Perfil clínico de los pacientes con aneurisma cerebral atendidos en el Hospital Carlos Andrade Marín / Clinical profile of patients with cerebral aneurysms treated at Carlos Andrade Marín Hospital

INTRODUCCIÓN. En Ecuador, las enfermedades cerebrovasculares son la tercera causa de muerte en la población general; existen pocos datos en la literatura médica sobre la hemorragia subaracnoidea aneurismática y aneurismas no rotos, por lo que fue fundamental describir un perfil clínico. OBJETIVO. Caracterizar la clínica de los pacientes con diagnóstico de aneurisma cerebral. MATERIALES Y MÉTODOS. Estudio observacional descriptivo. Población de 450 y muestra de 447 pacientes con diagnóstico de aneurisma cerebral atendidos en la Unidad de Neurología del Hospital Carlos Andrade Marín, periodo enero 2010 a diciembre 2018. Los datos clínicos e imagenológicos fueron recolectados a través de la revisión de historias clínicas digitales obtenidas del sistema informático MIS/AS400, y se analizaron en el programa estadístico International Business Machines Statistical Package for the Social Sciences, versión 23. RESULTADOS. Se identificaron 605 aneurismas en 447 pacientes. El 80,5% (360; 447) presentó aneurismas rotos, de éstos el 81,4% (293; 360) tuvo un solo aneurisma. El factor de riesgo más frecuente fue la hipertensión arterial con el 44,3% (198; 447), las manifestaciones observadas fueron: hemorragia subaracnoidea con el 98,9% (356; 360) en aneurismas rotos; y cefalea con el 65,5% (57; 87) en aneurismas no rotos. DISCUSIÓN. Se encontró datos relevantes no coincidentes con la literatura científica mundial, como el bajo número de aneurismas asintomáticos y no rotos, comparados con su contraparte. CONCLUSIÓN. Se evidenció que los aneurismas intracraneales produjeron una amplia gama de manifestaciones clínicas, que fluctuaron desde la hemorragia subaracnoidea como la más frecuente en el grupo de aneurismas rotos, hasta pacientes completamente asintomáticos en el grupo de aneurismas no rotos.

INTRODUCTION. In Ecuador, cerebrovascular diseases are the third leading cause of death in the general population; there are few data in the medical literature on aneurysmal subarachnoid hemorrhage and unruptured aneurysms, so it was essential to describe a clinical profile. OBJECTIVE. To characterize the clinical profile of patients diagnosed with cerebral aneurysm. MATERIALS AND METHODS. Descriptive observational study. Population of 450 and sample of 447 patients with a diagnosis of cerebral aneurysm seen in the Neurology Unit of the Carlos Andrade Marín Hospital, period January 2010 to December 2018. Clinical and imaging data were collected through the review of digital medical records obtained from the MIS/AS400 computer system, and were analyzed in the statistical program International Business Machines Statistical Package for the Social Sciences, version 23. RESULTS. A total of 605 aneurysms were identified in 447 patients. A total of 80,5% (360; 447) had ruptured aneurysms, of which 81,4% (293; 360) had a single aneurysm. The most common risk factor was hypertension with 44,3% (198; 447), the manifestations observed were: subarachnoid hemorrhage with 98,9% (356; 360) in ruptured aneurysms; and headache with 65,5% (57; 87) in unruptured aneurysms. DISCUSSION. We found relevant data not consistent with the world scientific literature, such as the low number of asymptomatic and unruptured aneurysms, compared with its counterpart. CONCLUSION. It was evidenced that intracranial aneurysms produced a wide range of clinical manifestations, ranging from subarachnoid hemorrhage as the most frequent in the group of ruptured aneurysms, to completely asymptomatic patients in the group of unruptured aneurysms.

Arteriopathy in pediatric stroke: an underestimated clinical entity / Arteriopatia em crianças com acidente vascular cerebral: uma entidade clínica subestimada

ABSTRACT Background: Pediatric arterial ischemic stroke (AIS), which was thought to be a rare disorder, is being increasingly recognized as an important cause of neurological morbidity, thanks to new advances in neuroimaging. Objective: The aim of this study was to review the main etiologies of stroke due to arteriopathy in children. Methods: Using a series of cases from our institution, we addressed its epidemiological aspects, physiopathology, imaging findings from CT, MR angiography, MR conventional sequences and MR DWI, and nuclear medicine findings. Results: Through discussion of the most recent classification for childhood AIS (Childhood AIS Standardized Classification and Diagnostic Evaluation, CASCADE), we propose a modified classification based on the anatomical site of disease, which includes vasculitis, varicella, arterial dissection, moyamoya, fibromuscular dysplasia, Takayasu's arteritis and genetic causes (such as ACTA-2 mutation, PHACE syndrome and ADA-2 deficiency). We have detailed each of these separately. Conclusions: Prompt recognition of AIS and thorough investigation for potential risk factors are crucial for a better outcome. In this scenario, neurovascular imaging plays an important role in diagnosing AIS and identifying children at high risk of recurrent stroke.

RESUMO Introdução: O acidente vascular cerebral (AVC) pediátrico, considerado um distúrbio raro, está sendo cada vez mais reconhecido como importante causa de morbidade neurológica, graças aos novos avanços na neuroimagem. Objetivo: Revisar as principais etiologias do AVC por arteriopatia em crianças. Métodos: Utilizando-se de uma série de casos de nossa instituição, abordamos seus aspectos epidemiológicos, fisiopatológicos e de imagem na angiotomografia computadorizada e angiorressonância magnética, sequências convencionais e avançadas de ressonância magnética e medicina nuclear. Resultados: Com base na classificação mais recente de AVC na infância (Classificação Padronizada e Avaliação Diagnóstica do AVC na Infância - CASCADE) propusemos uma classificação modificada com base no local anatômico da doença, que inclui vasculite, varicela, dissecção arterial, Moyamoya, displasia fibromuscular, arterite de Takayasu e causas genéticas (como mutação ACTA-2, síndrome PHACE e deficiência de ADA-2), detalhando cada uma separadamente. Conclusões: O reconhecimento imediato do AVC na infância e a investigação minuciosa de possíveis fatores de risco são cruciais para um melhor resultado. Nesse cenário, a imagem neurovascular desempenha papel importante no diagnóstico de AVC e na identificação de crianças com alto risco de recorrência.

Cerebral Proliferative Angiopathy: Case Report

Proliferative angiopathy (PA) is a rare cerebral vascular disease in which anomalous vessels continually recruit additional feeder arteries, amid a functional brain parenchyma. We report the case of a young woman with progressive history of headache, motor deficit, seizures and drowsiness. She received a misdiagnosis of brain arteriovenous malformation (AVM) and evolved with dysarthria and cognitive decline after an unsuccessful embolization performed at another institution. We opted for conservative treatment with periodic control by imaging tests. Proliferative angiopathy differs in natural history, prognosis, histopathology and treatment of the usual AVMs. Endovascular procedures aggravate the neurological deficits, which are usually progressive and tend to worsen over time.

A angiopatia proliferativa (AP) é uma doença vascular cerebral rara em que vasos anômalos recrutam continuamente artérias nutridoras adicionais em um parênquima cerebral normal. Relatamos um caso de uma mulher jovem com história progressiva de cefaleia, déficit motor, convulsões e sonolência. Ela recebeu um diagnóstico incorreto da malformação arteriovenosa (MAV) cerebral e evoluiu com disartria e declínio cognitivo após uma embolização malsucedida realizada em outra instituição. Optamos pelo tratamento conservador com controle periódico por testes de imagem. A AP difere das MAVs usuais em relação a história natural, prognóstico, histopatologia e tratamento. Os procedimentos endovasculares agravam os déficits neurológicos, que geralmente são progressivos e tendem a piorar ao longo do tempo.

Seguridad y eficacia a corto plazo del cierre de orejuela izquierda con dispositivo WATCHMAN ® en fibrilación auricular no valvular en pacientes con alto riesgo de sangrado / Short-term safety and efficacy of left atrial appendage closure using WATCHMAN ® device for non-valvular atrial fibrillation in patients with a high risk of bleeding

Resumen Objetivo: Evaluar la seguridad y eficacia del cierre percutáneo de la orejuela izquierda en pacientes con fibrilación auricular no valvular con alto riesgo de sangrado o con contraindicación para anticoagulación oral. Métodos: Estudio prospectivo no aleatorizado en una cohorte de pacientes con fibrilación auricular con contraindicación o dificultades con anticoagulación oral y puntaje de CHA2DS2-VASc ≥ 2 y de HASBLED ≥ 2, elegibles para doble antiagregación con aspirina y clopidogrel. Resultados: Se incluyeron 53 pacientes, con edad promedio de 72,24 ± 9,22 años, de los cuales 54,72% eran hombres; 20,75% tenían fibrilación auricular paroxística, 15,1% persistente y 64,15% permanente. Además, 18,9% tenían insuficiencia cardíaca, 22,64% enfermedad coronaria, 92,45% hipertensión arterial, 41,51% eran mayores de 75 años, 18,9% eran diabéticos y 37,7% tenían enfermedad cerebrovascular previa. El promedio del puntaje de CHADS2 y CHA2DS2-VASc fue de 2,73 ± 1,34 y 4,24 ± 1,54, respectivamente. El procedimiento fue exitoso en un 98% (52/53). Sólo en un caso no fue posible implantar el dispositivo por causas anatómicas. No hubo eventos adversos serios relacionados con la implantación; durante el procedimiento se registró un episodio de derrame pericárdico leve que no requirió drenaje. En los 45 días de seguimiento, 2 pacientes (3,77%) desarrollaron enfermedad cerebrovascular y se registró un deceso por causa no cardíaca (1,89%). Conclusiones: El cierre percutáneo de la orejuela izquierda con dispositivo WATCHMAN® es un procedimiento seguro y eficaz en pacientes de alto riesgo con fibrilación auricular no valvular y contraindicación o dificultades para la anticoagulación oral.

Abstract Motivation: To assess the safety and efficacy of percutaneous left atrial appendage closure in patients with non-valvular atrial fibrillation with a high risk of bleeding or a contraindication to oral anticoagulation drugs. Methods: Prospective non-randomised study of a cohort of patients with atrial fibrillation who had a contraindication to or difficulties with oral anticoagulation, CHA2DS2-VASc ≥ 2 and HASBLED ≥ 2 scores, and who were eligible for dual antiaggregation therapy with aspirin and clopidogrel. Results: 53 patients with an average age of 72.24 ± 9.22 years were included, out of whom 54.72% were men, 20.75% had paroxysmal, 15.1% persistent and 64.15% permanent atrial fibrillation, respectively. Besides, 18.9% suffered from heart failure, 22.64% from coronary disease, 92.45% from arterial hypertension, 41.51% were over 75 years old, 18.9% were diabetic and 37.7% had a history of cerebrovascular disease. Average CHADS= y CHA=DS2-VASc scores were of 2.73 ± 1.34 and 4.24 ± 1.54 respectively. Procedure was successful in 98% of the cases (52/53). It was not possible to implant the device in only one case due to anatomical reasons. There were no severe adverse events related to the insertion; during the procedure an episode of mild pericardial effusion that did not require drainage was registered. DUring the 45-day follow up period, 2 patients (3.77%) developed a cerebrovascular disease, and there was one noncardiac death (1.89%). Conclusions: The percutaneous left atrial appendage closure with device is a safe and efficient procedure in high-risk patients with non-valvular atrial fibrillation and contraindications to or difficulties for oral anticoagulation therapy.

Post-stroke psychosis: how long should we treat? / Psicose após acidente vascular cerebral: até quando devemos tratar?

Abstract Objective: To describe a rare case of a patient who developed psychotic symptoms after a right stroke that disappeared with antipsychotic treatment, but appears to need low-dose maintenance antipsychotic therapy. Case description: A 65-year-old man presented at the psychiatric emergency service with a history of persistent delusional jealousy, visual illusions and agitation with onset about 1 month after a right posterior cerebral artery ischemic stroke. These symptoms only disappeared with therapeutic dosages of an antipsychotic drug (3 mg/day of risperidone). At 2-year follow-up, he no longer had delusional activity and the antipsychotic treatment was gradually discontinued over the following year. However, 1 week after full cessation, the patient once more became agitated and suspicious and was put back on risperidone at 0.25 mg/day, resulting in rapid clinical remission. One year after the return to low-dose risperidone, the patient's psychopathology is still under control and he is free from psychotic symptoms. Comments: Psychosis is a relatively rare complication after stroke. To our knowledge, no cases of post-stroke psychosis that apparently require continuous low-dose antipsychotic treatment have been reported to date. Our case suggests that low-dose maintenance antipsychotic therapy may be needed for certain patients with post-stroke psychosis, especially for those with risk factors and non-acute onset.

Resumo Objetivo: Descrever o caso raro de um paciente que desenvolveu sintomas psicóticos após um acidente vascular cerebral (AVC) no nível do hemisfério direito que remitiram com tratamento antipsicótico, mas parece precisar de uma terapêutica de manutenção com antipsicótico em baixa dosagem. Descrição de caso: Um homem de 65 anos apresentou-se no serviço de urgência psiquiátrica por um quadro persistente de delírio de ciúmes, ilusões visuais e agitação com início cerca de 1 mês após AVC isquêmico no nível da artéria cerebral posterior direita. Esses sintomas só desapareceram com doses terapêuticas de antipsicótico (risperidona 3 mg/dia). Após 2 anos de seguimento, o paciente não mais apresentava atividade delirante, e o tratamento antipsicótico foi progressivamente descontinuado durante o ano seguinte. No entanto, 1 semana após a suspensão total, o paciente começou a ficar agitado e desconfiado, tendo-se reiniciado a risperidona 0,25 mg/dia, com rápida remissão clínica. O paciente está medicado com esta baixa dose de antipsicótico há um ano, permanecendo psicopatologicamente compensado e sem sintomas psicóticos. Comentários: A psicose é uma complicação relativamente rara após AVC. Segundo nosso conhecimento, não há casos descritos até ao momento de psicose após AVC que, aparentemente, requerem uma dose baixa contínua de antipsicótico. Nosso caso sugere que uma terapêutica de manutenção com antipsicótico em baixa dosagem pode ser necessária para determinados pacientes com psicose após AVC, especialmente para aqueles com fatores de risco e início não agudo dos sintomas.

Arteritis de Takayasu: Etiolog¡a inhabitual de infarto cerebral. Reporte de un caso / Takayasu arteritis: an unusual etiology of ischemic stroke. A case report

La arteritis de Takayasu (AT) es una vasculitis crónica de grandes vasos que afecta a la aorta y a sus principales ramas. La presentación clínica inicial generalmente se manifiesta con síntomas constitucionales inespecíficos, perode forma ocasional puede debutar con isquemia de un órgano determinado. Presentamos el caso de una mujer de 31años de edad sin ascendencia japonesa, sin factores de riesgo vasculares, que presentó de forma súbita déficit motoren hemicuerpo derecho y alteración del lenguaje. Al examen físico se encontró ausencia de pulso en una arteriadistal y una diferencia en la presión arterial en los miembros superiores. La angiografía por sustracción digital mostró oclusión de la arteria subclavia y carótida común izquierda, así como estenosis severa de la arteria subclavia derecha en su parte media.Se diagnosticó AT de acuerdo a los criterios diagnósticos del Colegio Americano de Reumatólogos de 1990 ylos Criterios modificados de Ishikawa. La paciente recibió tratamiento médico y de la rehabilitación con buena respuesta. La AT debe considerarse como posibilidad etiológica en todos los pacientes jóvenes que presenten uninfarto cerebral. Su diagnóstico precoz es crucial, ya que esta patología es sensible al tratamiento médico y se asociacon buenos resultados clínicos.

Takayasu arteritis (TA) is a chronic large vessel vasculitis that affects the aorta and its main branches. The initialclinical presentation is generally with non-specific constitutional symptoms, but occasionally it may debut with aparticular organ ischemia. We report the case of a 31-year-old woman, who presented suddenly a motor deficit inthe right hemibody and language impairment. Physical examination revealed the lack of a pulse in a distal artery and the difference in blood pressure between upper limbs. Digital subtraction angiography showed occlusion of the left subclavian artery and left common carotid artery and severe stenosis of the right subclavian artery in the middle portion. AT was diagnosed according to the diagnostic criteria of the American College of Rheumatologists, 1990. The patient received medical treatment and rehabilitation with good response. AT as an etiologic possibility should be considered in all young patients who have a stroke. Early diagnosis is crucial because this pathology is sensitive to medical treatment and it is associated with good clinical results.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) in Argentina / Arteropatia cerebral autosomal dominante com infartos subcorticais e leucoencefalopatia (CADASIL) na Argentina

CADASIL is the most common cause of hereditary stroke and vascular dementia. Published information about this disease in South America is scant. We describe clinical and demographic characteristics of 13 patients (10 families) with CADASIL from Argentina.Methods Medical records, diagnostic tests and family history of patients with CADASIL were reviewed.Results Thirteen patients with CADASIL (10 families) were included. All patients had European ancestry. Initial presentation was stroke in most patients (n = 11). Stroke patients later developed cognitive complaints (n = 9), migraine with aura (n = 1), apathy (n = 4) and depression (n = 6). External capsule and temporal lobe involvement on MRI were characteristic imaging findings. Two patients died after intracerebral hemorrhage.Conclusion This is the first report of non-related patients with CADASIL in South America addressing ancestry. Since European ancestry is not highly prevalent in all South American countries, there may be variable incidence of CADASIL within this region.

CADASIL é a causa mais frequente de acidente vascular cerebral e demência hereditários. São poucas as publicações sobre esta doença na América do Sul. Aqui descrevemos dados clínicos e demográficos de 13 pacientes (10 famílias) da Argentina com CADASIL.Métodos Prontuários médicos testes diagnósticos e história familiar de pacientes com CADASIL foram revisados.Resultados Treze pacientes com CADASIL (10 famílias) foram incluídos. Todos os pacientes tinha ancestralidade europeia. A apresentação inicial foi acidente vascular cerebral na maioria dos pacientes (n = 11). Pacientes com acidente vascular cerebral depois desenvolveram alterações cognitivas (n = 9), enxaqueca com aura (n = 1), apatia (n = 4) e depressão (n = 6). Os achados de imagem característicos da RM foram na cápsula externa e no lobo temporal. Dois pacientes morreram por hemorragia intracerebral.Conclusão Este é o primeiro relato de série de casos de pessoas não relacionadas entre si que apresentavam CADASIL na América do Sul, discutindo ancestralidade. Uma vez que a ascendência europeia tem prevalência variada em diferentes países da América do Sul, é possível que esta seja uma variável de incidência de CADASIL nesta região.

Role of BK(Ca) channels in diabetic vascular complications / 中华医学杂志(英文版)

<p><b>OBJECTIVE</b>This review focuses on the role of the large conductance calcium-activated potassium (BKCa) channels in diabetic vascular complications.</p><p><b>DATA SOURCES</b>Relevant articles published in English or Chinese from 1981 to present were selected from PubMed. The search terms were "BKCa channels" and "diabetes". Important references from selected articles were also retrieved.</p><p><b>STUDY SELECTION</b>Articles regarding the role of BKCa channels in diabetic vascular complications and relevant mechanisms were selected.</p><p><b>RESULTS</b>The BKCa channels are abundantly expressed in vascular smooth cells and play an important role in regulation of vascular tone. Multiple studies indicated that the expression and function of BKCa channels are altered by different mechanisms in diabetic vascular diseases such as coronary arterial disease, cerebral arterial disease, and diabetic retinopathy.</p><p><b>CONCLUSION</b>BKCa channels may play an important role in diabetic vascular complications and may be an effective therapeutic target for relieving and reducing the burden of diabetic vascular complications.</p>

Unruptured middle cerebral artery aneurysm in a patient with systemic lupus erthematosus: a diagnostic challenge

A 22-year-old female patient presented to the Emergency Department of a tertiary care hospital with symptoms of headache and nausea. She has been on a regular follow-up for the preceding three and a half years after being diagnosed as systemic lupus erythematosus [SLE]. She had been treated earlier for SLE nephritis in the same institution, and had two relapses of nephrotic syndrome in the last three and a half years for which she had been treated and had achieved complete remission. All possibilities of headaches in background of SLE were considered. CNS examination was inconclusive. There was no nuchal rigidity or no cranial nerve deficits. Fundoscopy and Plain CT scan of brain were normal. The possibility of CNS-lupus was considered considering the high values of antiphospholipid antibodies [APLA]. Treatment was initiated accordingly; however, there was no improvement in her symptoms. Although being rare in a patient with SLE, the possibility of an aneurysm was considered. Four vessel digital substraction angiography revealed two unruptured aneurysms of 7.2 mm and 3.9 mm in the left middle cerebral artery [MCA] territory. Craniotomy and aneurysmal clipping was done successfully, and the patient was relieved of her symptoms. A high degree of suspicion towards a rarer cause clinched the diagnosis of a left MCA territory stem artery aneurysm. This rationale of strong suspicion and discussion of differential diagnosis brought a change in the management of the patient

Utilidad de la espectroscopia por resonancia magnética en fetos con resistencias arteriales normales y resistencias arteriales elevadas / Usefulness of magnetic resonance spectroscopy in fetuses with normal arterial resistence and elevated arterial resistance

Determinar si la espectroscopia por resonancia magnética puede utilizarse en la evaluación del desarrollo cerebral de fetos con resistencias arteriales normales y resistencias arteriales elevadas y predecir daño neuronal. Unidad de Perinatología del Hospital Universitario de Caracas. Estudio prospectivo. Se midieron las resistencias arteriales del cordón umbilical y de la arteria cerebral media a nivel del segmento M2 a sesenta embarazadas de edad de gestación entre 26 y 36 semanas. Imágenes sagitales coronales y axiales del cuerpo y cerebro se obtuvieron de todos los fetos. La espectroscopia cerebral se realizó con la técnica del univoxel, con tiempo de eco corto e intermedio. Se analizaron las relaciones N-acetil aspartato/creatina, N-acetil aspartato/colina, colina/creatina, colina/N-acetil aspartato, mioInositol/N-acetil aspartato e mioInositol/creatina. La prueba estadística se realizó mediante frecuencias absolutas, porcentajes, medias, desviaciones estándar y el test de Fisher. Treinta presentaron resistencias arteriales normales (fetos control) y treinta presentaron resistencias elevadas. Las resistencias del cordón umbilical fueron significativamente mayores en fetos con resistencias arteriales elevadas que en fetos control. La morfo-anatomía fue normal en todos los fetos. En los fetos control, N-acetil aspartato/colina y N-acetil aspartato/creatina aumentaron con la edad gestacional y colina/N-acetil aspartato, mioInositol/N-acetil aspartato y mioinositol/creatina disminuyeron. Las relaciones en fetos con resistencias arteriales elevadas presentaron mucha variabilidad y un 69 por ciento de los espectros presentaron lactato. La espectroscopia por resonancia magnética puede evaluar el desarrollo cerebral de fetos y la presencia de lactato cerebral refleja una condición de hipoxia que puede predecir daño neurológico

To determine if proton magnetic resonance spectroscopy could be used to evaluate fetal brain development with normal and high arterial resistances, and to predict neurological damage. Unidad de Perinatología del Hospital Universitario de Caracas.Umbilical cord and brain median artery at M2 segment level arterial resistances were measured to sixty pregnant women with gestation age of 26 to 36 weeks. Thirty had normal arterial resistances (control fetuses) and thirty had high arterial resistances. Body and cerebral axial, coronal and sagittal images were obtained from all fetuses. Cerebral spectroscopy was performed with short and medium-length eco time. Single voxel was located in the basal ganglia. N-acetylaspartate/creatine, N-acetylaspartate/choline, choline/creatine, choline/N-acetylaspartate, mio-inositol/N-acetilaspartate and mio-inositol/creatine ratios were analyzed. Absolute frequencies, percentages, median, standard deviations and Fisher test were used for statistical analysis. Fetuses with high umbilical cord arterial resistances were significant higher than the obtained for control fetuses. Anatomical images were normal in all fetuses. N-acetylaspartate/choline and N-acetylaspartate/creatine increased and choline/N-acetylaspartate, myo-inositol/N-acetylaspartate and myo-inositol/creatine decreased with gestational age in control fetuses. Large variability resulted on metabolite ratios of fetuses with high umbilical cord arterial resistances. No significant differences on metabolites ratios were found between control fetuses and fetuses with high umbilical cord arterial resistances. Lactate was detected in 68 percent of brain fetuses with high umbilical cord arterial resistances. Conclusion: Proton magnetic resonance spectroscopy is able to evaluate fetal brain development and brain lactate, which is indicative of hypoxia, might predict neurological damage

Acute Non-Traumatic Cortical Subarachnoid Hemorrhage

Most nontraumatic subarachnoid hemorrhages are induced by the rupture of a saccular aneurysm. Acute nontraumatic cortical subarachnoid hemorrhage at the convexity of a cerebral hemisphere is a relatively rare occurrence with various vascular or nonvascular causes. Furthermore, the clinical manifestation of acute nontraumatic cortical subarachnoid hemorrhage differs from that of aneurysmal rupture. We experienced five cases of acute nontraumatic cortical subarachnoid hemorrhage with diverse neurological symptoms. Consecutive workup revealed the various etiologies of that hemorrhage.

Hallazgos imaginológicos en el síndrome de phaces: reporte de caso / Imaging findings in phaces syndrome: case report

Los hemangiomas de tipo capilar son los tumores de la infancia más frecuentes, principalmente en niños menores de un año de edad y usualmente afectan la cabeza y el cuello. Por lo general, están solitarios; sin embargo, aproximadamente un 20% de los niños con grandes hemangiomas cervicofaciales tendrán una de las anomalías asociadas en el síndrome de PHACES, un raro síndrome neurocutáneo de predominio en el sexo femenino, con características mayores, como malformaciones cerebrales en la fosa posterior, hemangiomas de tipo capilar, anomalías arteriales, coartación de aorta, defectos cardiacos y anormalidades oculares. Cuando se asocia con hendidura esternal o rafe supraumbilical, es referido como síndrome de PHACES. Se presenta el caso de una niña de cuatro años de edad con hemangioma facial congénito asociado con anomalías vasculares cerebrales y de la fosa posterior.

Capillary hemangiomas of infancy are the most common childhood tumors, mainly in children under 1 year old, and they usually involve the head and neck. They are usually solitary, but about 20% of the children with large cervicofacial hemangiomas will have one of the anomalies associated with PHACES syndrome. PHACES is a rare neurocutaneous syndrome with female predominance and features such as: brain malformations in the posteriorfossa, hemangiomas, arterial anomalies, coarctation of the aorta, heart defects, and ocular abnormalities. When associated with sternal slit and/or supraumbilical Raphe, it is referredto as PHACES syndrome. The case of a 4-year-old child with congenital facial hemangioma associated to the posterior fossa and with cerebral vascular anomalies is presented.

Clinical application of the three-dimensional CT of the flat-panel digital subtraction angiography system / 南方医科大学学报

<p><b>OBJECTIVE</b>To evaluate the clinical value of the three-dimensional (3D) CT module of the flat-panel digital subtraction angiography (DSA) system.</p><p><b>METHODS</b>A retrospective analysis was conducted among 278 patients receiving examination with rotational 3D-CT of INNOVA 3100 flat-panel DSA system. AW4.3-04 workstation was used to perform the 3D reconstruction and INNOVA CT reconstruction, and the imaging data were analyzed in comparison with the clinical results.</p><p><b>RESULTS</b>The 3D-CT of the flat panel DSA system displayed the conditions of cerebral aneurysms in 54 cases, cerebral arteriovenous malformation in 25 cases, and the intracranial conditions in 24 cases. The blood supply and tumor vessels were clearly displayed in 57 cases, and the effects of embolization and endovascular stenting were evaluated in 27 and 21 cases, respectively. The rotational 3D-CT was used to evaluate complete embolization in 24 cases, and failed to display the feeding arteries of small tumors in 11 cases. The vascular lesions, biliary tract lesions, and the occurrence of hemorrhage during interventional therapy were observed in 58, 5 and 25 cases, respectively.</p><p><b>CONCLUSION</b>The 3D-CT module of the flat-panel DSA system can easily display abnormal vascular lesions and provide comprehensive anatomical information to facilitate interventional therapies and complication monitoring.</p>

Fenestration of the anterior cerebral artery detected by magnetic resonance angiography / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Fenestration of the proximal anterior cerebral artery (ACA) A1 segment is a rare anatomic variation. The purpose of the this study was to report the incidence of fenestration in the proximal segment of the anterior cerebral artery and to delineate its configurations on cranial MR angiography.</p><p><b>METHODS</b>Magnetic resonance angiography (MRA) was performed in 762 patients using 1.5 T imagers during the period July 2007 through September 2008. All images were obtained by the three-dimensional time-of-flight (3D TOF) technique. Volume rendering (VR) images in the horizontal rotation view were displayed stereoscopically. The presence of fenestration in the proximal segment of the anterior cerebral artery was identified and evaluated retrospectively by MRA.</p><p><b>RESULTS</b>Six patients (four men and two women, 15 to 63 years of age, median age 50 years) had proximal ACA fenestration. The appearance rate of ACA fenestration was 0.8% (6/762). All 6 fenestrations were located at the A1 segment: three of them were with a slit-like shape and three were with a convex-lens-like shape, 5 of the right A1 segment, 1 of the left A1 segment.</p><p><b>CONCLUSION</b>Recognizing ACA fenestration is important to interpret cranial MR angiographys and helpful to make a plan for neurosurgical procedures or neurological intervention.</p>

Study on optimum stimulation parameter for Shuigou (GV 26) in Xingnao Kaiqiao needling method / 中国针灸

<p><b>OBJECTIVE</b>to investigate the influence of acupuncture parameter on acupuncture effect and to probe the optimum stimulation parameter for Shuigou (GV 26) in Xingnao Kaiqiao needling method.</p><p><b>METHODS</b>The rat model of middle cerebral artery obstruction (MCAO) was replicated and "Shuigou" (GV 26) was stimulated by 9 acupuncture parameters combined by two factors at 3 levels, i. e. frequency 1, 2, 3 times/second, and needling duration 5 s, 60 s, 180 s. The effects of acupuncture at "Shuigou" (GV 26) with the 9 different acupuncture parameters on cerebral blood flow (CBF) in the MCAO rat were investigated by orthogonal test, factor analysis and one-way ANOVA.</p><p><b>RESULTS</b>Acupuncture effect was influenced by acupuncture frequency, acupuncture duration and their combination. Among them, the acupuncture duration was the most important factor. The best acupuncture effect could be attained by using as long acupuncture duration as possibly with the fastest acupuncture frequency.</p><p><b>CONCLUSION</b>In the Xingnao Kaiqiao needling method, acupuncture at "Shuigou" (GV 26) with fastest frequency and enough long duration can get the best acupuncture effect, which are the optimum stimulation parameters for "Shuigou" (GV 26).</p>