Stroke in systemic lupus erythematosus: epidemiology, mechanism, and long-term outcome.

OBJECTIVE: To determine stroke prevalence, mechanisms, and long-term outcome in a cohort of Hispanic patients with systemic lupus erythematosus (SLE). METHODS: We analyzed demographical data, the timing between SLE diagnosis and stroke onset, stroke type, recurrence, and outcomes from an institutional database of 4451 patients with SLE followed from 1993 to 2018. RESULTS: We observed 139 strokes (3.1%), for an incidence rate of 1.25 per 1000 person-years: 81 (58.3%) acute ischemic stroke (AIS), 19 (13.7%) subarachnoid hemorrhage (SAH), 17 (12.2%) cerebral venous thrombosis, 13 (9.4%) intracerebral hemorrhage (ICH), and 9 (6.5%) transient ischemic attack. Median time from SLE diagnosis to acute stroke was 60 months (interquartile range 12-132 months). AIS had a bimodal presentation with 26% occurring within the first year and 30% >10 years after SLE diagnosis. In contrast, 75% of ICH cases occurred >3 years (and 34% >10 years) after SLE diagnosis. The most important cause of AIS was secondary antiphospholipid syndrome (48%). Hypertension was associated with 69% of ICH cases, while aneurysmal rupture was observed in 78% of SAH cases. Excellent recovery at hospital discharge was observed in 65%. Stroke recurrence was observed in 7%. The long-term all-cause fatality rate was 8%. CONCLUSIONS: The prevalence of stroke in this cohort was 3.1%. Ischemic strokes had a bimodal presentation, occurring either early after SLE diagnosis or after a several-year delay. Half of the hemorrhagic strokes occurred >10 years after the diagnosis of SLE. Clinical outcome was usually good with a relatively low recurrence rate.

Intrathecal formation of anticardiolipin antibodies in a patient with SLE-related relapsing longitudinal myelitis: a possible pathogenic connection.

BACKGROUND: Nontraumatic acute transverse myelitis (ATM) can occur in response to infectious, inflammatory and vascular triggers; 1% of patients with systemic lupus erythematosus (SLE) develop ATM, but the mechanism remains unknown. OBJECTIVE: The objective of this case report is to describe a case of intrathecal formation of anticardiolipin antibodies (aCL) during SLE-related ATM. METHODS: A single patient analysis was conducted. RESULTS: A 26-year-old housewife was diagnosed with SLE at age 19. Circulating aCL antibodies were positive at diagnosis. At age 21, she developed an episode of severe sepsis. At 23 years of age she developed an episode of ATM that left her paraplegic with a D10 sensory level, from which she recovered partially. Three years later, she developed a clinical relapse of ATM. During that second episode, serum levels of aCL were within normal limits, while cerebrospinal fluid levels were increased, suggesting intrathecal production of aCL. CONCLUSION: Here, we present a case of a woman who developed relapsing SLE-related longitudinally extensive ATM in whom intrathecal formation of aCL was demonstrated, suggesting that local production and cross-recognition of nervous tissue by those autoantibodies may be myelopathic.

Natural history of longitudinally extensive transverse myelitis in 35 Hispanic patients with systemic lupus erythematosus: good short-term functional outcome and paradoxical increase in long-term mortality.

Background and objective Acute transverse myelitis (TM) is an infrequent neurological complication of systemic lupus erythematosus (SLE). Short-term outcome varies widely between cohorts. Little is known about the epidemiology and long-term functional outcome of TM associated to SLE. Methods Patients with SLE and acute TM were identified during hospital admission, visits to the Emergency Room or the Neurology Outpatient Clinic. We evaluated ambispectively those patients with SLE presenting with clinical myelopathy and corroborated with spinal MRI. Cases were divided as partial (non-paralyzing) or complete (paralyzing). We determined long-term functional outcome as well as mortality in those patients with follow-up periods of at least five years. Results We identified 35 patients (partial, n = 15; complete, n = 20) in which complete clinical and imaging data were available (26 with follow-up ≥ 5 years). Patients with complete TM were significantly older than those with partial forms. Positive antiphospholipid antibodies were observed in 80% of patients, suggesting a possible mechanistical role. Surprisingly, functional recovery at one year was in general good; however, we observed a five-year mortality of 31% because of sepsis (in 10 cases) or pulmonary embolism (in one case). Conclusions Short-term outcome of SLE-related TM is generally good, and recurrence rate is low. However, we observed a long-term fatality rate of 31% for reasons unrelated to TM, suggesting that TM is a manifestation of severe immune dysregulation and a predictor of severity and mortality in patients with SLE.

Tiempo de llegada hospitalaria y pronóstico funcional después de un infarto cerebral: resultados del estudio PREMIER / Hospital arrival time and functional outcome after acute ischaemic stroke: Results from the PREMIER study

Introducción: La información sobre el tiempo de llegada hospitalaria después de un infarto cerebral (IC) se ha originado en países con unidades especializadas en ictus. Existe poca información en naciones emergentes. Nos propusimos identificar los factores que influyen en el tiempo de llegada hospitalaria a 1, 3 y 6 h y su relación con el pronóstico funcional después del ictus. Métodos: Se analizó la información de pacientes con IC incluidos en el estudio Primer Registro Mexicano de Isquemia Cerebral (PREMIER) que tuvieran tiempo definido desde el inicio de los síntomas hasta la llegada hospitalaria. El desenlace funcional se evaluó mediante la escala modificada de Rankin a los 30 días, 3, 6 y 12 meses. Resultados: De 1.096 pacientes con IC, 61 (6%) llegaron en < 1 h, 250 (23%) en < 3 h y 464 (42%) en < 6 h. Favorecieron la llegada temprana en < 1 h: el antecedente familiar de cardiopatía isquémica y ser migrañoso; en < 3 h: edad 40-69 años, antecedente familiar de hipertensión, antecedente personal de dislipidemia y cardiopatía isquémica, así como la atención en hospital privado; en < 6 h: antecedente familiar de hipertensión, ser migrañoso, ictus previo, cardiopatía isquémica y atención en hospital privado. La llegada hospitalaria tardía se asoció a ictus lacunar y alcoholismo. Solo el 2,4% recibió trombólisis. Independientemente de la trombólisis, la llegada en < 3 h se asoció a menor mortalidad a los 3 y 6 meses, además de menos complicaciones intrahospitalarias. Conclusiones: Una proporción importante de pacientes tuvo un tiempo de llegada hospitalaria temprana; sin embargo, menos del 3% recibió trombólisis. Aunque muchos factores se asociaron a la llegada temprana, es prioritario identificar las barreras intrahospitalarias que obstaculizan la trombólisis

Introduction: Information regarding hospital arrival times after acute ischaemic stroke (AIS) has mainly been gathered from countries with specialised stroke units. Little data from emerging nations is available. We aim to identify factors associated with achieving hospital arrival times of less than 1, 3, and 6 hours, and analyse how arrival times are related to functional outcomes after AIS. Methods: We analysed data from patients with AIS included in the PREMIER study (Primer Registro Mexicano de Isquemia Cerebral) which defined time from symptom onset to hospital arrival. The functional prognosis at 30 days and at 3, 6, and 12 months was evaluated using the modified Rankin Scale. Results: Among 1096 patients with AIS, 61 (6%) arrived in <1 hour, 250 (23%) in <3 hours, and 464 (42%) in <6 hours. The factors associated with very early (<1 hour) arrival were family history of ischemic heart disease and personal history of migraines; in <3 hours: age 40-69 years, family history of hypertension, personal history of dyslipidaemia and ischaemic heart disease, and care in a private hospital; in <6 hours: migraine, previous stroke, ischaemic heart disease, care in a private hospital, and family history of hypertension. Delayed hospital arrival was associated with lacunar stroke and alcoholism. Only 2.4% of patients underwent thrombolysis. Regardless of whether or not thrombolysis was performed, arrival time in <3 hours was associated with lower mortality at 3 and 6 months, and with fewer in-hospital complications. Conclusions: A high percentage of patients had short hospital arrival times; however, less than 3% underwent thrombolysis. Although many factors were associated with early hospital arrival, it is a priority to identify in-hospital barriers to performing thrombolysis

Lifetime prevalence and underdiagnosis of migraine in a population sample of Mexican women.

OBJECTIVE: The objective of this report is to evaluate migraine, migraine characteristics, and underdiagnosis of migraine in a large population sample of Mexican women. METHODS: Participants are part of a prospective cohort of Mexican teachers. Between 2011 and 2013, 77,855 participants completed a detailed questionnaire on headache characteristics. Migraine was defined according to criteria of the International Classification of Headache Disorders (ICDH-II). RESULTS: We found lifetime migraine prevalence was 19%, prevalence peaked at 40-44 years (20.4%) and only 45.1% participants with migraine had a previous diagnosis of the disease. CONCLUSION: Estimated lifetime prevalence of migraine was higher than previous reports in Latin America. Migraine may be underdiagnosed and undertreated in Mexico despite its considerable burden.

Strategies to improve recovery in acute ischemic stroke patients: Iberoamerican Stroke Group Consensus.

Stroke is not only a leading cause of death worldwide but also a main cause of disability. In developing countries, its burden is increasing as a consequence of a higher life expectancy. Whereas stroke mortality has decreased in developed countries, in Latin America, stroke mortality rates continue to rise as well as its socioeconomic dramatic consequences. Therefore, it is necessary to implement stroke care and surveillance programs to better describe the epidemiology of stroke in these countries in order to improve therapeutic strategies. Advances in the understanding of the pathogenic processes of brain ischemia have resulted in development of effective therapies during the acute phase. These include reperfusion therapies (both intravenous thrombolysis and interventional endovascular approaches) and treatment in stroke units that, through application of management protocols directed to maintain homeostasis and avoid complications, helps to exert effective brain protection that decreases further cerebral damage. Some drugs may enhance protection, and besides, there is increasing knowledge about brain plasticity and repair mechanisms that take place for longer periods beyond the acute phase. These mechanisms are responsible for recovery in certain patients and are the focus of basic and clinical research at present. This paper discusses recovery strategies that have demonstrated clinical effect, or that are promising and need further study. This rapidly evolving field needs to be carefully and critically evaluated so that investment in patient care is grounded on well-proven strategies.

Hospital arrival time and functional outcome after acute ischaemic stroke: results from the PREMIER study.

INTRODUCTION: Information regarding hospital arrival times after acute ischaemic stroke (AIS) has mainly been gathered from countries with specialised stroke units. Little data from emerging nations is available. We aim to identify factors associated with achieving hospital arrival times of less than 1, 3, and 6 hours, and analyse how arrival times are related to functional outcomes after AIS. METHODS: We analysed data from patients with AIS included in the PREMIER study (Primer Registro Mexicano de Isquemia Cerebral) which defined time from symptom onset to hospital arrival. The functional prognosis at 30 days and at 3, 6, and 12 months was evaluated using the modified Rankin Scale. RESULTS: Among 1096 patients with AIS, 61 (6%) arrived in <1 hour, 250 (23%) in <3 hours, and 464 (42%) in <6 hours. The factors associated with very early (<1 hour) arrival were family history of ischemic heart disease and personal history of migraines; in <3 hours: age 40-69 years, family history of hypertension, personal history of dyslipidaemia and ischaemic heart disease, and care in a private hospital; in <6 hours: migraine, previous stroke, ischaemic heart disease, care in a private hospital, and family history of hypertension. Delayed hospital arrival was associated with lacunar stroke and alcoholism. Only 2.4% of patients underwent thrombolysis. Regardless of whether or not thrombolysis was performed, arrival time in <3 hours was associated with lower mortality at 3 and 6 months, and with fewer in-hospital complications. CONCLUSIONS: A high percentage of patients had short hospital arrival times; however, less than 3% underwent thrombolysis. Although many factors were associated with early hospital arrival, it is a priority to identify in-hospital barriers to performing thrombolysis.

Aspirina frente a anticoagulación en pacientes jóvenes con infarto cerebral secundario a síndrome antifosfolípido primario / Aspirin versus anticoagulation in young patients with cerebral infarction secondary to primary antiphospholipid syndrome

Introducción. El síndrome antifosfolípido primario (SAP) es un factor de riesgo independiente para infarto cerebral. Objetivo. Evaluar el riesgo de recurrencia, comparar los diferentes tratamientos y determinar los factores de riesgo asociados con recurrencia y complicaciones hemorrágicas en pacientes con infarto cerebral y SAP. Pacientes y métodos. Los datos prospectivamente recogidos de 92 pacientes menores de 45 años (71% mujeres; media de edad: 33,8 ± 8,9 años), con diagnósticos confirmados de infarto cerebral y SAP, tratados con anticoagulantes (n = 54) o aspirina (n = 38), se analizaron restrospectivamente. El seguimiento se realizó con evaluación neurológica cada 6 a 12 meses. Las medidas de pronóstico fueron: recurrencia de infarto cerebral, hemorragia intracerebral sintomática y sangrado menor. Resultados. Durante una mediana de seguimiento de 54 meses (rango: 12-240 meses), ocurrieron ocho (9%) infartos cerebrales recurrentes, sin diferencia entre el tratamiento con aspirina (n = 0) o anticoagulantes (n = 8). La tasa anual de recurrencia fue de 0,014 personas/año de seguimiento. La historia de trombosis previa y de abortos espontáneos fue más habitual en pacientes con recurrencia. Los pacientes tratados con aspirina provenían con mayor frecuencia de medio rural. Cuatro pacientes anticoagulados desarrollaron complicaciones hemorrágicas; dos, hemorragias menores, y dos, hematomas subdurales. El 76% de los casos evolucionó con buen pronóstico funcional (escala de Rankin modificada: 0-2). Conclusión. Con las limitaciones de un estudio no aleatorizado, nuestros datos sugieren que el riesgo de infarto cerebral arterial recurrente en pacientes jóvenes con infarto cerebral secundario a SAP es bajo, no homogéneo y probablemente independiente del tipo de antitrombótico utilizado (AU)

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 (AU)

Cerebrovascular complications during pregnancy and postpartum: clinical and prognosis observations in 240 Hispanic women.

BACKGROUND AND PURPOSE: Although pregnancy and postpartum have long been associated with stroke, there is a dearth of information in Latino-American populations. The aim of this study was to describe the cerebrovascular complications occurring during pregnancy/postpartum and compare the characteristics amongst stroke types occurring in this period in Hispanic women. PATIENTS AND METHODS: We studied 240 women with cerebrovascular complications during pregnancy and the first 5 weeks postpartum, from our stroke registry. Patients were classified into three groups: cerebral venous thrombosis (CVT), ischaemic stroke (IS), and intracerebral hemorrhage (ICH). For each group, clinical data, timing of the event, and outcome were analyzed. RESULTS: Of the 240 women, 136 had CVT (56.7%), 64 IS (26.7%), and 40 ICH (16.6%). In 72 women (30%), the event occurred during pregnancy, in 153 (64%) during postpartum, and in 15 (6%) closely related to labor. CVT was more common in the first trimester of pregnancy and in the second and third weeks following delivery; whilst IS and ICH were seen mainly during pregnancy and the first 2 weeks following delivery. Pre-eclampsia/eclampsia was more common in patients with ICH (57.5%) and IS (36%) than in those with CVT (9.6%) (P < 0.001). An excellent recovery (modified Rankin Scale: 0-1) was observed amongst women with CVT (64%) and IS (50%) compared to ICH (32%), (P = 0.004). CONCLUSIONS: Pre-eclampsia/eclampsia is a frequent risk factor in patients with ICH and IS, but not in CVT. Stroke types clustered different within the pregnancy-postpartum period. A good prognosis is observed in patients with CVT.

Hemorragia subaracnoidea no aneurismática. Estudio de seguimiento a largo plazo / Nonaneurysmal subarachnoid hemorrhage. Study of long-term follow-up

Introducción. La hemorragia subaracnoidea (HSA) no aneurismática representa del 15 al 20 % del total de casos de HSA. Su pronóstico puede variar de recuperación completa a diferentes y graves complicaciones. Describimos una serie de casos con HSA no aneurismática, sus características clínicas, tomográficas y sus causas, así como el pronóstico a largo plazo. Pacientes y métodos. Cincuenta pacientes con diagnóstico de HSA y dos angiografías cerebrales negativas para aneurisma fueron seguidos durante un tiempo medio de 62 meses. Se registraron los datos demográficos de importancia y factores de riesgo vascular. En la fase aguda se evaluaron mediante la escala clínica de Hunt y Hess y la escala topográfica de Fisher. La distribución de la hemorragia se catalogó como ausente, perimesencefalica, focal, ventricular o difusa. Durante el seguimiento se registró la presencia de resangrado, muerte y la evolución funcional, medida por la escala modificada de Rankin. De acuerdo con esta escala se consideró como pronóstico favorable el Rankin de 0 a 2. Resultados. Esta serie representa el 8,6% de todos los casos de HSA en nuestro hospital. En 6 casos (12%) existió una relación causal entre el uso de fármacos simpaticomiméticos y el desarrollo de la HSA. En el 80% de ellos no se logró documentar la causa de la hemorragia, mientras que en el 20% se encontraron diversas causas (trombosis venosa cerebral en 4 [8 %], disección espontánea de arteria vertebral en 2 [4%], vasculitis secundaria a neurocisticercosis en 2 (4%), angioma cavernoso en 1 (2%) y malformación arteriovenosa espinal en 1). En ninguno de los casos se presentó resangrado y sólo 1 paciente falleció. En 45 pacientes (90%) el pronóstico funcional final fue bueno (Rankin: 0-2). No encontramos diferencias significativas entre el patrón tomográfico de la hemorragia, la condición clínica inicial y el pronóstico a largo plazo. Conclusiones. Nuestros hallazgos muestran una frecuencia baja de HSA no aneurismática en nuestra población y una diversidad de causas mayor a la aportada por otras series. Se confirmó el buen pronóstico funcional en estos casos

Introduction. Nonaneurysmal subarachnoid hemorrhage (SAH) accounts for 15% to 20% of all the cases of SAH. Its prognosis may vary from complete recovery to different and serious complications. We describe a series of cases with nonaneurysmal SAHs, their clinical and tomographic characteristics and causes as well as long term prognosis. Patients and methods. 50 patients diagnosed of SAH and two negative brain angiographies for aneurysm were followed-up for an average period of 62 months. The demographic data of importance, vascular risk factors, were recorded. They were evaluated during the acute phase with the Hunt and Hess clinical scale and Fisher topographic scale. The distribution of the hemorrhage was listed as absent, perimesencephalic, focal, ventricular or diffuse. Presence of rebleeding, death and the functional course, measured by the Rankin modified scale, were recorded during the follow-up. According to this scale, Rankin of 0 to 2 was considered as a favorable prognosis. Results. This series represents 8.6 of all the SAH cases in our hospital. In 6 cases (12%), there was a causal relationship between the use of sympathicomimetic drugs and the development of SAH. In 80% of them, it was not possible to document the cause of the hemorrhage, while different causes (cerebral venous thrombosis in 4 [8%], spontaneous dissection of the vertebral artery in 2 [4%], vasculitis secondary to neurocysticerosis in 2 [4%], cavernous angioma in 1 [2%] and spinal arteriovenous malformation in 1) were found. Rebleeding did not occur in any of the cases and only one patient died. In 45 patients (90 %), the final functional prognosis was good (Rankin 0–2). We found no significant differences between the tomographic pattern of the hemorrhage, initial clinical condition and long term prognosis. Conclusions. Our findings show a low frequency of nonaneurysmal SAH in our population and a diversity of causes greater than those reported by other series. The good functional prognosis in these cases was confirmed

Subarachnoid hemorrhage as a complication of systemic lupus erythematosus.

BACKGROUND: Subarachnoid hemorrhage (SAH) is a rare complication of systemic lupus erythematosus (SLE). METHODS: We made a retrospective search for patients with SLE and nontraumatic SAH from 1990 to 2006. RESULTS: We found 10 patients with SLE and primary SAH of a total of 1,077 patients with SLE (0.93%); mean age of onset was 37.4 +/- 15.25 years and the mean duration of SLE at the onset of SAH was 98.3 +/- 50.32 months. SLEDAI and chronic damage scores were 3.67 +/- 5.20 (n = 9) and 2.90 +/- 1.45 (n = 10), respectively; 60% of patients had high Hunt-Hess scores and in only 50% of cases a saccular aneurysm was identified. CONCLUSIONS: SAH presents in about 1% of SLE patients. Long duration of SLE and chronic damage scores might be associated risk factors.

Response of thymectomy: clinical and pathological characteristics among seronegative and seropositive myasthenia gravis patients.

OBJECTIVE: To identify the response to thymectomy in patients with seronegative and seropositive myasthenia gravis (SPMG). We analyzed the associated diseases, thymus histology, and the severity of symptoms between the two groups. MATERIAL AND METHODS - DESIGN: Descriptive, comparative. STUDY UNITS: Fourteen patients with seronegative myasthenia gravis (SNMG) and 57 patients with SPMG who had a thymectomy between 1987 and 1997, with at least 3 years of follow-up. The patients were divided into four groups; (1) Remission, (2) Improvement, (3) No change and (4) Deterioration. RESULTS: Fourteen patients (20%) were seronegative and 57 were seropositive (80%). In the group of patients with SNMG, three patients were in remission (21%), five with improvement (36%), five with no change (36%) and one with worsening (7%). In the group of patients with SPMG, 12 were in remission (21%), 17 with improvement (30%), 25 with no change (44%) and three (5%) with worsening. The patients with SNMG were older, with less associated diseases and with a lower frequency of thymomas. CONCLUSIONS: The response to thymectomy was similar between the two groups. It has been suggested that seronegative patients have a better prognosis, but our results show no differences.

[Systemic lupus erythematosus with affection to brainstem: report of three cases]. / Lupus erimatoso sistémico con afectación del tronco encefálico: presentación de tres casos.

INTRODUCTION: The frequency with which the central nervous system (CNS) is affected by systemic lupus erythematosus (SLE) varies, according to different series, between 13 and 59%, whereas the brain stem is affected in 5%. CASE REPORTS: Case 1: a 33 year old male who was submitted to a Nissen funduplicature as a treatment of (hypo)incoercible hiccups. The singultus persisted and some time after a paraplegia appeared. Magnetic resonance (MRI) showed images in the medulla oblongata, and in the cervical and thoracic spine. A biopsy was also performed to examine the cervical lesions and vasculitis was diagnosed. The patient began treatment with prednisone (1 mg/kg) and two months after symptoms had begun to improve he presented an episode of bilateral optic neuritis. Until this last event, the immunological studies had been positive. Case 2: female aged 19 who had had SLE for eight months. The illness began suddenly with bilateral paralysis of the sixth cranial nerve, vertical and horizontal nystagmus, dysdiadochokinesia, truncal ataxia, 4/5 muscular strength in the upper limbs and 3/5 in the lower limbs, and left flexor plantar response, but indifferent on the right hand side. MR showed T2 hyperintensities in the pons, medulla oblongata and the junction of medulla and upper spinal cord. Case 3: female aged 31 with sudden onset of the illness, characterised by diplopy and presence of internuclear ophthalmoplegia. Brain MR showed images of T1 hypointense and T2 hyperintense in the pontobulbar region. CONCLUSION: A brain stem disorder in patients suffering from SLE is one of the rarest manifestations of this pathological condition of the CNS and is probably caused by vasculitis

Effect of clopidogrel on platelet aggregation and plasma concentration of fibrinogen in subjects with cerebral or coronary atherosclerotic disease.

Acetylsalicylic acid inhibits thromboxane A2 production and reduces the risk of vascular occlusive events by 20% to 25%. Ticlopidine inhibits ADP-dependent platelet aggregation and reduces the same risk by 30% to 35%, but produces some adverse effects. Clopidogrel is a ticlopidin-related antiplatelet drug, with the same mechanism of action; it reduces the expression of the glycoprotein IIb/IIIa, the fibrinogen receptor on the platelet surface. Clopidogrel has the same clinical efficacy of ticlopidin and has a decreased incidence of adverse effects. The effect of one daily dose of 75 mg of clopidogrel on platelet function in 90 subjects was evaluated; 41 with coronary artery disease and 49 with cerebral vascular disease. Before treatment and after 6 and 12 weeks, bleeding time and fibrinogen plasma concentration were also evaluated. There was a reduction in 5-microM ADP-induced platelet aggregation of 38%+/-27% at 6 weeks and 44%+/-29% at 12 weeks in patients with coronary artery disease; 35%+/-41%, 29%+/-59% in the cerebral vascular disease group; and 36%+/-36% and 35%+/-49% in the total group. Reduction of 20 microg/mL collagen-induced platelet aggregation was not significant in any group. Plasma fibrinogen levels did not vary during treatment. Bleeding time was significantly prolonged in all studied groups. There were no hemorrhagic complications; only digestive discomfort in less than 3% of patients. Clopidogrel efficiently reduces ADP-induced platelet aggregation and prolongs bleeding time and is a safe and efficacious antiplatelet drug.

Lupus erimatoso sistémico con afectación del tronco encefálico:presentación de tres casos / Systemic lupus erythematosus with affection to brainstem: report of three cases

Introducción. La frecuencia de la afectación del sistema nervioso central (SNC) por lupus eritematoso sistémico (LES) varía, de acuerdo con distintas series, entre un 13 y un 59 por ciento, mientras que el tronco encefálico se ve afectado en un 5 por ciento. Casos clínicos. Caso 1: hombre de 33 años de edad, al que se le practica una funduplicatura tipo Nissen por presentar un cuadro de singultus (hipo)incoercible. Se constató la persistencia de singultus y apareció con posterioridad una paraplejía. La resonancia magnética (RM) mostró imágenes en el bulbo y en la columna cervical y torácica. Se realizó también una biopsia de las lesiones cervicales y se diagnosticó vasculitis. El paciente inició un tratamiento con prednisona (1 mg/kg) y dos meses después de la mejoría de los síntomas presentó un episodio de neuritis óptica bilateral. Hasta este último evento hubo positividad a todos los estudios inmunológicos. Caso 2: mujer de 19 años de edad con LES de ocho meses de evolución. La enfermedad se inició de manera súbita con parálisis del sexto nervio craneal bilateral, nistagmo vertical y horizontal, disdiacocinesia, ataxia troncal, fuerza muscular 4/5 para los miembros superiores y 3/5 para los inferiores, y respuesta plantar flexora izquierda, pero indiferente en el lado derecho. La RM mostró hiperintensidades en T2, localizadas en puente, bulbo y unión bulbomedular. Caso 3: mujer de 31 años de edad con un inicio súbito de la enfermadad, caracterizada por diplopía y presencia de oftalmoplejía internuclear. La RM cerebral mostró imágenes en región pontobulbar hipointensas en T1 e hiperintensas en T2. Conclusión. La afección del tronco cerebral en pacientes con LES es una de las manifestaciones más raras de esta patología en el SNC y probablemente esté causada por vasculitis (AU)

Síndrome de Antón asociado a vasculitis de sistema nervioso central. Respuesta / Response. Central nervous system vasculitis-associated Anton's syndrome

No disponible

[Cardiovascular risk factors and carotid atherosclerosis detected by ultrasonography]. / Factores de riesgo cardiovascular y aterosclerosis carotídea detectada por ultrasonografía.

OBJECTIVES: To assess the frequency of carotid atherosclerosis and its relation to cardiovascular risk factors in a general elderly population of Mexico City. MATERIAL AND METHODS: B-mode ultrasonography was performed to investigate carotid atherosclerosis in 145 CUPA (a research project) participants, between July 1993 and January 1996. The outcome was then related to cardiovascular risk factors. RESULTS: Prevalence of ultrasound-detected carotid atherosclerosis was 64.8%. Intimal-medial thickening was detected in 64 subjects (44.1%) and carotid plaques in 82 (56.5%); Fifty-two subjects had both intimal-medial thickening and plaques. However, only 8 subjects had carotid plaques with severe stenosis (5.5%). There were no significant differences in the prevalence of atherosclerotic lesions (male 61.9%, female 66.0%). Carotid atherosclerosis was significantly associated with age (p < 0.0001), high blood pressure (p < 0.001), isolated systolic hypertension (p = 0.01), hypercholesterolemia (p = 0.04), and diabetes mellitus (p = 0.06). Prevalence of carotid atherosclerosis increased progressively with the number of vascular risk factors. CONCLUSIONS: There was a high prevalence of carotid atherosclerosis in this general elderly population of Mexico City, and was almost equal to that reported in developed western countries. Age, hypertension, hypercholesterolemia, and diabetes were the strongest predictors of atherosclerosis.

[Sonographic patterns by transcranial Doppler in acute cerebral infarction]. / Patrones sonográficos por Doppler transcraneal en el infarto cerebral agudo.

AIM: To evaluate the correlations between the patterns of Transcranial Doppler (TCD) and the extent and pathophysiologic mechanism of the ischemia as well as the prognosis of patients with acute ischemic stroke. METHODS: 37 patients with ischemic stroke within the first 24 hours of evolution were examined using TCD, neuroimaging, and neurologic state at admission and disarcharge. The TCDs were grouped into four categories: normal, stenotic, hemispheric asymmetry and trunk occlusion of the middle cerebral artery (MCA); they were correlated with the extent of brain damage, pathophysiologic mechanism of the stroke and prognosis. RESULTS: Normal TCD was highly predictive of lacunar infarction secondary to small vassels disease (p = 0.01) and good recovery (p < 0.02). The stenotic and hemispheric asymmetry patterns correlated highly with a cortical infarctions (p < 0.05) and a cardioembolic mechanism. The occlusion of the MCA was highly correlated with a large infarction (p < 0.01) and with poor outcome and death (p = 0.004). CONCLUSIONS: Our data show that TCD has a value in predicting the prognosis and the severity, location and pathophysiologic mechanism of cerebral strokes.

[Prevalence of carotid atherosclerosis in a cohort of Mexico City]. / Prevalencia de aterosclerosis carotídea en una población de la ciudad de México.

In order to investigate the prevalence of atherosclerosis in Mexico, high resolution ultrasound and color Doppler flow imaging of carotid arteries were carried out in a group of participants in CUPA project, a cohort study started in 1989 among persons 60 years and older living permanently in a high rise in México City. Imaging studies included identification of 4 atherosclerosis related abnormalities: 1) intima media thickness; 2) kinkings and tortuousness; 3) non-stenosing plaques; and 4) significant carotid stenosis (> 50%). Analysis of 198 Doppler ultrasonographic studies in 56 males and 142 females showed an overall prevalence of atherosclerosis related lesions of 65.6%, with increasing frequency by age groups: 33% in younger than 65 year-old, 71% in 65-74 years, and up to 88% in the 75 years and older group. The prevalence of high grade stenosis was low (6%) whereas the overall frequency of non-stenosing plaques and intima-media thickness was higher than 60%. Intima-media thickness was more common in males while non-stenosing plaques and high grade stenosis were more frequent in females. However, there were not significant differences among women and men when atherosclerotic lesions were analyzed by age groups. This is the first report on the prevalence of atherosclerosis in a Mexican population using ultrasonography. Findings of the investigation document the high prevalence of atherosclerosis among elderly resident in Mexico City.