Comparison of right-to-left shunt characteristics in cryptogenic embolic ischemic stroke and non-cardioembolic ischemic stroke / Comparação das características do shunt direita-esquerda em pacientes com AVC isquêmico criptogênio e AVC não cardioembólico

Abstract Background: Patent foramen ovale (PFO) has been considered a potential mechanism of embolic stroke of undetermined origin. Objective: The aim of the present study was to identify the features of the right-to-left shunt (RLS) in patients with undetermined embolic ischemic stroke and compare them with those of patients with non-cardioembolic ischemic stroke. Methods: A retrospective study was conducted with 168 patients with stroke and RLS separated into the following two groups: the undetermined embolic stroke group (UES group) and non-cardioembolic stroke group (NCES group). All patients were assessed by transcranial Doppler to evaluate the presence and quantification of microembolic signals (MES) at rest and under Valsalva maneuver. Results: Of all patients evaluated in the current study, 96 were included in the UES group and 72 in the NCES group. In the UES group, 65 patients had RLS with ≥10 MES (67.7%), which was higher than that observed in the NCES group (51.4%, p=0.038). According to the moment of the cardiac cycle, 75 patients (78.1%) in the UES group had a positive test at rest compared to 42 (58.3%) in the NCES group (p=0.007). Conclusions: The current study demonstrated that almost 70% of patients with undetermined embolic stroke and PFO presented a large RLS and more than 75% had RLS at rest. These findings suggest that the size of the shunt should be taken into account when evaluating whether PFO could be a possible mechanism underlying cryptogenic stroke.

RESUMO Antecedentes: Uma das potenciais fontes embólicas no acidente vascular cerebral (AVC) de origem indeterminada é o forame oval patente (FOP). Objetivo: O objetivo do presente estudo foi identificar as características do shunt direita-esquerda em paciente com AVC de etiologia indeterminada, presumidamente embólica, e comparar tais características com pacientes apresentando AVC por outras causas não embólicas. Métodos: Trata-se de um estudo retrospectivo com 168 pacientes com AVC e forame oval patente, separados em dois grupos: AVC embólico de etiologia indeterminada e AVC por outras causas não embólicas. Todos os pacientes foram submetidos a Doppler transcraniano, para avaliar a presença de shunt direita-esquerda por meio do teste de embolia paradoxal. Além da quantificação de microbolhas, também foi avaliada a presença de shunt em repouso e sob manobra de Valsalva. Resultado: Do total, 96 pacientes foram incluídos no primeiro grupo (AVC indeterminado) e 72, no segundo grupo (AVC não embólico). No primeiro grupo, 65 pacientes exibiram shunt com passagem de mais de 10 microbolhas (67,5%), enquanto no segundo grupo isso aconteceu em 51,4% (p=0,038) dos casos. Além disso, 75 pacientes (78,1%) do primeiro grupo tiveram teste positivo ao repouso, comparados com 42 pacientes (58,3%) no segundo grupo (p=0,007). Conclusão: O presente estudo demonstrou que até 70% dos pacientes com AVC de etiologia indeterminada e forame oval apresentaram shunts maiores; em mais de 75%, houve passagem de microbolhas ao repouso. Esses achados sugerem que as características do shunt, como quantidade de microbolhas e passagem ao repouso, devem ser levadas em consideração na avaliação do FOP como possível mecanismo subjacente ao AVC.

Small vessel occlusion and syphilis in patients with first-ever ischemic stroke / Oclusão de pequenos vasos e sífilis em pacientes com o primeiro acidente vascular cerebral isquêmico

ABSTRACT Background: Syphilis is an endemic disease, particularly in low- and middle-income countries, with vascular involvement in large vessels (aortitis), but no clear relationship with stroke patients, except for those who presented with meningovascular neurosyphilis. Objective: To investigate the relationship between a positive history of syphilis determined by serological testing and ischemic stroke etiology, particularly small vessel disease (SVD). Methods: In total, 269 first-ever ischemic stroke patients admitted to the stroke unit were tested for syphilis. Patients with neurosyphilis were excluded. All patients were classified according to the ASCOD phenotyping as SVD — when SVD was the potential causal mechanism (S1) — or non-SVD — when SVD was uncertain (S2), unlike (S3), or not detected (S0). Results: Syphilis was positive in 32 (12%) patients. When comparing patients with positive and negative serology, the only significant difference was SVD as the causal mechanism (S1) in patients with positive results: 9 (28%) vs. 22 (9%), p<0.01. Conclusion: The current study showed that the frequency of positive syphilis serological test was higher in patients with first-ever ischemic stroke and SVD as the potential causal mechanism. This finding could be related to the endothelial dysfunction occurring in syphilis.

RESUMO Introdução: A sífilis é uma doença endêmica, especialmente em países de baixa e média renda, com acometimento vascular descrito em grandes vasos (aortite), porém nenhuma relação clara foi reconhecida em paciente com acidente vascular cerebral, exceto para aqueles com sífilis meningovascular. Objetivos: Investigar a relação entre história positiva de sífilis determinada pelo status sorológico e o mecanismo do acidente vascular cerebral isquêmico, particularmente doença de pequenos vasos. Métodos: Ao todo, 269 pacientes com AVC isquêmico foram testados para sífilis. Pacientes com diagnóstico de neurossífilis foram excluídos. Todos os pacientes foram classificados segundo o fenótipo ASCOD quando a doença de pequenos vasos era o mecanismo causal provável (S1) ou não-pequenos vasos quando este mecanismo era incerto (S2), pouco provável (S3) ou não detectado (S0). Resultados: O teste para sífilis foi positivo em 32 (12%) pacientes. Quando comparados, pacientes com sorologia positiva e o grupo com teste não reagente, a única diferença significativa foi a doença de pequenos vasos como mecanismo causal (S1) em pacientes com sorologia positiva: 9 (28%) vs. 22 (9%), p<0.01. Conclusão: O presente estudo mostra que o teste sorológico positivo para sífilis tem maior ocorrência em pacientes com o primeiro AVC isquêmico com a doença de pequenos vasos como um mecanismo causal possível. Tal achado pode estar relacionado à disfunção endotelial que ocorre durante a sífilis.

Interactions between remote ischemic conditioning and post-stroke sleep regulation / 医学前沿

Sleep disturbances are common in patients with stroke, and sleep quality has a critical role in the onset and outcome of stroke. Poor sleep exacerbates neurological injury, impedes nerve regeneration, and elicits serious complications. Thus, exploring a therapy suitable for patients with stroke and sleep disturbances is imperative. As a multi-targeted nonpharmacological intervention, remote ischemic conditioning can reduce the ischemic size of the brain, improve the functional outcome of stroke, and increase sleep duration. Preclinical/clinical evidence showed that this method can inhibit the inflammatory response, mediate the signal transductions of adenosine, activate the efferents of the vagal nerve, and reset the circadian clocks, all of which are involved in sleep regulation. In particular, cytokines tumor necrosis factor α (TNFα) and adenosine are sleep factors, and electrical vagal nerve stimulation can improve insomnia. On the basis of the common mechanisms of remote ischemic conditioning and sleep regulation, a causal relationship was proposed between remote ischemic conditioning and post-stroke sleep quality.

Heart rate variability as an autonomic biomarker in ischemic stroke / Variabilidade da frequência cardíaca como biomarcador autonômico em pacientes com acidente vascular cerebral isquêmico

ABSTRACT Stroke is one of the leading causes of mortality and disability worldwide. Autonomic dysfunction after ischemic stroke is frequently associated with cardiac complications and high mortality. The brain-heart axis is a good model for understanding autonomic interaction between the autonomic central network and the cardiovascular system. Heart rate variability (HRV) analysis is a non-invasive approach for understanding cardiac autonomic regulation. In stroke patients, HRV parameters are altered in the acute and chronic stages of the disease, having a prognostic value. In this literature review we summarize the main concepts about the autonomic nervous system and HRV as autonomic biomarkers in ischemic stroke.

RESUMO O acidente vascular cerebral (AVC) é uma das principais causas de mortalidade e deficiência no mundo inteiro. Alterações do sistema nervoso autônomo após AVC estão frequentemente associadas a complicações cardíacas e alta mortalidade. O eixo cérebro-coração é um modelo apropriado para entender as interações entre a rede central autonômica e o sistema cardiovascular. A análise da variabilidade da frequência cardíaca (VFC) é uma aproximação não invasiva para o entendimento da regulação autonômica cardíaca. Em doentes que sofreram um AVC, os parâmetros da VFC se encontram alterados nas fases aguda e crônica da doença, com a possibilidade de valor prognóstico. Nesta revisão da literatura, apresentamos os principais conceitos sobre o sistema nervoso autônomo e a variabilidade da frequência cardíaca como biomarcador autonômico no acidente vascular cerebral isquêmico.

Predictors of left atrial thrombus in acute ischemic stroke patients without atrial fibrillation: A single-center cross-sectional study

SUMMARY INTRODUCTION: The present study aimed to determine independent predictors of left atrial thrombus (LAT) in acute ischemic stroke (AIS) patients without atrial fibrillation (AF) using transesophageal echocardiography (TEE). METHODS: In this single-center, retrospective study, we enrolled 149 consecutive AIS patients. All of the patients underwent a TEE examination to detect LAT within 10 days following admission. Multivariate logistic regression analysis was performed to assess independent predictors of LAT. RESULTS: Among all cases, 14 patients (9.3%) had a diagnosis of LAT based on the TEE examination. In a multivariate analysis, elevated mean platelet volume (MPV), low left-ventricle ejection fraction (EF), creatinine, and reduced left-atrium appendix (LAA) peak emptying velocity were independent predictors of LAT. The area under the receiver operating characteristic curve analysis for MPV was 0.70 (95%CI: 0.57-0.83; p = 0.011). With the optimal cut-off value of 9.45, MPV had a sensitivity of 71.4% and a specificity of 63% to predict LAT. CONCLUSION: AIS patients with low ventricle EF and elevated MPV should undergo further TEE examination to verify the possibility of a cardio-embolic source. In addition, this research may provide novel information with respect to the applicability of MPV to predict LAT in such patients without AF.

RESUMO INTRODUÇÃO: O presente estudo teve como objetivo determinar indicadores independentes do trombo auricular esquerdo (LAT) em doentes com acidente vascular cerebral isquêmico agudo (AIS) sem fibrilação auricular (AF) utilizando ecocardiografia transesofágica (TEE). MÉTODOS: Neste único centro, estudo retrospectivo, inscrevemos 149 pacientes consecutivos com AIS. Todos os pacientes foram submetidos a exame de TEE para detectar LAT no prazo de dez dias após a admissão. A análise de regressão logística multivariada foi realizada para avaliar preditores independentes do final. RESULTADO: Entre todos os casos, 14 pacientes (9,3%) tiveram um diagnóstico de exame tardio no TEE. Numa análise multivariada, volume médio de plaquetas (VMP) elevado, fração de ejeção do ventrículo esquerdo baixo (EF), creatinina e uma velocidade de pico de esvaziamento do átrio esquerdo reduzida (LAA) foram indicadores independentes da LAT. A área sob a análise da curva característica de operação do receptor para VMP foi de 0,70 (95% IC: 0, 57-0, 83; p=0,011). Com o valor-limite ideal de 9,45, o VMP teve uma sensibilidade de 71,4% e uma especificidade de 63% para prever mais tarde. CONCLUSÃO: Os doentes AIS com EF ventricular baixa e VMP elevado devem ser submetidos a um exame de TEE adicional para determinar a possibilidade de origem cardioembólica. Além disso, esta investigação pode fornecer novas informações sobre a aplicabilidade do VMP para prever tardiamente os doentes sem AF.

Association between serum non-high-density lipoprotein cholesterol and cognitive dysfunction after acute ischemic stroke: a cross-sectional study

This study aimed to explore the association between serum non-high-density lipoprotein cholesterol (non-HDL-C) and cognitive dysfunction risk in patients with acute ischemic stroke (AIS). This cross-sectional study enrolled 583 AIS patients. Biochemical markers and lipid profile were collected after admission. AIS patients were classified into high group (non-HDL-C ≥3.4 mM) and normal group (non-HDL-C <3.4 mM). Mini-Mental State Examination scale (MMSE), Montreal Cognitive Assessment scale (MoCA), Activities of Daily Living (ADL) scale, Neuropsychiatric Inventory (NPI), and Hamilton Depression scale 21 version (HAMD-21) were applied on the third day after admission. Compared with the control group, patients of the high group had higher body mass index and higher frequency of intracranial artery stenosis, and exhibited higher levels of non-HDL-C, total cholesterol, triglycerides, low-density lipoprotein cholesterol, homocysteine, fasting blood glucose, and glycosylated hemoglobin (HbA1c), and lower levels of high-density lipoprotein cholesterol (all P<0.05). Compared with the control group, patients of the high group had significantly lower MMSE and MoCA scores (MMSE: 26.01±4.17 vs 23.12±4.73, P<0.001; MoCA: 22.28±5.28 vs 20.25±5.87, P<0.001) and higher scores on the NPI and HAMD-21 (both P<0.001). MMSE (r=-0.306, P<0.001) and MoCA scores (r=-0.251, P<0.001) were negatively associated with non-HDL-C level. Multivariate regression analysis revealed that non-HDL-C level (OR=1.361, 95%CI: 1.059-1.729, P=0.016) was independently associated with the presence of cognitive dysfunction after adjusting for confounding factors. High serum non-HDL-C level might significantly increase the risk of cognitive dysfunction after AIS.

Relationship between Circadian Rhythm Disorder of Blood Pressure and Ischemic Stroke / 中国医学科学院学报

Hypertension plays an important role in the pathogenesis of stroke,which,however,is only known at the blood pressure level.The relationship between circadian rhythm of blood pressure(especially the circadian rhythm disorder of blood pressure)and stroke has been a hot research topic.This article reviews the concept of circadian rhythm of blood pressure,classification of circadian rhythm disorder of blood pressure,and the relationship of circadian rhythm disorder of blood pressure with ischemic stroke.

Angiographic Findings in Refractory Delayed Cerebral Ischemia

Background Delayed cerebral ischemia (DCI) follows a refractory course in a subgroup of patients with aneurysmal subarachnoid hemorrhage (SAH), leading to diffuse ischemic injury. The role of angiographic vasospasm (AV) is unknown. Our goal is to study the angiographic alterations and the clinical profile of refractory DCI patients. Methods Retrospective study of patients with SAH who presented with DCI treated with medical and endovascular therapy, with a refractory evolution, defined asmultiple ischemic infarction and brain death. Results Out of a cohort of 336 patients, 7 (2%) developed refractory DCI. The median age of the patients was 48 (38­60) years old. Five patients had ruptured anterior communicating artery (ACoA) aneurysms. Four patients were treated with coil embolization, and three with microsurgical clipping. Angiographic vasospasm was classified as severe in 5 cases. Compromise of bilateral circulation was detected in six patients. Distal circulation vasospasm occurred in five cases. Slow circulatory transit times were observed in three patients. Conclusion Angiographic findings such as bilateral circulatory compromise and distal vasospasm were frequent alterations. Further studies are required to establish the association of these findings with the clinical outcomes.

The impact of acute kidney injury on fatality of ischemic stroke from a hospital-based population in Joinville, Brazil / O impacto da insuficiência renal aguda na letalidade do acidente vascular cerebral isquêmico de uma população de base hospitalar em Joinville, Brasil

Abstract Introduction: The occurrence of acute kidney injury (AKI) after ischemic stroke has been associated to a worse prognosis. There is a lack of Brazilian studies evaluating this issue. This study aimed to describe the impact of AKI after a first-ever ischemic stroke in relation to fatality rate in 30 days. Methods: This was a retrospective hospital-based cohort. We included patients who had their first ischemic stroke between January to December 2015. AKI was defined by an increase of serum creatinine in relation to baseline value at admission ≥ 0.3 mg/dL or a rise in serum creatinine level by 1.5 times the baseline value at any point in the first week after admission. We performed a univariate and multivariate analysis to evaluate the presence of AKI with fatality in 30 days. Results: The final study population (n=214) had mean age of 66.46 ± 13.73 years, 48.1% were men, the mean NIHSS was 6.33 ± 6.27 and 20 (9.3%) presented AKI. Patients with AKI were older, had a higher score on the NIHSS, and had higher creatinine values on hospital discharge. The 30-day mortality was higher in the AKI subgroup compared to non-AKI (35% vs. 6.2%, p < 0.001). AKI was an independent predictor of fatality after an ischemic stroke but limited by severity of stroke (NIHSS). Conclusion: The presence of AKI is an important complication after ischemic stroke. Despite its impact on 30-day fatality, the predictive strength of AKI was limited by the severity of stroke.

Resumo Introdução: A ocorrência de insuficiência renal aguda (IRA) após acidente vascular cerebral isquêmico (AVCI) está associada a pior prognóstico. Há uma deficiência de estudos brasileiros a respeito dessa questão. O presente estudo teve como objetivo descrever o impacto da IRA após o primeiro episódio de AVCI em relação à taxa de letalidade em 30 dias. Métodos: A presente coorte retrospectiva de base hospitalar incluiu pacientes que sofreram seu primeiro AVCI entre janeiro e dezembro de 2015. IRA foi definida por elevações da creatinina sérica em relação ao valor basal na internação ≥ 0.3 mg/dL ou aumento da creatinina sérica equivalente a 1,5 vez o valor basal em qualquer instante durante a primeira semana após a internação. Foi realizada análise univariada e multivariada para avaliar a presença de IRA com letalidade em 30 dias. Resultados: A população final do estudo (n = 214) apresentou média de idade de 66,46 ± 13,73 anos; 48,1% eram homens; a média de pontuação no NIHSS foi 6,33 ± 6,27; e 20 (9,3%) apresentaram IRA. Pacientes com IRA tinham idade mais avançada, pontuação maior na NIHSS e valores mais elevados de creatinina no momento da alta hospitalar. A mortalidade em 30 dias foi maior no subgrupo com IRA em comparação ao grupo sem IRA (35% vs. 6,2%, p < 0,001). IRA foi preditor independente de mortalidade após AVCI, porém limitado pela gravidade do acidente vascular cerebral (NIHSS). Conclusão: A presença de IRA é uma complicação importante após AVCI. Apesar de seu impacto na letalidade de 30 dias, a força preditiva da IRA foi limitada pela gravidade do AVC.

Ceguera cortical como manifestación inicial de endocarditis trombótica no bacteriana / Cortical blindness as initial manifestation of nonbacterial thrombotic endocarditis

La endocarditis trombótica no bacteriana, antiguamente conocida como endocarditis marántica, es una entidad infrecuente en la que se desarrollan vegetaciones estériles, compuestas por fibrina en las válvulas del corazón. Suele diagnosticarse en el momento de la autopsia o en enfermedades oncológicas avanzadas. Las neoplasias malignas más frecuentemente asociadas con esta entidad son las de pulmón, páncreas, estómago y adenocarcinomas de origen primario desconocido. Es necesario descartar la endocarditis infecciosa y establecer la presencia de vegetaciones valvulares mediante ecocardiografía. Presentamos el caso de una paciente con diagnóstico reciente de adenocarcinoma de estómago en estadio avanzado que presentó ceguera cortical e imágenes compatibles con isquemia cerebral. El ecocardiograma transesofágico mostró dos vegetaciones en válvula mitral. Los hemocultivos fueron negativos. Se enfatiza la importancia de sospechar endocarditis trombótica no bacteriana en enfermos con cáncer y embolismo sistémico.

Nonbacterial thrombotic endocarditis, formerly known as marantic endocarditis, it is an infrequent entity in which sterile, fibrin vegetations develop on heart valve leaflets. It is often diagnosed at the time of autopsy or in late-stage malignancies. The most common malignancies associated with nonbacterial thrombotic endocarditis are lung, pancreatic, gastric cancer and adenocarcinomas of an unknown primary site. Diagnosis requires ruling out infective endocarditis and establishing the presence of valvular vegetations using echocardiography. We report the case of a patient with a recent diagnosis of advanced gastric adenocarcinoma who presented with cortical blindness. The computed tomography was compatible with cerebral ischemia. The transoesophageal echocardiogram showed two vegetations in mitral valve. Blood cultures were negative. We emphasize the importance of suspecting nonbacterial thrombotic endocarditis in patients with cancer and systemic embolism.

Effects of physical exercise on skeletal muscles of rats with cerebral ischemia

Physical exercise is a known preventive and therapeutic alternative for several cerebrovascular diseases. Therefore, the objective of the present study was to evaluate the motor performance and histomorphometry of the biceps brachii, soleus, and tibialis anterior muscles of rats submitted to a treadmill training program prior to the induction of cerebral ischemia via occlusion of the middle cerebral artery (OMCA). A total of 24 Wistar rats were distributed into four groups: Sham-Sed: sedentary control animals (n=6), who underwent sham surgery (in which OMCA did not occur); Sham+Ex: control animals exercised before the sham surgery (n=6); I-Sed: sedentary animals with cerebral ischemia (n=6); and I+Ex: animals exercised before the induction of ischemia (n=6). The physical exercise consisted of treadmill training for five weeks, 30 min/day (5 days/week), at a speed of 14 m/min. The results showed that the type-I fibers presented greater fiber area in the exercised ischemic group (I+Ex: 2347.96±202.77 µm2) compared to the other groups (Sham-Sed: 1676.46±132.21 µm2; Sham+Ex: 1647.63±191.09 µm2; I+Ex: 1566.93±185.09 µm2; P=0.0002). Our findings suggested that the angiogenesis process may have influenced muscle recovery and reduced muscle atrophy of type-I fibers in the animals that exercised before cerebral ischemia.

The safety and efficacy of tPA intravenous thrombolysis for treating acute ischemic stroke patients with a history of cerebral hemorrhage

Alteplase (tPA) intravenous thrombolysis is an effective treatment for acute ischemic stroke (AIS) when administered within 4.5 h of initial stroke symptoms. Here, its safety and efficacy were evaluated among AIS patients with a previous history of cerebral hemorrhage. Patients who arrived at the hospital within 4.5 h of initial stroke symptoms and who were treated with tPA intravenous thrombolysis or conventional therapies were analyzed. The 90-day modified Rankin scale (90-d mRS) was used alongside mortality and incidence of symptomatic intracerebral hemorrhage (SICH) rates to evaluate the curative effect of these therapies. Among 1,694 AIS patients, 805 patients were treated with intravenous thrombolysis, including patients with (n=793) or without (n=12) a history of cerebral hemorrhage, and the rate of incidence of SICH significantly differed between them (8.3 vs 4.3%, P=0.039). No significant difference was found in 90-d mRS measurements (41.7 vs 43.6%, P=0.530) and 90-d mortality rates (8.3 vs 6.5%, P=0.946). A total of 76 AIS patients with a history of cerebral hemorrhage received tPA thrombolytic therapy (n=12) or conventional therapy (n=64), and a significant difference was noted in the 90-d mRS scores between the two groups (41.7 vs 23.4%, P=0.029), while no significant difference was found in SICH measurements (8.3 vs 4.6%, P=0.610) and 90-d mortality rates (8.3 vs 9.4%, P=0.227). A history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy; tPA intravenous thrombolysis does not increase SICH measurements and mortality rates in patients with a history of cerebral hemorrhage, and they may benefit from thrombolytic therapy.

Anesthetic management of endovascular treatment for acute ischemic stroke: Influences on outcome and complications / Manejo anestésico do tratamento endovascular para acidente vascular cerebral isquêmico agudo: influências no resultado e complicações

Abstract Background and objectives: The emerging use of endovascular therapies for acute ischemic stroke, like intra-arterial thrombectomy, compels a better understanding of the anesthetic management required and its impact in global outcomes. This article reviews the available data on the anesthetic management of endovascular treatment, comparing general anesthesia with conscious sedation, the most used modalities, in terms of anesthetic induction and procedure duration, patient mobility, occlusion location, hemodynamic parameters, outcome and safety; it also focuses on the state-of-the-art on physiologic and pharmacologic neuroprotection. Contents: Most of the evidence on this topic is retrospective and contradictory, with only three small randomized studies to date. Conscious sedation was frequently associated with better outcomes, but the prospective evidence declared that it has no advantage over general anesthesia concerning that issue. Conscious sedation is at least as safe as general anesthesia for the endovascular treatment of acute ischemic stroke, with equivalent mortality and fewer complications like pneumonia, hypotension or extubation difficulties. It has, however, a higher frequency of patient agitation and movement, which is the main cause for conversion to general anesthesia. Conclusions: General anesthesia and conscious sedation are both safe alternatives for anesthetic management of patients submitted to endovascular thrombectomy. No anesthetic management is universally recommended and hopefully the ongoing randomized clinical trials will shed some light on the best approach; meanwhile, the choice of anesthesia should be based on the patient's individual characteristics. Regarding neuroprotection, hemodynamic stability is currently the most important strategy, as no pharmacological method has been proven effective in humans.

Resumo Justificativa e objetivos: O uso emergente de terapias endovasculares para acidente vascular cerebral isquêmico agudo, como a trombectomia intra-arterial, nos obriga a uma compreensão melhor do manejo anestésico necessário e seu impacto nos resultados globais. Este artigo revisa os dados disponíveis sobre o manejo anestésico do tratamento endovascular, comparando anestesia geral com sedação consciente, as modalidades mais utilizadas, quanto à indução anestésica e duração do procedimento, mobilidade do paciente, localização da oclusão, parâmetros hemodinâmicos, desfecho e segurança; abordando também o estado da arte da neuroproteção fisiológica e farmacológica. Conteúdo: A maioria das evidências sobre esse tópico é retrospectiva e contraditória, com apenas três pequenos estudos randômicos realizados até o momento. A sedação consciente foi frequentemente associada a melhores resultados, mas as evidências prospectivas indicaram que não há vantagem sobre a anestesia geral em relação a essa questão. A sedação consciente é no mínimo tão segura como a anestesia geral para o tratamento endovascular do AVC isquêmico agudo, com mortalidade equivalente e menos complicações, como pneumonia, hipotensão ou extubações difíceis. Porém, a sedação consciente apresenta uma frequência maior de agitação e movimento do paciente, sendo a principal causa de conversão para a anestesia geral. Conclusões: Anestesia geral e sedação consciente são alternativas seguras para o manejo anestésico de pacientes submetidos à trombectomia endovascular. Não há um manejo anestésico que seja universalmente recomendado e esperamos que os ensaios clínicos randomizados em andamento possam lançar alguma luz sobre a melhor abordagem; enquanto isso, a escolha da anestesia deve basear-se nas características individuais do paciente. Em relação à neuroproteção, a estabilidade hemodinâmica é atualmente a estratégia mais importante, uma vez que nenhum método farmacológico se mostrou eficaz em humanos.

Cerebrovascular ischemia following ultrasound-guided foam sclerotherapy / Isquemia cerebral após escleroterapia com espuma guiada por ultrassom

Cerebral ischemia is a very rare and harmful complication of ultrasound-guided foam sclerotherapy for treatment of varicose veins. This case describes a documented cerebrovascular ischemia in Broca's area following ultrasound-guided foam sclerotherapy. Less than one hour after intravenous injection of 10 ml of sclerosing foam, an otherwise healthy woman experienced aphasia without any other signs of neurological changes. When she arrived home, a complete inability to talk was observed. The event was misdiagnosed by another doctor as an allergic reaction. Next morning she came to the office to report the allergic reaction, where an appropriate diagnosis was made. She recovered just two days after the injection, but signs of recent cerebral ischemia were seen in Broca's area on magnetic resonance and transesophageal bubble study echocardiogram revealed a patent foramen ovale. Although rare, we must make great effort to prevent these events instead of treating them

A isquemia cerebral é uma complicação muito rara e perigosa da escleroterapia com espuma guiada por ultrassom no tratamento de varizes. Este caso descreve uma isquemia cerebral da área de Broca após escleroterapia com espuma guiada por ultrassom. Menos de uma hora após injeção de 10 mL de espuma, uma até então saudável mulher apresentou afasia, sem quaisquer outros sinais neurológicos. No caminho para casa, uma completa incapacidade de fala foi observada. Levada ao hospital mais próximo, foi diagnosticada com reação alérgica. Na manhã seguinte, compareceu ao consultório para relatar a reação alérgica, quando um correto diagnóstico foi feito. Ela ficou recuperada dois dias depois do procedimento, mas uma ressonância magnética mostrou sinais de isquemia recente da área de Broca e um ecocardiograma transesofágico mostrou um forame oval patente. Embora raros, devemos concentrar nossos esforços em prevenir tais eventos para que não precisem de tratamento

Cryptogenic Acute Ischemic Stroke: Assessment of the Performance of a New Continuous Long-Term Monitoring System in the Detection of Atrial Fibrillation / AVC Isquêmico Agudo Criptogênico: Avaliação do Desempenho de um Novo Sistema de Monitorização Contínua e Prolongada, via Telefonia Celular, na Detecção de Fibrilação Atrial

Abstract Background: Long-term monitoring has been advocated to enhance the detection of atrial fibrillation (AF) in patients with stroke. Objective: To evaluate the performance of a new ambulatory monitoring system with mobile data transmission (PoIP) compared with 24-hour Holter. We also aimed to evaluate the incidence of arrhythmias in patients with and without stroke or transient ischemic attack. Methods: Consecutive patients with and without stroke or TIA, without AF, were matched by propensity score. Participants underwent 24-hour Holter and 7-day PoIP monitoring. Results: We selected 52 of 84 patients (26 with stroke or TIA and 26 controls). Connection and recording times were 156.5 ± 22.5 and 148.8 ± 20.8 hours, with a signal loss of 6,8% and 11,4%, respectively. Connection time was longer in ambulatory (164.3 ± 15.8 h) than in hospitalized patients (148.8 ± 25.6 h) (p = 0.02), while recording time did not differ between them (153.7 ± 16.9 and 143.0 ± 23.3 h). AF episodes were detected in 1 patient with stroke by Holter, and in 7 individuals (1 control and 6 strokes) by PoIP. There was no difference in the incidence of arrhythmias between the groups. Conclusions: Holter and PoIP performed equally well in the first 24 hours. Data transmission loss (4.5%) occurred by a mismatch between signal transmission (2.5G) and signal reception (3G) protocols in cell phone towers (3G). The incidence of arrhythmias was not different between stroke/TIA and control groups.

Resumo Fundamentos: Monitorização prolongada permite maior detecção de fibrilação atrial (FA) em pacientes com acidente vascular cerebral (AVC) isquêmico criptogênico. Não há consenso sobre a duração ideal da monitorização ou o valor prognóstico da FA de curta duração. Objetivos: Avaliar o desempenho de um novo sistema de monitorização ambulatorial (PoIP) com transmissão por telefonia celular, comparado ao Holter 24 horas, e a ocorrência de arritmias comparando pacientes com e sem AVC ou ataque isquêmico transitório (AIT). Métodos: Pacientes consecutivos com e sem AVC/AIT, sem FA, foram pareados pelo escore de propensão. Foi utilizado Holter 24 horas e o PoIP por 7 dias. Resultados: Selecionamos 52 de 84 pacientes (26 com AVC/AIT agudo e 26 controles). O tempo de conexão foi de 156,5 ± 22,5 horas e o de gravação no servidor foi de 148,8 ± 20,8 horas, com perdas de 6,8 e 11,4%, respectivamente. Houve maior tempo de conexão nos pacientes ambulatoriais (164,3 ± 15,8 h) que nos hospitalizados (148,8 ± 25,6h) (p = 0,02) com tempo de gravação semelhante (153,7 ± 16,9 e 143 ± 23,3 h). Detectamos FA pelo Holter em 1 paciente com AVC e pela monitorização prolongada em 7 (1 controle e 6 AVC). Não houve diferença na incidência de outras arritmias entre os grupos. Conclusões: Holter e PoIP tiveram desempenho equivalente nas primeiras 24 horas. O menor tempo de monitorização nos pacientes hospitalizados ocorreu por sinal de baixa intensidade. Perda de dados (4,5%) ocorreu por discrepância entre protocolos de transmissão (2,5G) e recepção pelas antenas (3G). A incidência de arritmias não diferiu entre os grupos AVC/AIT e controle.

Association between blood pressure and acute phase stroke case fatality rate: a prospective cohort study / Associação entre níveis de pressão arterial e letalidade na fase aguda do acidente vascular cerebral: estudo de coorte prospectivo

ABSTRACT Objective ed to investigate the association between blood pressure and acute phase stroke lethality in a Brazilian intensive care unit. Methods This was an observational, prospective cohort study of hemorrhagic and ischemic stroke intensive care patients. The primary outcome was all-cause mortality during the first seven days. Results There were 146 patients, aged 66 ± 13.4 years, 56% men, 89% Caucasian, 69% had ischemic stroke, and 80% were hypertensive. The median of the National Institutes of Health Stroke Scale score was 16. There were 101 ischemic stroke patients and 45 hemorrhagic stroke patients. In the ischemic stroke patients, logistic regression analysis identified low systolic blood pressure as an independent ominous prognostic factor and the optimal cut off was a mean of systolic blood pressure ≤ 131 mmHg during the first 48 hours from admission for prediction of death. No association was found for hemorrhagic stroke. Conclusions There was a negative association between systolic blood pressure and case fatality ratio of acute phase stroke in ischemic stroke intensive care patients.

RESUMO Objetivo Investigar a associação entre pressão arterial e letalidade do acidente vascular cerebral (AVC) em uma unidade de terapia intensiva brasileira. Métodos estudo de coorte prospectivo de pacientes com AVC hemorrágico (AVC-H) ou isquêmico (AVC-I) internados em terapia intensiva. O desfecho primário foi a letalidade por todas as causas nos primeiros sete dias. Resultados Avaliados 146 pacientes, idade: 66 ± 13,4 anos, 56% homens, 89% brancos, 69% AVC-I e 80% hipertensos. A mediana do NIH foi de 16. Os pacientes com AVC-I foram 101 e 45 com AVC-H. Para AVC-I, a análise de regressão logística identificou baixa pressão arterial sistólica como um fator prognóstico negativo e o melhor corte foi uma média da pressão arterial sistólica nas primeiras 48 h de admissão ≤ 131 mmHg para a predição da morte. Para o AVC-H, nenhuma correlação foi encontrada. Conclusões houve associação negativa entre a pressão arterial sistólica e a letalidade do AVC-I em fase aguda em pacientes de terapia intensiva.

Evolución de la Enfermedad Cerebrovascular Isquémica Aguda en pacientes con Síndrome Metabólico / Evolution of Acute Ischemic Cerebrovascular Disease in patients with Metabolic Syndrome

Introducción: La isquemia cerebral es la de mayor incidencia y prevalencia entre las enfermedades cerebrovasculares y con frecuencia se asocia a la presencia del síndrome metabólico, pues muchos de sus factores de riesgo conforman este síndrome. Objetivo: Determinar la relación entre la evolución del paciente con Enfermedad Cerebrovascular Isquémica aguda y la presencia de Síndrome Metabólico. Material y Métodos: Se realizó un estudio analítico prospectivo con una muestra de 100 pacientes. Se conformaron 2 grupos, uno con pacientes con Síndrome Metabólico(SM), según criterios del NCEP/ATPIII (III Panel de Tratamiento del Adulto del Programa Nacional de Educación en Colesterol) (grupo A), y otro sin Síndrome Metabólico (grupo B) .En ambos grupos se aplicó la escala de NIHSS para evaluar la severidad y evolución de la enfermedad cerebrovascular. Resultados: En el grupo con SM prevalecieron los del sexo masculino (60 por ciento), el color de piel blanca (52 por ciento) y la media de edad fue de 61,2 años. Los principales antecedentes patológicos personales fueron Hipertensión Arterial, Cardiopatías y Tabaquismo. La severidad de la enfermedad cerebrovascular al ingreso fue peor en el grupo A (media 13,2), los que tuvieron mayor número de complicaciones neurológicas: hipertensión endocraneana y convulsiones (12 por ciento), y no neurológicas: bronconeumonía (40 por ciento) y úlceras de decúbito (28 por ciento), con un riesgo superior: OR: 6,2. Al egreso, 36 por ciento de los pacientes con SM empeoraron, según escala de NIHSS. Conclusiones: El Síndrome metabólico constituye un factor que incrementa en la Enfermedad cerebrovascular isquémica el riesgo de complicaciones, y empeora su evolución y pronóstico(AU)

Introduction: Cerebrovascular ischemia represents the highest incidence and prevalence among cerebrovascular diseases. It is frequently associated with Metabolic Syndrome because many risk factors for cerebrovascular ischemia correspond to this entity. Objective: To determine the relationship between the evolution of the patient with Acute Ischemic Cerebrovascular Disease (AICVD) and the presence of Metabolic Syndrome (MS). Material and Methods: An analytical prospective study was conducted with a sample of 100 patients, which were divided into two groups: group A, that was composed of patients with Metabolic Syndrome (MS) according to NCEP/ATPIII criteria (The Adult Treatment Panel III of the National Cholesterol Education), and group B that was composed of patients without Metabolic Syndrome. The National Institutes of Health Stroke Scale (NIHSS) was applied in both groups to evaluate the severity and evolution of cerebrovascular disease. Results: The Male sex (60 percent), and white people (52 percent) prevailed in the group with MS, and the mean age was 61,2 years. The main personal pathological antecedents were Arterial hypertension, cardiopathies, and smoking habit. The severity of cerebrovascular disease on admission was worse in group A (mean: 13,2). These patients presented a greater number of neurological complications such as: intracranial hypertension and convulsions (12 percent); they also presented non-neurological complications such as: bronchopneumonia (40 percent), and ulcers resulting from time spent on supine position (28 percent) with a higher risk (OR: 6,2). After discharge from hospital, 36 percent of patients with MS got worse, according to Scale NIHSS. Conclusions: The metabolic syndrome is a risk factor that increases the risk of complications in Ischemic Cerebrovascular Disease and worsens its evolution and prognosis(AU)

Epilepsia asociada al accidente cerebrovascular / Post-stroke epilepsy

El accidente cerebrovascular (ACV) es la causa más común de convulsiones y epilepsia observada en estudios poblacionales de adultos. Las convulsiones ocurren dentro de las 24 horas posteriores al ACV en un alto porcentaje de pacientes. La patogénesis de estas convulsiones de inicio temprano puede estar relacionada con cambios iónicos locales y liberación de altos niveles de neurotransmisores excito-tóxicos en el área lesionada. Una lesión permanente con cambios en la excitabilidad neuronal parece ser responsable de convulsiones de inicio tardío después del ACV. Los factores de riesgo más comúnmente identificados con el comienzo agudo o tardío de las convulsiones post ACV son la gravedad y la localización cortical. La mayoría de las convulsiones post ACV son focales al inicio pero pueden generalizarse secundariamente, el estatus epiléptico es poco frecuente. La eficacia de las drogas antiepilépticas para estas convulsiones no ha sido rigurosamente evaluada en estudios controlados, aunque la mayoría de las convulsiones pueden ser controladas con un solo agente. Dada la frecuencia relativamente baja de convulsiones recurrentes después del ACV y la ausencia de predictores absolutos de epilepsia post ACV, la decisión de cuándo tratar a los pacientes con una convulsión después de un ACV es difícil.

Stroke is the most common cause of seizures and epilepsy in population stuies of adults. Seizures occur within 24 hours of the stroke in a high percent of patients. The pathogenesis of these early-onset seizures may be related to local ion shifts and release of high levels of excitotoxic neurotransmitters in the area of ischemic injury. The risk of late-onset seizures may increase over time, an underlying permanent lesion that leads to persistent chnges in neuronal excitability appears to be responsible for late-onset seizures after stroke. The most consistently identified risk factors for acute and late post-stroke seizures are stroke severity and cortical location. Most seizures following stroke are focal at onset, but secondary generalization is common, particularly in patients with late-onset seizures. Status epilepticus is relatively uncommon. The efficacy of antiepileptic drugs for these post-stroke seizures has not been rigorously assessed in controlled trials, although most seizures can be controlled with a single agent. Given the relatively low frequency of recurrent seizures after stroke, and an absence of absolute predictors of poststroke epilepsy, the decision of when to treat patients for a post-stroke seizure is difficult.

Traumatic injury to the internal carotid artery by the hyoid bone: a rare cause of ischemic stroke

Central nervous system (CNS) ischemic events, besides being a common and devastating disease, are accompanied by severe disability and other morbidities. The cause of such events is not always that simple to diagnose, and among the young, a broad spectrum of possibilities should be considered. We present the case of a young man who presented two episodes of CNS ischemia with a 1 year gap between them, which occurred in the same situation while he was walking and carrying a heavy backpack. The second event first presented as a transient ischemic attack followed by a stroke the day after. The diagnostic work-up showed an indentation of the greater cornu of the hyoid bone over the internal carotid artery, which injured the media and intimal layers. At the arterial injury site, a micro thrombus was found, which explained the source of the embolic event to the CNS. The patient was operated on, and the procedure included the resection of the posterior horn of the hyoid bone, the resection of the injured segment of the internal carotid artery followed by carotid­carotid bypass with the great saphenous vein. The postoperative period and the recovery were uneventful as was the 5-month follow-up. We call attention to this unusual cause of stroke and present other cases reported in the literature.