Infarto cerebeloso en el puerperio inmediato / Cerebella infarction in the immediate puerperium

La enfermedad cerebrovascular durante la gestación es rara. El presente trabajo tiene como objetivo describir las características clínicas de una paciente con embolismos de la arteria humeral derecha y tallo encefálico en el periodo expulsivo de un parto eutócico sin foco embolígeno causante de dicho accidente cerebrovascular. Se presenta el caso de una parturienta de 29 años con 40,2 semanas de edad gestacional que durante el periodo expulsivo de un parto eutócico comenzó a presentar dolor intenso en el miembro superior derecho con cambios de coloración y temperatura e impotencia funcional, imposibilidad para la apertura palpebral bilateral, vómitos sin náuseas, disartria y dificultad en los movimientos oculares...

The cerebrovascular disease during pregnancy is uncommon. The objective of present paper is to describe the clinical features of a patient with embolisms of the right humeral artery and of the brainstem at expulsion period of a spontaneous labor without emboligen focus causing this cerebrovascular accident...

Infarto cerebeloso en el puerperio inmediato / Headache after a dural puncture in obstetric patient

La enfermedad cerebrovascular durante la gestación es rara. El presente trabajo tiene como objetivo describir las características clínicas de una paciente con embolismos de la arteria humeral derecha y tallo encefálico en el periodo expulsivo de un parto eutócico sin foco embolígeno causante de dicho accidente cerebrovascular. Se presenta el caso de una parturienta de 29 años con 40,2 semanas de edad gestacional que durante el periodo expulsivo de un parto eutócico comenzó a presentar dolor intenso en el miembro superior derecho con cambios de coloración y temperatura e impotencia funcional, imposibilidad para la apertura palpebral bilateral, vómitos sin náuseas, disartria y dificultad en los movimientos oculares...

The cerebrovascular disease during pregnancy is uncommon. The objective of present paper is to describe the clinical features of a patient with embolisms of the right humeral artery and of the brainstem at expulsion period of a spontaneous labor without emboligen focus causing this cerebrovascular accident...

Influencia de los anticoagulantes orales en la historia natural del infarto cerebral cardioembólico / The influence of oral anticoagulants in the natural history of cardioembolic cerebral infarctions

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Angiogenesis and improved cerebral blood flow in the ischemic boundary area detected by MRI after administration of sildenafil to rats with embolic stroke.

To dynamically investigate the long-term response of an ischemic lesion in rat brain to the administration of sildenafil, male Wistar rats subjected to embolic stroke were treated with sildenafil (n=11) or saline (n=10) at a dose of 10 mg/kg administered subcutaneously 24-h after stroke and daily for an additional 6 days. Magnetic resonance images were acquired and functional performance was measured in all animals at 1 day, 2 days and weekly for 6 weeks post-stroke. All rats were sacrificed 6 weeks after stroke and endothelial barrier antigen immunostaining was employed for morphological analysis and quantification of cerebral vessels. Map-ISODATA was computed from T(1), T(2) and T(1sat) maps. ISODATA derived tissue signatures characterize the degree of ischemic injury. Based on the map-ISODATA calculated at 6 weeks, the ischemic lesion for each animal was divided into two specific regions, the ischemic boundary and ischemic core. The temporal profiles of cerebral blood flow (CBF) and tissue signature were retrospectively tracked in these two regions and were compared with histological evaluation and functional outcome. After 1 week of sildenafil treatment, the ischemic lesion exhibited two significantly different regions, with higher CBF level and correspondingly, lower tissue signature value in the boundary region than in the core region. Sildenafil treatment did not significantly reduce the lesion size, but did enhance angiogenesis. Functional performance was significantly increased after sildenafil treatment compared with the control group. Administration of sildenafil to rats with embolic stroke enhances angiogenesis and selectively increases the CBF level in the ischemic boundary, and improves neurological functional recovery compared to saline-treated rats.

Analysis of thrombi retrieved from cerebral arteries of patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: Information regarding the histological structure of thromboemboli that cause acute stroke provides insight into pathogenesis and clinical management. METHODS: This report describes the histological analysis of thromboemboli retrieved by endovascular mechanical extraction from the middle cerebral artery (MCA) and intracranial carotid artery (ICA) of 25 patients with acute ischemic stroke. RESULTS: The large majority (75%) of thromboemboli shared architectural features of random fibrin:platelet deposits interspersed with linear collections of nucleated cells (monocytes and neutrophils) and confined erythrocyte-rich regions. This histology was prevalent with both cardioembolic and atherosclerotic sources of embolism. "Red" clots composed uniquely of erythrocytes were uncommon and observed only with incomplete extractions, and cholesterol crystals were notably absent. The histology of thromboemboli that could not be retrieved from 29 concurrent patients may be different. No thrombus >3 mm wide caused stroke limited to the MCA, and no thrombus >5 mm wide was removed from the ICA. A mycotic embolus was successfully removed in 1 case, and a small atheroma and attached intima were removed without clinical consequence from another. CONCLUSIONS: Thromboemboli retrieved from the MCA or intracranial ICA of patients with acute ischemic stroke have similar histological components, whether derived from cardiac or arterial sources. Embolus size determines ultimate destination, those >5 mm wide likely bypassing the cerebral vessels entirely. The fibrin:platelet pattern that dominates thromboembolic structure provides a foundation for both antiplatelet and anticoagulant treatment strategies in stroke prevention.

Hyperacute therapy of ischemic stroke: intravenous thrombolysis.

Stroke is the third most common cause of death in the United States following heart disease and cancer. Following the success of thrombolysis for myocardial infarction in the early 1990s, major trials for evaluation of this new therapeutic approach for ischemic stroke were initiated. The majority of ischemic strokes are due to occlusion of a cerebral vessel by a blood clot. Occlusion of a cerebral blood vessel leads to a core of infracted tissue surrounded by a relatively hypoperfused but viable brain tissue (the ischemic penumbra), which can be potentially salvaged by rapid recanalization of the target vessel. The underlying rationale for introduction of thrombolytic drugs is the lysis of an obliterating thrombus and reestablishment of blood flow. In this article we review the major intravenous thrombolysis trials leading to approval of intravenous recombinant tissue plasminogen activator, the only FDA approved treatment available today for acute ischemic stroke.

Map-ISODATA demarcates regional response to combination rt-PA and 7E3 F(ab')2 treatment of embolic stroke in the rat.

PURPOSE: To investigate the ability of map-ISODATA (Iterative Self-Organizing Data Analysis Technique) to classify the different categories of ischemic damage in the lesion and to evaluate a combined (thrombolysis plus antiplatelet) treatment efficacy in an embolic stroke of rat. MATERIALS AND METHODS: Rats subjected to embolic stroke with (N=12) and without (N=10) rt-PA and 7E3 F(ab')2 treatment (4 hours after embolization) were followed (at 2, 24, and 48 hours post-MCAO) with magnetic resonance imaging (MRI) using T1, T2, and apparent diffusion coefficient of water (ADCw). ISODATA was computed from T1, T2, and ADCw maps. The signatures characterized by the map-ISODATA were compared with histological quantitative evaluation and were employed to demarcate the specific regions in the lesion. RESULTS: The signature described by map-ISODATA is highly correlated with the degree of tissue damage in the lesion and can distinguish the severity of ischemic tissue injury. Based upon map-ISODATA, ischemic lesion area can be divided into three specific regions, each characterized by a distinct evolution of injury and treatment response. The combined treatment significantly reduces the lesion size between 24 and 48 hours and improves the outcome 48 hours post-MCAO compared with the control group. CONCLUSION: Map-ISODATA provides an accurate means to identify lesion area, to distinguish ischemic damage, and to detect treatment response. 7E3 F(ab')2 extends the rt-PA treatment window to at least four hours after the onset of embolic stroke of rat.

Is heparin treatment the optimal management for cerebral venous thrombosis? Effect of abciximab, recombinant tissue plasminogen activator, and enoxaparin in experimentally induced superior sagittal sinus thrombosis.

BACKGROUND: Based on a newly developed model of reversible superior sagittal sinus (SSS) thrombosis in the rat, we investigated the effect of thrombolytic and anticoagulant treatment on recanalization, brain parenchymal changes, and motor deficits. METHODS: Thrombosis of the SSS was induced by topical application of ferric chloride. Occlusion was confirmed by magnetic resonance angiography (MRA). Six hours after operation, single treatment with 10 mg recombinant tissue plasminogen activator (rtPA)/kg and 6 mg abciximab/kg or subcutaneous injection of 450 IU/kg enoxaparin twice daily was started, each group containing 10 rats. Follow-up MRI with T2- and diffusion-weighted images was performed on the first, second, and seventh postoperative day. RESULTS: Control and enoxaparin-treated animals developed diffuse brain edema without infarction or intracerebral bleeding. This was indicated by an increase of T2 relaxation time and a decrease of the apparent diffusion coefficient in the parasagittal and lateral cortex. In these groups, the degree of recanalization after 7 days was comparable (48% versus 52%). Enoxaparin-treated animals showed significant amelioration of functional deficits. Clinical outcome was best in the abciximab-treated group, with a residual sinus occlusion of 36% after 1 week. Highest recanalization was achieved by lysis with rtPA (85%). CONCLUSIONS: Enoxaparin treatment in rats with cerebral venous thrombosis significantly influences clinical outcome. However, it has no effect on recanalization. GPIIb/IIIa antagonists and rtPA accelerate thrombolysis. They may represent an alternative in treatment of cerebral venous thrombosis.

[Medical treatment for cerebral atherothrombosis]. / Traitement médical de l'athérothrombose cérébrale.

Atherothrombotic ischemic stroke is associated with multiple vascular risk factors, including mainly hypertension, diabetes, and hyperlipidemia. Medical therapy of cerebral atherothrombosis implies control of these vascular risk factors and antithrombotic drugs as well. This paper reviews the current therapeutic guidelines according to the randomized trials for primary and secondary stroke prevention.

Thrombolytic therapy for delayed, in-hospital stroke after cardiac surgery.

Five patients who had delayed stroke after cardiac surgery underwent intraarterial administration of a fibrinolytic agent for thromboembolism (n = 4) or thrombosis (n = 1) of the cerebral artery. Complete recanalization of the occluded artery was obtained in 3 patients and partial recanalization in 2. Additional angioplasty for basilar artery stenosis was performed in 1 patient. No patients exhibited rebleeding into the pericardial space or wound bleeding. All patients survived with moderate or full functional recovery. Immediate cerebral angiography and local thrombolysis may improve functional outcome and survival in patients with postcardiotomy cerebral thromboembolism.

Streptokinase in the treatment of venous sinus thrombosis: a case report.

We present a case of cerebral venous thrombosis diagnosed by magnetic resonance venography, magnetic resonance imaging, and angiography. Selective direct thrombolytic treatment with streptokinase via highly selective venography was successful.

[Embolic stroke with mobile thrombus in carotid artery induced by antiphospholipid antibody syndrome].

We report a 56-year-old woman suffering from an embolic brain infarction in her right frontal lobe. Carotid ultrasonogram showed a mass-shaped thrombus with little atherosclerotic change of underlying intima-media in the right common carotid artery. The thrombus was reduced with treatment and changed to mobile slender thrombus on admission. No other embolic sources were detected even using transesophageal echocardiography. Her blood test indicated existence of antiphospholipid antibody syndrome (APS) complicated with mixed connective tissue disease as an etiology of this uncommon carotid thrombus. The thrombus disappeared completely after two-week intensive antithrombotic therapy. This is a valuable report that arterial thrombi accompanied by APS could be detected by carotid ultrasound and observed until thrombus was disappeared. When we manage APS patients, it is important to rule out thrombus formation in the carotid artery using ultrasonography from the point of stroke prevention.

Interferon-beta administration confers a beneficial outcome in a rabbit model of thromboembolic cerebral ischemia.

We demonstrate that treatment with the cytokine human interferon-beta (IFN-beta) resulted in a beneficial outcome in a rabbit model of thromboembolic cerebral ischemia. Rabbits administered subcutaneously with IFN-beta prior to (pre-treatment) or after (post-treatment) the introduction of an autologous blood clot into the middle cerebral artery have consistently smaller subcortical infarct volumes compared to control (untreated) counterparts. The average subcortical infarct volume of pre-treatment rabbits is 46.3+/-9.3 mm(3) (n=4), and that of post-treatment rabbit is 40.0+/-23.1 mm(3) (n=4). Both are significantly lower (P=0.003 and P=0.004, respectively) than the average subcortical infarct volume of control rabbits (121.6+/-32.9 mm(3), n=5). Although the precise mechanism responsible for the beneficial effect of IFN-beta on stroke is not yet clear, our results are in line with the known anti-inflammatory potential and anti-apoptotic function of IFN-beta.

Measuring caffeine-induced changes in middle cerebral artery blood velocity using transcranial Doppler in patients recovering from ischaemic stroke.

Acute ingestion of caffeine is known to reduce cerebral blood flow in normal volunteers and in certain patient groups. There is no evidence that this causes problems in the normal population. However, there may be implications if a similar reduction occurs in patients recovering from an ischaemic stroke, in whom local blood flow has already been reduced. Transcranial Doppler provides a non-invasive method for measuring changes in middle cerebral artery (mca) blood velocity. A method for obtaining consistent. reliable measurements was developed and used in a double blind, randomized, crossover study on 20 patients (18 M, 2 F; mean age 70) recovering from ischaemic stroke in the mca territory. Middle cerebral artery blood velocity was measured bilaterally using transcranial Doppler before and after 250 mg caffeine (equivalent to about two cups of filter coffee) or matched placebo. Caffeine caused an average 12% reduction in blood velocity compared to placebo in the hemisphere affected by the stroke (95%c CI 8%-16%, p < 0.00001), and a 12% reduction in the non-affected hemisphere (95% CI 6%-18%, p < 0.001). The clinical implications are unclear at present, and imaging techniques will be required to establish whether caffeine does reduce flow to hypo-perfused regions.

Abciximab for the treatment of acute distal embolization associated with internal carotid artery angioplasty.

Carotid artery angioplasty and stent placement (CAS) can be complicated by procedure-related distal embolization and thrombus formation, potentially resulting in neurological sequelae. Patient A had CAS of left internal carotid artery and had loss of vision in the left eye with no flow in the left ophthalmic artery. Patient B had CAS of right internal carotid artery and developed left sided hemiparesis with total occlusion of the right middle cerebral artery. A selective intra-arterial injection of 5 mg of abciximab locally followed by a bolus of 5 mg of abciximab intravenously resulted in complete resolution of the filling defect on repeat angiography after 10 min in both patients.

Recurrent cerebral embolism and impending detachment of a previous nonmobile left atrial thrombus following initiation of anticoagulant therapy in a patient with nonvalvular atrial fibrillation.

A 65-year-old female with nonvalvular atrial fibrillation who presented with a transient ischemic attack was admitted to our hospital. Transesophageal echocardiography (TEE) revealed a nonmobile thrombus attached to the wall of the left atrial appendage. She suffered from a new episode of syncope on the 8th day following initiation of anticoagulant therapy. Follow-up TEE indicated not only that the left atrial (LA) thrombus decreased in size but also that the previous nonmobile thrombus became mobile and showed impending detachment. Urgent surgery was subsequently performed to remove the LA thrombus, and the patient recovered uneventfully. In conclusion, anticoagulant therapy may precipitate partial fragmentation or partial detachment of LA thrombus.

[Intra-arterial fibrinolysis in vertebrobasilar system]. / Fibrinólisis intrarterial en el territorio vertebrobasilar.

INTRODUCTION: The acute vertebrobasilar occlussion is usually a life-treatening disease leading to death or major disability. The treatment with heparin and the selective fibrinolysis no show good results, for this reason the local intra-arterial fibrinolysis appear as the choice treatment in patients with stroke and a agiography with basilar artery occlussion or intracranial vertebral artery occlusion. This tecnique has been proved to be effective treatment for selected patients with acute thromboembolic occlusion of the middle cerebral artery, ophthalmic artery and vertebrobasilar system, reducing the mortality in the vertebrobasilar system from 90% to 40%. CLINICAL CASE: We present a 63 years-old man with a vertebrobasilar thrombosis of a probable cardioembolic origen. He was treated with r-TPA local intra-arterial fibrinolysis, to get a recanalization of vertebrobasilar system. In the control TC we see a haemorragic sufusion in the brain stem. The follow-up see a patient with tetraparesis and palsy of the low cranial nerves and normal superior cerebral functions. CONCLUSIONS: The local intra-arterial fibrinolysis is the choise treatment in the vertebrobasilar thrombosis because the high morbimortality of this patology and the inefficacy of the others therapeutics. The result depend of many factors as the thrombo location, the neurologic state, the evolution time, the start of treatment, the colateral circulation, the nervous tissue reserve, etc, that have dificult predict the result, but it is best of the natural history of the disease. Is necesary, change the concept of emergency and the attitude front the isquemic cerebral disease at the sanitary leaders, the doctors, and the general population, for dispose of more means to cofront this pathology, which permit diminish the morbimortality and reduce the grade of incapacity.

Immediate postoperative thrombolytic therapy: an aggressive strategy for neurologic salvage when cerebral thromboembolism complicates carotid endarterectomy.

A 42-year-old man with a high-grade left internal carotid artery (ICA) stenosis demonstrated on a duplex scan was referred to us. A cerebral arteriogram confirmed a greater than 90% left internal carotid stenosis, but with the unexpected finding of a moderate amount of thrombus in the proximal ICA. He underwent emergent left carotid endarterectomy, but during the operation, only a small amount of thrombus was identified as adherent to the atherosclerotic plaque. he awakened in the operating room with a dense right hemiplegia and aphasia. Immediate reexploration demonstrated a patent endarterectomy site, a distal thromboembolectomy was performed without extraction of thrombus, and urokinase (250,000 Units) was infused into the distal ICA. He reawakened with an unchanged right hemiplegia and aphasia. The patient then underwent an urgent postoperative carotid and cerebral arteriogram that demonstrated an embolus to the middle cerebral artery. he was treated with the superselective infusion of urokinase (500,000 Units), with almost complete resolution of the clot. Over the course of the next 48 hours, the patient made a nearly complete neurologic recovery, and he was discharged from the hospital with only a slight facial droop. At 2 months' follow-up he was completely neurologically healthy. To our knowledge this is the first reported case of urokinase administered in the immediate postoperative period in the angiography suite to treat a thromboembolus complicating a carotid endarterectomy.