Short-term outcomes after a neonatal arterial ischemic stroke.

PURPOSE: The purpose of this study is to determine the frequency and radiological predictors of recurrent acute symptomatic seizures (RASS) and motor impairment at discharge after a neonatal arterial ischemic stroke (NAIS). METHODS: In a nonconcurrent cohort study, 33 full-term newborns with NAIS confirmed by MRI are admitted into our hospital between January 2003 and December 2012. Stroke size, calculated as stroke volume divided by whole brain volume (WBV), was categorized as > or < 3.3% of WBV. A univariate analysis of categorical variables was performed using Fisher's exact test. A multivariate analysis was performed using logistic regression models including all variables with a p value < 0.1 in the univariate analysis. RESULTS: The median age at NAIS was 2 days (IQR, 1-5.6), 36.4% were girls. The stroke size was > 3.3 of WBV in 48.5% of the cases, and 54.5% showed multifocal lesions. Involvement of the cerebral cortex (54.5%), thalamus (48.5%), posterior limb of the internal capsule (36.4%), basal ganglia (36.4%), and brainstem (28.2%) were found. At discharge, 45.5% of newborns had a motor deficit, and 27.3% had at least two seizures. Multivariate analyses revealed that stroke size > 3.3% of WBV (OR: 8.1, CI: 1.2-53.9) and basal ganglia involvement (OR: 12.8, CI: 1.7-95.4) predicted motor impairment at discharge. Cortical involvement of temporal and frontal lobes (OR: 14, CI: 2.2-88.1; and OR: 9.1, CI: 1.2-72.6) were predictive of RASS. CONCLUSION: Stroke size and location are independent risk factors for adverse short-term neurological outcomes in full-term newborns following a NAIS.

Hipopituitarismo postraumatismo encefalocraneano: revisión de la literatura y algoritmo de estudio y abordaje terapéutico

Hypopituitarism after moderate or severe traumatic brain injury (TBI) is usually underdiagnosed and therefore undertreated. Its course can be divided in an acute phase during the first 14 days after TBI with 50 to 80% risk of hypopituitarism, and a chronic phase, beginning three months after the event, with a prevalence of hypopituitarism that ranges from 2 to 70%. Its pathophysiology has been addressed in several studies, suggesting that a vascular injury to the pituitary tissue is the most important mechanism during the acute phase, and an autoimmune one during chronic stages. In the acute phase, there are difficulties to correctly interpret pituitary axes. Hence, we propose a simple and cost-effective algorithm to detect and treat a potential hypothalamic-pituitary-adrenal axis impairment and alterations of sodium homeostasis, both of which can be life-threatening. In the chronic phase, post-concussion syndrome is the most important differential diagnosis. Given the high prevalence of hypopituitarism, we suggest that all pituitary axes should be assessed in all patients with moderate to severe TBI, between 3 to 6 months after the event, and then repeated at 12 months after trauma by a specialized team in pituitary disease.

[Hypopituitarism after traumatic brain injury]. / Hipopituitarismo postraumatismo encefalocraneano: revisión de la literatura y algoritmo de estudio y abordaje terapéutico.

Hypopituitarism after moderate or severe traumatic brain injury (TBI) is usually underdiagnosed and therefore undertreated. Its course can be divided in an acute phase during the first 14 days after TBI with 50 to 80% risk of hypopituitarism, and a chronic phase, beginning three months after the event, with a prevalence of hypopituitarism that ranges from 2 to 70%. Its pathophysiology has been addressed in several studies, suggesting that a vascular injury to the pituitary tissue is the most important mechanism during the acute phase, and an autoimmune one during chronic stages. In the acute phase, there are difficulties to correctly interpret pituitary axes. Hence, we propose a simple and cost-effective algorithm to detect and treat a potential hypothalamic-pituitary-adrenal axis impairment and alterations of sodium homeostasis, both of which can be life-threatening. In the chronic phase, post-concussion syndrome is the most important differential diagnosis. Given the high prevalence of hypopituitarism, we suggest that all pituitary axes should be assessed in all patients with moderate to severe TBI, between 3 to 6 months after the event, and then repeated at 12 months after trauma by a specialized team in pituitary disease.

[Prognostic value of granular pattern of growth hormone secreting tumors]. / Caracterización de tumores secretores de hormona de crecimiento de acuerdo al patrón granular y su rol en el pronóstico.

BACKGROUND: Classification of growth hormone (GH) - secreting tumors by the granular pattern might predict their clinical behavior in acromegalic patients. There are several other prognostic factors. AIM: To compare the features at presentation and cure rates of patients with GH secreting tumors according to the granular pattern, and to define independent prognostic factors for surgical treatment in these patients. MATERIAL AND METHODS: A retrospective, observational study of 85 active acromegalic patients surgically treated in two medical centers. RESULTS: Seventy-four patients (87%) were classified as having densely granulated (DG) and 11 (13%) as sparsely granulated (SG) tumors. The latter were less active biochemically, had a higher rate of macroadenoma and cavernous sinus invasion and had a lower rate of biochemical cure than the DG group. Several characteristics were associated with disease persistence but only age (Odds ratio (OR) = 0.93) and cavernous sinus invasion (OR = 21.7) were independently associated in the logistic regression model. CONCLUSIONS: The sparsely granulated pattern is associated with a more aggressive behavior, but the main determinants of prognosis are age and cavernous sinus invasion.

Caracterización de tumores secretores de hormona de crecimiento de acuerdo al patrón granular y su rol en el pronóstico / Prognostic value of granular pattern of growth hormone secreting tumors

Background: Classification of growth hormone (GH) - secreting tumors by the granular pattern might predict their clinical behavior in acromegalic patients. There are several other prognostic factors. Aim: To compare the features at presentation and cure rates of patients with GH secreting tumors according to the granular pattern, and to define independent prognostic factors for surgical treatment in these patients. Material and Methods: A retrospective, observational study of 85 active acromegalic patients surgically treated in two medical centers. Results: Seventy-four patients (87%) were classified as having densely granulated (DG) and 11 (13%) as sparsely granulated (SG) tumors. The latter were less active biochemically, had a higher rate of macroadenoma and cavernous sinus invasion and had a lower rate of biochemical cure than the DG group. Several characteristics were associated with disease persistence but only age (Odds ratio (OR) = 0.93) and cavernous sinus invasion (OR = 21.7) were independently associated in the logistic regression model. Conclusions: The sparsely granulated pattern is associated with a more aggressive behavior, but the main determinants of prognosis are age and cavernous sinus invasion.

Risk factors for in-hospital and follow-up mortality after childhood arterial ischemic stroke.

OBJECTIVES: To explore risk factors contributing to 30-day and long-term survival in children with a first episode of arterial ischemic stroke (AIS). STUDY DESIGN: Single center prospective observational study including 119 children aged between 30 days and 18 years, with a first episode of AIS between 2003 and 2015. Diagnosis was confirmed with magnetic resonance images. Outcomes included 30-day mortality and survival up to 8 years of follow-up. Demographic (e.g., gender, age), clinical (e.g., stroke severity measured by the Pediatric National Institute of Health Stroke Scale (NIHSS), clinical presentation, underlying conditions), radiological (e.g., involved circulation, location), and stroke recurrence data, were used to predict outcomes. Data analyses included logistic and Cox regression multivariate models with Firth's bias correction. RESULTS: 30-day mortality was 11.7% (n = 14). A total of 23 (19.3%) children died during the follow-up. 30-day mortality was only predicted by stroke severity (OR = 1.11, 95% CI = 1.02-1.26) in children > 2 years. Survival was predicted by stroke severity (HR = 1.05, 95% CI = 1.01-1.09), congenital heart disease (HR = 3.62, 95% CI = 1.33-10.93), prothrombotic states (HR = 3.51, 95% CI = 1.25-9.32), and anterior plus posterior circulation stroke (HR = 2.43, 95% CI = 1.42-4.61, p 0.026). Stroke recurrence (n= 23; 19.3%) was not a significant predictor of follow-up mortality. CONCLUSIONS: This study identified groups with greater acute and long-term mortality after a first episode of AIS in childhood. Specific interventions focused on these risk groups may decrease mortality rates. Further studies need to confirm our findings by adding children from other centers.

Clinical and radiological risk factors for poststroke epilepsy in childhood.

BACKGROUND: There are few studies evaluating risk factors for poststroke epilepsy (PSE) after an arterial ischemic stroke (AIS) in childhood. This study aimed to evaluate clinical and radiological predictors for PSE in a cohort of children with a first-ever AIS. METHODS: A retrospective analysis of a single-center prospective consecutive cohort of children beyond neonatal age with a first-ever AIS admitted at the Pontifical Catholic University of Chile's Clinical Hospital between 2003 and 2013. All participants had a brain magnetic resonance imaging at the time of diagnosis. All children underwent follow-up for at least three years with an annual clinical evaluation. We used the current epilepsy definition of the International League Against Epilepsy. Studied variables include demographics, clinical manifestations at onset, stroke risk factors, and radiological characteristics of AIS. Cox proportional hazards regression analysis was used to evaluate PSE risk adjusted for clinical and radiological variables. RESULTS: Among 98 children who met the study criteria, 41 (41.8%) with PSE. Following multivariate analysis, it was determined that the predictors of PSE include young age at AIS (hazard ratio [HR] = 0.91; confidence interval [CI] = 0.84-0.99), the occurrence of acute symptomatic seizures (HR = 3.29; CI = 1.35-8.01), cortical infarction (HR = 5.01; CI = 2.00-12.6), and multifocal infarction (HR = 3.27; CI = 1.01-10.8). CONCLUSION: Seizures, young age, cortical lesions, and multiple infarction at the time of stroke are independent risk factors for PSE in children following a first-ever AIS.

Frecuencia y determinantes de epilepsia luego de un primer ictus isquémico arterial en una cohorte de niños / Frequency and risk factors for the development of epilepsy after an arterial ischemic stroke in a children's cohort

Existen pocos estudios evaluando los factores de riesgo para el desarrollo de epilepsia posterior a un ictus isquémico arterial (IIA) en la infancia. Objetivo: Evaluar los predictores clínicos y radiológicos para epilepsia post-ictus (EPI) en una cohorte de niños chilenos con un primer IIA. Metodología: Estudio analítico longitudinal observacional prospectivo de una cohorte de niños con diagnóstico de IIA entre 1 mes y 18 años, enrolados de forma consecutiva en la base de datos de Patología Cerebrovascular del Hospital Clínico de la Pontificia Universidad Católica de Chile entre los años 2003 y 2013. Todos los participantes con imágenes por resonancia magnética encefálica al momento del diagnóstico. Las variables estudiadas incluyeron características clínicas y radiológicas del evento agudo asociadas a EPI según estudios previos. Creamos un modelo multivariado por regresión logística para estimar los Odds Ratios (ORs) y sus respectivos intervalos de confianza al 95% (ICs) de cada variable estudiada para EPI (significancia <0,05). Resultados: De 81 niños reclutados, 41 (50,6%) con EPI. El análisis multivariado determinó que los predictores independientes de EPI incluyen edad menor al momento del IIA (OR=0,81; IC=0,69-0,95), ocurrencia de crisis sintomáticas agudas (OR=8,63; IC=2,03-36,7), infarto cortical (OR=17,2; IC=3,12-95,3) y arteriopatías del sistema nervioso central (OR=12; IC=1,47-97,8). Conclusiones: las crisis agudas, menor edad, infarto cortical y arteriopatías son factores de riesgo independientes para EPI en niños con un primer IIA. Palabras clave: accidente vascular encefálico pediátrico; epilepsia postictal, ictus isquémico, arteriopatía, infarto cortical.

Abstract. There are few studies evaluating the risk factors for the development of epilepsy after an arterial ischemic stroke (IIA) in childhood. Objective: To assess the clinical and radiological predictors for epilepsy post-stroke (EPI) in a cohort of Chilean children with a first IIA. Methodology: prospective observational longitudinal analytical study of a cohort of children with a IIA diagnosis, from 1 month to 18 years old, consecutively enrolled in the brain stroke database of the Hospital of the Pontificia Universidad Católica de Chile between 2003 and 2013. All participants had a brain magnetic resonance performed at the time of the diagnosis. The variables studied included clinical and radiological features of the acute event associated to EPI according to previous studies. We created a multivariate logistic regression model to estimate the Odds Ratios (ORs) and their respective intervals of confidence 95% (ICs) of each variable studied for EPI (significance < 0,05). Results: of 81 children recruited, 41 (50.6%) had EPI. The multivariate analysis determined that the independent predictors of PPE include: younger age at the time of the IIA (OR = 0. 81; IC = 0, 69-0, 95), occurrence of acute symptomatic crisis (OR = 8, 63; IC = 2, 03-36, 7), cortical infarction (OR = 17, 2; IC = 3, 12-95, 3) and arteriopathies of the central nervous system (OR = 12; IC = 1, 47-97, 8). Conclusions: acute crises, younger age, cortical infarction and arterial disease are independent risk factors for EPI in children with a first IIA.Key words: Pediatric brain vascular accident; epilepsy postictal, ischemic stroke, arterial disease, cortical infarction

Congenital Hydrocephalus: Gómez-López-Hernández syndrome. An underdiagnosed Syndrome. A clinical case. / Hidrocefalia Congénita: Síndrome de Gómez-López-Hernández, un síndrome subdiagnosticado. Caso clínico.

INTRODUCTION: Hydrocephalus is defined as complex conditions influenced by genetic and environmental factors. Excluding hydrocephalus acquired from infection or brain tumors, congenital hydrocephalus with a genetic cause may occur isolated (hydrocephalus isolated, pure or non-syndromatic) or as a component of a genetic syndrome (syndromic hydrocephalus). OBJECTIVE: To present a syndromic congenital hydrocephalus with a known diagnosis, in order to be considered in the study of this pathology and to perform a review of hydrocephaly with a genetic cause. CLINICAL CASE: Preschool with a prenatal diagnosis of hydrocephalus and rhombencephalosynapsis, karyotype and study of TORCH was normal. At the moment of birth, the prenatal diagnoses were confirmed and a malformation of cerebral cortical development was excluded. During the first week of life, perito neal ventricle shunt was performed. A reevaluation at age 4, the absence of corneal reflexes bilate ral parietal and congenital focal alopecia associated with rhombencephalosynapsis, meet definitive criteria for cerebello-trigeminal-dermal displasia or Gómez-López-Hernández syndrome (GLHS). CONCLUSIONS: GLHS is an uncommon neurocutaneous syndrome, possibly a sporadic condition that is underdiagnosed. Due to the new imaging and genetic technologies pre and post-natal, today it is possible to achieve a better and more accurate diagnosis of hydrocephalus with a genetic origin, in which the high suspicion of teams of clinical specialists is essential. Without accurate diagnosis, we can not access to a long-term prognosis, prevention of aggregate morbidity or an adequate genetic counseling, which are required in today's pediatrics.

Hidrocefalia Congénita: Síndrome de Gómez-López-Hernández, un síndrome subdiagnosticado. Caso clínico / Congenital Hydrocephalus: Gómez-López-Hernández syndrome. An underdiagnosed Syndrome. A clinical case

Resumen: Introducción: Las hidrocefalias son condiciones complejas influenciadas por factores genéticos y ambientales. Excluyendo las hidrocefalias adquiridas por infección o tumores encefálicos, las hidrocefalias congénitas de causa genética pueden ocurrir de forma aislada (hidrocefalia aislada, pura o no sindromática) o como componente de un síndrome genético definido (hidrocefalia sindromática). Objetivo: Presentar una hidrocefalia congénita sindromática con un diagnóstico co nocido, y realizar una revisión de la literatura. Caso clínico: Preescolar con diagnóstico prenatal de hidrocefalia y romboencefalosinapsis, cariotipo y estudio de TORCH normales. Al nacer se confirmaron los diagnósticos prenatales y se excluyó malformación del desarrollo cortical cerebral. En la primera semana de vida se realizó derivación ventrículo peritoneal. En una reevaluación a la edad de 4 años, la ausencia de reflejos corneales y alopecia parietal bilateral asociado a romboencefalosinapsis reunieron los criterios diagnósticos definitivos de una displasia cerebelo-trigémino dermal (Síndrome de Gómez, López-Hernández (SGLH)). Conclusiones: El SGLH es un síndro me neurocutáneo infrecuente, posiblemente una condición esporádica que está subdiagnostica da. Con las nuevas tecnologías imageneológicas y genéticas pre y post natales podemos acceder a un diagnóstico de precisión de las hidrocefalias de origen genético, en el cual la alta sospecha de equipos de especialistas clínicos es esencial. Sin el diagnóstico preciso no podemos acceder a un pronóstico a largo plazo, prevención de morbilidad agregada y un consejo genético adecuado, que son requeridos en la pediatría actual.

Abstract: Introduction: Hydrocephalus is defined as complex conditions influenced by genetic and environmental factors. Excluding hydrocephalus acquired from infection or brain tumors, congenital hydrocephalus with a genetic cause may occur isolated (hydrocephalus isolated, pure or non-syndromatic) or as a component of a genetic syndrome (syndromic hydrocephalus). Objective: To present a syndromic congenital hydrocephalus with a known diagnosis, in order to be considered in the study of this pathology and to perform a review of hydrocephaly with a genetic cause. Clinical case: Preschool with a prenatal diagnosis of hydrocephalus and rhombencephalosynapsis, karyotype and study of TORCH was normal. At the moment of birth, the prenatal diagnoses were confirmed and a malformation of cerebral cortical development was excluded. During the first week of life, perito neal ventricle shunt was performed. A reevaluation at age 4, the absence of corneal reflexes bilate ral parietal and congenital focal alopecia associated with rhombencephalosynapsis, meet definitive criteria for cerebello-trigeminal-dermal displasia or Gómez-López-Hernández syndrome (GLHS). Conclusions: GLHS is an uncommon neurocutaneous syndrome, possibly a sporadic condition that is underdiagnosed. Due to the new imaging and genetic technologies pre and post-natal, today it is possible to achieve a better and more accurate diagnosis of hydrocephalus with a genetic origin, in which the high suspicion of teams of clinical specialists is essential. Without accurate diagnosis, we can not access to a long-term prognosis, prevention of aggregate morbidity or an adequate genetic counseling, which are required in today's pediatrics.

Espectro de neuromielitis óptica: descripción de una cohorte según los criterios diagnósticos de 2015 / Neuromyelitis optica spectrum disorders: profile of a cohort according to the 2015 diagnostic criteria

Introducción. Los nuevos criterios diagnósticos de 2015 del espectro de neuromielitis óptica (NMO) están comenzando a utilizarse en diferentes poblaciones en el mundo. Objetivo. Describir las características clinicorradiológicas y pronósticas de pacientes diagnosticados de NMO con los criterios de 2015. Pacientes y métodos. Analizamos retrospectivamente 36 pacientes diagnosticados de NMO con los actuales criterios. Se generaron cuatro grupos según la serología de antiacuaporina 4 (positivos, negativos, desconocidos y negativos más desconocidos agrupados). Se compararon sus características clinicorradiológicas y se evaluaron posibles variables pronósticas de discapacidad. Resultados. Encontramos siete pacientes seropositivos, 12 negativos y 17 desconocidos. La edad de inicio fue de 36 ± 16 años, con mayor proporción de mujeres (4 a 1). La duración de la enfermedad fue de 7,4 ± 7,6 años. Los síntomas iniciales más frecuentes fueron mielitis (61%), neuritis óptica (33%) y síndrome del área postrema (11%). La lesión más frecuente en la resonancia magnética fue la mielitis longitudinalmente extensa (75%). Todos los pacientes recibieron tratamiento agudo, y el preventivo se utilizó en el 81%; la azatioprina y el rituximab fueron los que más se usaron. La mediana de la Expanded Disability Status Scale (EDSS) fue de 2 al final del seguimiento. No hubo diferencias significativas en las variables clinicorradiológicas entre los distintos grupos de pacientes. La edad de inicio fue pronóstica y presenta correlación directa con la EDSS. El inicio antes de los 30 años fue protector y, después de los 50 años, un factor de riesgo para mayor discapacidad. Conclusiones. Los actuales criterios permiten describir diferentes cohortes. La edad de inicio parece ser un factor pronóstico para desarrollar discapacidad (AU)

Introduction. The new 2015 criteria for neuromyelitis optica spectrum disorders (NMOSD) have been recently incorporated in the study of different international cohorts. Aim. To describe clinical-radiological characteristics and prognostic factors in patients with NMOSD according to the 2015 criteria. Patients and methods. Retrospective analysis of 36 patients diagnosed with NMOSD according to serologic AQP4 status (positive, negative, unknown and negative + unknown). Clinical and radiological characteristics were compared and possible disability prognostic factors were evaluated. Results. AQP4 were positive in 7 patients, negative in 12 and unknown in 17. Age of presentation was 36.6 ± 16 years, with higher female proportion (4:1). Mean disease duration was 7.4 ± 7.6 years. Most frequent presenting symptoms were acute myelitis (61%), optic neuritis (33%) and area postrema syndrome (11%). Most frequent MRI lesion was longitudinally extensive transverse myelitis (75%). All patients received acute treatment during attacks, and preventive treatment was used in 81% (azathioprine and rituximab mostly prescribed). Median EDSS was 2.0 at the end of follow-up. No differences were observed in any of the variables comparing serologic status. Age of first attack was prognostic, with direct correlation with EDSS. First attack in < 30 years was protective, meanwhile > 50 years old patients had increased risk of disability. Conclusions. The 2015 criteria allow the description and classification of NMOSD patients within different cohorts. Age of first attack seems to be a prognostic factor for developing disability (AU)

Strain auricular izquierdo y biomarcadores cardíacos como predictores de accidente cerebrovascular en pacientes con fibrilación auricular de reciente comienzo / Left atrial strain and biomarkers for stroke in patients with recent onset atrial fibrillation

Introducción: La miopatía y fibrosis auricular representan el sustrato protrombótico y proarrítmico en pacientes con fibrilación auricular (FA). Estudios recientes muestran relación entre el strain auricular izquierdo (SAI), eventos cardiovasculares y recurrencia en pacientes con FA. La asociación entre SAI y bio-marcadores cardíacos como predictores de accidente cerebrovascular silente (ACVs) en pacientes con FA de reciente comienzo (FArc) no ha sido estudiada. Objetivo: Determinar si la asociación entre SAI y biomarcadores cardíacos contribuye a la predicción de ACV en pacientes con FArc. Métodos: Se realizó un estudio prospectivo que permitió reclutar 57 pacientes con FArc (primer episodio de < de 8 semanas de evolución). Obtenido consentimiento informado (CI) se realizó recolección de datos clínicos y muestras de sangre para determinación de Pro-BNP, Dimero-D y GDF-15. Se realizó resonancia nuclear magnética cerebral (RNMc) y ecocardiograma transtorácico (ETT) durante los primeros 3 días de inclusión y en ritmo sinusal. Para la evaluación de SAI se consideró la curva de deflexión positiva durante la sístole ventricular (SAIs), derivada de speckle tracking, considerando el promedio de 5 ciclos. Se utilizó Mann Whitney U test y Spearman Rho para análisis estadístico. Resultados: La edad promedio fue 70±8,2 años y el 70% fueron hombres. El CHA2DS2-VASc score promedio fue 3,1±1 y el promedio de pro-BNP, Di-mero-D y GDF-15 fue 96,1±12,4 pg/ml, 990±140 ng/ ml y 12 ng/ml respectivamente. 15% de los pacientes (n=9) presentaban ACVs en la RNMc al momento del diagnóstico. Se observó, además, que los pacientes con ACV presentaban un SAIs más bajo que los pacientes sin eventos (5,5±1,1% y 14,6±7,3% respectivamente p=0.04). Adicionalmente, se encontró una correlación significativa entre SAIs y pro-BNP, Dimero-D y GDF-15. Conclusiones: En este trabajo se evidenció que el 15% de los pacientes con FArc presenta ACVs al momento del diagnóstico. El SAIs bajo se correlaciona de forma inversa con los biomarcadores de sobrecarga, trombogénesis, fibrosis auricular y presencia de ACV silente. Estos resultados pueden ser utilizados para una mejor estratificación del riesgo de ACV en pacientes con FA.

Introduction: Atrial myopathy and fibrosis constitute a pro-arrhythmic and pro-thromboembolic substrate in patients with atrial fibrillation (AF). Recent studies using left atrial strain (LAS) have shown that LAS contributes to predict AF recurrence in patients with paroxysmal AF. The association between LAS and cardiac biomarkers in predicting silent stroke (SS) in patients with new AF has not been studied. Aim: The association of LAS and cardiac biomarkers contribute to predict SS in patients with new AF. Methods: We have prospectively evaluated 57 consecutive patients with new AF (first episode with less than 8 weeks of evolution). Baseline clinical characteristics and blood samples for determinations of Pro-BNP, D-Dimer and GDF-15 were obtained. Brain magnetic resonance (BMRI) and 2D Echo were performed within 3 days. In sinus rhythm, the positive deflection during ventricular systole of the LAS curve derived from speckle tracking was considered (mean of 5 cycles) (LASS). Mann Whitney U test and Spearman Rho were used for statistical analysis. Results: Mean age was 70±8,2 years, 70% were men. The mean CHA2DS2-VASc score was 3,1±1. Mean pro-BNP, D-Dimer and GDF-15 were 96,1±12,4 pg/ml, 990±140 ng/ml and 12 ng/ml, respectively. Fifteen percent of patients (n=9) had evidence of previous SS in BMRI. Patients with SS had significantly less LASS than patients without events (5,5±1,1% and 14,6±7,3% respectively p=0,04). In addition, a significant correlation between LASs and pro-BNP, D-Dimer and GDF-15 was found. Conclusion: Evidence of SS was found in 15% of patients with new AF. This was associated with LASs impairment, which was inversely correlated with cardiac biomarkers of LV overload, thrombogenesis and LA fibrosis. These findings could be utilized for a better risk stratification of stroke in patients with new AF.

Angiomas venosos y cefalea en pediatría: un caso clínico / Venous angiomas and headache in children: A case report

Introducción: Los angiomas venosos (AV) son entidades benignas que infrecuentemente presentan síntomas. Objetivo: Reporte de un caso y revisión del tema. Caso clínico: Escolar, de sexo femenino, 6 años, que inicia cefaleas bifrontales frecuentes 3-4 veces por semana, en relación con trabajo académico, de carácter opresivo, no pulsátil, sin náuseas ni vómitos, rango de intensidad entre 4-6/10. Se inició manejo con calendario de cefaleas, apoyo escolar y evaluación psicológica. La tomografía computarizada cerebral solicitada informó de angioma venoso de núcleo caudado izquierdo, razón por la cual se realizó una resonancia magnética cerebral más angiorresonancia que confirmó angioma venoso y excluyó complicación o asociación a otra malformación vascular. La cefalea respondió bien a terapia psicopedagógica y psicológica. La frecuencia de cefaleas disminuyó a 10-12 al año, agrupadas en periodos de mayores demandas académicas. La paciente es controlada durante 12 años, hasta el egreso de la enseñanza media, sin complicaciones y con un buen manejo de la cefalea tensional. Conclusión: En el estudio de una cefalea el hallazgo de un AV puede ser incidental; una vez reunidos los criterios internacionales de cefalea tensional e iniciado el tratamiento para ello, la monitorización de los AV debe ser clínica. Las complicaciones del AV son infrecuentes y el tratamiento quirúrgico es excepcional.

Introduction: Venous angiomas (VA) are benign entities; however infrequent symptomatic cases may occur. Objective: Case report and literature review. Case report: A 6 year old girl was referred with a history of bi-frontal, non-pulsatile, headache with no nausea or vomiting. Headache intensity was 4-6/10. The episodes were frequent, 3-4 times per week. Triggers include academic work. Computed tomography showed a small VA in left caudate nucleus, which was confirmed by a brain MRI, with no evidence of inflammatory or ischaemic changes, or another vascular malformation. Psychological and psycho-pedagogic techniques were used, combined with relaxation and cognitive-behavioural techniques to reduce the intensity and frequency. There was a good outcome, and the headache decreased to 10 episodes per year. The patient was monitored for 12 years until graduation from high school. The VA remained without complications. Conclusions: In the study of a headache, a VA usually is an incidental finding. The International Classification of Headache Disorders III provides specific criteria of frequent episodic tension-type headache, and allows us begin specific therapy for it. Monitoring of non-symptomatic VA cases should be clinical. The surgical management of these entities is exceptional.

[Venous angiomas and headache in children. A case report]. / Angiomas venosos y cefalea en pediatría: un caso clínico.

INTRODUCTION: Venous angiomas (VA) are benign entities; however infrequent symptomatic cases may occur. OBJECTIVE: Case report and literature review. CASE REPORT: A 6 year old girl was referred with a history of bi-frontal, non-pulsatile, headache with no nausea or vomiting. Headache intensity was 4-6/10. The episodes were frequent, 3-4 times per week. Triggers include academic work. Computed tomography showed a small VA in left caudate nucleus, which was confirmed by a brain MRI, with no evidence of inflammatory or ischaemic changes, or another vascular malformation. Psychological and psycho-pedagogic techniques were used, combined with relaxation and cognitive-behavioural techniques to reduce the intensity and frequency. There was a good outcome, and the headache decreased to 10 episodes per year. The patient was monitored for 12 years until graduation from high school. The VA remained without complications. CONCLUSIONS: In the study of a headache, a VA usually is an incidental finding. The International Classification of Headache Disorders III provides specific criteria of frequent episodic tension-type headache, and allows us begin specific therapy for it. Monitoring of non-symptomatic VA cases should be clinical. The surgical management of these entities is exceptional.

Spin-lattice distribution MRI maps nigral pathology in progressive supranuclear palsy (PSP) during life: a pilot study.

An MRI biomarker for Parkinsonism has long been sought, but almost all attempts at conventional field strengths have proved unsatisfactory, since patients and controls are not separated. The exception is Spin-Lattice Distribution MRI (SLD-MRI), a technique which detects changes in the substantia nigra (SN) due to changes in the spin-lattice relaxation time, T1. This easily separates patients with Parkinson's disease (PD) from control subjects at 1.5 Tesla, suggesting that it may be sensitive to presymptomatic disease. SLD-MRI demonstrates a topography of signal change within the SN which is the same as the known topography of pathological change, where the lateral portions of the nucleus are more affected than the medial. In a further step towards its validation, we apply SLD-MRI to a disease control, Progressive Supranuclear Palsy (PSP), the most common of the atypical forms of Parkinsonism. In PSP the topography of pathological change in the SN is reversed. We therefore hypothesized that PSP would show a topography of SLD-MRI signal change in the SN that is the reverse of PD (i.e. the medial portion is more affected than the lateral). All 7 patients showed such a topography of MR signal, and all patients were separated from control subjects. Although this is a step toward validation of SLD-MRI with respect to sensitivity and disease specificity, nevertheless we stress that this is a pilot project only. Validation will only be possible when comparing larger cohorts of PSP, PD and control subjects.

Stroke patterns in neonatal group B streptococcal meningitis.

Neonatal group B streptococcus meningitis causes neurologic morbidity and mortality. Cerebrovascular involvement is a common, poorly studied, and potentially modifiable pathologic process. We hypothesized that imaging patterns of focal brain infarction are recognizable in neonatal group B streptococcal meningitis. A consecutive case series included term neonates with the following: (1) bacterial meningitis, (2) acute group B streptococcal infection (positive cerebrospinal fluid/blood culture), (3) brain magnetic resonance imaging within 14 days, and (4) acute intraparenchymal focal infarctions (restricted diffusion). Lesions within known arterial territories were classified as arterial ischemic stroke. Clinical presentations, investigations, and neurologic outcomes were recorded. Eight newborns (50% female) with focal infarction were identified. Five presented early (<1 week), and all manifested clinical shock and elevated acute-phase reactants. Less than 50% had prenatal group B streptococcal screening, while 2 of 3 screened were negative. Two distinct patterns of focal infarction were identified: (1) deep perforator arterial stroke to basal ganglia, thalamus, and periventricular white matter (7/8, 88%), and (2) superficial injury with patchy, focal infarctions of the cortical surface (6/8, 75%). Outcomes (mean 23.8 months) were poor, with severe disability or death in 6/8 (75%). Recognizable stroke patterns contribute to severe neurologic outcomes and represent a potentially modifiable pathophysiologic process in neonatal group B streptococcal meningitis.

Carotid artery dissection: endovascular treatment. Report of 12 patients.

OBJECTIVE: The purpose of this article is to report our experience with endovascular treatment of internal carotid artery (ICA) dissection with the use of stents. BACKGROUND: Carotid dissection is an important cause of ischemic stroke in young and middle-aged patients. There are some patients in whom invasive management is recommended. METHODS: Twelve patients (eight females, four males), mean age of 50 years (range 35-80 years) with ICA dissection, were treated with the endovascular approach during a 24-month period. Patients included in this study underwent magnetic resonance (MR) and digital subtraction angiography (DSA) for diagnosis. Over this time period, 162 patients with ICA dissections were seen at our institution. Indications for endovascular treatment were: recurrent ischemic events despite adequate anticoagulant treatment in seven cases, contraindication to anticoagulation in four cases, and one case with significant mismatch between diffusion and perfusion weighted MR. Eleven dissections were spontaneous and one was traumatic. The follow-up was performed clinically with Doppler ultrasound (US) and MR at 6, 12, and 24 months. RESULTS: Stent deployment was successful in all cases. Acute symptoms were resolved in 66.7% of patients. No patients deteriorated their neurological status. There were no new clinical events, stent stenosis or occlusion on 24 months follow-up. CONCLUSION: Our results showed an excellent clinical outcome of the treated patients. This suggests promising results with the use of endovascular treatment in selected patients.

Inversion recovery MRI in idiopathic Parkinson disease is a very sensitive tool to assess neurodegeneration in the substantia nigra: preliminary investigation.

RATIONALE AND OBJECTIVES: Segmented inversion recovery (IR) ratio imaging (SIRRIM) has been established as a sensitive tool to assess neurodegeneration of the substantia nigra pars compacta (SN(C)) in patients with idiopathic Parkinson disease (IPD). The obtained results suggest the possibility of magnetic resonance imaging (MRI) as a biological marker for IPD. The strength and a parsimonious analysis of the technique are discussed to assess the potential of using MRI as a biological marker for IPD and improve the differential diagnosis of sporadic Parkinson disease. Our hypothesis states that the magnetic resonance SIRRIM technique allows direct visualization and quantitation of neural cell loss in the SN(C) and therefore could become a reliable biological marker for Parkinson disease. To achieve this goal, some key aspects of data acquisition and data analysis need to be addressed. The clinical impact of the SIRRIM technique could be considerable, considering that it might become a viable surrogate to other techniques. PATIENTS AND METHODS: Twelve patients with IPD and 12 age-matched control subjects were imaged by using the SIRRIM technique based on two IR imaging sequences that were designed to suppress white and gray matter to assess loss of neural cells in situ by means of a ratio image (white matter suppressed image to gray matter suppressed image). The radiological index was correlated with the Unified Parkinson Disease Rating Scale (UPDRS) for patients with IPD. RESULTS: All patients with IPD were identified correctly, and full dichotomization between healthy volunteers and patients was obtained with our database. Our SIRRIM technique shows that it can be used to rule out Parkinson disease from essential tremor and other forms of Parkinsonism, such as progressive supranuclear palsy and multisystem atrophy. In addition, it is sensitive enough to identify patients with early-stage IPD. CONCLUSION: The hypothesis of using SIRRIM as a biological marker to assess IPD is supported by excellent correlation with clinical UPDRS scoring and has proved useful for the evaluation and quantitation of neurodegeneration with our SIRRIM technique, showing, in addition, that the differential diagnosis of IPD can be improved. Technical aspects of acquisition and data processing that need to be addressed can be overcome. It ultimately confirms that our objectives can be achieved and allows us to expect assessment of the progressive development of neurodegeneration in longitudinal studies and the putative neuroprotective approaches taken during the evolution of the disease.

[Intra-arterial thrombolysis in basilar artery thrombosis. Recovery of two patients with locked-in syndrome]. / Trombolisis intraarterial en trombosis de la arteria basilar. Recuperación de dos pacientes con síndrome de enclaustramiento.

Locked-in syndrome is a dramatic clinical condition, the patient is awake, can listen and breath, but is unable to move any muscle, conserving only the vertical eye movements. The most common cause of locked-in syndrome is the thrombosis of the basilar artery and commonly leads to death, frequently due to pneumonia. Intravenous and intra arterial thrombolysis have been used successfully in a selective group of patients with ischemic stroke. There is only one report of two patients with locked-in syndrome who were treated successfully with intra arterial thrombolysis. Other authors, based in their experiences, do not recommend this treatment. We report two female patients aged 63 and 26 years, with Locked-in syndrome due to a basilar thrombosis who were treated successfully with intra arterial thrombolysis using recombinant tissue plasminogen activator (r-TPA). The lapses between the onset of the symptoms and thrombolysis were 5 and 8 hours respectively. A complete recanalization was obtained in both patients during the thrombolysis. One year after, the first patient has only a moderate ataxia, walking with assistance and the other has a normal neurological examination.

[Malignant infarct of the middle cerebral artery in a patient with bacterial meningitis]. / Infarto maligno de la arteria cerebral media en una paciente con meningitis bacteriana.

The mortality of acute bacterial meningitis (BM) has remained stable in the last decades in spite of the use of new antibiotics, probably due to vascular complications. We report a 68-year-old woman with BM who had a malignant infarction of left middle cerebral artery territory 72 hours after admission to the hospital. The patient experienced a bad evolution and died four days after admission. The arterial involvement in patients with BM is explained by vasospasm of large arteries and vasculitis of small arteries. The medical treatment of a malignant middle cerebral artery infarct has a high mortality.