Diagnosis of CADASIL disease in normotensive and non-diabetics with lacunar infarct.

BACKGROUND: CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is characterized by recurrent cerebral ischemic episodes of the lacunar subtype usually without traditional vascular risk factors. We investigated the frequency of CADASIL among selected patients with cerebral ischemia of the lacunar subtype. METHODS: we studied patients under 65 years old who presented cerebral ischemia of the lacunar subtype without hypertension, diabetes mellitus or other causes that explained the cerebral ischemia. On the skin biopsies, we performed immunostaining analysis on 5µm frozen sections with monoclonal antibody anti-Notch 3 (1E4). We also performed a genetic analysis of the Notch 3 gene (exons 3,4,5,6,11 and 19). RESULTS: of 1.519 patients analyzed, only 57 (3.7%) fulfilled the selection criteria, and 30 of them accepted to participated in the study. We studied 30 patients, mean age was 53 years (range 34 to 65), 50% were men and all patients suffered a lacunar stroke. Immunostaining analysis was positive in two patients (6.6%) and the genetic analysis confirmed a mutation characteristic of CADASIL in exon 4 nt 622C/T (Arg 182 Cys) and 694 T/C (Cys206Arg) respectively. CONCLUSIONS: CADASIL disease was present in 6.6% of patients younger than 65 years with a lacunar stroke and without hypertension or diabetes mellitus. Screening for CADASIL should be considered in these patients.

Proliferation in the human ipsilateral subventricular zone after ischemic stroke.

BACKGROUND: It is uncertain whether neurogenesis occurs in humans after stroke. We studied the morphologic changes that occurred in the subventricular zone (SVZ) in patients who died following an acute ischemic stroke. METHODS: We examined coronal brain slices from patients who died after a first-ever cerebral nonlacunar infarction in the middle cerebral artery territory. We evaluated the morphologic changes in the ipsilateral and contralateral SVZ by light and electron microscopy. Using immunochemistry with Ki-67 and PCNA, we detected cell proliferation. We used Tuj-1 for immature neurons and PSA-NCAM for migrating cells. RESULTS: The study included 7 patients with a mean age of 82 +/- 5 (mean +/- SD) years; 4 were men. They died a mean of 10 +/- 5 days after the ischemic stroke. Brain samples were obtained a mean of 4 +/- 2 hours after death. In comparison with the contralateral SVZ, the following changes were observed in the ipsilateral SVZ: an increase in the width of the gap and ribbon layers, as well as in the cell density of the ribbon layer, an enlargement of the cytoplasmic volume of astrocytes, and an increase of Ki-67-positive cells. In the ipsilateral SVZ, mitoses and cells that stained for either Tuj-1 or PSA-NCAM markers were observed more frequently than in the contralateral SVZ. CONCLUSION: We found unequivocal evidence of active cell proliferation in the ipsilateral subventricular zone following an acute ischemic stroke in our patients.

Blood pressure is not associated with haematoma enlargement in acute intracerebral haemorrhage.

BACKGROUND AND PURPOSE: We performed an observational study that compared baseline and subsequent blood pressure (BP) measurements and its association with haematoma enlargement (HE) in patients with intracerebral haemorrhage (ICH). METHODS: We prospectively studied consecutive patients with supratentorial spontaneous ICH within the first 6 h after the onset of symptoms. HE was defined as an increase >or=33% in the volume of haematoma on the CT obtained 24-48 h after the onset of symptoms as compared with the CT at admission. We recorded systolic BP (SBP), diastolic BP (DBP) and mean BP (MBP) at admission and at 6, 12, 18 and 24 h after onset; the maximum SBP, DBP and MBP during the study period; the maximum SBP and DBP within intervals; the mean of all BP readings; administration of antihypertensive agents. RESULTS: We studied 60 patients whose mean age was 72.1 +/- 11.3 years. HE was observed in 27 (45%) patients. No statistically significant differences were observed in any of the analyses that compared BP parameters between the HE and non-HE groups (two-way anova). CONCLUSIONS: In an exploratory analysis, we did not find an association between BP and HE within the first 24 h after an acute ICH.

Ecocardiografía transtorácica realizada por neurólogos en patología vascular: estudio piloto / Transthoracic echocardiopraphy in stroke performed by neurologist: pilot study

El objetivo de nuestro estudio es comparar la concordancia entre la ecocardiografía transtorácica (ETT) realizada por neurólogos y cardiólogos en el cribado de fuentes cardioembólicas en pacientes con isquemia cerebral. Métodos. Evaluamos de forma prospectiva y consecutiva 27 pacientes con isquemia cerebral. A todos se les realizó una ETT por un neurólogo que había sido entrenado previamente durante un mes en la técnica, e independientemente, por un cardiólogo cuyos resultados fueron considerados como la referencia estándar. Según el riesgo de cardioembolismo, los hallazgos en la ETT fueron clasificados como normales, de moderado o alto riesgo según los criterios TOAST. La concordancia en el diagnóstico de fuente cardioembólica entre ambos exploradores fue evaluado con el test Kappa de Cohen (K). Una K>0,6 se consideró como buena concordancia. Resultados. De 27 pacientes con isquemia cerebral, la edad media fue de 68,7 ± 10,2 años y 70 % fueron hombres. En 9 pacientes el cardiólogo detectó una fuente cardioembólica, y de ellos, 8 pacientes también por el neurólogo (1 paciente con calcificación del anillo mitral no fue detectado). En 2 pacientes con mala ventana ecocardiográfica, el neurólogo infraestimó la función ventricular. El diagnóstico fue concordante entre ambas exploraciones en un 88,9 % de los pacientes (K: 0,77; p = 0,001). Conclusiones. Comparado con el cardiólogo, un neurólogo entrenado realiza la ETT con una buena fiabilidad. En los casos con mala ventana ecocardiográfica o con hallazgos patológicos, éstos deberían ser confirmados por el cardiólogo (AU)

Introduction. The aim of this study is to assess concordance between transthoracic echocardiography (TTE) performed by neurologists and cardiologists for the screening of cardioembolic sources in patients with ischemic stroke. Methods. We examined prospectively 27 consecutive patients with ischemic stroke. A potential source of embolism in all of the patients was sought by means of a TTE study. This study was performed by one neurologist after one-month full-time training on the technique and independently by one cardiologist whose results were considered as the reference standard. Regarding the risk of cardioembolism, findings from TTE studies were considered as normal, or indicative of either moderate or high risk, according to the TOAST criteria. Agreement between the two observers on the diagnosis of cardioembolic source was analyzed with the Cohen's Kappa Test (K). A K > 0,6 was considered as good agreement. Results. The 27 patients studied had a mean age of 68,7 ± 10,2 years and 70 % were men. A cardioembolic source was detected in 9 patients by the cardiologist and 8 of these were also identified by the neurologist: in 1 patient a mitral annulus calcification was not detected in the examination performed by the neurologist. In 2 patients with poor echocardiographic window, the neurologist underestimated the left ventricular function. Diagnostic agreement between both examinations was 88,9 % (K: 0,77; p = 0,001). Conclusion. Compared with cardiologists, trained neurologists show a fairly high degree of accuracy in the TTE screening of patients with stroke. Those cases with poor echocardiographic window or with abnormal findings should be confirmed by the cardiologists (AU)

Diagnostic yield of prothrombotic state studies in cryptogenic stroke.

OBJECTIVES: Around 30% of ischemic strokes are considered cryptogenic. We analyzed the diagnostic yield of prothrombotic state (PS) studies in patients with an initial cryptogenic stroke (CS). MATERIAL AND METHODS: We prospectively included consecutive CS patients according to the TOAST criteria. PS included plasmatic determinations of antiphospholipid (APL) antibodies and lupus anticoagulant (LA), S (SPd) and C (CPd) protein deficiencies, and genetic analysis of the prothrombin gene mutation (PT G20210A) and the factor V Leiden mutation (FV G1691A). We recorded age, sex and vascular risk factors. RESULTS: From a total of 89 patients (mean age 56.9 +/- 14.3 years, 53% men), we identified 16 PS in 15 patients (16.85%): APL-6, LA-2, SPd-2, CPd-1, PT G20210A -3 and FV G1691A -2. One patient presented an association (APL and PT G20210A). CONCLUSIONS: One of every six patients with initial CS present a PS. Age or sex and conventional cardiovascular risk factors were not related to PS study findings, supporting the relevance of such studies in all patients with an initial CS.

Aspirin or anticoagulants in stenosis of the middle cerebral artery: A randomized trial.

BACKGROUND: We report the results of an open, randomized, multicenter trial that compared the efficacy of aspirin to oral anticoagulants (OA) for the prevention of vascular events in patients with symptomatic stenosis of the middle cerebral artery (MCA). METHODS: Participants were randomly assigned to receive 300 mg/day of aspirin or a dose of OA (target INR 2-3). The MCA stenosis was demonstrated by conventional angiography or by at least two noninvasive examinations. Patients had either transient ischemic attack or cerebral infarct (CI) attributable to the MCA stenosis within 90 days before inclusion. The primary endpoint was: nonfatal CI, nonfatal acute myocardial infarct, vascular death and major hemorrhage. The patients were followed-up for a minimum of 1 year and a maximum of 3 years. RESULTS: The study included 28 patients (14 in each treatment group); the average age was 67 +/- 9.9 years. Men constituted 68% of the patients. After a mean follow-up of 23.1 +/- 10.9 months, there were no recurrences of CI in both groups. No endpoint was reported in the aspirin group, but 2 patients in the OA group (14.3%) exhibited vascular events: 1 acute myocardial infarct and 1 intracerebral hemorrhage). However, this difference was not statistically significant (p = 0.48). CONCLUSIONS: Our study suggests that aspirin is the treatment of choice for the prevention of vascular events in patients with symptomatic MCA stenosis.

[Percutaneous transluminal angioplasty of the subclavian artery in Takayasu disease: results of long-term follow-up]. / Angioplastia transluminal percutánea de arteria subclavia en la enfermedad de Takayasu: resultados a largo plazo.

Takayasu arteritis is a chronic inflammatory arteriopathy of unknown etiology affecting the aorta and proximal portion of its main branches. Although it was initially reported in young women of Oriental descent, its current worldwide distribution is known to affect both sexes. In the last decade, percutaneous transluminal angioplasty (PTA) has emerged as a viable alternative in its treatment. However, the percentage of restenosis is more common in Takayasu disease than atherosclerotic lesions (21% vs 10%), probably due to diffuse inflammatory vascular involvement. Since the introduction of stent, this technique has emerged as a viable alternative to treatment of atherosclerotic stenotic lesions, although its efficacy and safety in Takayasu disease is still unclear. Herein, we report our experience in a woman with subclavian steal syndrome in whom Takayasu disease was diagnosed and treated with subclavian artery angioplasty and stent, with a good outcome during four years of follow-up.

Angioplastia transluminal percutánea de arteria subclavia en la enfermedad de Takayasu: resultados a largo plazo / Percutaneous transluminal angioplasty of the subclavian artery in Takayasu disease: results of long-term follow-up

La arteritis de Takayasu es una arteriopatía inflamatoria crónica idiopática que afecta preferentemente a la arteria aorta y la porción proximal de sus grandes ramas. Aunque fue descrita inicialmente en mujeres jóvenes de origen oriental, en la actualidad se conoce su distribución mundial con afectación en ambos sexos. Durante la última década la angioplastia percutánea transluminal (APT) se ha demostrado eficaz en el tratamiento de esta enfermedad. Sin embargo, la proporción de reestenosis es mayor que la observada en la patología ateroesclerótica (21 frente a 100/0) posiblemente debido a la afectación difusa arterial y al proceso inflamatorio de base 1. Desde la introducción del stent esta técnica emerge como alternativa válida en el tratamiento de las estenosis arteriales ateromatosas, aunque su eficacia y seguridad en la patología inflamatoria permanece sin aclarar. Presentamos el caso de una mujer afecta de arteritis de Takayasu con síndrome de robo de la subclavia, tratada con angioplastia y colocación de stent, con un tiempo de seguimiento de 4 años, sin recurrencias durante este período

Takayasu arteritis is a chronic inflammatory arteriopathy of unknown etiology affecting the aorta and proximal portion of its main branches. Although it was initially reported in young women of Oriental descent, its current worldwide distribution is known to affect both sexes. In the last decade, percutaneous transluminal angioplasty (PTA) has emerged as a viable altemative in its treatment. However, the percentage of restenosis is more common in Takayasu disease than atherosclerotic lesions (21 % vs 10 %), probably due to diffuse inflammatory vascular involvement. Since the introduction of stent, this technique has emerged as a viable altemative to treatment of atherosclerotic stenotic lesions, although its efficacy and safety in Takayasu disease is still unclear. Herein, we report our experience in a woman with subclavian steal syndrome in whom Takayasu disease was diagnosed and treated with subclavian artery angioplasty and stent, with a good outcome during four years of follow-up

Stroke and pulmonary thromboembolism after a long flight.

In the economy class syndrome (ECS) the patient presents a deep venous thrombosis (DVT) with or without pulmonary thromboembolism (PTE) during or after a long trip as a result of prolonged immobilization. Economy class stroke syndrome is an infrequent ECS variant in which ischemic stroke is associated with a patent foramen ovale (PFO). Few cases have been published in the literature to date. We present a patient who suffered a PTE and an ischemic stroke immediately after a transoceanic flight. A 36-year-old woman with no significant medical or familial history flew economy class from Lima, Peru, to Madrid, Spain. On disembarkation she presented sudden dyspnea and a depressed level of consciousness, global aphasia, and right hemiparesis. A pulmonary scintigraphy showed a PTE and a cranial MRI revealed an ischemic infarct in the left middle cerebral artery territory. We simultaneously performed a transesophageal echocardiography and a transcranial Doppler and observed a massive right-to-left shunt through a PFO. The patient was a heterozygous carrier of the C46T mutation of coagulation factor XII. The appearance of a stroke following a long trip is suggestive of paradoxical embolism through a PFO, mainly if it is associated with a DVT and/or a PTE. The cause of the initial event, the DVT, could be a prothrombotic state.

Hemostatic markers of recanalization in patients with ischemic stroke treated with rt-PA.

OBJECTIVE: To determine whether pretreatment markers of coagulation and fibrinolysis are related to recanalization and functional outcome. METHODS: The authors included patients treated with IV rt-PA with occlusion on baseline transcranial Doppler (Thrombolysis in Brain Ischemia [TIBI] criteria) in whom recanalization within 6 hours was monitored. At baseline, the authors recorded data about demographics, vascular risk factors, the NIH Stroke Scale (NIHSS) score, early CT signs, etiology, blood glucose, and time to rt-PA. The authors also measured plasmatic markers of coagulation (fibrinogen, prothrombin fragments 1 + 2, Factor XIII, Factor VII) and fibrinolysis (alpha2-antiplasmin, Plasminogen Activator Inhibitor, Functional Thrombin Activatable Fibrinolysis Inhibitor [fTAFI]). A favorable outcome was defined as a modified Rankin score < 2 at 3 months. RESULTS: The authors studied 63 patients with a mean age of 67.3 +/- 12.5 years. The median NIHSS score was 16. Patients who recanalized had lower concentrations of alpha2-antiplasmin (87.5 +/- 18% vs 96.5 +/- 12.5%, p = 0.023) and fTAFI (91.7 +/- 26.7% vs 104.4 +/- 21%, p = 0.039). A multivariant logistic regression analysis showed that the level of alpha2-antiplasmin was the only predictive variable of recanalization (OR 0.95, 95% CI 0.91, 0.99, p = 0.038), while the NIHSS score was the only predictive variable of functional outcome (OR 0.81, 95% CI 0.72, 0.92, p = 0.001). CONCLUSION: Baseline levels of alpha2-antiplasmin were predictive of recanalization but were not related to the long-term outcome in patients treated with rt-PA within the first 3 hours.

[Carotid thrombus and cerebral infarction as the initial clinical manifestation of polycythemia vera]. / Trombo carotídeo e infarto cerebral como manifestación clínical inicial de policitemia vera.

Polycythemia vera (PV) can produce cerebral infarction. The mechanisms proposed by most authors are hyperviscosity-related diminished cerebral blood flow and platelet function abnormalities. We present a 36-year-old woman whose initial clinical manifestation of PV consisted of cerebral ischemia due to a carotid thrombus, as well as occlusion of the middle cerebral artery and cortical branches of the anterior cerebral artery demonstrated by angiography. To our knowledge, this is the first published case of cerebral infarction in PV caused by a thrombus of an extracranial artery. Therefore, PV can produce ischemic stroke due to thrombosis not only in small distal arteries or arterioles but also in the carotid artery or main branches. Treatment of intraluminal thrombus in non-arteriosclerotic carotid artery is discussed. Myeloproliferative disorders, including PV, must be suspected in all stroke patients with an elevated platelet count, even in those who have potential causes of reactive thrombocytosis.

Reasons for exclusion from thrombolytic therapy following acute ischemic stroke.

Despite evidence for the efficacy of thrombolytic therapy in acute ischemic stroke, only 1 to 7% of patients receive this therapy. The authors sought to determine the reasons for exclusion from tissue plasminogen activator (tPA) in an acute setting and found avoidable causes in 18% of patients. Improvements in intrahospital coordination would increase the number of patients who might benefit from tPA treatment at the authors' center.

Hemorragia intracerebral por hiperperfusión cerebral tras angioplastia carotídea de lesión en tándem. A propósito de un caso / Intracerebral haemorrhage by cerebral hyperperfusión after carotid angioplasty in a tandem lesion. A case report

La hemorragia intracerebral por hiperperfusión tras angioplastia carotídea presenta una frecuencia del 1,2-4,4 por ciento según las series. Hasta la fecha no se ha descrito en la bibliografía ningún caso de hemorragia intracerebral tras angioplastia carotídea de lesión en tándem. Presentamos el caso de un paciente que sufrió una hemorragia intracerebral por síndrome de hiperperfusión tras angioplastia carotídea de dos estenosis de la arteria carótida interna (ACI) izquierda (extracraneal e intracraneal). Se trata de un varón de 58 años que presentó accidente isquémico transitorio (AIT) carotídeo izquierdo de repetición a pesar de tratamiento antiagregante. Al realizar el estudio vascular se objetivó estenosis en la ACI izquierda extracraneal del 76 por ciento e intracraneal de 96 por ciento, y estenosis de la ACI derecha extracraneal del 59 por ciento. Se realizó angioplastia y colocación de stent de las dos estenosis de la ACI izquierda. A las 48 h de la angioplastia presenta hemorragia intracerebral izquierda masiva, falleciendo a las pocas horas. La hemorragia intracerebral por hiperperfusión es una complicación infrecuente de la angioplastia carotídea. Para disminuir su incidencia se deberían valorar los factores de riesgo de la misma, así como mantener un control estricto de la tensión arterial durante y tras la intervención. Nuestro caso es el primero publicado en una lesión en tándem. Es posible que el mecanismo fisiopatológico sea una restitución excesivamente rápida del calibre arterial normal (AU)

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[Intracerebral haemorrhage by cerebral hyperperfusion after carotid angioplasty in a tandem lesion. A case report]. / Hemorragia intracerebral por hiperperfusión cerebral tras angioplastia carotídea de lesión en tándem. A propósito de un caso.

Intracerebral hemorrhage (ICH) by hyperperfusion after carotid angioplasty has a frequency of 1.2 % - 4.4% in the literature. Until now no case of ICH after carotid angioplasty in a tandem lesion has been reported. We present the case of a patient who suffered an ICH due to the hyperperfusion syndrome, after carotid angioplasty of two stenotic lesions of the left internal carotid artery (ICA) (intracranial and extracranial). He was a 58 year old man who suffered repetitive left carotid TIA despite being treated with antiplatelet therapy. An angiogram showed 76 % extracranial stenosis and 96 % intracranial stenosis of the left ICA as well as 59 % extracranial stenosis of right ICA. Angioplasty with stenting of the two stenosis of the left ICA was performed. After 48 hours of the angioplasty, the patient presented a massive ICH and died a few hours later. ICH by hyperperfusion is an infrequent complication of the carotid angioplasty. The risk factors of the ICH should be evaluated in order to decrease their incidence as well as to maintain an intensive control of the arterial pressure during and after the procedure. This case is the first one published after angioplasty of a tandem lesion. It is possible that the pathophysiologic mechanism involved was an excessively rapid restitution of the normal arterial size.

New concepts in lacunar stroke etiology: the constellation of small-vessel arterial disease.

OBJECTIVE: To update the less frequent etiologies causing lacunar infarcts (LIs). To highlight recent advances in risk factors, clinical syndromes, topography, complementary tests and long-term prognosis in this subtype of ischemic stroke. PATIENTS AND METHODS: The most important studies are analyzed, from CM Fisher works, selecting those referring to LIs of unusual etiology, and recent advances and controversies in the clinical management of LI are discussed. RESULTS: LIs are found in approximately 11% of patients admitted with stroke. The pure motor hemiparesis (55%) constitutes the most usual lacunar syndrome. However, lacunar syndromes may not be caused by LIs in 10-20% of cases. LIs caused by microembolism and cholesterol embolism from the aortic arch are reviewed. Hematological diseases can also cause LI, such as polycythemia rubra vera, essential thrombocythemia and primary antiphospholipidic antibody syndrome. Other etiologies are carotid plaque embolism, severe stenosis of a perforated arteriole and amyloid angiopathy. Infectious arteritis by neurolues, neurocysticercosis, neuroborreliosis, by AIDS or Helicobacter pylori infection have also been associated with the presence of LIs. Likewise, inflammatory arteritis in systemic lupus erythematosus or granulomatous angiitis, cocaine abuse and panarteritis nodosa have been related to LI, although in the latter LI would be caused by a thrombotic microangiopathy and not by vasculitis. CONCLUSIONS: LI is an ischemic stroke subtype with a characteristic clinical presentation and a short-term favorable prognosis. Although high blood pressure constitutes the main risk factor and the main etiology, LIs may be caused, in less than 5% of cases, by various etiologies, mainly hematological diseases and infectious or inflammatory arteritis. It is essential to make a correct etiological diagnosis for LI as treatment will be different according to its etiology.

Prognostic value of Pulsatility Index in acute intracerebral hemorrhage.

OBJECTIVE: To investigate whether data obtained by transcranial Doppler (TCD) have prognostic value in patients with intracerebral hemorrhage (ICH). METHODS: A prospective study of patients with an acute (<12 hours from onset of symptoms) spontaneous supratentorial ICH was conducted. Mortality was assessed at 30-day follow-up. TCD parameters were obtained from both middle cerebral arteries: systolic, diastolic, and mean velocities and Pulsatility Index (PI) from the affected and unaffected hemispheres. The following variables were included in a univariate analysis: age, sex, hematoma volume, hypodense volume around the hematoma, total volume, midline shift, ventricular size, Glasgow Coma Scale score, intraventricular hemorrhage, body temperature, white cell count, blood glucose, mean blood pressure, and TCD data. A multivariate analysis was performed with variables that showed significance in the univariate analysis. Receiver-operator characteristic (ROC) curves were obtained. RESULTS: Forty-eight patients (age 66.5 +/- 12.5 years; 28 men) were studied. Mortality at 30 days was 31%. The only predictor of mortality was the Glasgow Coma Scale score (odds ratio [OR] 0.67, CI 0.53 to 0.84, p = 0.001), whereas the PI from the unaffected hemisphere was correlated with mortality (OR 2.3, CI 0.92 to 5.72, p = 0.07). The area under the ROC curve was 0.92. A cutoff for PI from the unaffected hemisphere of 1.75 showed a specificity of 94% and a sensitivity of 80% as a predictor of death at 30 days. CONCLUSIONS: The PI of the unaffected hemisphere may be a predictor of death in acute ICH. These findings suggest that intracranial hypertension is the most likely cause of death in most patients with ICH.

[Leukoaraiosis. Clinical importance and prognosis]. / Leucoaraiosis. Importancia clínica y pronóstica.

Advance in the health care systems, in medical knowledge and improvements in quality of life have contributed to the fact that life expectancy of the persons in developed countries exceeds 80 years of age. This has made it possible to observe the increase in frequency of common diseases of the elderly, one of the most relevant of which is dementia. The two most frequent etiologies of dementia are the degenerative one, with Alzheimer's disease (AD) as the main cause, and those of vascular etiology or vascular dementia, within which subcortical arteriosclerotic encephalopaty or Binswanger's disease (BD) are found with low prevalence. Since, on one hand, diagnosis of the dementias is not enough or definitive by clinical means, and on the other hand, the pathological diagnosis does not modify the evolution of disease, emphasis is presently placed on diagnosis by neuroimaging studies. In recent years, with the coming of the computerized tomography (CT) and the magnetic resonance (MR), it has been possible to observe lesions in the white matter of the brain hemisphere in patients with these two etiologic groups of dementias, that is, degenerative and vascular, as well as in elderly patient without cognitive deterioration, with or without vascular risk factors.

[Asystolias in the acute phase of brain stroke. Report of a case]. / Asistolias en la fase aguda del infarto cerebral. A propósito de un caso.

Brain areas involved in heart autonomic control are not well characterized. Insulae have been proposed as control centers. A lesion in these areas may induce a cardiac autonomic dysfunction (arrhythmias, atrioventricular conduction abnormalities). Asystolia has not been previously reported. A 65-year-old man suffered an acute ischemia of the right middle cerebral artery (MCA) territory. NIHSS score was 19 points. Brain CT scan was normal. Transcranial Doppler (TCD) showed occlusion of the right MCA. Fibrinolysis was initiated 135 minutes after stroke onset with TCD monitoring. Twenty minutes later he suffered cardiac arrest with asystolia trace in the ECG monitor. Fibrinolysis was stopped during resuscitation. Four minutes later, he recovered with the same NIHSS score. Aggressive resuscitation maneuvers were not necessary. A repeated brain CT scan showed infarct signs in the whole MCA territory and a new TCD did not show any change. Serial blood analyses including cardiac nzymes were normal. The patient experienced four brief cardiac arrests in the next nine hours, so a temporary cardiac pacemaker was placed for four days. He was treated with aspirin and was discharged 14 days after admission. He has not experienced recurrences during a 6-month follow-up. We could not diagnose the etiology of the cardiac arrests. All the episodes occurred in the acute stroke stage and arrhythmia, atrioventricular block, myocardial ischemia or structural lesions were not found in the cardiac study. We propose that ischemia in the right insula induced sudden and transitory interruptions of the sympathetic cardiac tone.

Leucoaraiosis. Importancia clínica y pronóstica / Leukoaraiosis: Clinical importance and prognosis

El avance en los sistemas sanitarios, en los conocimientos médicos y las mejoras en la calidad de vida, han contribuido a que la expectativa de vida de las personas en los países desarrollados pueda superar los 80 años. Esto ha permitido observar el aumento de la frecuencia de enfermedades comunes en la tercera edad, de las cuales, una de las más relevantes es la demencia. Las dos etiologías más frecuentes de la demencia son la degenerativa, con la enfermedad de Alzheimer como causa principal, y las de etiología vascular o demencia vascular, dentro de la cual se encuentra con una prevalencia baja la encefalopatía arterioesclerótica subcortical o enfermedad de Binswanger. Dado que, por una parte, el diagnóstico de las demencias no es suficiente ni definitivo por medios clínicos, y por otra parte, el diagnóstico patológico no modifica la evolución de la enfermedad, actualmente se pone énfasis en el diagnóstico por estudios de neuroimagen. En los últimos años, con el advenimiento de la tomografía computarizada (TC) y la resonancia magnética (RM), se han podido observar lesiones en la sustancia blanca de los hemisferios cerebrales de pacientes de estos dos grupos etiológicos de demencia, la degenerativa y la vascular, así como en pacientes de edad avanzada sin deterioro cognitivo con o sin factores de riesgo vascular (AU)

Asistolias en la fase aguda del infartocerebral. A propósito de un caso / Asystolias in the acute phase of brain stroke. Report of a case

Las áreas cerebrales involucradas en el control autonómico cardíaco no están bien caracterizadas. Las ínsulas han sido propuestas como centros de control. Una lesión en estas áreas puede inducir una disfunción autonómica cardíaca (arritmias, anormalidades de la conducción aurículo-ventricular). La asistolia no ha sido informada previamente. Un varón de 65 años sufrió una isquemia en el territorio de la arteria cerebral media (ACM) derecha. La escala NIHSS sumó 19 puntos, la tomografía computarizada (TC) craneal fue normal y el Doppler transcraneal (DTC) mostró una oclusión de la ACM derecha. Se inició la fibrinólisis a los 135 minutos. Veinte minutos después el paciente sufrió un paro cardiorrespiratorio (PCR) por asistolia. La fibrinólisis fue suspendida durante la reanimación. Cuatro minutos después el paciente se recuperó con la misma puntuación NIHSS, no siendo necesarias maniobras agresivas de reanimación. Una nueva TC craneal mostró signos de infarto en el territorio de la ACM y un nuevo DTC no mostró ningún cambio. Las enzimas cardíacas consecutivas fueron normales. El paciente experimentó cuatro PCR más en las siguientes 9 horas, por lo que se colocó un electrocatéter durante 4 días. Fue dado de alta y tratado con aspirina, no experimentando recurrencias durante 6 meses de seguimiento. No pudimos diagnosticar la etiología de los PCRs. Todos los episodios ocurrieron en la fase aguda de la isquemia cerebral y en el estudio cardiológico no objetivamos arritmias, bloqueos auriculoventriculares, isquemia miocárdica o lesiones estructurales. Proponemos que la isquemia en la ínsula derecha indujo repentinas y transitorias interrupciones del tono simpático cardíaco (AU)

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