A neglected symptom? Parietal gait lateropulsion as primary manifestation of acute is-chemic stroke. / ¿Un síntoma negado? Lateropulsión parietal de la marcha como manifestación inicial de ictus isquémico agudo.

INTRODUCTION: Gait disorders are commonly overlooked as a presenting manifestation of stroke and underrepresented in case series. We describe four cases of sudden-onset gait lateropulsion as primary manifestation of parietal lobe stroke. CASE REPORT: Four patients presented after sudden-onset gait lateropulsion. On neurological examination, all patients had at least one cortical sensory deficit and wide-based gait with lateropulsion towards the side of the cortical deficit. Neuroimaging revealed a subacute parietal lobe stroke contralateral to the side of gait lateropulsion. In two patients we found bilateral lateropulsion with predominance towards the side of cortical deficit and increase of unsteadiness with eye closure (an apparent Romberg sign), with neuroimaging revealing bilateral parietal strokes (subacute contralateral and chronic ipsilateral to gait lateropulsion). CONCLUSION: We report gait lateropulsion as a novel primary manifestation of acute stroke of the parietal lobe (parietal gait lateropulsion). Given its role as the destination of proprioceptive pathways, parietal strokes can result in gait lateropulsion, with bilateral lesions even mimicking sensory ataxia with bilateral lateropulsion and unsteadiness upon eye closure.

TITLE: ¿Un síntoma negado? Lateropulsión parietal de la marcha como manifestación inicial de ictus isquémico agudo.Introducción. Los trastornos de la marcha no suelen considerarse dentro de las manifestaciones de presentación del ictus y están subrepresentados en las series de casos. Presentamos cuatro casos de lateropulsión de la marcha de inicio súbito como manifestación primaria de ictus del lóbulo parietal. Caso clínico. Cuatro pacientes se presentaron tras el inicio súbito de lateropulsión de la marcha. En el examen neurológico, todos tenían al menos un déficit sensitivo cortical, marcha de base amplia con lateropulsión ipsilateral al déficit cortical. En la neuroimagen se corroboró un ictus subagudo parietal contralateral al lado de lateropulsión de la marcha. Dos pacientes tenían lateropulsión bilateral con predominio ipsilateral al déficit cortical e incremento de inestabilidad con los ojos cerrados (simulando signo de Romberg), en quienes la neuroimagen demostró un ictus parietal bilateral (subagudo contralateral, crónico ipsilateral al lado de lateropulsión de la marcha). Conclusión. Describimos la lateropulsión de la marcha como una nueva manifestación inicial de ictus agudo del lóbulo parietal (lateropulsión parietal de la marcha), contralateral al lado de desviación de la marcha. Dado el papel del parietal como destino de las vías de propiocepción, los ictus pueden originar alteraciones de la marcha, con lesiones bilaterales que semejan ataxia sensitiva con inestabilidad al eliminar la aferencia visual.

¿Un síntoma negado? Lateropulsión parietal de la marcha como manifestación inicial de ictus isquémico agudo / A neglected symptom? Parietal gait lateropulsion as primary manifestation of acute is-chemic stroke

Introducción: Los trastornos de la marcha no suelen considerarse dentro de las manifestaciones de presentación del ictus y están subrepresentados en las series de casos. Presentamos cuatro casos de lateropulsión de la marcha de inicio súbito como manifestación primaria de ictus del lóbulo parietal.Caso clínico: Cuatro pacientes se presentaron tras el inicio súbito de lateropulsión de la marcha. En el examen neurológico, todos tenían al menos un déficit sensitivo cortical, marcha de base amplia con lateropulsión ipsilateral al déficit cortical. En la neuroimagen se corroboró un ictus subagudo parietal contralateral al lado de lateropulsión de la marcha. Dos pacientes tenían lateropulsión bilateral con predominio ipsilateral al déficit cortical e incremento de inestabilidad con los ojos cerrados (simulando signo de Romberg), en quienes la neuroimagen demostró un ictus parietal bilateral (subagudo contralateral, crónico ipsilateral al lado de lateropulsión de la marcha). Conclusión: Describimos la lateropulsión de la marcha como una nueva manifestación inicial de ictus agudo del lóbulo parietal (lateropulsión parietal de la marcha), contralateral al lado de desviación de la marcha. Dado el papel del parietal como destino de las vías de propiocepción, los ictus pueden originar alteraciones de la marcha, con lesiones bilaterales que semejan ataxia sensitiva con inestabilidad al eliminar la aferencia visual.(AU)

Introduction: Gait disorders are commonly overlooked as a presenting manifestation of stroke and underrepresented in case series. We describe four cases of sudden-onset gait lateropulsion as primary manifestation of parietal lobe stroke. Case report: Four patients presented after sudden-onset gait lateropulsion. On neurological examination, all patients had at least one cortical sensory deficit and wide-based gait with lateropulsion towards the side of the cortical deficit. Neuroimaging revealed a subacute parietal lobe stroke contralateral to the side of gait lateropulsion. In two patients we found bilateral lateropulsion with predominance towards the side of cortical deficit and increase of unsteadiness with eye closure (an apparent Romberg sign), with neuroimaging revealing bilateral parietal strokes (subacute contralateral and chronic ipsilateral to gait lateropulsion).Conclusion: We report gait lateropulsion as a novel primary manifestation of acute stroke of the parietal lobe (parietal gait lateropulsion). Given its role as the destination of proprioceptive pathways, parietal strokes can result in gait lateropulsion, with bilateral lesions even mimicking sensory ataxia with bilateral lateropulsion and unsteadiness upon eye closure.(AU)

Impact of Arrhythmia in Hospital Mortality in Acute Ischemic Stroke Patients: A Retrospective Cohort Study in Northern Mexico.

BACKGROUND: Atrial fibrillation has been associated with higher morbidity and mortality rates in acute ischemic stroke patients (AIS). However, there is scarce information regarding the clinical outcomes and strokes' characteristics among AIS patients with other type of arrhythmias. OBJECTIVE: Our study aims to analyze the hospital mortality rate, stroke characteristics, and clinical and demographical data of patients with any post-stroke arrhythmia. METHODS: Retrospective cohort study of AIS patients with 24h-Holter monitoring during hospital admission recruited between 2015-2020, outcomes were measured using the modified Rankin scale. RESULTS: 597 patients (61.13±13.61 years; 352 men) were included. Arrhythmias were diagnosed in 33 (5.5%), with atrial fibrillation as the most common finding (82%). Age was related to a higher rate of arrhythmia (P = 0.014). A larger prevalence of cardioembolic strokes (69.7% vs 16.6%, P < 0.05) and AIS in the middle cerebral artery's vascular territory (78.8% vs 58.7%, P < 0.05) were found amongst patients with an arrhythmia. No significant association was found between NIHSS at admission with neither incidence of arrhythmia nor mortality. Within the arrhythmia group, three in-hospital deaths were reported: one AF, one ventricular arrhythmia and one second-degree atrioventricular block. In a logistic regression analysis, patients with any kind of arrhythmia had a higher mortality rate (9.1% vs 1.2%, P = 0.011; OR 6.766, 95% CI 1.552 - 29.500). CONCLUSION: Arrhythmia detection after an AIS was associated with increased in-hospital mortality. Risk factors related to arrhythmia detection were a higher mean age, cardioembolic strokes and AIS affecting the middle cerebral artery.

[Diffusion tensor imaging of the corticospinal pathway and its association with the prognosis of acute cerebral infarction: experience with a cohort in Mexico]. / Imagen del tensor de difusión de la vía corticoespinal y su asociación con el pronóstico del infarto cerebral agudo: experiencia de una cohorte en México.

INTRODUCTION: Magnetic resonance diffusion tensor imaging through the fraction of anisotropy allows evaluation of the integrity of the motor pathways after cerebral infarction. AIMS: To correlate the fraction of anisotropy with the clinical scales and the prognosis of cerebral infarction. SUBJECTS AND METHODS: Prospective study of patients with cerebral infarction to compare the fraction of anisotropy in different regions of interest with functional evaluations and with controls free of infarction. A subgroup of subjects with rehabilitation underwent an initial MRI scan and another at three months, with clinical follow-up for six months. RESULTS: Thirty-eight consecutive patients with middle cerebral artery infarction were included. The fraction of anisotropy values were lower in the ipsilateral corticospinal pathway than the fraction of anisotropy of the corticospinal pathway of the controls. The values of the fraction of anisotropy in the ipsilateral corticospinal pathway were associated with the value of the functional scale on admission. Changes in the fraction of anisotropy values between the initial MRI and the scan performed at three months correlated with the score on the functional scale and the modified Rankin scale at three and six months. CONCLUSIONS: The value of the fraction of anisotropy in the ipsilateral internal capsule is associated with the presence of a lesion and with its presenting symptoms. Changes in the fraction of anisotropy at three months suggest long-term clinical recovery.

TITLE: Imagen del tensor de difusión de la vía corticoespinal y su asociación con el pronóstico del infarto cerebral agudo: experiencia de una cohorte en México.Introducción. La imagen del tensor de difusión por resonancia magnética a través de la fracción de anisotropía permite evaluar la integridad de las vías motoras después de un infarto cerebral. Objetivo. Correlacionar la fracción de anisotropía con las escalas clínicas y el pronóstico del infarto cerebral. Sujetos y métodos. Estudio prospectivo de pacientes con infarto cerebral para comparar la fracción de anisotropía en diferentes regiones de interés con evaluaciones funcionales y con controles sin infarto. En un subgrupo con rehabilitación, se realizó una resonancia magnética inicial y a los tres meses, con un seguimiento clínico durante seis meses. Resultados. Se incluyó a 38 pacientes consecutivos con infarto cerebral de la arteria cerebral media. Los valores de la fracción de anisotropía fueron menores en la vía corticoespinal ipsilateral que en la vía corticoespinal de los controles. Los valores de la fracción de anisotropía en la vía corticoespinal ipsilateral se asociaron con el valor de la escala funcional en el momento de su admisión. Los cambios en los valores de la fracción de anisotropía entre la resonancia magnética inicial y a los tres meses se correlacionaron con la puntuación en la escala funcional y en la escala de Rankin modificada a los tres y a los seis meses. Conclusiones. El valor de la fracción de anisotropía en la cápsula interna ipsilateral se asocia a la presencia de lesión y a su presentación clínica. Los cambios en la fracción de anisotropía a los tres meses sugieren la recuperación clínica a largo plazo.

[Obstructive sleep apnea syndrome and its relationship with ischaemic stroke]. / Sindrome de apnea obstructiva del sueño y su relacion con el ictus isquemico.

AIM: To describe the main physiopathological mechanisms of obstructive sleep apnea syndrome (OSAS) associated with the development of stroke. DEVELOPMENT: Sleep breathing disorders have a high prevalence in the healthy population, among them, the OSAS is the most recognized. This syndrome has been associated with vascular diseases such as stroke, hypertension, atrial fibrillation, among others. Stroke has a high global prevalence and is considered a catastrophic disease. The physiopathological mechanisms are of great importance to understand the relationship that exists between OSAS and stroke. Both diseases are associated with molecular, cellular, and autonomic nervous system changes, with systemic cardiovascular repercussions and in particular with the vascular health of the brain. CONCLUSIONS: The relationship between OSAS and ischaemic stroke is evident. The advance in the identification of molecular markers and low-cost studies for the identification of OSAS will allow implementing strategies to reduce their consequences in cardiovascular diseases, mainly in ischaemic stroke.

TITLE: Sindrome de apnea obstructiva del sueño y su relacion con el ictus isquemico.Objetivo. Describir los principales mecanismos fisiopatologicos del sindrome de apnea obstructiva del sueño (SAOS) asociados con el desarrollo de ictus. Desarrollo. Los trastornos de la respiracion del sueño tienen alta prevalencia en la poblacion sana, entre los que el SAOS es el mas reconocido. Este sindrome se ha asociado con enfermedades vasculares como el ictus, la hipertension arterial y la fibrilacion auricular, entre otras. El ictus posee una alta prevalencia mundial y se considera una enfermedad catastrofica. Los mecanismos fisiopatologicos son de gran importancia para comprender la relacion que existe entre SAOS e ictus. Ambos trastornos se asocian con cambios moleculares, celulares y del sistema nervioso autonomo, con repercusiones cardiovasculares sistemicas y, en particular, con la salud vascular del cerebro. Conclusiones. La relacion del SAOS y el ictus isquemico es evidente. El avance en la identificacion de marcadores moleculares y en estudios de bajo coste para la identificacion de SAOS permitira implementar estrategias para reducir sus consecuencias en las enfermedades cardiovasculares, principalmente en el ictus isquemico.

[Wernekink's commissural syndrome due to a stroke of the midbrain-pons union]. / Sindrome comisural de Wernekink secundario a un ictus de la union mesencefalo-protuberancial.

TITLE: Sindrome comisural de Wernekink secundario a un ictus de la union mesencefalo-protuberancial.

Predictors for malignant middle cerebral artery infarctions: a postmortem analysis.

BACKGROUND: Early detection of malignant infarction of the middle cerebral artery (MI-MCA) is important because of possible treatment by hemicraniectomy. OBJECTIVE: To investigate the anatomic and vascular predictors of MI-MCA. METHOD: The authors evaluated 192 consecutive autopsies of patients with nonlacunar cerebral infarction affecting the MCA territory. MI-MCA was defined by an infarct with temporal or central brain herniation and brain swelling. The autopsy protocol included a systematic analysis of intracranial arteries (including the bony segments of carotid and vertebral arteries and the circle of Willis), extracranial arteries, the aortic arch, and the heart. RESULTS: A total of 45 patients with MI-MCA were identified. Their median (range) survival time was 6 (0 to 20) days as compared with 18 (0 to 2,040) days for non-MI-MCA patients. Compared with non-MI-MCA, MI-MCA cases more frequently involved the superficial and deep MCA territory and were more frequently associated with anterior cerebral and anterior choroidal artery territory infarcts. Hemorrhagic transformation, Duret hemorrhages, carotid occlusion, and ipsilateral abnormalities of the circle of Willis were also more frequent (p < 0.05). Multivariable analysis showed that younger age, female sex, absence of stroke history, higher heart weight, carotid artery occlusion, and abnormal circle of Willis ipsilaterally were all independently associated with MI-MCA (p < 0.03). CONCLUSIONS: Typical pathologic pattern for development of malignant infarction of the middle cerebral artery is a carotid occlusion with abnormal ipsilateral circle of Willis in a young patient who had a first-ever large hemispheric stroke including the superficial territory with possibly a slight predominance of female sex.

Albendazole trial at 15 or 30 mg/kg/day for subarachnoid and intraventricular cysticercosis.

Thirty-six patients with subarachnoid and intraventricular cysticercosis were randomly assigned to receive albendazole at 15 or 30 mg/kg/day plus dexamethasone for 8 days. Results favored a higher dose, with larger cyst reduction on MRI at 90 and 180 days and higher albendazole sulfoxide levels in plasma. An albendazole course at 30 mg/kg/day combined with corticosteroids is safe and more effective than the usual dose. A single treatment was insufficient in intraventricular and giant cysts.

Bilateral acute subdural hematoma from ruptured posterior communicating artery aneurysm. A case report.

SUMMARY: Brain tumors, hematological diseases and vascular malformations like fistulas or arteriovenous malformations are the most well known causes of non-traumatic subdural hematoma (SDH) (1). Although spontaneous subdural hematoma from ruptured intracranial aneurysm has been reported (2), SDH with non radiographic evidence of subarachnoid hemorrhage is very rare (3,4). Moreover, a patient with acute and bilateral spontaneous subdural hematoma secondary to ruptured left posterior communicating artery aneurysm has not been reported to date. The clinical findings and etiologic mechanisms are discussed.

Additional Rescue Stent Placement for Stabilization of a Prolapsed Coil during Stent-assisted Coil Embolization of a Wide-Neck Intracranial Aneurysm.

SUMMARY: We report a case of a 55-year-old man carrying two unruptured internal carotid artery (ICA) wide-neck aneurysms. In the same session, the smaller aneurysm was treated by coils using the remodeling technique and the large aneurysm was treated by stent-assisted coil embolization. During the stent-assisted procedure for the large aneurysm, the microcatheter tip moved from the aneurysm into the parent artery causing a prolapse of some coil loops into the vessel lumen. The distal part of the coil was tangled within the stent's struts, therefore, in order to introduce the entire coil, an attempt was made to withdraw the prolapsed loops of the coil within the microcatheter and concomitantly repositioning the microcatheter into the residual aneurysm neck through the stent struts. However this maneuver was unsuccessful. An attempt to retrieve gently the coil also failed and the coil prematurely detached. For maintaining the patency of the arterial lumen and to reduce the embolic risk, a second stent was used to pin the free coil loops. The rescue stent was positioned within the coil loops and its deployment allowed a circumferential expansion of some loops around the stent perimeter while other loops were flattened against the wall of the artery. The parent artery remained patent at one-year follow-up angiographic study. No clinical complications were observed.

The clinical spectrum of neurological manifestations in AIDS patients in Mexico.

BACKGROUND: Neurological complications may be present clinically in up to 39% of patients infected with HIV or AIDS. Some reports have shown different profiles of neurological illness related to geographic variations and the population studied. METHODS: This retrospective study describes the neurological manifestations of patients with AIDS seen between 1990 and 1998 at a single neurological referral hospital in Mexico City. RESULTS: One hundred forty-nine patients were included, 133 males (89%) and 16 females (10.7%). The average age was 33.8 years (9 to 75 years). Upon admission, only 50 patients (33.6%) were known to be seropositive to HIV-1. In 75 patients (50.3%), the neurological illness was definitory of AIDS and also was its first recognized clinical manifestation. The most common infection problems were brain toxoplasmosis (32.2%), meningeal cryptococcosis (21.5%), tuberculosis (8.7%), and AIDS-dementia complex (8.7%). There were eight (5.4%) cases of ischemic cerebrovascular disease and four (2. 7%) neoplasms. Two primary brain lymphomas and single cases of astrocytoma and oligodendroglioma, progressive multifocal leukoencephalopathy (PML), aseptic meningitis, acute encephalitis, transverse myelitis, myopathy, and cranial neuropathy were also seen. CONCLUSION: In comparison with other studies of neurological complications of AIDS, opportunistic infections amenable to treatment in our population were more common. A high case fatality rate was observed, as was a large proportion of patients in whom the neurological illness was the first manifestation of HIV infection or AIDS due to denied, unknown, or unrecognized risk factors for HIV infection.