Consenso sobre accidente cerebrovascular isquémico agudo / Consensus on acute ischemic stroke

El accidente cerebrovascular es la tercera causa de muerte y la primera de discapacidad en la Argentina. Los eventos isquémicos constituyen el 80% de los casos. Los accidentes vasculares cerebrales requieren la implementación de protocolos sistematizados que permitan reducir los tiempos en la atención, la morbilidad y mortalidad. En el consenso participaron especialistas de nueve sociedades médicas relacionadas con la atención de pacientes con enfermedad cerebrovascular. Se consensuó un temario separado en capítulos y para la redacción de los mismos se conformaron grupos de trabajo con miembros de diferentes especialidades médicas. Se discutió y acordó para cada tema el nivel de recomendación en base a la mejor evidencia clínica disponible para cada tópico. Se realizó una adaptación al ámbito local de las recomendaciones cuando se consideró necesario. El sistema de la American Heart Association se utilizó para redactar las recomendaciones y su grado de evidencia. La corrección y edición fue realizada por cinco revisores externos, que no participaron en la redacción y con amplia experiencia en enfermedad vascular. Finalizado el documento preliminar, se organizó una reunión general con todos los integrantes de los grupos de trabajo y los revisores para redactar las recomendaciones definitivas. El consenso abarca la atención del paciente con accidente cerebrovascular isquémico en la fase pre-hospitalaria, evaluación inicial en la central de emergencias, terapias de recanalización (trombolisis y/o trombectomía mecánica), craniectomía descompresiva, neuroimágenes y cuidados clínicos en la internación.

Stroke is the third cause of death and the first cause of disability in Argentina. Ischemic events constitute 80% of cases. It requires the implementation of systematized protocols that allow reducing the time of care, morbidity and mortality. Specialists from nine medical societies related to the care of patients with cerebrovascular disease participated in the consensus. A separate agenda was agreed upon in chapters and for the writing of them, work groups were formed with members of different medical specialties. The level of recommendation was discussed and agreed upon for each topic based on the best clinical evidence available for each of them. An adaptation to the local scope of the recommendations was made when it was considered necessary.The American Heart Association system was used to draft the recommendations and their level of evidence. The correction and editing were done by five external reviewers, who did not participate in the writing and with extensive experience in vascular pathology. Once the preliminary document was finalized, a general meeting was held with all the members of the working groups and the reviewers to reach final recommendations. The consensus covers the management of ischemic stroke in the pre-hospital phase, initial evaluation in the emergency center, recanalization therapies (thrombolysis and/ or mechanical thrombectomy), decompressive craniectomy, neuroimaging and clinical care in the hospital.

Microangiopatía trombótica atrombocitopénica: un diagnóstico no realizado con los criterios actuales / Athrombocitopenic thrombotic microangiopathy: diagnosis not performed with the present criteria

Las microangiopatías trombóticas (MAT), que incluyen la púrpura trombótica trombocitopénica (PTT) y al síndrome urémico-hemolítico (SUH), se diagnostican habitualmente por la presencia de anemia hemolítica no inmune y trombocitopenia, lo que lleva a tratarlas con plasmaféresis. Se reporta el caso de una paciente de 51 años que ingresó con insuficiencia renal aguda-subaguda de etiología desconocida cuya biopsia renal mostró microangiopatía trombótica pero sin trombocitopenia ni anemia hemolítica. Por lo tanto dicha patología no siempre seria diagnosticada con los criterios actuales, debiendo utilizarse otros marcadores como ADAMTS-13.

The disease category of thrornbotic microangiopathy (TM) encompass diffcrent entities such as thrombocvtopenic thrombotic purpura (TTP) and uremic hemolytic syndrorne (UHS) , both strongly related and whose diagnosis relies on the presence of non immune hemolytic anemia and trombocytopenia, findings that should urge the caring physician to start plasmapheresis promptly. We report the case of a 51 year old woman admitted with acute-subacute renal failure of unknown etiology whose renal biopsy finding was thrombotic microangiopathy, in absence of thrombocytopenia and haemolytic anemia. This inusual case and according to published literature can not be diagnosed on standard accepted criteria and others markers like ADAMTS-13 should be considered.

Síndrome febril prolongado e infección de aneurisma de aorta abdominal por Salmonella enteritidis / Prolonged fever syndrome and infection of abdominal aortic aneurism due to Salmonella enteritidis

Endovascular infection of atherosclerotic aorta is a rare event in the setting of aged patients gram negative bacteremia of the salmonella group. Until the beginning of the 60s this meant an ominous diagnosis with an almost unavoidable fatal prognosis. Presently, this trend has been reverted, mostly due to an earlier diagnosis, the development of more sophisticated imaging techniques, the correct use of broad spectrum bactericidal antibiotics and prompt surgical management. Paradoxically, the incidence of arterial infections has increased in recent years, specially in old people with atherosclerotic abdominal aortic aneurysms, in whom infective endocarditis could not be demonstrated. We describe the case of a 65 year old man, with a history of long-standing non-insulin-dependent diabetes, presenting with protracted fever, weight loss and thigh pain. Blood cultures and serologic studies as well as several echocardiograms yielded negative results. An abdominal CT scan showed an infrarenal aortic aneurysm raising the clinical suspicion of arterial infection of abdominal aorta. The patient underwent surgery because of highly presumptive diagnosis of complicated aortic aneurysm. The resection was followed by an in situ graft. There was no evidence of disruption or gross collection. Samples of the aortic wall and perianeurysmatic fluid grew Salmonella enteritides. We describe the main etiopathogenic and clinic features of the entity highlighting the high sensitivity and specificity of the CT scan in the identification and characterization of infected aortic aneurysm. Certain features may firmly suggest this diagnosis without using preoperative aortography.