisted for several hours. No neurological deficit was evidenced on physical examination. Digital subtraction angiography identified an incomplete thrombosis of the left brachiocephalic vein with retrograde flow in the internal jugular vein, sigmoid sinus, and transverse sinus on the left side. This case illustrates that cerebral venous congestion due to CVD can produce neurological symptoms. Furthermore, we systematically review the literature to identify the characteristics of the cases described so far. This allows clinicians to know the entity and have a high index of suspicion in a hemodialysis patient who develops neurological symptoms.

Pseudotumoral Presentation of Cerebral Amyloid-Beta Angiopathy: Case Report and Review of Literature.

OBJECTIVE: Cerebral amyloid angiopathy-related inflammation (CAA-RI) is a rare and potentially treatable encephalopathy that usually affects people older than 50 years old and has an acute or subacute clinical presentation characterized by rapidly evolving cognitive decline, focal deficits and seizures. In a small subset of patients the disease can adopt a pseudotumoral form in the neuroimages that represents a very difficult diagnostic challenge. METHODS: Here in we report a patient with a tumour-like presentation of histopathologically confirmed CAA-RI. RESULTS: We also conducted a search and reviewed the clinical and radiological features of 41 cases of pseudotumoral CAA-RI previously reported in the literature in order to identify those characteristics that should raise diagnostic suspicions of the disease, there by avoiding unnecessary surgical treatments. CONCLUSION: The therapy of CAA-RI with steroids is usually effective and clinical and radiological remission can be achieved in the first month in approximately 70% of cases.

[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.

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.

Convexity Subarachnoid Hemorrhage Secondary to Adalidumab in a Patient with Ulcerative Colitis.

The TNF-α antagonists are the drugs used for the treatment of ulcerative colitis (UC). Nontraumatic convexity subarachnoid hemorrhage is an infrequent nonaneurysmal subtype of subarachnoid bleeding caused mainly by reversible cerebral vasoconstriction syndrome (RCVS), cerebral amyloid angiopathy, and posterior reversible encephalopathy syndrome (PRES). We present a 26-year-old female patient with a diagnosis of UC taking Adalimumab. She received her last doses the same day she was admitted to our hospital for an acute severe UC exacerbation. Steroids were added to the treatment. Five days after admission she presented a thunderclap headache with photophobia, nausea, and vomiting. An MRI was performed showing left frontal convexity subarachnoid hemorrhage and hyperintense lesions on T2-weighted and FLAIR sequences located in both occipital lobes, left cerebellar hemisphere, and brainstem. Digital angiography was unremarkable. Adalimumab was discontinued but persisted on treatment with steroids. The patient evolved with complete resolution of her symptoms and was discharged with a normal neurological exam. Two months later, she was asymptomatic and her MRI revealed superficial siderosis secondary to cSAH with resolution of white matter hyperintensities. Convexity subarachnoid hemorrhage in our patient could be secondary to PRES or to RCVS. Analogous MRI findings can be observed in both syndromes, along with similar clinical and angiographic findings. This suggests that both conditions may reflect different manifestations of the same pathology, in which vascular tone and endothelial dysfunction play a major role. To our knowledge, this is the first report of a patient with severe UC and convexity subarachnoid hemorrhage associated with Adalimumab.

La severidad de cetoacidosis diabética tiene poca relación con los niveles de lipasa sérica / The severity of diabetic ketoacidosis is barely associated with serum lipase levels

Introducción: La cetoacidosis diabética (CAD) es una complicación metabòlica aguda que afecta a los pacientes diabéticos. Las anormalidades metabólicas propias de la CAD favorecen el incremento de los niveles de lipasa y amilasa, así como la formación de cuerpos cetónicos, lo que empeora el estado de acidosis y el desequilibrio hídroelectrolítico. Estas alteraciones, aunadas a las manifestaciones clínicas asociadas a la CAD, son fuente de interpretación errónea con cuadros de abdomen agudo. Aunque no se conoce un significado clínico claro, los niveles de hiperlipasemia parecen variar en función de la severidad de la CAD, por lo que en el presente estudio exploramos esta posible correlación. Material y métodos: Estudio observacional con diseño transversal analítico y comparativo, que incluyó a pacientes de medicina interna en los hospitales generales de Xoco, Balbuena y Ticomán, de la Secretaría de Salud del Distrito Federal, con diagnóstico de CAD, distintos niveles de lipasa y en ausencia de pancreatitis aguda, patología gástrica o de glándula parótida. El grado de severidad de CAD se determinó con base en la información del expediente clínico. Se consideró hiperlipasemia con un valor de lipasa > 38 Ul/l). Resultados: Se incluyó a 45 pacientes con CAD, de los que se excluyó a 4. Los 41 pacientes estudiados, se dividieron en 3 grupos de acuerdo a la severidad de la CAD. La prevalencia general de hiperlipasemia fue de 51.2%, con una distribución de 42.8, 33.3 y 23.9%, entre la población con CAD leve, moderada y severa, respectivamente. Se encontró que los niveles de lipasa de los grupos de CAD leve y severa eran distintos, pero no hubo diferencia al considerar únicamente la población que mostró hiperlipasemia. Se encontró una correlación inversa, aunque baja, entre la severidad de CAD y los niveles de lipasa sérica (r = -0.37, IC del 95%, -0.07 a -0.6; p = 0.01), así como una relación de la lipasa con el pH (r = 0.3), el HCO3 (r = 0.3) y la brecha aniónica (r = -0.23), de acuerdo al análisis de regresión múltiple. Este estudio sugiere que la presencia de hiperlipasemia carece de valor como marcador de severidad de la CAD. Conclusión: Existe una tendencia a la relación inversa entre los niveles lipasa y la severidad de la CAD, que a la luz del conocimiento actual no se puede dar un valor significativo para la interpretación clínica.

Introduction: Diabetic ketoacidosis (DKA) is an acute metabolic complication which affects diabetic patients. DKA metabolic abnormalities promote the increase of lipase and amylase serum levels, as well as the overproduction of ketone bodies, worsening the acidosis state and hydroelectrolytic balance. These abnormalities, together with the clinical features associated with DKA are potential sources for misinterpreting the symptoms as acute abdomen. Although the clinical meaning is unclear, hyperlipasemia levels seem to vary according to the severity of DKA; hence, this likely correlation is assessed in this study. Material and methods: Observational cross-sectional analytic comparative study, including internal medicine patients from the following general hospitals: Xoco, Balbuena and Ticomán (SSDF). The patients were diagnosed with DKA, showing different lipase levels with no acute pancreatitis, gastric and/or parotid gland pathology. The severity of DKA was assessed based on the clinical record. Hyperlipasemia was considered as a lipase serum level of >38 UI/L. Results: Forty-five patients with DKA were included and 4 were excluded. The 41 patients studied were divided in 3 groups according to their DKA severity. The general prevalence of hyperlipasemia was 51.2%, with a distribution of 42.8%, 33.3% and 23.9% among patients with mild, moderate and severe DKA, respectively. Lipase levels between the groups with mild and severe DKA were different; however, no difference was found when comparing only patients showing hyperlipasemia. Furthermore, a low inverse correlation was found between DKA severity and serum lipase levels (r=0.37), HCO3 (r=0.3) and anion gap (r=0.23), according to multiple regression analysis. This study suggests that the presence of hyperlipasemia is not a good marker to indicate the severity of DKA. Conclusion: Lipase levels and DKA severity show an inverse correlation, which, according to current knowledge, should have no significant value for clinical interpretation.