Undulating toe movements in brain death.

For many years, death implied immobility. Nevertheless, there are anecdotal reports of spontaneous or reflex movements (SRMs) in patients with Brain death (BD). The presence of some movements can preclude the diagnosis of BD, and consequently, the possibility of organ donation for transplantation. McNair and Meador [(1992), Mov Dord7: 345-347] described the presence of undulating toe flexion movements (UTF) in BD patients. UTF consists in a sequential brief plantar flexion of the toes. Our aim was to determine the frequency, characteristics and predisposing factors of UTF movements in a prospective multicenter cohort study of patients with BD. Patients with confirmed diagnosis of BD were assessed to evaluate the presence of UTF using a standardized protocol. All patients had a routine laboratory evaluation, CT scan of the head, and EEG. Demographic, clinical, hemodynamic and blood gas concentration factors were analyzed. amongst 107 BD patients who fulfilled the AAN requirements, 47 patients (44%) had abnormal movements. UTF was observed in 25 (23%) being the most common movement (53%). Early evaluation (OR 4.3, CI95% 1.5-11.9) was a predictor of UTF in a multivariate regression model. The somato-sensory evoked potential (SSEPs) as well as brainstem auditory evoked potentials (BAEPs) did not elicit a cortical response in studied patients with UTF. This spinal reflex is probably integrated in the L5 and S1 segments of the spinal cord. Abnormal movements are common in BD, being present in more than 40% of individuals. UTF was the most common spinal reflex. In our sample, early evaluation was a predictor of UTF. Health care professionals, especially those involved in organ procurement for transplantation, must be aware of this sign. The presence of this motor phenomenon does not preclude the diagnosis of BD.

Cataleptic postures in thalamic hemorrhage: case report.

We report a case of catalepsy associated with thalamic hemorrhage. A 72 year-old hypertensive woman had acute onset of right-sided weakness and speech disturbances. She was on anticoagulants because of aortic valve replacement. When postures were imposed, the patient maintained the left upper limb raised for several minutes, even in uncomfortable or bizarre positions. A CT scan of the head revealed a left thalamic hemorrhage. Cataleptic postures have been reported in few cases with acute stroke.

Southern Buenos Aires stroke project.

BACKGROUND: Ethnic differences and vascular risk factors are the major determinants of stroke subtypes. Nevertheless, specific data from undeveloped countries is difficult to obtain. Natives from South America may have a higher frequency of penetrating small vessel disease and hemorrhagic stroke. However, there are few studies in South America supporting these findings. OBJECTIVE: We analyze demographic, ethnic, risk factors, clinical characteristics, and stroke subtypes in all patients with acute stroke admitted to our hospital. METHODS: We studied all consecutive acute stroke patients admitted to the Ramos Mejia Hospital in Buenos Aires from 1997 to 1999. Our hospital serves a determined population of Southern Buenos Aires. Data were collected prospectively on patients' admission in a form especially designed for this study including vascular risk factors, clinical features, epidemiological characteristics, and neuroradiological findings. Stroke subtypes were determined according to the TOAST classification. RESULTS: Among 361 acute stroke patients, 31% had hemorrhagic stroke. It was more frequent among Natives (34%) than Caucasians (27%) (P<0.002). Ischemic stroke subtypes were as follows: 105 (42%) patients had lacunar, 31 (12%) atherosclerotic stroke, 53 (21%) cardioembolic infarction, and 16 (6%) other causes of stroke. Forty-five (18%) patients were classified as undetermined. Small vessel disease was higher among Caucasians (35%) than Natives (24%). CONCLUSIONS: Penetrating artery disease (42%) and intracranial hemorrhage (31%) were the most common stroke subtypes, being more frequent than reported in the literature. Natives had significantly higher frequency of hemorrhagic stroke than Caucasians.

Multiple simultaneous intracerebral hemorrhages: clinical features and outcome.

BACKGROUND: The simultaneous occurrence of intracerebral hemorrhages in different arterial territories is an uncommon clinical event. Its predisposing factors and pathophysiological mechanisms are not clearly defined. OBJECTIVE: To analyze the frequency, risk factors, clinical features, neuroimaging findings, and outcome of multiple simultaneous intracerebral hemorrhages (SIHs). PATIENTS AND METHODS: We studied all patients with acute stroke admitted to our hospital from July 18, 1997, through December 18, 1999. Multiple SIHs were defined as the presence of 2 or more intracerebral hemorrhages affecting different arterial territories with identical computed tomographic density profiles. Patients with a history of traumatic brain injury were excluded from this study. Diagnostic investigation included routine blood and urine tests, coagulation studies, a chest radiograph, electrocardiogram, 2-dimensional transthoracic echocardiography, and computed tomography of the head without contrast medium. Disability was assessed using the National Institutes of Health Stroke Scale and Modified Rankin Scale. RESULTS: Among 142 patients with hemorrhagic stroke, we found 4 (2.8%) with SIHs. All 4 patients had a history of uncontrolled arterial hypertension. We excluded other potential causes of multiple SIHs by using appropriate diagnostic tests. The most common clinical manifestations were headache and weakness. Localization of hematomas was supratentorial, except for one patient who had both infratentorial and supratentorial hemorrhages. The mean National Institutes of Health score on admission was 15 and the Modified Rankin Scale score was higher than 4 at 3 months. CONCLUSIONS: In our study, all patients with multiple SIHs had arterial hypertension and a poor outcome. Additional analytic studies, including new imaging techniques, can help to elucidate the association between arterial hypertension and multiple SIHs, risk factors, and underlying mechanisms of this clinical condition.

Facial myokymia in brain death.

BACKGROUND: Brain death (BD) is the irreversible loss of all functions of the brain and brainstem. Spontaneous and reflex movements of the limbs have been described in this condition. However, facial myokymia (FM) in BD has not been previously reported. The origin of that motor phenomenon in alive patients is still uncertain, since supranuclear, nuclear and peripheral mechanisms have been proposed. OBJECTIVE: We describe the presence of FM in a patient who fulfilled the criteria for BD. A 40-year-old-man had right-sided weakness and impaired consciousness. After 14 h admission, he fulfilled the criteria for BD. A CT scan of the head showed a large putaminal hemorrhage. The EEG was isoelectric. At that time, fine spontaneous twitches of the left cheek were noticed. They consisted of repetitive and rhythmic movements in groups of 3-5 lasting for < 5 s. These movements appeared every 2-10 min during 6 h. DISCUSSION: Spinal reflexes have been described in BD. The presence of any movements other than the recognized reflexes may question this diagnosis and limit organ procurement for transplantation. The recognition of FM as an accepted movement in BD patients has practical and legal implications.

[Hypophonia in lacunar stroke]. / Hipofonía en ictus lacunar.

INTRODUCTION: Hypophonia has been defined as a reduction in speech volume. It is an uncommon finding in acute stroke, mainly related to multiple deep infarcts. CLINICAL CASE: An 82 year old hypertensive woman was admitted to our hospital presenting acute right sided weakness and low speech volume. She was hypophonic and unable to yell. Language was fluent without paraphasic errors. A diffusion weighted magnetic resonance showed a small hyperintense lesion in the left corona radiata. No other lesions were detected. CONCLUSIONS: Although, the precise anatomic area involved in the brain has not been clearly precised yet, hypophonia may be also due to isolated lacunar affecting the penetrating arteries in the corona radiata. Further studies are necessary to better understand the nature and the prognosis of this phenomenon.

Activated protein C resistance in patients with arterial ischemic stroke.

BACKGROUND: Activated C protein resistance (APC-R) has recently been reported to be a common cause of thrombophilia; it may be acquired or caused by a genetic defect (factor V Leiden mutation). It is clear that there is an association between APC-R and venous thrombosis. It has been suggested that there is a possible relationship of APC-R with arterial ischemic stroke (IS), but case-control studies have not given enough clues for considering APC-R as a main risk factor. OBJECTIVES: To assess the incidence of APC-R in patients with IS of several ethiologies in Buenos Aires. PATIENTS AND METHODS: Seventy-two patients with IS were assessed for signs or symptoms of previous clinical thrombophilia and the presence of vascular risk factors (RF). They were searched for APC-R (COATEST, APC resistance-V, with a predilution of the samples) test. Determinations were carried out between 1 to 4 months after the ischemic episode. The plasma of 50 healthy control subjects (blood donors) was used as controls. RESULTS: None of the patients had signs of previous thrombophilia; 57 (79.2%) had RF for IS, and 3 (4.2%) had APC-R (all of them with RF). One subject in the control group (2%) showed a low APC response (1/50). The occurrence of APC-R among patients with stroke was not significantly higher when compared with the occurrence of APC-R among the control subjects. CONCLUSIONS: In the present series, the incidence of factor V Leiden related APC-R in the group with IS was similar to the healthy population. Other risk factors were associated in patients showing APC-R.

Pneumothorax and pneumoperitoneum during the apnea test: how safe is this procedure?

Apnea test is a crucial requirement for determining the diagnosis of brain death (BD). There are few reports considering clinical complications during this procedure. We describe a major complication during performing the apnea test. We also analyse their practical and legal implications, and review the complications of this procedure in the literature. A 54 year-old man was admitted for impaired consciousness due to a massive intracerebral hemorrhage. Six hours later, he had no motor response, and all brainstem reflexes were negative. The patient fulfilled American Academy of Neurology (AAN) criteria for determining BD. During the apnea test, the patient developed pneumothorax, pneumoperitoneum, and finally cardiac arrest. Apnea test is a necessary requirement for the diagnosis of brain death. However, it is not innocuous and caution must be take in particular clinical situations. Complications during the apnea test could be more frequent than reported and may have practical and legal implications. Further prospective studies are necessary to evaluate the frequency and nature of complications during this practice.

Differences in stroke subtypes among natives and caucasians in Boston and Buenos Aires.

BACKGROUND AND PURPOSE: Several issues regarding ethnic-cultural factors, sex-related variation, and risk factors for stroke have been described in the literature. However, there have been no prospective studies comparing ethnic differences and stroke subtypes between populations from South America and North America. It has been suggested that natives from Buenos Aires, Argentina, may have higher frequency of hemorrhagic strokes and penetrating artery disease than North American subjects. The aim of this study was to validate this hypothesis. METHODS: We studied the database of all consecutive acute stroke patients admitted to the Ramos Mejia Hospital (RMH) in Buenos Aires and to the Beth Israel Deaconess Medical Center (BIMC) in Boston, Massachusetts, from July 1997 to March 1999. Stroke subtypes were classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. All information on patients (demographic, clinical, and radiographic) was recorded prospective to the assessment of the stroke subtype. RESULTS: Three hundred sixty-one and 479 stroke patients were included at RMH and BIMC stroke data banks, respectively. Coronary artery disease was significantly more frequent in BIMC (P:<0.001), whereas tobacco and alcohol intake were significantly more frequent in RMH (P:<0.001). Intracerebral hemorrhage (P:<0.001) and penetrating artery disease (P:<0.001) were significantly more frequent in the RMH registry, whereas large-artery disease (P:<0.02) and cardioembolism (P:<0.001) were more common in the BIMC data bank. CONCLUSIONS: Penetrating artery disease and intracerebral hemorrhage were the most frequent stroke subtypes in natives from Buenos Aires. Lacunar strokes and intracerebral hemorrhage were more frequent among Caucasians from Buenos Aires than Caucasians from Boston. Poor risk factor control and dietary habits could explain these differences.

Arteriosclerosis and the promise of GPIIb/IIIa inhibitors in stroke.

Ischemic mechanisms in pa2000Mar;58(1)1-10 studied for more than 150 years. Antiplatelet agents did show benefit in secondary prevention. Aspirin is the most common antiaggregant in clinical use today. However, the benefit produced by the "best" antiplatelet regimen in stroke prevention is lower than 40%. The adherence of circulating platelets to the subendothelium is mediated by glycoprotein (GP) residing on the cell's surface. GPIIb/IIIa is the most important platelet membrane receptor that mediates the process of platelet aggregation, and thrombus formation. Thus, new drugs that block the GPIIb/IIIa receptor have recently emerged. Clinical trials using these agents have shown effectiveness in acute coronary syndromes. However, the absence of studies in cerebrovascular disease and the potential hemorrhagic complications questioned their use in stroke prevention. We review the clinical trials using the new GPIIb/IIIa agents in myocardial ischemia, and consider the potential implications for cerebrovascular disease.

Spontaneous and reflex movements in brain death.

Spontaneous and reflex movements may be found in patients with brain death (BD). The authors prospectively evaluated their frequency using a standardized protocol. Among 38 patients who fulfilled criteria for BD, the authors found 15 (39%) with spontaneous or reflex movements. The most common movement was finger jerks. Undulating toe flexion sign, triple flexion response, Lazarus sign, pronation-extension reflex, and facial myokymia also were seen. These movements may be more common than reported and do not preclude the diagnosis of BD.

[Fluctuation in bilateral thalamic infarction: diffusion study using magnetic resonance]. / Fluctuación en infarto talámico bilateral: estudio con difusión por resonancia magnética.

INTRODUCTION: Bilateral paramedian thalamic infarcts are uncommon. The most frequent clinical manifestations are acute impairment of consciousness, oculomotor abnormalities and cognitive disturbances. A fluctuating course has not been previously reported. CLINICAL CASE: A 66 year-old woman with a past history of arterial hypertension and diabetes was admitted to our hospital presenting four episodes of decreased consciousness and vertical gaze paresis. Neurological examination between episodes was unremarkable. Diffusion-weighted magnetic resonance imaging revealed high-signal lesions in both paramedian thalamic areas. CONCLUSIONS: Fluctuating impairment of consciousness may be a clinical presentation of bilateral paramedian thalamic infarction. Atheromatous occlusion of the mouth of the paramedian thalamic penetrating artery is the most common cause. Neurological findings and diffusion-weighted images may help to define the extension and the underlying pathophysiological mechanism.

Catalepsy after stroke.

Catalepsy denotes a tendency to maintain postures. We prospectively looked for catalepsy in 216 acute stroke patients. We found five patients with cataleptic postures. They were seen on the nonparetic side in all cases. Other movement abnormalities seen in the catatonic syndrome were absent. CT scans of the head showed ischemic infarctions in the middle cerebral artery territory in the five cases. Cataleptic postures associated with hemispheric lesions due to stroke may be a more common phenomenon than is believed, and their mechanism remains to be elucidated.

[Genetical aspects in cerebrovascular disease]. / Aspectos genéticos en la enfermedad cerebrovascular.

INTRODUCTION: Stroke is a pathophysiological heterogeneous syndrome with numerous genetic influences. DEVELOPMENT: Previous populational studies had demonstrated the familial correlation. The parental history of stroke has been associated with stroke in the descendant with a significant relative risk of 2. A study of mono- and dizygotic twins found a fivefold risk of stroke among monozygotic compared with dizygotic. Other modifiable and non-modifiable risk factors are involve in cerebrovascular disease. Recently, the gene that codifies the angiotensin converting enzyme has been determine. An insertion/deletion polymorphism of was associated with increased levels of angiotensin converting enzyme. ApoE4 and high levels of homocysteine has been reported as a risk factors for cerebral infarction. Apoptotic mechanisms have recently been discovered in rats models of ischemia. Caspases inhibitors have shown a reduction of 40% in the cerebral infarction area. CONCLUSION: The purpose of this work is to analyze the genetic factors that constitute an influence in stroke.