[Asymptomatic encephalic calcifications in postsurgical hypoparathyroidism]. / Calcificaciones encefálicas asintomáticas en el hipoparatiroidismo posquirúrgico.

INTRODUCTION: Encephalic calcifications (EC) are a frequent finding in neuroimaging of CT scans, which have many causes,both symptomatic and asymptomatic. This paper has aimed to report a series of patients who had had a previous thyroidectomy years earlier in whom the presence of hypoparathyroidism (HP) EC and their clinical manifestations had been analyzed. PATIENTS AND METHODS: A group of 38 women who had undergone a thyroidectomy from 14 to 45 years ago were evaluated. The EC was mild in 2 cases, located exclusively in the pale globe and putamen. It was moderate in two other patients, the calcinosis spreading towards the caudate nucleus, and one patient was considered severe or very extended, affecting the basal ganglia, cerebellum and white matter of semioval centers. RESULTS: Six patients (15%) had HP; five of them (13%) with EC. The neurological examination and the UPDRS scale were normal, including negative Chvostek and Trousseau signs. Cognition was evaluated with: Mini-Mental State Examination, Clock Drawing test, Alzheimer's Disease Assessment Scale-cognitive, Trail Making Test Part A and B and the Clinical Dementia Rating, of which were normal. In these six patients, serum calcium (Ca) and parathormone (PTH) levels were reduced and phosphorus values increased. CONCLUSIONS: It is likely that the EC are sub-diagnosed in postsurgical HP due to the absence of symptoms. There is still an ongoing debate on the appearance of symptoms and extension of EC, possibly when the Ca and PTH variables only have a moderate reduction, corresponding to a variable that avoids manifestations.

Calcificaciones encefálicas asintomáticas en el hipoparatiroidismo posquirúrgico / Asymptomatic encephalic calcifications in postsurgical hypoparathyroidism

Introducción. Las calcificaciones encefálicas (CE) alcanzan a observarse mediante tomografía computarizada cerebral (TCC), originándose por múltiples causas, y pudiendo ser sintomáticas o asintomáticas. El objetivo es comunicar una serie de pacientes con tiroidectomía lejana en donde fue analizada la presencia de hipoparatiroidismo (HP), CE y sus manifestaciones clínicas. Pacientes y métodos. Fueron evaluadas 38 mujeres con antecedentes de cirugía de tiroides entre 14 y 45 años atrás. Las CE fueron consideradas leves en 2 casos, ubicadas exclusivamente en el globo pálido y putamen; en otras 2 pacientes moderadas, extendiéndose a los núcleos caudados, y en una de las pacientes severas o muy extendidas, afectando a los ganglios basales, el cerebelo y la sustancia blanca de los centros semiovales. Resultados. Seis pacientes tuvieron HP (15%) y 5 de ellas presentaban CE (13%). Los exámenes neurológicos y la escala UPDRS fueron normales, incluyendo los signos de Chvostek y Trousseau negativos. Para evaluar cognición se utilizaron: prueba de Folstein, dibujo del reloj, ADAS-cog, prueba del laberinto secuencial con partes A y B y clasificación de la demencia clínica, resultando todas normales. Las concentraciones en sangre de calcio (Ca) y paratohormona (PTH) estaban disminuidas, y los valores de fósforo plasmático aumentados. Conclusiones. Las CE en el HP posquirúrgico están probablemente sub-diagnosticadas debido a la ausencia de síntomas. Permanece la controversia sobre la aparición de los síntomas y la extensión de las CE, posiblemente cuando la PTH y el Ca solo tienen un descenso moderado, corresponda a una variable que evita las manifestaciones (AU)

Introduction: Encephalic calcifications (EC) are a frequent finding in neuroimaging of CT scans, which have many causes,both symptomatic and asymptomatic. This paper has aimed to report a series of patients who had had a previous thyroidectomy years earlier in whom the presence of hypoparathyroidism (HP) EC and their clinical manifestations had been analyzed.Patients and methods: A group of 38 women who had undergone a thyroidectomy from 14 to 45 years ago were evaluated. The EC was mild in 2 cases, located exclusively in the pale globe and putamen. It was moderate in two other patients, the calcinosis spreading towards the caudate nucleus, and one patient was considered severe or very extended, affecting the basal ganglia, cerebellum and white matter of semioval centers. Results: Six patients (15%) had HP; five of them (13%) with EC. The neurological examination and the UPDRS scale were normal, including negative Chvostek and Trousseau signs. Cognition was evaluated with: Mini-Mental State Examination, Clock Drawing test, Alzheimer's Disease Assessment Scale-cognitive, Trail Making Test Part A and B and the Clinical Dementia Rating, of which were normal. In these six patients, serum calcium (Ca) and parathormone (PTH) levels were reduced and phosphorus values increased. Conclusions:It is likely that the EC are sub-diagnosed in postsurgical HP due to the absence of symptoms. There is still an ongoing debate on the appearance of symptoms and extension of EC, possibly when the Ca and PTH variables only have a moderate reduction, corresponding to a variable that avoids manifestations (AU)

Improvement in motor and cognitive impairment after hyperbaric oxygen therapy in a selected group of patients with cerebrovascular disease: a prospective single-blind controlled trial.

BACKGROUND: Clinical and experimental evidence suggests that a localized decrease in oxygen brain tissue availability contributes to the neurological deficit in patients with cerebrovascular disease (CVD) who also present with frontal leukoaraiosis (LA) (periventricular hypodensity on CT scan) and lacunar infarcts. In a prospective controlled trial blinded to patients but not to investigators, we tested the effect of HBO2 on this group of patients. METHODS: Selected patients with symptomatic CVD, LA and lacunar infarcts received daily exposures of 45 minutes for 10 days to hyperbaric oxygen (n=18, HBO2 group) or hyperbaric air (n=8, control group). The control group subsequently received HBO2. Scores of conventional scales for motor and cognitive functions were obtained and videotaped before and after exposure. After the exposures, participants were followed on a monthly basis with systematic clinical neurological examination for up to 6 months. Results. There was a statistically significant improvement in all scales for the HBO2 group compared with the placebo group and in the placebo group after receiving HBO2 (p<0.05). Neurological improvement persisted in the majority of patients for up to 6 months. Repetition of the HBO2 protocol in 9 patients in whom symptoms recurred after 6 months resulted in improvement of symptoms. CONCLUSIONS: These data provide evidence consistent with the notion that HBO2 improves neurological function in patients with CVD, lacunar infarcts and frontal LA. Because of the lack of investigator blinding and a relatively small sample size in this study, larger, randomized controlled studies are needed to further test this hypothesis and to further define the role of oxygen therapy for brain repair in chronic brain disease.

Triflusal vs aspirin for prevention of cerebral infarction: a randomized stroke study.

BACKGROUND: Triflusal is an antiplatelet agent that has shown clinical advantages when compared with aspirin in the secondary prevention of vascular events. TAPIRSS (Triflusal versus Aspirin for Prevention of Infarction: a Randomized Stroke Study) explored the efficacy and safety of triflusal in the secondary prevention of stroke in a Latin American homogeneous population with the ultimate aim of preparing for a larger trial in the same setting. METHODS: A double-blind, multicenter, randomized, pilot trial was conducted in Buenos Aires, Argentina, from October 1996 to November 1999. The study sample was 431 patients, randomized to receive aspirin 325 mg daily or triflusal 600 mg daily for a mean of 586 days. All patients had experienced either an ischemic stroke or TIA within 6 months from enrollment. Data from 429 patients were analyzed. RESULTS: No differences were observed in the primary endpoint that combined the incidence of vascular death, cerebral ischemic infarction, nonfatal myocardial infarction, or major hemorrhage (aspirin 13.9%, triflusal 12.7%; odds ratio [OR] 1.11, 95% CI 0.64 to 1.94) or in the individual analysis of each component of the primary endpoint. In a post hoc analysis, the overall incidence of major and minor hemorrhagic events was significantly lower in triflusal-treated patients (aspirin 8.3%, triflusal 2.8%; OR 3.13, 95% CI 1.22 to 8.06). CONCLUSIONS: This pilot trial has not found differences between triflusal and aspirin in the prevention of vascular complications after TIA or ischemic stroke, although given the wide CI, potentially important group differences could not be ruled out. Triflusal may be associated with a lower risk of hemorrhagic complications. A larger, prospective clinical trial is necessary to verify these results.

[Classification of the cerebrovascular diseases. Iberoamerican Cerebrovascular diseases Society]. / Clasificación de las enfermedades cerebrovasculares. Sociedad Iberoamericana de Enfermedades Cerebrovasculares.

OBJECTIVES: In view of the several terminologies in countries belonging to the Iberoamerican Cerebrovascular diseases Society it seemed appropriate that the Executive Committee should propose a unified cerebrovascular diseases classification and nomenclature. DEVELOPMENT: Based on the classifications of strokes NINCDS, TOAST, Laussane Stroke Registry, OCSP and that of the cerebrovascular diseases group of the Sociedad Española de Neurología, we devised a system for classification of cerebrovascular diseases with the objective of harmonizing the nomenclature and criteria of Iberomerican countries. We chose the word stroke as the most suitable for the definition of cerebrovascular diseases. These were then divided into symptomatic and non symptomatic. The symptoms were then divided into those of transient ischaemic accidents (TIA) and stroke, and then into ischaemic and haemorrhagic. We established the aetiological subtypes of focal cerebral ischaemia (TIA and ischaemic stroke) as: disease of the great vessels or atherothrombotic, cardio embolic, occlusive small vessel disease, of unusual cause or of unknown origin. Haemorrhagic stroke was divided into subarachnoid haemorrhage and cerebral haemorrhage, which was then subdivided according to the site. CONCLUSION: We consider that this nomenclature is simple and easy to use and in concordance with the international classifications, which permits the use of common terminology that is easily translated into English.

Clasificación de las enfermedades cerebrovasculares.Sociedad Iberoamericana de Enfermedades Cerebrovasculares / Classification of the cerebrovascular diseases. Iberoamerican cerebrovascular diseases society

Objetivos. Ante la existencia de diversas terminologías en los países del ámbito de la Sociedad Iberoamericana de enfermedades cerebrovasculares (ECV), pareció oportuno a la junta directiva proponer una clasificación y nomenclatura de las ECV unificada. Desarrollo. Basándonos en las clasificaciones de ictus NINCDS, TOAST, Laussane Stroke Registry, OCSP y la realizada por el grupo de enfermedades cerebrovasculares de la Sociedad Española de Neurología, se ha elaborado una clasificación de las enfermedades cerebrovasculares con el objetivo de unificar nomenclatura y criterios en los países iberoamericanos. Se ha elegido la palabra ictus como la más adecuada para definir la ECV. Se ha dividido a su vez en sintomática y asintomática. Dentro de la sintomática se divide en accidente isquémico transitorio (AIT) e ictus, y éste a su vez en isquémico y hemorrágico. Se han establecido los subtipos etiológicos de isquemia cerebral focal (AIT e ictus isquémico) como: enfermedad de grandes vasos o aterotrombótico, cardioembólico, enfermedad oclusiva de pequeño vaso, de causa inhabitual y de origen indeterminado. El ictus hemorrágico se divide en hemorragia subaracnoidea (HSA) y hemorragia cerebral, ésta a su vez subdividida según la topografía de la misma. Conclusión. Consideramos que esta nomenclatura es sencilla y de fácil aplicación, y en sintonía con las clasificaciones internacionales, lo que nos permite tener unos términos comunes y de fácil translación al inglés (AU)

[Hyperbaric oxygenation in subcortical frontal syndrome due to small artery disorders with leukoaraiosis]. / Oxigenoterapia hiperbárica en el síndrome frontal subcortical por enfermedad de pequeñas arterias con leucoaraiosis.

INTRODUCTION: Frontal leukoaraiosis (LA) is a common finding in patients with subcortical small-vessel disease and currently its pathogenesis is attributed to ischemic-hypoxic mechanisms. It associates to a vascular subcortical frontal syndrome (VSFS) for which an effective treatment does not exist. CLINICAL CASES: We present four subjects from a prospective patient-blind controlled pilot trial to study efficacy and safety of hyperbaric oxygen therapy (HBO) vs hyperbaric air in VSFS with LA. All of them had frontal or extended LA on computed tomography scan and lacunes in basal ganglia and centrum ovale, with moderate to severe gait disorders, urinary dysfunction, cognitive impairment, and dependence in the daily living activities. Deficits had begun two to ten years before and had remained stable three months previous to the treatment. Patients were assessed with validated scales and tests one week before and after being administrated ten daily sessions of HBO at 2.5 atmospheres absolute for 45 minutes with a multiplace chamber. Serious adverse effects did not occur. After treatment a noticeable gait, urinary and cognitive improvement was observed in all subjects, increasing their independence. They remained clinically improved during four to five months, after which the previous deficits reappeared. Then, three patients received ten daily sessions of air at 1.1 atmospheres absolute for 45 minutes (controls) and the other a new HBO regimen, which improved as the first time. From the controls, there were no changes in two, while the other did only improve cognitively. CONCLUSION: These patients show that HBO is effective and safety in reversing, at least partially, although at great length, chronic neurological deficits associated to vascular frontal LA, highlighting that a functional reserve therapeutically useful exists.

Early onset Alzheimer's disease in a South American pedigree from Argentina.

We report the clinical, SPET, immunohistochemical and DNA features of an early-onset familial Alzheimer's disease (FAD) in an Argentine pedigree of South American indian ethnic background. Pedigree spans 5 generations comprising more than 110 biological relatives. Clinical data supported the diagnosis of early onset FAD (mean age at onset 38.9 years) in 10 family members, including 3 with pathological confirmation (mean age at death 48.5). The pattern of transmission suggested autosomal dominant inheritance. Prominent features were mood changes, early language impairment, myoclonus, seizures and cerebellar signs. SPET displayed bilateral frontal, temporo-parietal and cerebellar hypoperfusion in early stages and in an asymptomatic member at risk, suggesting that SPET may have predictive value in this family. Immunohistochemistry showed beta amyloid deposits within neuritic plaques and vessel walls and no anti-PrP immunoreactivity. DNA analysis showed no abnormalities in the beta amyloid precursor protein gene. The identification of additional genetic defects in well characterized independent FAD pedigrees will contribute to the understanding of the pathogenesis of Alzheimer's disease.

Infarto en el territorio de la arteria coroidea anterior por accidente quirúrgico / Incidental surgical infarct in the territory of the anterior choroidal artery

Se comunican 2 casos de infarto en el territorio de la Arteria Coroidea Anterior. Ambas pacientes, mujeres de 19 y 47 años, fueron admitidas por clínica y tomografía computada (TC) de hemorragia subaracnoidea. En el postquirúrgico inmediato, de ectasia pediculada carotídea, vimos: desviación de cabeza y ojos a derecha,disartria,negligencia, así como hemiparesia con disestesias a izquierda. La angiografía (AG) verificadora de vasos de cuello y cerebro, mostró la correcta aplicación del clip en el cuello de sendos aneurismas. Ambas completaron la recuperación clínica antes del séptimo día y meses más tarde padecieron la primera crisis parcial compleja. Se observaron imágenes hipodensas temporales profundas y posteriores en TC. Nuestras pacientes continúan asintomáticas con carbamazepina. De 80 casos reportados, 38 fueron por cirugía adrede, ninguno casual y el resto ictales. Nuestros casos serían los únicos impensados. Consideramos que estos infartos tienen la suficiente categoría como para conformar una entidad clínica independiente

Infarto en el territorio de la arteria coroidea anterior por accidente quirúrgico / Incidental surgical infarct in the territory of the anterior choroidal artery

Se comunican 2 casos de infarto en el territorio de la Arteria Coroidea Anterior. Ambas pacientes, mujeres de 19 y 47 años, fueron admitidas por clínica y tomografía computada (TC) de hemorragia subaracnoidea. En el postquirúrgico inmediato, de ectasia pediculada carotídea, vimos: desviación de cabeza y ojos a derecha,disartria,negligencia, así como hemiparesia con disestesias a izquierda. La angiografía (AG) verificadora de vasos de cuello y cerebro, mostró la correcta aplicación del clip en el cuello de sendos aneurismas. Ambas completaron la recuperación clínica antes del séptimo día y meses más tarde padecieron la primera crisis parcial compleja. Se observaron imágenes hipodensas temporales profundas y posteriores en TC. Nuestras pacientes continúan asintomáticas con carbamazepina. De 80 casos reportados, 38 fueron por cirugía adrede, ninguno casual y el resto ictales. Nuestros casos serían los únicos impensados. Consideramos que estos infartos tienen la suficiente categoría como para conformar una entidad clínica independiente

Ritmo circadiano y accidente cerebrovascular / Stroke and circadian rhythm

La variación diaria en la aparición de Accidente Cerebro Vascular (ACV) fue examinada en 255 pacientes. Estos incluyeron 173 isquemias y 82 hemorragias intraparenquimatosas (HI). Los pacientes fueron ordenados en despiertos y dormidos, y distribuidos en 4 períodos de 6 horas cada uno. La frecuencia de aparición de ACV isquémico fue significativa (p<0,001) para el período de 08 a 14 horas (46,6%); para las HI también fue significativa (p<0,001) para el mismo período (46,3%). Se analizaron otras variables: edad, sexo y tipo de lesión relacionándolas con el estado del paciente (despierto-dormido) y con el momento (día-noche) en que ocurrió el ACV. El análisis de los pacientes con ACV isquémico y hemorrágico con manifestación al despertar mostró una frecuencia significativa (p<0,001) para las isquemias (81,3%) que para las HI (18,7%)

Ritmo circadiano y accidente cerebrovascular / Stroke and circadian rhythm

La variación diaria en la aparición de Accidente Cerebro Vascular (ACV) fue examinada en 255 pacientes. Estos incluyeron 173 isquemias y 82 hemorragias intraparenquimatosas (HI). Los pacientes fueron ordenados en despiertos y dormidos, y distribuidos en 4 períodos de 6 horas cada uno. La frecuencia de aparición de ACV isquémico fue significativa (p<0,001) para el período de 08 a 14 horas (46,6%); para las HI también fue significativa (p<0,001) para el mismo período (46,3%). Se analizaron otras variables: edad, sexo y tipo de lesión relacionándolas con el estado del paciente (despierto-dormido) y con el momento (día-noche) en que ocurrió el ACV. El análisis de los pacientes con ACV isquémico y hemorrágico con manifestación al despertar mostró una frecuencia significativa (p<0,001) para las isquemias (81,3%) que para las HI (18,7%)