Factores de riesgo y causas de ACV isquémico en pacientes jóvenes (18-49 años) en Colombia: una revisión sistemática / Risk factors and causes of ischemic stroke in young patients (18-49 years) in Colombia: a systematic review

INTRODUCCIÓN: El ataque cerebrovascular (ACV) es la principal causa de discapacidad en el mundo. Su incidencia está en aumento, incluso en jóvenes. Por lo anterior, los factores de riesgo y etiologías diversas del ACV en jóvenes deben estudiarse para planear acciones preventivas. Por eso en Colombia es necesario conocer dichos factores y etiologías analizando los estudios sobre el tema. METODOLOGÍA: Se hizo búsqueda y análisis de artículos sobre causas y factores de riesgo de ACV isquémico en Colombia publicados en Pubmed, Lilacs, Scielo, Google Scholar. Luego de revisar títulos y resúmenes se excluyeron los que no se referían a jóvenes entre 18 y 49 años o ACV isquémico, revisiones de tema, duplicados. Finalmente se analizaron 20 artículos. RESULTADOS Y DISCUSIÓN: La mayor parte de los estudios eran reporte o series de casos, sumaron 60 personas. No hubo predominio de sexo, excepto en los casos de síndrome antifosfolípido (SAF) que fueron mujeres, a diferencia de la mayoría de las series mundiales. La mayor frecuencia fue 56% para otras causas determinadas como SAF y disección de vasos craneocervicales, superior a otros reportes. Hubo una frecuencia baja de enfermedad de gran vaso, similar a otros estudios. La enfermedad de pequeño vaso fue mayor a otros reportes en Latinoamérica. CONCLUSIONES: La mayor parte de la información provino de reportes y series de caso que podrían no reflejar la frecuencia real de causas y factores de riesgo. Merece atención la neurocisticercosis y sustancias psicoactivas como causas de ACV propias de la revisión en colombiana.

INTRODUCTION: Stroke is the leading cause of disability in the world. Its incidence is increasing, even in young people. Therefore, the risk factors and various etiologies of stroke in young people should be studied to plan preventive actions. That is why in Colombia it is necessary to know these factors and etiologies analyzing the studies on the subject. METHODS: Search and analysis of articles on causes and risk factors of ischemic stroke in Colombia published in Pubmed, Lilacs, Scielo, Google Scholar. After reviewing titles and abstracts, those that did not refer to young people between 18 and 49 years, reviews, did not refer to ischemic strokes, duplicates, were excluded. Finally, 20 articles were analyzed. RESULTS AND DISCUSSION: Most of the studies were report or case series, they added 60 people. There was no predominance of sex, except in the cases of antiphospholipid síndrome (APS) that were women, unlike most of the world series. The highest frequency was 56% for other determined causes such as APS and craniocervical vessel dissection, higher than other reports. There was a low frequency of large vessel disease, similar to other studies. Small vessel disease was higher than other reports in Latin America. CONCLUSIONS: Most of the information came from reports and case series that may not reflect the real frequency of causes and risk factors. Neurocysticercosis and psychoactive substances as causes of stroke proper of the review in Colombia deserve attention.

La Von Economo's encephalitis lethargica and the Spanish flu pandemic in Bogotá and Medellín (Colombia): An historic review one hundred years after / La encefalitis letárgica de von Economo y la pandemia de la gripe española en Bogotá y Medellín: reseña histórica cien años después.

Von Economo's encephalitis is a neuropsychiatric disorder of possible autoimmune origin, which affects basal ganglia. This reaction may occur secondary to infection by different viral or bacterial agents. Given that it appears after the acute episode has disappeared, molecular mimetism has been proposed to explain the autoimmune lesion. Several cases have been reported through time, but it was with the 1918 flu pandemic, known as the Spanish flu, that lethargic encephalitis reached epidemic levels with cases reported until 1923 in various countries. The Spanish flu pandemic appeared in Colombia at the end of 1918 in several cities but it affected especially Bogotá where the highest number of patients and deaths was reported. Our purpose with the present work was to commemorate the arrival of the Spanish flu to our country after one hundred years, as well as to reflect on its main complications, which included some lethargic encepahilitis cases.

La encefalitis letárgica de von Economo es un trastorno neuropsiquiátrico de posible origen autoinmunitario, en el cual se afectan los ganglios basales. Esta reacción puede ocurrir luego de una infección aguda por diversos agentes virales o bacterianos. Dado que aparece cuando ya se ha resuelto el cuadro agudo, se ha propuesto el mecanismo del mimetismo molecular para explicar la lesión autoinmunitaria. Se han reportado diversos casos a lo largo del tiempo, pero fue con la pandemia de influenza de 1918, conocida como la gripe española, que la encefalitis letárgica alcanzó niveles de epidemia, con casos reportados hasta 1923 en diversos países. La pandemia de la gripe española se extendió a Colombia durante los últimos meses de 1918 y afectó varias ciudades, principalmente Bogotá, donde se reportó el mayor número de enfermos y muertos. Con este trabajo se busca rememorar, cien años después, el ingreso de la gripe española a nuestro país y sus principales complicaciones, entre las que se describieron algunos casos de encefalitis letárgica.

La encefalitis letárgica de von Economo y la pandemia de la gripe española en Bogotá y Medellín: reseña histórica cien años después

La encefalitis letárgica de von Economo es un trastorno neuropsiquiátrico de posible origen autoinmunitario, en el cual se afectan los ganglios basales. Esta reacción puede ocurrir luego de una infección aguda por diversos agentes virales o bacterianos. Dado que aparece cuando ya se ha resuelto el cuadro agudo, se ha propuesto el mecanismo del mimetismo molecular para explicar la lesión autoinmunitaria. Se han reportado diversos casos a lo largo del tiempo, pero fue con la pandemia de influenza de 1918, conocida como la gripe española, que la encefalitis letárgica alcanzó niveles de epidemia, con casos reportados hasta 1923 en diversos países. La pandemia de la gripe española se extendió a Colombia durante los últimos meses de 1918 y afectó varias ciudades, principalmente Bogotá, donde se reportó el mayor número de enfermos y muertos. Con este trabajo se busca rememorar, cien años después, el ingreso de la gripe española a nuestro país y sus principales complicaciones, entre las que se describieron algunos casos de encefalitis letárgica.

Von Economo's encephalitis is a neuropsychiatric disorder of possible autoimmune origin, which affects basal ganglia. This reaction may occur secondary to infection by different viral or bacterial agents. Given that it appears after the acute episode has disappeared, molecular mimetism has been proposed to explain the autoimmune lesion. Several cases have been reported through time, but it was with the 1918 flu pandemic, known as the Spanish flu, that lethargic encephalitis reached epidemic levels with cases reported until 1923 in various countries. The Spanish flu pandemic appeared in Colombia at the end of 1918 in several cities but it affected especially Bogotá where the highest number of patients and deaths was reported. Our purpose with the present work was to commemorate the arrival of the Spanish flu to our country after one hundred years, as well as to reflect on its main complications, which included some lethargic encepahilitis cases.

[Racemose neurocysticercosis: Neuroimaging guides the diagnosis].

Neurocysticercosis is the leading cause of parasitosis of the central nervous system and acquired epilepsy in developing countries. The clinical manifestations of neurocysticercosis, especially its racemose variant, are pleomorphic and unspecific, characteristics that hinder the diagnosis and make it a challenge for the clinician.The objective of this report was to describe two cases of racemose neurocysticercosis in which neuroimaging led to the definitive diagnosis. The first case involved a patient with persistent headache and focal neurological signs. She required multiple paraclinical tests that led to the definitive diagnosis of racemose neurocysticercosis with secondary cerebral vasculitis. Despite medical and surgical treatment the patient died after multiple complications.The second case involved a patient with a history of neurocysticercosis, who consulted for chronic intractable vomiting. She required multiple paraclinical tests that led to the diagnosis of vomiting of central origin secondary to racemose neurocysticercosis and entrapment of the fourth ventricle. After medical and surgical treatment the patient showed slight improvement. In these two cases it was evident how proper interpretation of neuroimages is essential for the diagnosis of racemose neurocysticercosis.

Neurocisticercosis racemosa (sic), diagnóstico orientado por neuroimágenes / Racemose neurocysticercosis: Neuroimaging guides the diagnosis

Resumen La neurocisticercosis es la primera causa de parasitosis del sistema nervioso central y de epilepsia adquirida en países en desarrollo. Sus manifestaciones clínicas, especialmente de la variante racemosa (sic), son pleomorfas e inespecíficas, características que hacen de su diagnóstico un desafío para el clínico. El objetivo de este informe fue describir dos casos de neurocisticercosis racemosa (sic), en los cuales las neuroimágenes permitieron hacer el diagnóstico definitivo. El primer caso se trató de una paciente con cefalea persistente y signos neurológicos focales, que requirió múltiples exámenes paraclínicos para, finalmente, llegar al diagnóstico definitivo de neurocisticercosis racemosa (sic) con vasculitis cerebral secundaria. A pesar del tratamiento médico y quirúrgico, la paciente falleció después de diversas complicaciones. El segundo caso se trató de una paciente con antecedentes de neurocisticerosis, que consultó por vómito crónico incoercible y, también requirió múltiples exámenes paraclínicos para concluir que se trataba de un vómito de origen central, secundario a neurocisticercosis racemosa (sic) y obstrucción del cuarto ventrículo. Después del tratamiento médico y quirúrgico, la paciente presentó una leve mejoría. En estos dos casos se evidenció que la adecuada interpretación de las neuroimágenes es fundamental para el diagnóstico de la neurocisticercosis racemosa (sic).

Abstract Neurocysticercosis is the leading cause of parasitosis of the central nervous system and acquired epilepsy in developing countries. The clinical manifestations of neurocysticercosis, especially its racemose variant, are pleomorphic and unspecific, characteristics that hinder the diagnosis and make it a challenge for the clinician. The objective of this report was to describe two cases of racemose neurocysticercosis in which neuroimaging led to the definitive diagnosis. The first case involved a patient with persistent headache and focal neurological signs. She required multiple paraclinical tests that led to the definitive diagnosis of racemose neurocysticercosis with secondary cerebral vasculitis. Despite medical and surgical treatment the patient died after multiple complications. The second case involved a patient with a history of neurocysticercosis, who consulted for chronic intractable vomiting. She required multiple paraclinical tests that led to the diagnosis of vomiting of central origin secondary to racemose neurocysticercosis and entrapment of the fourth ventricle. After medical and surgical treatment the patient showed slight improvement. In these two cases it was evident how proper interpretation of neuroimages is essential for the diagnosis of racemose neurocysticercosis.

Validation of Thwaites Index for diagnosing tuberculous meningitis in a Colombian population.

OBJECTIVE: To determine the diagnostic accuracy of Thwaites Index (TI) in a Colombian population to distinguish meningeal tuberculosis (MTB) from bacterial meningitis (BM) and from non-tuberculous meningitis. Exploratory analyses were conducted to assess the TI's validity for patients with human immunodeficiency virus (HIV) and children above six-years-old. METHODS: The study included 527 patients, the TI was calculated and results compared with those of a reference standard established by expert neurologists. Sensitivity, specificity, area under the curve of receiver-operator characteristics (AUC-ROC) and likelihood ratios were calculated. RESULTS: The AUC-ROC to distinguish MTB from non-tuberculous meningitis was 0.72 (95% CI: 0.67-0.77) for HIV negative adults. AUC-ROC was 0.62 (95% CI: 0.50-0.74) for HIV positive adults and 0.83 (95% CI: 0.68-0.97) for children. For distinguishing MTB from BM the AUC-ROC was 0.78 (95% CI: 0.73-0.83); furthermore, the AUC-ROC was 0.57 (95% CI: 0.31-0.83) for HIV positive adults and 0.86 (95% CI: 0.73-0.99) for children. CONCLUSION: The TI was sensitive but not specific when used to distinguish MTB from BM in HIV negative adults. In HIV positive adults the index had low diagnostic accuracy. Moreover, the TI showed discrimination capability for children over 6years; however, research with larger samples is required in these.

Síntomas de miastenia grave en un paciente con antecedente de timectomía por timoma invasor / Symptoms of myasthenia gravis in a patient with a history of thymectomy for invasive thymoma

Introducción. La miastenia grave es una enfermedad autoinmunitaria mediada por anticuerpos. Entre 10 y 15 % de quienes la padecen tienen timoma y su presencia se asocia con una mayor gravedad de los síntomas, crisis miasténicas y fracaso del tratamiento de primera línea. La timectomía se recomienda en pacientes jóvenes con miastenia grave generalizada y en todos los pacientes con timoma. Caso clínico. Se presenta el caso de una mujer de 43 años que, en el 2005, presentó una primera crisis miasténica asociada con un timoma invasor que se trató con timectomía y radioterapia. Durante los siguientes tres años, presentó síntomas graves y dos crisis más, que obligaron a suministrarle respiración mecánica asistida e inmunoglobulina. Al cabo del tratamiento, no se evidenciaron signos de recurrencia en las tomografías de tórax con contraste. Entre el 2009 y el 2012, la gravedad de los síntomas fue menor. En el 2013, estos se exacerbaron y una resonancia magnética de tórax con contraste reveló una lesión en el mediastino anterior, ya observada en el 2011, sugestiva de tejido residual o fibrosis. Se inició el tratamiento usual con inmunoglobulina y se hizo una tomografía por emisión de positrones cuyos resultados no fueron concluyentes, por lo que se llevó a cabo una nueva resección y se constató que no había recurrencia del tumor. Conclusiones. Los pacientes con miastenia grave y aquellos con timoma asociado, deben someterse a la timectomía como parte del tratamiento. Sin embargo, la exacerbación de los síntomas o su reaparición después del procedimiento no necesariamente implica una nueva alteración en el timo.

Introduction: Myasthenia gravis is an antibody-mediated autoimmune disease. Approximately 10-15% of patients present with a thymoma, the presence of which is associated with greater severity of symptoms, myasthenic crisis, and irresponsiveness to front-line therapy. A thymectomy is recommended in young patients with generalized myasthenia gravis and in all patients presenting with thymoma. Clinical case: The patient was a 43-year-old woman, who first showed symptoms of myasthenic crisis in 2005 and presented with invasive thymoma managed with thymectomy and radiotherapy. In the subsequent three years, the patient presented with severe symptoms and two myasthenic crises that required mechanical ventilation and immunoglobulin treatment. Contrast chest computed tomography examinations showed no recurrence. Between 2009 and 2012, the patient experienced decreased symptom severity. In 2013, the patient presented with an exacerbation of symptoms; a contrast chest magnetic resonance scan showed a lesion in the anterior mediastinum, previously observed in 2011, suggestive of residual tissue as opposed to fibrosis. Regular management was started with immunoglobulins; a positron emission tomography scan was inconclusive, requiring a new resection, which showed no evidence of tumor recurrence. Conclusions: Patients with myasthenia gravis and those with myasthenia-related thymoma both share thymectomy as an element of treatment. However, following the procedure, exacerbation or reappearance of symptoms does not necessarily represent new alterations in the thymus.

[Symptoms of myasthenia gravis in a patient with a history of thymectomy for invasive thymoma]. / Síntomas de miastenia grave en un paciente con antecedente de timectomía por timoma invasor.

INTRODUCTION: Myasthenia gravis is an antibody-mediated autoimmune disease. Approximately 10-15% of patients present with a thymoma, the presence of which is associated with greater severity of symptoms, myasthenic crisis, and irresponsiveness to front-line therapy. A thymectomy is recommended in young patients with generalized myasthenia gravis and in all patients presenting with thymoma. CLINICAL CASE: The patient was a 43-year-old woman, who first showed symptoms of myasthenic crisis in 2005 and presented with invasive thymoma managed with thymectomy and radiotherapy. In the subsequent three years, the patient presented with severe symptoms and two myasthenic crises that required mechanical ventilation and immunoglobulin treatment. Contrast chest computed tomography examinations showed no recurrence. Between 2009 and 2012, the patient experienced decreased symptom severity. In 2013, the patient presented with an exacerbation of symptoms; a contrast chest magnetic resonance scan showed a lesion in the anterior mediastinum, previously observed in 2011, suggestive of residual tissue as opposed to fibrosis. Regular management was started with immunoglobulins; a positron emission tomography scan was inconclusive, requiring a new resection, which showed no evidence of tumor recurrence. CONCLUSIONS: Patients with myasthenia gravis and those with myasthenia-related thymoma both share thymectomy as an element of treatment. However, following the procedure, exacerbation or reappearance of symptoms does not necessarily represent new alterations in the thymus.

Accuracy of the Babinski sign in the identification of pyramidal tract dysfunction.

BACKGROUND: The extensor plantar response described by Joseph Babinski (1896) indicates pyramidal tract dysfunction (PTD) but has significant inter-observer variability and inconsistent accuracy. The goal of this study was to determine the accuracy of the Babinski sign in subjects with verified PTD. METHODS: We studied 107 adult hospitalized and outpatient subjects evaluated by neurology. The reference standard was the blinded and independent diagnosis of an expert neurologist based on anamnesis, physical examination, imaging and complementary tests. Two neurologists elicited the Babinski sign in each patient independently, blindly and in a standardized manner to measure inter-observer variability; each examination was filmed to quantify intra-observer variability. RESULTS: Compared with the reference standard, the Babinski sign had low sensitivity (50.8%, 95%CI 41.5-60.1) but high specificity (99%, 95%CI 97.7-100) in identifying PTD with a positive likelihood ratio of 51.8 (95%CI 16.6-161.2) and a calculated inter-observer variability of 0.73 (95%CI 0.598-0.858). The intraevaluator reliability was 0.571 (95%CI 0.270-0.873) and 0.467 (95%, CI 0.019-0.914) respectively, for each examiner. CONCLUSION: The presence of the Babinski sign obtained by a neurologist provides valid and reliable evidence of PTD; due to its low sensitivity, absence of the Babinski sign still requires additional patient evaluation if PTD is suspected.

Encefalitis de Bickerstaff: informe de caso y revisión de la literatura / Bickerstaff brain encephalitis: Case report and literature review

En este artículo se presenta el caso clínico de un paciente de sexo masculino de 34 años que fue remitido al Instituto Neurológico de Colombia e internado en la unidad de cuidados intensivos neurológicos, por la sospecha inicial de un síndrome de Guillain-Barré. La presencia de alteraciones cognitivas durante su evolución, llevó a reconsiderar el diagnóstico presuntivo inicial por el de encefalitis de Bickerstaff. Se describen el tratamiento instaurado y la evolución del paciente, se hacen la revisión de la literatura y la discusión.

We describe the case of a 34-year-old male patient, who was referred to the Instituto Neurológico de Colombia with probable Guillain-Barré syndrome, requiring intensive care management. The presence of cognitive alterations during his evolution, lead the team to reconsider the initial diagnosis for the Bickerstaff´s brainstem encephalitis diagnosis. We aim to describe the patient´s treatment and evolution, as well as a brief review and discussion.

Encefalitis del tallo cerebral y mielitis por Listeria monocytogenes / Brainstem encephalitis and myelitis due to Listeria monocytogenes : a case report and literature review

La romboencefalitis por Listeria monocytogenes es una presentación poco común de la listeriosis del sistema nervioso central; sin embargo, es la presentación más común en personas inmunocompetentes. Aun más rara es la combinación de romboencefalitis con mielitis causada por L. monocytogenes ; no obstante, en este artículo se reporta un caso de encefalitis del tallo y mielitis grave en un paciente sin compromiso del sistema inmunitario. Se presenta un paciente de 21 años de edad, sin deficiencias del sistema inmunitario, que consumió productos lácteos no pasteurizados y, posteriormente, presentó un cuadro de cefalea, vómito, deterioro de su estado general y, finalmente, alteración del estado de conciencia y muerte. Consultó al Instituto Neurológico de Colombia y se hizo diagnóstico de encefalitis del tallo y mielitis por L. monocytogenes . Se discuten las diferencias entre el caso presentado y los reportados en la literatura científica. Ante un paciente con signos de compromiso del tallo cerebral, de posible origen infeccioso, es prudente iniciar tratamiento antibiótico para L. monocytogenes y, en caso de poca respuesta, escalar rápidamente en dicho tratamiento. También lo es extender el estudio radiológico hacia la columna vertebral, con el fin de descartar compromiso de la médula espinal.

Brainstem encephalitis caused by Listeria monocytogenes is an uncommon form of central nervous system listeriosis; however, it is the most common presentation in immunocompetent individuals. Here, we describe an even more rare combination of rhombencephalitis with severe myelitis caused by L. monocytogenes in an immunocompetent patient. We report the case of a 21-year-old immunocompetent patient who consumed unpasteurized dairy products and experienced headache and vomiting that progressed to an impaired general condition, altered consciousness and ultimately death. The patient had presented to the Neurological Institute of Colombia (INDEC in Spanish) for consultation and was diagnosed with brainstem encephalitis and myelitis caused by Listeria monocytogenes . The differences between this particular case and those reported in the literature will be discussed. It is advisable to initiate antibiotic treatment for Listeria monocytogenes if a patient shows signs of brainstem compromise of possible infectious origin and quickly intensify treatment if there is no or minimal response. It is also necessary to extend radiological assessment to include the spinal column to rule out spinal cord involvement.

[Brainstem encephalitis and myelitis due to Listeria monocytogenes: a case report and literature review]. / Encefalitis del tallo cerebral y mielitis por Listeria monocytogenes.

Brainstem encephalitis caused by Listeria monocytogenes is an uncommon form of central nervous system listeriosis; however, it is the most common presentation in immunocompetent individuals. Here, we describe an even more rare combination of rhombencephalitis with severe myelitis caused by L. monocytogenes in an immunocompetent patient. We report the case of a 21-year-old immunocompetent patient who consumed unpasteurized dairy products and experienced headache and vomiting that progressed to an impaired general condition, altered consciousness and ultimately death. The patient had presented to the Neurological Institute of Colombia (INDEC in Spanish) for consultation and was diagnosed with brainstem encephalitis and myelitis caused by Listeria monocytogenes . The differences between this particular case and those reported in the literature will be discussed. It is advisable to initiate antibiotic treatment for Listeria monocytogenes if a patient shows signs of brainstem compromise of possible infectious origin and quickly intensify treatment if there is no or minimal response. It is also necessary to extend radiological assessment to include the spinal column to rule out spinal cord involvement.

[Bickerstaff brain encephalitis: case report and literature review]. / Encefalitis de Bickerstaff: informe de caso y revisión de la literatura.

We describe the case of a 34-year-old male patient, who was referred to the Instituto Neurológico de Colombia with probable Guillain-Barré syndrome, requiring intensive care management. The presence of cognitive alterations during his evolution, lead the team to reconsider the initial diagnosis for the Bickerstaff's brainstem encephalitis diagnosis. We aim to describe the patient's treatment and evolution, as well as a brief review and discussion.

[Meningovascular neurosyphilis with basilar artery thrombosis, a case report and literature review]. / Neurosífilis meningovascular con trombosis de la arteria basilar.

Herein a case is described of a 54-years old patient, HIV negative, with cerebro-vascular disease by basilar artery thrombosis secondary to meningovascular neurosyphilis. Neurosyphilis is the impairment at any stage of the central nervous system by Treponema pallidum subspecies pallidum and includes asymptomatic and symptomatic forms of infection. The presentation can take many forms, depending on the location and extent of tissue damage. The currently recommended treatment is crystalline penicillin, 4 million units every 4 hours for 14 days.

Neurosífilis meningovascular con trombosis de la arteria basilar / Meningovascular neurosyphilis with basilar artery thrombosis, a case report and literature review

Se presenta el caso clínico de un paciente de 54 años, negativo para VIH, con enfermedad cerebrovascular por trombosis de la arteria basilar, secundaria a neurosífilis meningovascular. La neurosífilis es el compromiso del sistema nervioso central por Treponema pallidum subespecie pallidum en cualquier estadio de la entidad e incluye las formas asintomáticas y sintomáticas de la infección; sus formas de presentación son diversas y dependen de la localización y la extensión de las lesiones. La recomendación actual es el tratamiento con 4 millones de unidades de penicilina cristalina cada 4 horas por 14 días.

Herein a case is described of a 54-years old patient, HIV negative, with cerebro-vascular disease by basilar artery thrombosis secondary to meningovascular neurosyphilis. Neurosyphilis is the impairment at any stage of the central nervous system by Treponema pallidum subspecies pallidum and includes asymptomatic and symptomatic forms of infection. The presentation can take many forms, depending on the location and extent of tissue damage. The currently recommended treatment is crystalline penicillin, 4 million units every 4 hours for 14 days.

Síndrome de Moyamoya y complicaciones neurológicas en un paciente con enfermedad de células falciforme / Moyamoya syndrome and neurological complications in a patient with sickle cell disease

La enfermedad de células falciformes, aunque infrecuente, es una patología con una alta comorbilidad; el ataque cerebrovascular (ACV) y las malformaciones vasculares por deformidad endotelial, son complicaciones mayores y catastróficas en las pacientes con alteraciones falciformes, es por esto que el adecuado seguimiento de estos pacientes permite prevenir la alta tasa de complicaciones que esta enfermedad conlleva. Se presenta el caso de una mujer de raza negra de 24 años con enfermedad de células falciformes, con infartos cerebrales en la adolescencia y quien durante su gestación se complica con hemorragia intraventricular secundaria a múltiples malformaciones vasculares tipo Moyamoya, desarrollando un estado epiléptico convulsivo y deterioro neurológico irreversible.

Sickle cell disease, although infrequent, is a disease with high comorbidity, stroke and vascular malformations by endothelial deformity are major and catastrophic complications in patients with sickle cell disease, which is why proper monitoring of these patients can prevent the high rate of complications that this disease leads. The situation of a 24 years old african-american woman with sickle cell disease and several strokes during adolescence is exposed. The patient had a complicated pregnancy due to secondary intraventricular hemorrhage and multiple vascular malformations type Moyamoya. She developed a convulsive status epilepticus and an irreversible neurological impairment.

Linfoma primario del sistema nervioso central: serie de casos / Primary lymphoma of the central nervous system: case series

INTRODUCCIÓN: el linfoma primario del sistema nervioso central (LPSNC) corresponde a una causa de importante mortalidad dentro de los tumores primarios del sistema nervioso central, además existen pocos datos epidemiológicos actualmente, razón por la cual se decide hacer un reporte de casos en el grupo de neuropatología de la Universidad de Antioquia. OBJETIVO: describir el comportamiento de esta patología en un grupo de pacientes. MATERIALES Y MéTODOS: se revisaros los estudios patológicos e historias clínicas de 12 pacientes con diagnóstico de LPSNC en el servicio de neuropatología de la Universidad de Antioquia 2004 el 2011. RESUTADOS: se encontraron 12 pacientes que cumplían el criterio de inclusión. De estos pacientes el 61.5% fueron hombres y el 38.5% mujeres. La edad promedio al momento del diagnóstico fue de 42.6 años (1- 77 años). El Linfoma B no hodking de células gigantes con patrón difuso fue el tumor más frecuente con un 83.3 %, 8.35% corresponde a linfoma de células T, 8.35% a Linfoma de Burkitt; 33.3 % corresponden a pacientes inmunode-ficientes. CONCLUSIóN: en esta serie de pacientes con linfoma del sistema nervioso central se encontraron características clínicas similares a las encontradas en la literatura, quizás el único hallazgo disímil fue la mayor cantidad de pacientes sin aparente alteración en el sistema inmune.

INTRODUCTION: primary lymphoma of the central nervous system (PCNSL) is a major cause of mortality in primary tumors of the central nervous system, plus there are only a few epidemiological data today, these are the reasons why it was decided to make a report of cases in the group of neuropathology at the University of Antioquia. OBJETIVES: to describe the behavior of this disease in group of patients. MATERIALS AND METHODS: we reviewed the pathological studies and clinical records of 12 patients diagnosed with PCNSL in the service of neuropathology at the University of Antioquia from the years of 2004 to 2011. RESULTS: there were 12 patients who met the inclusion criteria. Of these patients, 61.5% were male and 38.5% women. The average age at diagnosis was 42.6 years (1 - 77 years). The giant cell, diffuse pattern B non-Hodgkin lymphoma was the most frequent tumor with 83.3%,T- cell lymphoma with 8.35%, Burkitt lymphoma 8.35%; 33.3% of the patients were immunodeficient. CONCLUSION: in this series of patients with central nervous system lymphoma similar clinical characteristics were found to those in the medical literature, perhaps the only different finding was a higher rate of patients without an apparent alteration in the immune system.

Epilepsia refractaria / Refractory epilepsy

La epilepsia refractaria o farmacorresistente es una condición frecuente en nuestra práctica neurológica cotidiana. Se considera que aproximadamente el 30% de pacientes con epilepsia de cualquier tipo van a persistircon crisis epilépticas a pesar de la terapia farmacológica. La definición de epilepsia farmacorresistente ha sido motivo de controversia entre los grupos de investigación a lo largo de las últimas décadas. La nueva propuesta de la Liga Internacional contra la Epilepsia (ILAE) para definir la falla del tratamiento médico y facilitar la selección de pacientes candidatos a procedimientos quirúrgicos es un gran avance hacia un mejor tratamiento para esta población. El objetivo del presente artículo es dar pautas que le permitan al neurólogo clínico identificar a los pacientes con epilepsia refractaria y dirigir los estudios diagnósticos que permitan seleccionar aquellos candidatos a un procedimiento quirúrgico curativo o paliativo. El éxito de dichos procedimientos está condicionado por la precisión diagnóstica en el protocolo prequirúrgico, donde el neurólogo desempeña un papel fundamental.

Drug resistant epilepsy is a very frequent condition seen at our clinical practice. Despite of antiepileptic drugsabout 30% of patients suffering from epilepsy will continue having seizures even if they are in combined schemes. The definition of pharmacoresistant epilepsy is subject of current controversy between researchgroups. However, the International League against Epilepsy (ILAE) has published recently a new consensusproposal defining drug resistant epilepsy. This new definition permits to select the group of patients that couldbe candidates to surgery. The aim of this review is to guide neurologists on the selection of patients sufferingfrom drug resistant epilepsy and to describe the main diagnosis procedures needs as preoperative assessment.