Validación de un laboratorio básico de neurosonología para la detección de estenosis carotídea cervical / Validation of a basic neurosonology laboratory for detecting cervical carotid artery stenosis

Introducción: La detección de estenosis arterial cervical e intracraneal es fundamental en el estudio del ictus isquémico, al ser el origen aterotrombótico el más prevalente en nuestro entorno. La ultrasonografía se ha convertido, por su accesibilidad y fiabilidad, en la técnica de elección para la primera aproximación al diagnóstico de esta patología, y debe ser validada en cada laboratorio en particular. El objetivo del presente trabajo es validar la técnica Doppler practicada en nuestro laboratorio para la detección de estenosis carotídea crítica. Pacientes y métodos: Se diseñó un estudio descriptivo observacional de evaluación de pruebas diagnósticas. Se compararon los resultados obtenidos sobre pacientes con diagnóstico de ictus mediante la técnica integrada Doppler carotídeo y transcraneal realizada por neurología, con los proporcionados por la técnica dúplex carotídeo, dependiente del servicio de radiología. El gold standard fue el resultado obtenido por una técnica arteriográfica (angio-RM, angio-TC o arteriografía convencional). Resultados: N = 228 pacientes. En la detección de estenosis carotídea > 70%, el Doppler cervical y transcraneal tenía una sensibilidad y especificidad del 96 y el 100%, respectivamente, frente al 87 y el 94% obtenidos por el dúplex exclusivamente cervical. Para las estenosis intracraneales detectadas mediante Doppler transcraneal, esos parámetros fueron del 78 y el 98%, respectivamente. Conclusiones: El estudio Doppler realizado en el laboratorio de neurosonología quedó validado como herramienta diagnóstica útil para la detección de estenosis carotídea cervical, siendo superior al dúplex cervical aislado, pese a la ausencia de modo B. Demostró, además, un valor adicional como técnica de detección de estenosis arterial intracraneal

Introduction: Most of the cases of ischaemic stroke in our setting are of atherothrombotic origin. Detecting intracranial and cervical carotid artery stenosis in patients with ischaemic stroke is therefore essential. Ultrasonography has become the tool of choice for diagnosing carotid artery stenosis because it is both readily accessibility and reliable. However, use of this technique must be validated in each laboratory. The purpose of this study is to validate Doppler ultrasound in our laboratory as a means of detecting severe carotid artery stenosis. Patients and methods: We conducted an observational descriptive study to evaluate diagnostic tests. The results from transcranial and cervical carotid Doppler ultrasound scans conducted by neurologists were compared to those from carotid duplex scans performed by radiologists in patients diagnosed with stroke. Arteriography was considered the gold standard (MR angiography, CT angiography, or conventional arteriography). Results: Our sample included 228 patients. Transcranial and cervical carotid Doppler ultrasound showed a sensitivity of 95% and specificity of 100% for detection of carotid artery stenosis > 70%, whereas carotid duplex displayed a sensitivity of 87% and a specificity of 94%. Transcranial carotid Doppler ultrasound achieved a sensitivity of 78% and a specificity of 98% for detection of intracranial stenosis. Conclusions: Doppler ultrasound in our neurosonology laboratory was found to be a useful diagnostic tool for detecting cervical carotid artery stenosis and demonstrated superiority to carotid duplex despite the lack of B-mode. Furthermore, this technique was found to be useful for detecting intracranial stenosis

Validation of a basic neurosonology laboratory for detecting cervical carotid artery stenosis. / Validación de un laboratorio básico de neurosonología para la detección de estenosis carotídea cervical.

INTRODUCTION: Most of the cases of ischaemic stroke in our setting are of atherothrombotic origin. Detecting intracranial and cervical carotid artery stenosis in patients with ischaemic stroke is therefore essential. Ultrasonography has become the tool of choice for diagnosing carotid artery stenosis because it is both readily accessibility and reliable. However, use of this technique must be validated in each laboratory. The purpose of this study is to validate Doppler ultrasound in our laboratory as a means of detecting severe carotid artery stenosis. PATIENTS AND METHODS: We conducted an observational descriptive study to evaluate diagnostic tests. The results from transcranial and cervical carotid Doppler ultrasound scans conducted by neurologists were compared to those from carotid duplex scans performed by radiologists in patients diagnosed with stroke. Arteriography was considered the gold standard (MR angiography, CT angiography, or conventional arteriography). RESULTS: Our sample included 228 patients. Transcranial and cervical carotid Doppler ultrasound showed a sensitivity of 95% and specificity of 100% for detection of carotid artery stenosis > 70%, whereas carotid duplex displayed a sensitivity of 87% and a specificity of 94%. Transcranial carotid Doppler ultrasound achieved a sensitivity of 78% and a specificity of 98% for detection of intracranial stenosis. CONCLUSIONS: Doppler ultrasound in our neurosonology laboratory was found to be a useful diagnostic tool for detecting cervical carotid artery stenosis and demonstrated superiority to carotid duplex despite the lack of B-mode. Furthermore, this technique was found to be useful for detecting intracranial stenosis.

Percheron artery syndrome: variability in presentation and differential diagnosis.

INTRODUCTION: Synchronous bilateral paramedian thalamic stroke (SBPTS), usually equated to Percheron artery infarction, is considered to be uncommon and difficult to diagnose clinically. Its characterization is based on the original description plus a few small series. AIM: To characterize SBPTS clinically by collecting cases and identifying the key difficulties for an early diagnosis. PATIENTS AND METHODS: Six cases at our centre plus another 115 located by systematic literature search and critical reading of articles fulfilled the criteria for SBPTS. An analysis was made of the variables age, gender, vascular risk factors, aetiology, alterations and fluctuations of consciousness, need for intubation, cognitive-behavioural disorders, pupillary changes, other neurological focal disorders and brainstem involvement on imaging studies. RESULTS: Of note in our series were disorders of consciousness (n=5), their fluctuations (n=3) and the diagnostic delay (seven days, with MRI in four patients). In only one case was a bilateral thalamic lesion seen on the initial CT. Joint analysis of all the cases showed a mean age of 61 years, a predominance of men (58%), the presence of vascular risk factors in 77%, a mainly cardioembolic aetiology (34% among those that were specified), sensory involvement in 75% (intubation in 7% and fluctuations in 16.5%), cognitive-behavioural disorders in 43%, oculomotor in 73%, pupillary in 31%, other in 67% and specified brainstem lesion in 37%. CONCLUSIONS: The SBPTS syndrome has a variable presentation with a low sensitivity on the initial CT, requiring brain MRI for typification. This explains the diagnostic difficulty and the fact that its frequency is probably underestimated.

Síndrome de Déjerine-Roussy de origen isquémico en un adolescente con foramen oval permeable / Déjerine- Roussy Syndrome of an ischaemic origin in an adolescent with patent forament ovale

Resumen. Introducción. El síndrome de Déjerine-Roussy o síndrome talámico se caracteriza por hemiparesia leve transitoria, hemicoreoatetosis, hemihipoestesia, hiperalgesia, alodinia y hemiataxia con astereognosia de intensidad variable, y se presenta ante lesiones de los núcleos posteriores del tálamo. Puede producirse por infarto cerebral estratégico, descrito en pacientes de edad avanzada con factores de riesgo vascular. El foramen oval permeable se ha sugerido como factor de riesgo de ictus isquémico en jóvenes, especialmente cuando se asocia a ‘aneurisma’ del septo auricular y sobre todo a estado procoagulante. Caso clínico. Varón de 18 años de edad con antecedentes familiares de enfermedad de Behçet, que presenta infartos cerebrales talámico e hipocampal derechos, siendo un foramen oval persistente con ‘aneurisma’ septal el único factor de riesgo encontrado tras un estudio exhaustivo. En ese momento no cumplía los criterios de la enfermedad de Behçet, y tras un amplio rastreo sistémico no se hallaron signos directos ni indirectos de trombosis venosa. Se realizó cierre percutáneo del foramen. Conclusión. Se trata del primer caso publicado de síndrome de Déjerine-Roussy como manifestación de infarto cerebral criptogénico asociado a foramen oval permeable en un adolescente. El conjunto de datos clínicos y complementarios permiten realizar una reconstrucción de la secuencia fisiopatológica que sitúan al foramen oval con ‘aneurisma’ septal asociado como único factor de riesgo objetivable, lo que asociado al estrés del paciente y de la familia motivó su cierre (AU)

Summary. Introduction. Déjerine-Roussy syndrome, or thalamic syndrome, is characterised by transient mild hemiparesis, hemichoreoathetosis, hemihypoesthesia, hyperalgesia, allodynia and hemiataxia with astereognosia that varies in intensity, and it appears in the presence of lesions in the posterior nuclei of the thalamus. It can be produced by strategic cerebral infarction, reported in elderly patients with vascular risk factors. Patent foramen ovale has been suggested as a risk factor for ischaemic stroke in young people, especially when associated to aneurysm of the auricular septum and above all to a procoagulating status. Case report. An 18-year-old male with a family history of Behçet’s disease, who presented right-side thalamic and hippocampal cerebral infarction; following an exhaustive study, patent foramen ovale with septal aneurysm was found as the only risk factor. At that time he did not satisfy criteria for Behçet’s disease, and thorough systemic screening did not reveal direct or indirect signs of venous thrombosis. Percutaneous closure of the foramen was performed. Conclusions. This is the first reported case of Déjerine-Roussy syndrome as a manifestation of cryptogenic cerebral infarction associated to patent foramen ovale in an adolescent. Taken as a whole, the clinical and complementary data enable us to reconstruct the pathophysiological sequence that position foramen ovale with an associated septal ‘aneurysm’ as the only detectable risk factor, which, when linked to the stress of the patient and the family, triggered its early closure (AU)

[Déjerine-Roussy syndrome of an ischaemic origin in an adolescent with patent foramen ovale]. / Síndrome de Déjerine-Roussy de origen isquémico en un adolescente con foramen oval permeable.

INTRODUCTION: Déjerine-Roussy syndrome, or thalamic syndrome, is characterised by transient mild hemiparesis, hemichoreoathetosis, hemihypoesthesia, hyperalgesia, allodynia and hemiataxia with astereognosia that varies in intensity, and it appears in the presence of lesions in the posterior nuclei of the thalamus. It can be produced by strategic cerebral infarction, reported in elderly patients with vascular risk factors. Patent foramen ovale has been suggested as a risk factor for ischaemic stroke in young people, especially when associated to aneurysm of the auricular septum and above all to a procoagulating status. CASE REPORT: An 18-year-old male with a family history of Behçet's disease, who presented right-side thalamic and hippocampal cerebral infarction; following an exhaustive study, patent foramen ovale with septal aneurysm was found as the only risk factor. At that time he did not satisfy criteria for Behçet's disease, and thorough systemic screening did not reveal direct or indirect signs of venous thrombosis. Percutaneous closure of the foramen was performed. CONCLUSIONS: This is the first reported case of Déjerine-Roussy syndrome as a manifestation of cryptogenic cerebral infarction associated to patent foramen ovale in an adolescent. Taken as a whole, the clinical and complementary data enable us to reconstruct the pathophysiological sequence that position foramen ovale with an associated septal 'aneurysm' as the only detectable risk factor, which, when linked to the stress of the patient and the family, triggered its early closure.

Réplica. Ausencias y ‘pseudoausencias’ frontales / Frontal absences and ‘pseudo-absences’. Reply

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Ausencias frontales: presentación de un caso / Frontal absences: a case report

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Esclerosis múltiple hemipléjica"seudoictal", una forma excepcionalde debut / "Pseudo-stroke" hemiplegic type multiple sclerosis, a rare form of debut

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