Hospital arrival time and functional outcome after acute ischaemic stroke: results from the PREMIER study.

INTRODUCTION: Information regarding hospital arrival times after acute ischaemic stroke (AIS) has mainly been gathered from countries with specialised stroke units. Little data from emerging nations is available. We aim to identify factors associated with achieving hospital arrival times of less than 1, 3, and 6 hours, and analyse how arrival times are related to functional outcomes after AIS. METHODS: We analysed data from patients with AIS included in the PREMIER study (Primer Registro Mexicano de Isquemia Cerebral) which defined time from symptom onset to hospital arrival. The functional prognosis at 30 days and at 3, 6, and 12 months was evaluated using the modified Rankin Scale. RESULTS: Among 1096 patients with AIS, 61 (6%) arrived in <1 hour, 250 (23%) in <3 hours, and 464 (42%) in <6 hours. The factors associated with very early (<1 hour) arrival were family history of ischemic heart disease and personal history of migraines; in <3 hours: age 40-69 years, family history of hypertension, personal history of dyslipidaemia and ischaemic heart disease, and care in a private hospital; in <6 hours: migraine, previous stroke, ischaemic heart disease, care in a private hospital, and family history of hypertension. Delayed hospital arrival was associated with lacunar stroke and alcoholism. Only 2.4% of patients underwent thrombolysis. Regardless of whether or not thrombolysis was performed, arrival time in <3 hours was associated with lower mortality at 3 and 6 months, and with fewer in-hospital complications. CONCLUSIONS: A high percentage of patients had short hospital arrival times; however, less than 3% underwent thrombolysis. Although many factors were associated with early hospital arrival, it is a priority to identify in-hospital barriers to performing thrombolysis.

Aspirin versus anticoagulation in intra- and extracranial vertebral artery dissection.

BACKGROUND AND PURPOSE: To evaluate the incidence and predictors of ischaemic recurrent stroke and the adverse events of antithrombotic therapy in patients with first intra- or extracranial vertebral artery dissection (VAD) who were treated with aspirin or oral anticoagulation (OA). METHODS: A 21-year database of consecutive patients with confirmed diagnoses of VAD (n = 110, 63% men; mean age 37.9 ± 8.5 years) without intracerebral hemorrhage and who were treated with aspirin or OA were analyzed retrospectively. In all cases, the admission diagnosis was ischaemic stroke. Three groups were defined according to the site of the dissection: (i) extracranial, (ii) intracranial, and (iii) intra-/extracranial. Clinical follow-up was obtained by neurologic examination. Outcome measures were (i) recurrent ischaemic events (ischaemic stroke or transient ischaemic attack) and (ii) intra- and extracranial major bleeding. RESULTS: No difference in age, smoking, or hypertension was found between patients treated with OA (n = 49) and those treated with aspirin (n = 50). Extracranial artery dissection (49%) had preponderance over intracranial (27%) or intra-/extracranial (23%) location. During the follow-up, recurrent ischaemic events were rare (one case). There were no bleeding complications. The treatment that was used did not influence the functional outcome or recanalization. A good functional outcome (modified Rankin score ≤ 2) was observed in 82 patients. CONCLUSIONS: Although this was a non-randomized study, our data suggest that the frequency of recurrent ischaemic stroke in patients with intra- or extracranial VAD is low and most likely independent of the type of antithrombotic treatment.

[Non-valvular atrial fibrillation and completed stroke: factors determining mortality, recurrence and prognosis after a first event in the Mexican population]. / Fibrilación auricular no valvular e infarto cerebral: determinantes de mortalidad, recurrencia y pronóstico después de un primer evento en población mexicana.

AIMS: Non-valvular atrial fibrillation (NVAF) accounts for 25% of completed strokes (CS) of a cardioembolic origin in patients over 60 years old. Our aim was to define the predictors of a good and poor prognosis after a CS secondary to an NVAF in our milieu. PATIENTS AND METHODS: We evaluated the risk factors (RF) and severity of CS in relation to death, functionality and recurrence at 5 years. 81 patients between the ages of 49 and 88 were followed up consecutively for 1 to 90 months; 38 (46.9%) of them were males. Multivariate analysis was performed with the following independent variables: age, gender, smoking, hypertension, heart disease, diabetes mellitus and characteristics of the stroke. The severity of the CS was assessed by means of the modified Rankin scale, which was dichotomised into a good prognosis (0-2) and a poor prognosis (> or = 3), both basal and at the end of the clinical control. We also evaluated the secondary preventive treatment used and its relation with recurrence, prognosis, death and complications. RESULTS: No RF was linked to a poor prognosis or recurrence; 88% had a poor prognosis. Antiplatelet drugs were used in 42% of cases and 39% received anticoagulants. A good final progression was observed in 9.5% of the patients treated with antiplatelet drugs versus 35% of those receiving anticoagulation therapy (p = 0.004). Severity of the CS on admission was worse in the aspirin group, with no differences in recurrence and mortality. A better prognosis was observed in patients from urban areas. CONCLUSIONS: Use of antiplatelet drugs, living in a rural area and a Rankin score of > or = 3 on admission are factors suggesting a poor prognosis in the clinical control at 5 years.

[Acute motor axonal neuropathy with hyperreflexia and central demyelination associated to anti-GA1 antibodies]. / Neuropatia axonal motora aguda con hiperreflexia y desmielinizacion central asociada a anticuerpos anti-GA1.

CASE REPORT: We report the case of a 37-year-old male who presented signs of acute motor axonal polyradiculoneuropathy that began three weeks after a three-day bout of gastroenteritis and was accompanied by a stiff neck, hyperreflexia and anti-GA1 antibodies. The symptoms developed within 12 hours, after beginning with the patient waking up in the middle of the night with a headache; the following morning he presented general weakness and cranial neuropathy and therefore decided to go to hospital. The neurological examination showed multiple cranial neuropathy, quadriparesis with hyperreflexia, bilateral Babinski and a stiff neck. Following treatment, first with methylprednisolone and then with gamma globulin, the development of the illness was halted. Neuroinfection due to lumbar puncture was ruled out and acute motor axonal polyradiculoneuropathy was confirmed in a second neuroconduction study performed seven days after admission. Magnetic resonance imaging revealed an area of demyelination in the white matter and the presence of anti-GA1 antibodies was detected in the serological analysis. Two years later, the patient performs activities of daily living, walks with assistance and has gone back to work. CONCLUSIONS: Acute motor axonal polyradiculoneuropathy with hyperreflexia, a stiff neck and central demyelination can be associated to anti-GA1 antibodies. Treatment with gamma globulin appears to curb development of the disease.

Fibrilación auricular no valvular e infarto cerebral: determinantes de mortalidad, recurrencia y pronóstico después de un primer evento en población mexicana / Non-valvular atrial fibrillation and completed stroke: factors determining mortality, recurrence and prognosis after a first event in the Mexican population

Objetivo. La fibrilación auricular no valvular (FANV) representa el 25% de los infartos cerebrales (IC) de origen cardioembólico en mayores de 60 años. Nuestro propósito fue definir los factores de buen y mal pronósticos después de un IC secundario a FANV en nuestro medio. Pacientes y métodos. Evaluamos los factores de riesgo (FR) y la gravedad del IC en relación con muerte, funcionalidad y recurrencia a cinco años. Se siguieron 81 pacientes consecutivos de entre 49 y 88 años, durante 1-90 meses; 38 (46,9%) fueron hombres. Se realizó un análisis multivariado con las siguientes variables independientes: edad, sexo, tabaquismo, hipertensión, cardiopatía, diabetes mellitus y características del infarto. La gravedad del IC se evaluó mediante la escala modificada de Rankin, dicotomizada en buen pronóstico (0-2) y mal pronóstico 3), basal y al final del control clínico. Evaluamos también el tratamiento de prevención secundaria utilizado y su relación con recurrencia, pronóstico, muerte y complicaciones. Resultados. Ningún FR se asoció con mal pronóstico o recurrencia; el 88% tuvo mal pronóstico. En el 42% se utilizaron antiagregantes, y en el 39% anticoagulantes. Se observó una buena evolución final en un 9,5% de los pacientes con antiagregantes frente a un 35% con anticoagulación (p 0,004). La gravedad del IC al ingreso fue peor en el grupo de aspirina, sin diferencias en recurrencia y mortalidad. Se observó mejor pronóstico en los pacientes provenientes de áreas urbanas. Conclusión. El uso de antiagregantes, vivir en área rural y un Rankin 3 al ingreso son factores de mal pronóstico en el control clínico a los cinco años

Aims. Non-valvular atrial fibrillation (NVAF) accounts for 25% of completed strokes (CS) of a cardioembolic origin in patients over 60 years old. Our aim was to define the predictors of a good and poor prognosis after a CS secondary to an NVAF in our milieu. Patients and methods. We evaluated the risk factors (RF) and severity of CS in relation to death, functionality and recurrence at 5 years. 81 patients between the ages of 49 and 88 were followed up consecutively for 1 to 90 months; 38 (46.9%) of them were males. Multivariate analysis was performed with the following independent variables: age, gender, smoking, hypertension, heart disease, diabetes mellitus and characteristics of the stroke. The severity of the CS was assessed by means of the modified Rankin scale, which was dichotomised into a good prognosis (0-2) and a poor prognosis 3), both basal and at the end of the clinical control. We also evaluated the secondary preventive treatment used and its relation with recurrence, prognosis, death and complications. Results. No RF was linked to a poor prognosis or recurrence; 88% had a poor prognosis. Antiplatelet drugs were used in 42% of cases and 39% received anticoagulants. A good final progression was observed in 9.5% of the patients treated with antiplatelet drugs versus 35% of those receiving anticoagulation therapy (p = 0.004). Severity of the CS on admission was worse in the aspirin group, with no differences in recurrence and mortality. A better prognosis was observed in patients from urban areas. Conclusions. Use of antiplatelet drugs, living in a rural area and a Rankin score of 3 on admission are factors suggesting a poor prognosis in the clinical control at 5 years