Hospital Arrival and Functional Outcome after Intracerebral Hemorrhage.

BACKGROUND: Intracerebral hemorrhage (ICH) is associated with an ominous outcome influenced by the time to hospital presentation. OBJECTIVE: This study aims to identify the factors that influence an early hospital arrival after ICH and the relationship with outcome. METHODS: In this multicenter registry, patients with confirmed ICH on CT scan and well-known time of symptoms onset were studied. Clinical data, arrival conditions, and prognostic scores were analyzed. Multivariate models were built to find independent predictors of < 6 h arrival (logistic regression) and in-hospital death (Cox proportional-hazards model). RESULTS: Among the 473 patients analyzed (51% women, median age 63 years), the median delay since onset to admission was 6.25 h (interquartile range: 2.5-24 h); 7.8% arrived in < 1 h, 26.3% in < 3 h, 45.3% in < 6 h, and 62.3% in < 12 h. The in-hospital, 30-day and 90-day case fatality rates were 28.8%, 30.0%, and 32.6%, respectively. Predictors of arrival in < 6 h were hypertension treatment (odds ratios [OR]: 1.675, 95% confidence intervals [CI]: 1.030-2.724), ≥ 3 years of schooling (OR: 1.804, 95% CI: 1.055-3.084), and seizures at ICH onset (OR: 2.416, 95% CI: 1.068-5.465). Predictors of death (56.9% neurological) were systolic blood pressure > 180 mmHg (hazards ratios [HR]: 1.839, 95% CI: 1.031-3.281), ICH score ≥ 3 (HR: 2.302, 95% CI: 1.300-4.074), and admission Glasgow Coma Scale < 8 (HR: 4.497, 95% CI: 2.466-8.199). Early arrival was not associated with outcome at discharge, 30 or 90 days. CONCLUSIONS: In this study, less than half of patients with ICH arrived to the hospital in < 6 h. However, early arrival was not associated with the short-term outcome in this data set.

A Practical Score for Prediction of Outcome After Cerebral Venous Thrombosis.

Background: Most patients with cerebral venous thrombosis (CVT) have independent survival in the short term. However, identification of high-risk individuals with an unfavorable outcome is a challenging task. We aimed to develop a CVT grading scale (CVT-GS) to aid in the short-term clinical decision-making. Methods: We included 467 consecutive patients with CVT who were hospitalized from 1981 to 2015 in two third-level referral hospitals. Factors associated with 30-day mortality were selected with bivariate analyses to integrate a Cox proportional-hazards model to determine components of the final scoring. After the scale was configured, the prognostic performance was tested for prediction of short-term death or moderately impaired to death [modified Rankin scale (mRS) > 2]. CVT-GS was categorized as mild, moderate or severe for the prediction of 30-day fatality rate and a probability of mRS > 2. Results: The 30-day case fatality rate was 9.0%. The CVT-GS (0-13 points; more points predicting poorer outcomes) was composed of parenchymal lesion size > 6 cm (3 points), bilateral Babinski signs (3 points), male sex (2 points), parenchymal hemorrhage (2 points), and level of consciousness (coma: 3 points, stupor: 2, somnolence: 1, and alert: 0). CVT was categorized as mild (0-2 points, 0.4% fatality rate), moderate (3-7 points, 9.9% fatality rate), or severe (8-13 points, 61.4% fatality rate). The CVT-GS had an accuracy of 91.6% for the prediction of 30-day mortality and 85.3% for mRS > 2. Conclusions: CVT-GS is a practical clinical tool for prediction of outcome after CVT. This score may aid in clinical decision-making and could serve to stratify patients enrolled in clinical trials.

The benefit of EXtending oral antiCOAgulation treatment (EXCOA) after acute cerebral vein thrombosis (CVT): EXCOA-CVT cluster randomized trial protocol.

Rationale After a cerebral vein thrombosis, there is an increased risk of further venous thromboembolic events. The optimal duration of anticoagulation after cerebral vein thrombosis is unknown. Aim To compare efficacy and safety of a policy of short- (3-6 months) versus long-term (12 months) anticoagulation (any type venous thromboembolic events) after cerebral vein thrombosis for the prevention of venous thromboembolic events. Sample size estimates A sample of 1428 patients (749 per arm) allows detecting a reduction from 10 to 5% in the risk of venous thromboembolic event recurrence with 80% power at 5% significance, with 3% dropout rate. Methods and design An international multicenter, prospective cluster-randomized trial with equal allocation between both interventions (ISRCTN25644448). Each cluster is a participating center, which accepted to be randomly allocated to one of the anticoagulation policies. Eligible patients are adults with radiologically confirmed cerebral vein thrombosis within 30 days, and stable to initiate post-acute anticoagulation. Patients judged by the investigator to be an absolute indication for permanent anticoagulation are excluded. Follow-up is at 6, 12 and 24 months. Study outcomes Primary efficacy outcome is any symptomatic and confirmed fatal/nonfatal venous thromboembolic event (recurrent-cerebral vein thrombosis or non-cerebral venous thromboembolic event). Primary safety outcomes include bleeding events during treatment periods and death from any cause. Discussion This study responds to a knowledge gap in the post-acute management of cerebral vein thrombosis patients by comparing short- versus long-term anticoagulation for the prevention of venous thromboembolic event recurrence.

Mexican-National Institute of Neurology and Neurosurgery-Stroke Registry: Results of a 25-Year Hospital-Based Study.

BACKGROUND AND PURPOSE: Stroke has been scarcely studied in Latin America (LA). The Mexican Institute of Neurology Stroke Registry was established in 1990 as a prospective computer-based database to register data obtained from patients admitted with stroke. Using this data, we attempted to define the profile of risk factors and outcomes. METHODS: The demographic data, stroke description, ancillary tests, vascular risk factors, and modified Rankin scale (mRs) were registered. Ischemic stroke subtyping was based on the Trial of Org 10,172 of the Acute Stroke Treatment classification. We followed-up patients using multiple overlapping methods. Primary outcomes included mRs, recurrence, and death at 30 days and at the end of follow-up. RESULTS: We included 4,481 patients with a median follow-up of 27 months, (17,281 person-years follow-up). The mean age was 52.8 ± 18 years. There were 2,229 males (50%) included in the study. CI was present in 64.9%, intracerebral hemorrhage (ICH) in 25.6%, and cerebral venous thrombosis (CVT) in 6.3%. Hypertension was the major risk factor (46.5%). The most common cause of CI was atherosclerosis (27%). ICH was mainly hypertensive (58%), and 60% of CVT were puerperal. Overall, the mortality rate was 24.5%. The recurrence rate was 16.9%. Poor outcome (mRs ≥ 3) was found in 56.2% of patients. The best outcomes were observed in CVT patients (74.5% mRs ≤ 2), whereas 72.1% ICH patients had mRs ≥3. CONCLUSION: This is one of the largest hospital-based registries in LA and shows significant differences with other previously published registries, including a younger age, relatively less hypertension, and larger proportion of CVT. Poor functional outcome was common. This study adds to the understanding of geographic differences in stroke characteristics and outcomes.

Public and Private Hospital Care Disparities of Ischemic Stroke in Mexico: Results from the Primer Registro Mexicano de Isquemia Cerebral (PREMIER) Study.

BACKGROUND AND AIMS: Mortality and bad outcome by stroke are higher in developing countries than in industrialized countries. Health-care system efficiency could explain these disparities. Our objective was to identify the impact on short- and middle-term outcomes of patients with acute ischemic stroke (AIS) among public and private Mexican medical care. METHODS: We analyzed data from patients with AIS included in the Primer Registro Mexicano de Isquemia Cerebral (PREMIER) study. Transient ischemic attacks (TIAs) and ambulatory patients were excluded. Mortality and good outcome were assessed by the modified Rankin Scale (mRS) and analyzed at 1, 3, and 12 months of follow-up. RESULTS: From 1246 patients with AIS included in the registry, 1123 were hospitalized, either in public (n = 881) or in private (n = 242) hospitals. There were no significant differences regarding age and gender. In private settings, patients had a higher educational level, a major frequency of dyslipidemia, a previous stroke and TIA, less overweight and obesity, a sedentary lifestyle, and diabetes; stroke severity, the rate of systemic complications, the length of stay, and in-hospital mortality were also lower; a major frequency of thrombolysis was observed when compared with public hospitals. Our study showed a better outcome (mRS score ≤2) in private scenarios and a higher mortality in patients treated in public hospitals at short- and middle-term follow-ups. CONCLUSIONS: A polarized medical practice was observed in the AIS care in this large multicenter cohort of Mexico. There is evidence of an advantage for private scenarios, possibly related with an optimal infrastructure or with a strong patient's economic status.

Outcome, Recurrence and Mortality after Non-Valvular Atrial Fibrillation Stroke: Long-Term Follow-Up Study.

OBJECTIVE: Non-valvular atrial fibrillation (NVAF) is a major risk factor for ischemic stroke (IS) and a powerful predictor of mortality. This study investigates early and long-term outcome among patients with IS secondary to NVAF and identify the main factors associated with poor outcome, recurrence, and death. METHODS: We analyzed the data from our consecutive NVAF acute IS database, over a period of 23 years. The endpoints were bad outcome (Modified Rankin Score ≥3), recurrence, and mortality at discharge, after 6 months, 12 months, and final follow-up. Multivariate Cox and Kaplan-Meier analysis were used to estimate the probability of death. RESULTS: 129 consecutive acute IS patients were included (77 [59.7%] females, mean age 70.2 ± 10.1 years). Discharge, 6 and 12 months bad outcome was 62%, 63%, and 61%, respectively. After a median follow-up of 17 months (IQR 6-54.5), 35.6% patients had bad outcome, 21.7% had recurrence and 36.4% died. The recurrence and death annual rates were 19.1% and 6.32%. The absence of oral anticoagulation (OAC) and NIHSS score > 12 were the strongest predictors of mortality. CONCLUSIONS: IS secondary to NVAF has a high rate of stroke recurrence and mortality in our population, with the absence of OAC and major stroke as the main risk factors.

Clinical Outcome of Anticoagulant Treatment in Head or Neck Infection-Associated Cerebral Venous Thrombosis.

BACKGROUND AND PURPOSE: Local infections of the head or neck are a cause of cerebral venous thrombosis. Treatment of infectious cerebral venous thrombosis with heparin is controversial. We examined whether this treatment was associated with intracranial hemorrhagic complications and poor clinical outcome. METHODS: We retrieved data from a prospective cohort study of 624 cerebral venous thrombosis patients. We compared patients with and without an infection of the head or neck and anticoagulated versus not anticoagulated. We examined death or dependency and new intracerebral hemorrhages. RESULTS: Six hundred four of 624 patients were eligible for the study. Fifty-seven patients had an infection of the head or neck (9.4%). Comparing data between infection and noninfection patients, the frequency of therapeutic doses of heparin was similar in both groups (82.5% versus 83.7%). New intracerebral hemorrhages were more common in patients with an infection (12.3% versus 5.3%; P=0.04), but death or dependency did not differ between patients with and without an infection (15.8% versus 13.7%). In patients with an infection of the head or neck, there was no significant difference in the frequency of new intracerebral hemorrhages and poor outcome between patients who did or did not receive therapeutic doses of heparin. CONCLUSIONS: New intracerebral hemorrhages were more frequent in patients with an infection. The use of therapeutic doses of heparin did not seem to influence the risk of new intracranial hemorrhages or poor clinical outcome, but the number of patients who did not receive anticoagulation was too small to draw firm conclusions about safety of heparin in adults with cerebral venous thrombosis and an infection of the head or neck.

Cerebral venous thrombosis in the absence of headache.

BACKGROUND AND PURPOSE: Although headache is the most common symptom in cerebral venous thrombosis, 5% to 30% of patients do not report headache at baseline. Characteristics of these patients have not been investigated. METHODS: In post hoc analysis of the International Study on Cerebral Vein and Dural Sinus Thrombosis study, patients who might not have been able to report headache (aphasia, stupor, coma, or mental status disorder) were excluded. RESULTS: Three hundred eighty-two of the original 624 patients (61%) were included, of whom 38 (10%) did not report headache at baseline. Patients without headache were older (mean age, 45 versus 37; P=0.001) and less often female (63% versus 77%; P=0.06). Paresis (42% versus 27%; P=0.05) and seizures (58% versus 32%; P=0.001) were more common in patients without headache, whereas papilledema was less common (8% versus 35%; P=0.001). Isolated cortical vein thrombosis (16% versus 2%; P=0.001), brain parenchymal lesions (66% versus 46%; P=0.02), and malignancies (18% versus 6%; P=0.009) were more common among patients without headache. Outcome at last follow-up was worse in patients without headache (modified Rankin Scale, 0-1; 76% versus 89%; P=0.04; mortality, 13% versus 5%; P=0.05), but after adjustment for prognostic variables, headache was not an independent predictor of outcome. CONCLUSIONS: Patients with cerebral venous thrombosis but without headache are a heterogeneous subgroup, in which older patients, men, and some associated conditions are over-represented. Patients without headache had a worse clinical outcome, but after adjustment for imbalances, headache was not an independent predictor of outcome.

The burden of stroke in México.

Regrettably, stroke has been scarcely studied in México, and the available data suffer from great variability in diagnostic testing, risk factor definitions, and poor generalizability. The current cumulative incidence of stroke in Mexico is 232.2 per 100,000, whereas prevalence among people aged 60 years or older is 18.2 per 1000. Hypertension and diabetes are the main risk factors. Ischemic stroke is the most frequent sub-type. Stroke mortality has been increasing during last years, and 30-day case fatality rate doubles at one-year follow-up. A remarkable finding of a hospital-based registry was that most of ischemic stroke cases are of undetermined etiology and even when a quarter of patients arrive on time for thrombolysis, less than 1% received this management.

Cerebral venous thrombosis causing posterior fossa lesions: description of a case series and assessment of safety of anticoagulation.

BACKGROUND: Isolated posterior fossa parenchymal lesions associated with cerebral venous thrombosis (CVT) are rare. Posterior fossa lesions are an independent predictor of death in CVT. We aim to describe the characteristics and outcome of patients with CVT and isolated posterior fossa lesions and assess the safety of anticoagulation in patients with posterior fossa lesions associated with CVT. METHODS: We retrieved data from all patients with posterior fossa parenchymal lesions in the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) cohort related to clinical features, therapy and outcome. Fisher's exact test was used to evaluate associations. To assess the safety of anticoagulation in CVT patients with posterior fossa lesions we considered all patients with a lesion in this topography, either isolated or with concomitant supratentorial lesions, and compared the rate of new intracranial haemorrhages on repeated imaging with the remaining cohort. RESULTS: Out of 624 patients, 12 had isolated posterior fossa lesions and 14 had posterior fossa lesion with accompanying supratentorial lesions. The lateral sinus was most frequently occluded (n = 11). Involvement of the superior sagittal sinus was significantly less frequent compared to the remaining patients of the cohort (p = 0.013). None of the patients with isolated posterior fossa lesion died but 3 remained dependent on follow-up. Poor outcome (modified Rankin Scale ≥3) was more frequent in patients with any posterior fossa lesion, even when on anticoagulation (29.2% vs. 11.9%; OR 3.04; 95% CI 1.2-7.6; p = 0.018). Of the 24 anticoagulated patients with a posterior fossa lesion, 3 (12.5%) had new haemorrhages on repeated imaging, compared with 30 out of 495 anticoagulated patients (6.1%) without posterior fossa lesions (p = 0.19). CONCLUSIONS: We describe the largest series of CVT patients with associated posterior fossa lesions. When compared to anticoagulated CVT patients without posterior fossa lesions, CVT patients with posterior fossa lesions on full anticoagulation did not have a significant increase in the rate of new intracranial haemorrhages.

Evaluation and management of a patient with possible cerebral venous thrombosis.

Cerebral venous thrombosis (CVT) is a relatively rare form of stroke usually affecting young individuals. CVT is characterized by the diversity of its neurologic manifestations, which require a high level of clinical suspicion for diagnosis and prompt, appropriate treatment. Multiple circumstances have been associated with CVT, such as prior medical conditions, transient situations, certain medications, and some predisposing conditions. Headache, focal neurologic deficit, and seizures are the most frequent clinical manifestations at onset. MRI in combination with venography has become the imaging modality of choice, as this technique has a high sensitivity and specificity for establishing a diagnosis. CT venography is an alternative to MRI because this technique produces similar diagnostic results. Pharmacologic treatment of CVT with anticoagulants is widely accepted. Per 100 cases, the recurrence of CVT is 2.8% and the mortality of CVT is 10%.

Serum uric acid and outcome after acute ischemic stroke: PREMIER study.

BACKGROUND: Current evidence shows that uric acid is a potent antioxidant whose serum concentration increases rapidly after acute ischemic stroke (AIS). Nevertheless, the relationship between serum uric acid (SUA) levels and AIS outcome remains debatable. We aimed to describe the prognostic significance of SUA in AIS. METHODS: We studied 463 patients (52% men, mean age 68 years, 13% with glomerular filtration rate <60 ml/min at hospital arrival) with AIS pertaining to the multicenter registry PREMIER, who had SUA measurements at hospital presentation. Multivariate models were constructed to analyze the association of SUA with functional outcome as assessed by the modified Rankin scale (mRS) at 30-day, 3-, 6- and 12-month follow-up. A mRS 0-1 was regarded as a very good outcome. RESULTS: Mean SUA concentration at hospital arrival was 6.1 ± 3.7 mg/dl (362.8 ± 220.0 µmol/l). Compared with cases with higher SUA levels at hospital admission, patients with ≤4.5 mg/dl (≤267.7 µmol/l; the lowest tertile of the sample) had more cases of a very good 30-day outcome (30.5 vs. 18.9%, respectively; p = 0.004). SUA was not associated with mortality or functional dependence (mRS >2) at 30 days, or with any outcome measure at 3, 6 or 12 months poststroke. After adjustment for age, gender, stroke type and severity (NIHSS <9), time since event onset, serum creatinine, hypertension, diabetes and smoking, a SUA ≤4.5 mg/dl (≤267.7 µmol/l) was positively associated with a very good short-term outcome (odds ratio: 1.76, 95% confidence interval: 1.05-2.95; negative predictive value: 81.1%), but not at 3, 6 or 12 months of follow-up. When NIHSS was entered in the multivariate model as a continuous variable, the independent association of SUA with outcome was lost. Compared with cases with higher levels, patients with SUA ≤4.5 mg/dl (≤267.7 µmol/l) were more frequently younger than 55 years, women, with mild strokes, with normal serum creatinine and fewer had hypertension. The time since event onset to hospital arrival was not significantly associated with AIS severity or SUA levels; nevertheless, a nonsignificant tendency was observed for patients with severe strokes and high SUA levels arriving in <24 h. CONCLUSIONS: A low SUA concentration is modestly associated with a very good short-term outcome. Our findings support the hypothesis that SUA is more a marker of the magnitude of the cerebral infarction than an independent predictor of stroke outcome.

Prognosis of cerebral vein thrombosis presenting as isolated headache: early vs. late diagnosis.

OBJECTIVE: To analyse the outcome of cerebral venous thrombosis (CVT) patients presenting with isolated headache, specifically to compare isolated headache patients with early vs. late CVT diagnosis. METHOD: In the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) database we compared the outcome of patients with isolated headache and a CVT diagnosed early (≤7 days from onset) vs. late (>7 days). We retrieved 100 patients with isolated headache, 52 patients with early CVT diagnosis (early isolated headache) and 48 with late CVT diagnosis (late isolated headache). RESULTS: Neurological worsening was more frequent within early isolated headache patients (23% vs. 8%) (p = 0.045). At the last follow-up (median 411 days), 93% patients had a complete recovery, and 4% were dead or dependent, with no significant difference between early isolated headache and late isolated headache. CONCLUSION: The outcome of CVT patients with isolated headache diagnosed early or late was similarly favourable, but there was a higher proportion of neurological worsening in the acute phase among early isolated headache patients, who need close neurological monitoring.

Long-term risk of recurrent stroke in young cryptogenic stroke patients with and without patent foramen ovale.

BACKGROUND: Among patients with a patent foramen ovale and cryptogenic ischemic stroke, the long-term prognosis is unclear. AIMS: This study aims to estimate the recurrence rate in young cryptogenic stroke patients with and without patent foramen ovale. PATIENTS AND METHODS: One hundred eighty-six cryptogenic stroke patients (aged 18-45 years) were prospectively followed for up to five-years. They were divided into two groups according to the echocardiographic presence of patent foramen ovale. All patients received aspirin (100 mg/day) for secondary prevention. RESULTS: Mean age was 32·3 (standard deviation 7·9) years. During the mean follow-up of 66 months five patients with patent foramen ovale had recurrent strokes compared with 11 patients without patent foramen ovale. The average annual rate of recurrent cerebral ischemia was 1·1% and 1·6% for patients with and without patent foramen ovale, respectively. The recurrence rate did not increase with the presence of patent foramen ovale, atrial septal aneurysm or other variables. More than 60% of the reported cases achieved a good functional outcome. CONCLUSIONS: Young patients with cryptogenic ischemic stroke with and without patent foramen ovale have a low recurrence rate in a long-term follow-up and most present a favorable outcome. Patent foramen ovale with or without atrial septal aneurysm did not increase the risk of recurrence.

Cerebral venous thrombosis in a Mexican multicenter registry of acute cerebrovascular disease: the RENAMEVASC study.

BACKGROUND: Cerebral venous thrombosis (CVT) is a rare form of cerebrovascular disease that is usually not mentioned in multicenter registries on all-type acute stroke. We aimed to describe the experience on hospitalized patients with CVT in a Mexican multicenter registry on acute cerebrovascular disease. METHODS: CVT patients were selected from the RENAMEVASC registry, which was conducted between 2002 and 2004 in 25 Mexican hospitals. Risk factors, neuroimaging, and 30-day outcome as assessed by the modified Rankin scale (mRS) were analyzed. RESULTS: Among 2000 all-type acute stroke patients, 59 (3%; 95% CI, 2.3-3.8%) had CVT (50 women; female:male ratio, 5:1; median age, 31 years). Puerperium (42%), contraceptive use (18%), and pregnancy (12%) were the main risk factors in women. In 67% of men, CVT was registered as idiopathic, but thrombophilia assessment was suboptimal. Longitudinal superior sinus was the most frequent thrombosis location (78%). Extensive (>5 cm) venous infarction occurred in 36% of patients. Only 81% of patients received anticoagulation since the acute phase, and 3% needed decompressive craniectomy. Mechanical ventilation (13.6%), pneumonia (10.2%) and systemic thromboembolism (8.5%) were the main in-hospital complications. The 30-day case fatality rate was 3% (2 patients; 95% CI, 0.23-12.2%). In a Cox proportional hazards model, only age <40 years was associated with a mRS score of 0 to 2 (functional independence; rate ratio, 3.46; 95% CI, 1.34-8.92). CONCLUSIONS: The relative frequency of CVT and the associated in-hospital complications were higher than in other registries. Thrombophilia assessment and acute treatment was suboptimal. Young age is the main determinant of a good short-term outcome.

Spontaneous intracerebral hemorrhage in Mexico: results from a Multicenter Nationwide Hospital-based Registry on Cerebrovascular Disease (RENAMEVASC).

INTRODUCTION: Scarce information exists on intracerebral hemorrhage (ICH) in Latin America, and the existent is derived from single-center registries with non-generalizable conclusions. The aim of this study is to describe the frequency, etiology, management and outcome of ICH in Mexico. PATIENTS AND METHODS: We studied consecutive patients with ICH pertaining to the National Multicenter Registry on Cerebro-vascular Disease (RENAMEVASC), conducted in 25 centers from 14 states of Mexico. The Intracerebral Hemorrhage Grading Scale (ICH-GS) at admission was used to assess prognosis at 30 days follow-up. RESULTS: Of 2,000 patients with acute cerebrovascular disease registered in RENAMEVASC, 564 (28%) had primary ICH (53% women; median age: 63 years; interquartile range: 50-75 years). Hypertension (70%), vascular malformations (7%) and amyloid angiopathy (4%) were the main etiologies. In 10% of cases etiology could not be determined. Main ICH locations were basal ganglia (50%), lobar (35%) and cerebellum (5%). Irruption into the ventricular system occurred in 43%. Median score of ICH-GS was 8 points: 49% had 5-7 points, 37% had 8-10 points and 15% had 11-13 points. The 30-day case fatality rate was 30%, and 31% presented severe disability. The 30-day survival was 92% for patients with ICH-GS 5-7 points, whereas it decreased to 27% in patients with ICH-GS 11-13 points. CONCLUSIONS: In Mexico, ICH represents about a third of the forms of acute cerebrovascular disease, and the majority of patients present severe disability or death at 30 days of follow-up. Hypertension is the main cause; hence, control of this important cardiovascular risk factor should reduce the health burden of ICH.

[Aspirin versus anticoagulation in young patients with cerebral infarction secondary to primary antiphospholipid syndrome]. / Aspirina frente a anticoagulacion en pacientes jovenes con infarto cerebral secundario a sindrome antifosfolipido primario.

INTRODUCTION: The primary antiphospholipid syndrome (PAS) is an independent risk factor for cerebral infarction. AIM. To evaluate the risk of recurrence, to compare different treatments and determine the risk factors associated with recurrence and hemorrhagic complications in patients with cerebral infarction and PAS. PATIENTS AND METHODS: Prospectively collected data from 92 patients under 45 years (71% female, mean age 33.8 ± 8.9 years) with confirmed diagnoses of cerebral infarction and PAS, treated with anticoagulants (n = 54) or aspirin (n = 38) were retrospectively analyzed. Clinical follow-up was obtained by neurological examination every 6 to 12 months. Outcome measures were: recurrence of CI, symptomatic intracerebral hemorrhage, and minor bleeding. RESULTS: During a median follow-up of 54 months (range: 12-240 months), there were 8 (9%) recurrent cerebral infarctions, with no difference between treatment with aspirin (n = 0) or anticoagulants (n = 8). The annual rate of recurrence was 0,014 person-years of follow-up. The history of previous thrombosis and spontaneous abortions were more frequent in patients with recurrence. Aspirin-treated patients more frequently came from rural areas. Four anticoagulated patients developed bleeding complications, two minor bleeding and two subdural hematomas. 76% of the cases evolved with good outcome (modified Rankin scale: 0-2). CONCLUSION: With the limitations of a nonrandomized study, our data suggest that the risk of recurrent arterial cerebral infarction in young patients with cerebral infarction secondary to PAS is low, probably non-uniform and independent of the type of antithrombotic.

[Systolic blood pressure and functional outcome in patients with acute stroke: a Mexican registry of acute cerebrovascular disease (RENAMEVASC)]. / Presión arterial sistólica y pronóstico funcional en pacientes con enfermedad vascular cerebral aguda: Registro mexicano de enfermedad vascular cerebral.

OBJECTIVE: To analyze the association between the admission systolic blood pressure (SBP) and 30-day outcome in patients with acute cerebrovascular disease. METHODS: The REgistro NAcional Mexicano de Enfermedad VAScular Cerebral (RENAMEVASC) is a hospital-based multicenter registry performed between November 2002 and October 2004. A total of 2000 patients with clinical syndromes of acute cerebrovascular disease confirmed by neuroimaging were registered. The modified Rankin scale was used for outcome stratification. RESULTS: We analyzed 1721 patients who had registered their SBP: 78 (4.5%) had transient ischemic attack, 894 (51.9%) brain infarction, 534 (30.9%) intracerebral hemorrhage, 165 (9.6%) subarachnoid hemorrhage and 50 (2.9%) cerebral venous thrombosis. Among 1036 (60.2%) patients with the antecedent of hypertension, only 32.4% had regular treatment. The 30-day case fatality rate presented a J pattern with respect to SBP, so that the risk of death was highest in <100 mmHg (37.5%), decreased between 100 and 139, and reached gradually a new zenith in ?220 mmHg (35.3%). The best functional outcome corresponded to patients who had SBP between 100 mmHg and 159 mmHg. In a Cox proportional hazards model, SBP <100 mmHg or ?220 mmHg was an independent risk factor for 30-day mortality (RR: 1.52, IC 95%: 1.07 - 2.15), as well as the antecedent of hypertension (RR: 1.33, IC 95%: 1.06 - 1.65) and age >65 years (RR: 2.16, IC 95%: 1.74 - 2.67). CONCLUSION: Both hypotension and significant arterial hypertension at hospital admission are associated with an adverse outcome after acute cerebrovascular disease. Nevertheless, a good functional outcome can be attained in a wide range of SBP.

Presión arterial sistólica y pronóstico funcional en pacientes con enfermedad vascular cerebral aguda: Registro mexicano de enfermedad vascular cerebral / Systolic blood pressure and functional outcome in patients with acute stroke: A Mexican registry of acute cerebrovascular disease (RENAMEVASC)

Objetivo: Analizar la asociación de la presión arterial sistólica (PAS) al ingreso hospitalario y la evolución clínica a 30 días en pacientes con enfermedad vascular cerebral (EVC) aguda. Métodos: El REgistro NAcional Mexicano de Enfermedad VAScular Cerebral (RENAMEVASC) es un registro hospitalario multicéntrico realizado de noviembre de 2002 a octubre de 2004. Se registraron 2000 pacientes con distintos síndromes clínicos de EVC aguda confirmados por neuroimagen. La estratificación de la evolución clínica se realizó mediante la escala de Rankin modificada. Resultados: Se analizaron 1721 pacientes con registro de la PAS: 78 (4.5%) con isquemia cerebral transitoria, 894 (51.9%) con infarto cerebral, 534 (30.9%) con hemorragia intracerebral, 165 (9.6%) con hemorragia subaracnoidea y 50 (2.9%) con trombosis venosa cerebral. De los 1036 (60.2%) pacientes con el antecedente de hipertensión, sólo 32.4% tenía un tratamiento regular. La tasa de mortalidad a 30 días presentó un patrón en J con respecto a la PAS, de tal manera que el riesgo de muerte fue máximo en <100 mmHg (37.5%), descendió entre 100 mmHg y 139 mmHg, para alcanzar gradualmente un nuevo cenit en >220 mmHg (35.3%). El mejor desenlace funcional correspondió a los pacientes que tuvieron una PAS entre 100 mmHg y 159 mmHg. Mediante un modelo de riesgos proporcionales de Cox se encontró que una PAS <100 mmHg o >220 mmHg fue un factor independiente de riesgo de muerte a 30 días (RR: 1.52, IC 95%: 1.07 - 2.15), al igual que el antecedente de hipertensión (RR: 1.33, IC 95%: 1.06 - 1.65) y edad >65 años (RR: 2.16, IC 95%: 1.74 - 2.67). Conclusión: Tanto la hipotensión como la hipertensión arterial significativa al ingreso hospitalario se asocian a un pronóstico adverso en la EVC aguda. No obstante, un buen pronóstico funcional se puede lograr en un amplio rango de cifras de PAS.

Objective: To analyze the association between the admission systolic blood pressure (SBP) and 30-day outcome in patients with acute cerebrovascular disease. Methods: The REgistro NAcional Mexicano de Enfermedad VAScular Cerebral (RENAMEVASC) is a hospital-based multicenter registry performed between November 2002 and October 2004. A total of 2000 patients with clinical syndromes of acute cerebrovascular disease confirmed by neuroimaging were registered. The modified Rankin scale was used for outcome stratification. Results: We analyzed 1721 patients who had registered their SBP: 78 (4.5%) had transient ischemic attack, 894 (51.9%) brain infarction, 534 (30.9%) intracerebral hemorrhage, 165 (9.6%) subarachnoid hemorrhage and 50 (2.9%) cerebral venous thrombosis. Among 1036 (60.2%) patients with the antecedent of hypertension, only 32.4% had regular treatment. The 30-day case fatality rate presented a J pattern with respect to SBP, so that the risk of death was highest in <100 mmHg (37.5%), decreased between 100 and 139, and reached gradually a new zenith in >220 mmHg (35.3%). The best functional outcome corresponded to patients who had SBP between 100 mmHg and 159 mmHg. In a Cox proportional hazards model, SBP <100 mmHg or >220 mmHg was an independent risk factor for 30-day mortality (RR: 1.52, IC 95%: 1.07 - 2.15), as well as the antecedent of hypertension (RR: 1.33, IC 95%: 1.06 - 1.65) and age >65 years (RR: 2.16, IC 95%: 1.74 - 2.67). Conclusion: Both hypotension and significant arterial hypertension at hospital admission are associated with an adverse outcome after acute cerebrovascular disease. Nevertheless, a good functional outcome can be attained in a wide range of SBP.

Decompressive surgery in cerebrovenous thrombosis: a multicenter registry and a systematic review of individual patient data.

BACKGROUND AND PURPOSE: Herniation attributable to unilateral mass effect is the major cause of death in cerebral venous thrombosis (CVT). Decompressive surgery may be lifesaving in these patients. METHODS: Retrospective registry of cases of acute CVT treated with decompressive surgery (craniectomy or hematoma evacuation) in 22 centers and systematic review of all published cases of CVT treated with decompressive surgery. The primary outcome was the score on the modified Rankin Scale (mRS) score at last follow-up, dichotomized between favorable (mRS score, 0-4) and unfavorable outcome (mRS score, 5 or death). Secondary outcomes were complete recovery (mRS score 0-1), independence (mRS score, 0-2), severe dependence (mRS score, 4-5), and death at last available follow-up. RESULTS: Sixty-nine patients were included and 38 were from the registry. Decompressive craniectomy was performed in 45 patients, hematoma evacuation was performed in 7, and both interventions were performed in 17 patients. At last follow-up (median, 12 months) only 12 (17.4%) had un unfavorable outcome. Twenty-six (37.7%) had mRS score 0 to 1, 39 (56.5%) had mRS score 0 to 2, 4 (5.8%) were alive with mRS score 4 to 5, and 11 (15.9%) patients died. Three of the 9 patients with bilateral fixed pupils recovered completely. Comatose patients were less likely to be independent (mRS score 0-2) than noncomatose patients (45% versus 84%; P=0.003). Patients with bilateral lesions were more likely to have unfavorable outcomes (50% versus 11%; P=0.004) and to die (42% versus 11%; P=0.025). CONCLUSIONS: In CVT patients with large parenchymal lesions causing herniation, decompressive surgery was lifesaving and often resulted in good functional outcome, even in patients with severe clinical conditions.