Assessment of enlarged perivascular spaces and their relation to target organ damage and mild cognitive impairment in patients with hypertension.

BACKGROUND AND PURPOSE: Enlarged perivascular spaces (EPVS) have been recently considered a feature of cerebral small vessel disease. They have been related to aging, hypertension and dementia but their relationship with hypertension related variables (i.e. target organ damage, treatment compliance) and mild cognitive impairment (MCI) is not fully elucidated. Our aims were to investigate the relation between basal ganglia (BG) and centrum semiovale (CSO) EPVS with vascular risk factors, hypertension related variables and MCI. METHODS: In all, 733 hypertensive individuals free of stroke and dementia from the Investigating Silent Strokes in Hypertensives, a magnetic resonance imaging Study (ISSYS) underwent brain magnetic resonance imaging and cognitive testing to diagnose MCI or normal cognitive aging. RESULTS: The numbers of participants presenting high grade (>10) EPVS at the BG and CSO were 23.3% and 40.0%, respectively. After controlling for vascular risk factors, high grade BG EPVS were associated with age (odds ratio 1.68; 95% confidence interval 1.37, 2.06), poor antihypertensive compliance (1.49; 1.03, 2.14) and the presence of microalbuminuria (1.95; 1.16, 3.28), whereas in the CSO only age (1.38; 1.18, 1.63) and male sex were associated with EPVS (1.73; 1. 24, 2.42). MCI was diagnosed in 9.3% of the participants and it was predicted by EPVS in the BG (1.87; 1.03, 3.39) but not in the CSO. This last association was greatly attenuated after correction for lacunes and white matter hyperintensities. CONCLUSIONS: Basal ganglia EPVS are associated with the presence of microalbuminuria and poor adherence to antihypertensive drugs. The BG EPVS relation with MCI is not independent of the presence of other cerebral small vessel disease markers.

[A study of right-left shunt in transient global amnesia]. / Estudio de shunt derecha-izquierda en la amnesia global transitoria.

INTRODUCTION: Transient global amnesia (TGA) is a disorder of unknown aetiology. In recent studies, TGA was associated with a right to left shunt (RLS). We studied the presence of the RLS in patients with TGA and we compared this series with patients who had suffered a transient ischaemic attack (TIA). PATIENTS AND METHODS: We included 66 consecutive TGA patients. In these patients a transcranial Doppler was performed to determine the presence of a RLS. We collected data on the TGA episode, vascular risk factors, migraine history, recurrence of TGA and neuroimaging in patients with and without RLS. We compared the prevalence of the RLS in TGA series with 59 patients with TIA. RESULTS: The prevalence of RLS was 21.2% in patients with TGA. The RLS was associated with the migraine history (40% versus 13%; p = 0.014) and a Valsalva manoeuvre as a triggering factor (50% versus 14.5%; p = 0.022). A greater prevalence of RLS was detected in patients with TIA (55.9% versus 21.2%; p < 0.001). CONCLUSIONS: The RLS prevalence in TGA patients is similar to the general population but significantly lower than the prevalence in TIA patients. The association with a Valsalva manoeuvre as a precipitating factor in the TGA patients with RLS could play a role in the aetiopathogenesis of the TGA.

Estudio de shunt derecha-izquierda en la amnesia global transitoria / study of right-left shunt in transient global amnesia

Introducción: La amnesia global transitoria (AGT) es una entidad de etiopatogenia incierta. En recientes estudios se cita la posible asociación entre la AGT y el shunt derechaizquierda (SDI). Por ello estudiamos la presencia de SDI en una serie de pacientes con AGT de nuestra población y la comparamos con otra población de pacientes con ataque isquémico transitorio (AIT). Pacientes y métodos: Recogimos de forma consecutiva 66 pacientes con AGT en los que se realizó un estudio de SDI mediante Doppler transcraneal. Comparamos las características clínicas del episodio, los factores de riesgo vascular, el antecedente de migraña, la recurrencia de AGT y la neuroimagen entre las AGT con y sin SDI. Comparamos la prevalencia de SDI con la de una serie de 59 casos de AIT de origen indeterminado. Resultados: En el grupo de AGT la prevalencia de SDI fue del 21,2%. La presencia de SDI se asoció con el antecedente de migraña (el 40 frente al 13%; p = 0,014) y una maniobra de Valsalva como factor desencadenante (el 50 frente al 14,5%; p = 0,022). Se observó una mayor frecuencia de SDI en el grupo de AIT (el 55,9 frente al 21,2%; p < 0,001). Conclusiones: La prevalencia de SDI en los pacientes con AGT es similar a la descrita en la población general, pero significativamente inferior a su prevalencia en aquellos con AIT de origen indeterminado. La asociación con una maniobra de Valsalva como desencadenante del episodio en las AGT con SDI podría implicar un mecanismo etiopatogénico en este subgrupo (AU)

Introduction: Transient global amnesia (TGA) is a disorder of unknown aetiology. In recent studies, TGA was associated with a right to left shunt (RLS). We studied the presence of the RLS in patients with TGA and we compared this series with patients who had suffered a transient ischaemic attack (TIA). Patients and methods: We included 66 consecutive TGA patients. In these patients a transcranial Doppler was performed to determine the presence of a RLS. We collected data on the TGA episode, vascular risk factors, migraine history, recurrence of TGA and neuroimaging in patients with and without RLS. We compared the prevalence of the RLS in TGA series with 59 patients with TIA. Results: The prevalence of RLS was 21.2% in patients with TGA. The RLS was associated with the migraine history (40% versus 13%; p = 0.014) and a Valsalva manoeuvre as a triggering factor (50% versus 14.5%; p = 0.022). A greater prevalence of RLS was detected in patients with TIA (55.9% versus 21.2%; p < 0.001). Conclusions: The RLS prevalence in TGA patients is similar to the general population but significantly lower than the prevalence in TIA patients. The association with a Valsalva manoeuvre as a precipitating factor in the TGA patients with RLS could play a role in the aetiopathogenesis of the TGA (AU)

Development of a clinical hepatic encephalopathy staging scale.

AIM: To develop a scale to assess the severity of hepatic encephalopathy using simple dichotomic items. METHODS: A list of 48 items was created by selecting items that are simple to recognize and categorize; it was applied to thirty-six cirrhotic in-patients with episodic encephalopathy, in addition to the adapted-West-Haven Criteria and the Glasgow Coma Score. The list underwent an item reduction process and principal component analysis; the metric characteristics were evaluated. RESULTS: Multiple neurological abnormalities were observed and a Clinical Hepatic Encephalopathy Staging Scale of nine items was constructed. The principal component analysis of the Clinical Hepatic Encephalopathy Staging Scale obtained two factors that explained 77% of the variance. The Clinical Hepatic Encephalopathy Staging Scale exhibited adequate internal consistency and reproducibility. The scores of the Clinical Hepatic Encephalopathy Staging Scale correlated to those of adapted-West-Haven Criteria and the Glasgow Coma Score. CONCLUSIONS: This study confirms that the evaluation of multiple neurological manifestations is not necessary to classify hepatic encephalopathy adequately, which can be simply undertaken by an assessment of the patient's orientation, alertness, ability to respond to commands and to talk. A list of nine items is proposed as a linear scale from normality (Clinical Hepatic Encephalopathy Staging Scale = 0) to deep coma (Clinical Hepatic Encephalopathy Staging Scale = 9).

Varón de 55 años con ictus y disnea / 55 year old male with stroke and dyspnea

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La policitemia como factor predisponente de amnesia global transitoria / Policithaemia as a ready factor of transitory global amnesia

La amnesia global transitoria (AGT) es un trastorno de memoria anterógrada de inicio brusco y de una duración inferior a 24 h que se ha relacionado con causas isquémicas, comiciales y migrañosas. Por otro lado, la policitemia está clasificada como un trastorno protrombótico que puede producir múltiples manifestaciones en el sistema nervioso central, desde ictus hasta trastornos psiquiátricos de tipo ansioso, y todos relacionados con la hipoperfusión cerebral secundaria a la hiperviscosidad. Presentamos dos pacientes que presentaron un episodio de amnesia global transitoria y que tenían una policitemia previa; además, en uno de los casos se encontró un hemangioblastoma cerebeloso. Hay numerosos casos en la literatura de lesiones intracraneales diagnosticadas a raíz de un episodio de AGT; sin embargo, no se ha descrito la relación entre la policitemia y la AGT. En la amnesia global transitoria se ha llegado a constatar una hipoperfusión de las regiones temporales y esto puede ser un mecanismo desencadenante; planteamos al posibilidad de que la policitemia sea un trastorno protrombótico que predisponga a padecer la amnesia global transitoria

Transitory global amnesia (TGA) is an upheaval where the patient has anterograde memory lost of abrupt beginning and an inferior duration to 24 h, that has been related to ischaemic, epileptogenic and migranous ethiology. On the other hand polycythaemia is classified like a prothrombotic disorder that can produce manifold manifestations in the central nervous system, from strokes to psychiatric disturbances of anxious type, and all related to the secondary cerebral hipoperfusión due to hyperviscosity. Two patients, who had a prevous diagnostic of polycythaemia suffered an episode of TGA, in addition in one of the two cases a cerebellar hemangioblastoma was found. There are numerous cases reported of brain tumors and other CNS findings diagnosed as a result of an episode of TGA, nevertheless on has not described to the relation between polycythaemia and the TGA. In the TGA a hipoperfusion of the temporal brain hemisphere has been documented and this can be a leading mechanism, so we propose that polycythaemia could ready to suffer a TGA

[Polycythaemia as a ready factor of transitory global amnesia]. / La policitemia como factor predisponente de amnesia global transitoria.

Transitory global amnesia (TGA) is an upheaval where the patient has anterograde memory lost of abrupt beginning and an inferior duration to 24 h, that has been related to ischaemic, epileptogenic and migranous ethiology. On the other hand polycythaemia is classified like a prothrombotic disorder that can produce manifold manifestations in the central nervous system, from strokes to psychiatric disturbances of anxious type, and all related to the secondary cerebral hipoperfusión due to hyperviscosity. Two patients, who had a previous diagnostic of polycythaemia suffered an episode of TGA, in addition in one of the two cases a cerebellar hemangioblastoma was found. There are numerous cases reported of brain tumors and other CNS findings diagnosed as a result of an episode of TGA, nevertheless on has not described to the relation between polycythaemia and the TGA. In the TGA a hypoperfusion of the temporal brain hemisphere has been documented and this can be a leading mechanism, so we propose that polycythaemia could ready to suffer a TGA.

Mitral papillary fibroelastoma as a cause of cardiogenic embolic stroke: report of two cases and review of the literature.

UNLABELLED: Papillary fibroelastoma (PFE) is a rare benign tumour that attaches to the endocardial surface, mostly on cardiac valves. Though usually asymptomatic, it can be the source of several complications. To date, 49 cases have been reported of embolic stroke with a PFE as the probable origin. CASE REPORTS: (i) a 39-year-old male presented with ischemic embolic stroke; the presence of a PFE was assessed by means of transoesophageal echocardiography and confirmed by pathological findings; (ii) a 32-year-old woman presented with sudden onset of left hemiparesis; a cardiogenic embolic stroke was suspected, and a diagnosis of PFE was made based on echocardiographic and pathological findings. In both cases, surgical excision of the tumours was performed with no recurrences at follow-up. Two mechanisms can explain the formation of emboli in PFE: dislodgement of the tumour leaves or fibrin-platelet aggregation on the endocardial surface of these leaves. Transthoracic echocardiography may lead to the suspicion of a PFE, but transoesophageal echocardiography is required for confirmation. Prompt surgical excision is indicated in most cases. Anticoagulation is only recommended in situations of high surgical risk and during the wait for surgery.

Asterixis associated with anatomic cerebral lesions: a study of 45 cases.

INTRODUCTION: Asterixis is an uncommon sign in structural central nervous system disorders. When asterixis is present, one cannot rule out the possibility of a focal lesion, but it is almost always due to a metabolic encephalopathy. PATIENTS AND METHODS: In the last five years all patients with uni- or bilateral neurologic asterixis attended in our hospital have been studied. Cerebral computed tomogram or magnetic resonance imaging was performed in all patients with uni or bilateral asterixis. RESULTS: We describe 45 patients with different forms of structural cerebral pathology who presented unilateral (37 patients) or bilateral (8 patients) asterixis not associated to either toxic or metabolic disorder. Central nervous system ischemic or hemorrhagic disorders were found to be the most frequent causes of asterixis (95.5%) and the thalamus the most frequent localization for unilateral asterixis to result (54%). CONCLUSIONS: Bilateral asterixis is not always associated with toxic or metabolic disorders and it may be a sign of some structural neurologic alterations. A good correlation was found between the presence of unilateral asterixis and structural intracranial disease.

[Prevalence of cognitive deterioration in a geriatric urban population]. / Prevalencia de deterioro cognitivo en una población urbana en edad geriátrica.

A descriptive study was carried out in Salt (Gerona) to evaluate the prevalence of cognitive impairment in a geriatric urban population and its relation with several variables which might have an influence on it. The cognitive status was evaluated with the score in the Mini-Mental State Examination (MMSE). A representative sample of 392 individuals was obtained out of an overall population of 2,394 registered persons above 65 years of age; 354 of them were interviewed. The overall rate of intellectual deterioration (MMSE less than 24) was 26.5%, and it was 8% for the important deterioration (MMSE less than 18). The presence of cognitive impairment was significantly correlated in multivariate analysis with advanced age, low educational level and limited personal autonomy.