Application of non-contrasted computed tomography and diffusion-weighted imaging protocols for endovascular treatment selection in patients with late-presenting or wake-up strokes / Aplicação de tomografia computadorizada sem contraste e protocolos de imagem ponderada em difusão para seleção de tratamento endovascular em pacientes com acidente vascular cerebral em fase tardia ou ao despertar

ABSTRACT Background: Among patients with acute ischemic stroke with a mismatch between deficit severity and infarct volume, thrombectomy performed within a 6-24 hours time window has efficacy and safety similar to treatment within 6 hours. However, whether magnetic resonance imaging with T2 diffusion-weighted imaging (DWI) is feasible remains to be validated. Objective: To investigate prognosis among stroke patients receiving endovascular treatment (EVT) within 6 hours and 6-24 hours using non-contrasted computed tomography (NCCT) and DWI. Methods: Overall, 209 anterior-circulation ischemic stroke patients with large-vessel occlusion who underwent EVT were divided into ≤ 6 hours and 6-24 hours groups. Patients presenting symptoms within 6 hours were treated if their NIHSS score was ≥ 7 and ASPECTS score was ≥ 5, whereas those with wake-up stroke (WUS) or presenting symptoms 6-24 hours after last seen well (WUS/late-presenting stroke, LPS) were managed if their NIHSS score was ≥ 7 and ASPECTS score was ≥ 5. Results: The percentages of patients undergoing intracranial stenting and intracranial ballooning without stenting significantly differed between two groups (p < 0.001). Grades 0, 1, 2a and 2b recanalization rates did not differ between the 6 hours and 6-24 hours groups (all p > 0.05). Grade 3 recanalization rate in the 6 hours group was significantly lower than in the 6-24 hours group (p = 0.043). The 3-month Rankin Scale score did not significantly differ between the two groups (p = 0.629). Conclusions: EVT is a safe and effective treatment for patients with WUS and LPS selected through NCCT and DWI-based simple imaging.

RESUMO Antecedentes: Entre pacientes com acidente vascular cerebral isquêmico (AVCI) agudo com divergência entre gravidade do déficit e volume do infarto, a trombectomia em 6 a 24 horas tem eficácia e segurança semelhantes ao tratamento em até 6 horas. Entretanto, a viabilidade da imagem ponderada em T2 com difusão (DWI) da ressonância magnética necessita validação. Objetivo: Investigar o prognóstico de pacientes com AVCI que recebem tratamento endovascular (EVT) em até 6 horas e de 6-24 horas usando tomografia computadorizada sem contraste (NCCT) e DWI. Métodos: Duzentos e nove pacientes com AVCI de circulação anterior submetidos a EVT foram divididos em ≤ 6 horas e 6-24 horas. Pacientes com sintomas até 6 horas foram tratados se NIHSS ≥ 7 e ASPECTS ≥ 5; aqueles com AVCI ao despertar (WUS) ou com sintomas entre 6-24 horas da última vez em que foram vistos bem (WUS/AVC de fase tardia, LPS) foram tratados se NIHSS ≥ 7 e ASPECTS ≥ 5. Resultados: As porcentagens de pacientes submetidos a implante de stent intracraniano e angioplastia intracraniana sem stent diferiram entre os dois grupos (p <0,001). As taxas de recanalização 0, 1, 2a e 2b não diferiram entre 6 horas e 6-24 horas (p> 0,05). A taxa de recanalização de grau 3 no grupo 6 horas foi menor do que 6-24 horas (p = 0,043). Pontuação na Escala Rankin (3 meses) não foi diferente (p = 0,629). Conclusões: EVT é um tratamento seguro e eficaz para pacientes com WUS e LPS selecionados por meio de imagens baseadas em NCCT e DWI.

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.

Electroencefalograma cuantitativo en la predicción precoz de la isquemia cerebral tardía en hemorragia subaracnoidea aneurismática: reporte de un caso / Quantitative electroencephalogram for prediction of delayed ischemia in subarachnoid haemorrhage: report of one case

Subarachnoid hemorrhage (SAH) is a devastating disease, with a mortality rate of 35%. Among patients who survive the initial bleeding, the leading cause of morbidity and mortality is delayed cerebral ischemia (DCI). Electroencephalography (EEG) can detect cerebral ischemia in the early stages. We report a 66-year-old female patient who consulted for ictal headache and impaired consciousness. On admission, she was confused, dysarthric, and with meningeal signs. Brain angio-CT showed SAH FISHER IV and an aneurysm of the left posterior cerebral artery. After excluding the aneurysm (by coiling), the patient recovered the altered consciousness. Continuous EEG monitoring was initiated. On the sixth day of follow up, she had a transient headache and apathy. The brain MRI showed low cerebral blood flow in the left frontotemporal area, without ischemic lesions. On the seventh day, she presented expression aphasia and right facial-brachial paresis. Angiography confirmed severe vasospasm in M1 and M2 segments bilaterally. Pharmacological angioplasty with nimodipine was performed, with an excellent radiological response, although not clinical. A second MRI was carried out on the eighth day, which showed a left insular infarction and generalized vasospasm. A second therapeutic angiography was performed; the patient persisted with aphasia and left central facial paresis. The quantitative EEG analysis performed retrospectively showed a generalized reduction in the spectral edge frequency 95 (SEF95; meaning slowing in the EEG signal) at the fourth day of follow up, three days earlier than the clinical and imaging diagnosis of DCI was established.

Características clínicas y tomográficas de pacientes con enfermedad cerebrovascular isquémica / Clinical and tomographic characteristics of patients with ischemic cerebrovascular disease

Introducción: El método clínico por sí solo no es definitivo para diagnosticar una enfermedad cerebrovascular, por lo que es importante el uso de medios de diagnóstico imagenológicos como la tomografía axial computarizada, que permite investigar los aspectos morfológicos y funcionales del cerebro. Objetivo: Describir las características clínicas y tomográficas de pacientes con infarto cerebral. Métodos: Se efectuó un estudio descriptivo y transversal de 269 pacientes con infarto cerebral, atendidos en el Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba, desde enero hasta diciembre de 2019. Resultados: Predominaron el sexo masculino (54,6 %), el grupo etario de 70-79 años, las afectaciones motoras (76,5 %), la alteración de la conciencia (51,3 %) y el trastorno del lenguaje (50,5 %). En 38 pacientes los resultados de la tomografía fueron negativos antes de las 24 horas de evolución y 64,0 % se consideraron mejorados con secuelas. Conclusiones: La tomografía antes de las 24 horas demuestra una baja positividad y los hallazgos evolucionan con el tiempo, aunque es posible reconocer varios signos precoces de ictus agudo en menos de 4-6 horas.

Introduction: The clinical method by itself is not definitive to diagnose a cerebrovascular disease, reason why the use of imaging diagnostic means, as the computerized axial tomography is important, as it allows to investigate the morphological and functional aspects of the brain. Objective: To describe the clinical and tomographic characteristics of patients with complete stroke. Methods: A descriptive and cross-sectional study of 269 patients with complete stroke, assisted in Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital was carried out in Santiago de Cuba, from January to December, 2019. Results: There was a prevalence of the male sex (54.6 %), 70-79 age group, motor disorders (76.5 %), alteration of the conscience (51.3 %) and language disorder (50.5 %). In 38 patients the results of the tomography were negative before the 24 hours of clinical course and 64.0 % were better with aftereffects of the disease. Conclusions: Tomography before the 24 hours demonstrates a low positivity and findings have a favorable clinical course as time goes by, although it is possible to recognize several early signs of acute ictus in less than 4-6 hours.

White matter hyperintensities: initial assessments / Hiperintensidades da substância branca: avaliações iniciais

The white matter hyperintensities (WMH, leucoaraiosis) represent the most common kind of ischemic vascular lesion of the white matter due to small vessel diseases, and occurs frequently in the elderly. Consequent to the neuroimaging identification arouse the need for their assessment. The group of Fazekas proposed a systematized semi-quantitative visual scale to score such lesions where two parameters were considered, extent and localization. The original scale was further modified, to a simplified version. Although other more complex scales have appeared, researchers remarked that the relatively simple Fazekas scale, in comparison to the complex ones and to volumetric measures, appeared to be sufficient when analyzing relationships between clinical parameters and WMH load in a clinical setting.

As hiperintensidades da substância branca (HSB, leucoaraiose) representam o tipo de lesão isquêmica mais comum da substância branca decorrente de doenças de pequenos vasos e ocorre frequentemente em idosos. Consequente à identificação por neuroimagem surgiu a necessidade de sua avaliação. O grupo de Fazekas propos uma escala visual semiquantitativa sistematizada para pontuar tais lesões, onde foram considerados dois parâmetros, extensão e localização. A escala original foi modificada para constituir uma versão mais simplificada. Embora outras escalas mais complexas tenham aparecido, pesquisadores comentaram que a relativamente simples escala de Fazekas, em comparação às mais complexas e a método volumétrico, mostrou-se suficiente quando é analisada a relação entre parâmetros clínicos e a carga de HSB em um cenário clínico.

Assessment of left atrial function by strain in patients with acute ischemic stroke left atrial function and acute stroke

SUMMARY OBJECTIVE: Myocardial speckle-tracking echocardiography can detect subtle abnormalities in the left atrial function. In this study, we aimed to investigate the relationship between left atrial myocardium and tissue function n assessed by two-dimensional speckle-tracking echocardiography and the National Institutes of Health Stroke Scale score in patients with acute ischemic stroke. METHOD: The study was composed of 80 patients (45 men, 35 women, mean age: 67±15 years) with acute ischemic stroke. The patients were divided into two groups based on the calculated National Institutes of Health Stroke Scale score (group 1, National Institutes of Health Stroke Scale score < 16; group 2, National Institutes of Health Stroke Scale score ≥ 16). Demographic, clinical, and laboratory data for all patients were collected. Cardiac functions were evaluated using two-dimensional speckle-tracking echocardiography within 48 hours from admission to the neurology care unit. RESULTS: There were no significant differences between the patients' clinical parameters. Left ventricular ejection fraction was significantly higher in group 1 than in group 2 (59.2±5.6 to 51.4±6.3, p=0.024). Left atrial longitudinal strain was significantly higher in group 1 than in group 2 (34.48±9.73 to 26.27±7.41, p=0.019). There were no significant differences between other echocardiographic parameters. CONCLUSION: Our results suggest that left atrial longitudinal strain is associated with stroke severity during admission in patients with acute ischemic stroke. Left atrial longitudinal strain is an indicator of left atrial myocardial function.

Progress in computer-assisted Alberta stroke program early computer tomography score of acute ischemic stroke based on different modal images / 生物医学工程学杂志

Clinically, non-contrastive computed tomography (NCCT) is used to quickly diagnose the type and area of ​​stroke, and the Alberta stroke program early computer tomography score (ASPECTS) is used to guide the next treatment. However, in the early stage of acute ischemic stroke (AIS), it's difficult to distinguish the mild cerebral infarction on NCCT with the naked eye, and there is no obvious boundary between brain regions, which makes clinical ASPECTS difficult to conduct. The method based on machine learning and deep learning can help physicians quickly and accurately identify cerebral infarction areas, segment brain areas, and operate ASPECTS quantitative scoring, which is of great significance for improving the inconsistency in clinical ASPECTS. This article describes current challenges in the field of AIS ASPECTS, and then summarizes the application of computer-aided technology in ASPECTS from two aspects including machine learning and deep learning. Finally, this article summarizes and prospects the research direction of AIS-assisted assessment, and proposes that the computer-aided system based on multi-modal images is of great value to improve the comprehensiveness and accuracy of AIS assessment, which has the potential to open up a new research field for AIS-assisted assessment.

The use of e-ASPECTS in acute stroke care: validation of method performance compared to the performance of specialists / O uso do e-ASPECTS no AVC agudo: validação da performance do método comparada com a performance dos especialistas

ABSTRACT Background: The rapid evaluation of non-contrast-enhanced computed tomography (NCCT) brain scans in patients with anterior stroke symptoms saves time and favors optimal and prompt treatment. e-ASPECTS is a tool that automatically calculates the Alberta Stroke Program Early CT Score (ASPECTS) values, leading to a more accurate and timely image evaluation. Objective: To determine the ability of e-ASPECTS in differentiating images with and without injury. Methods: One-hundred sixteen patients admitted to a stroke unit in a Brazilian tertiary hospital underwent a CT scan at admission and at least one control brain imaging (NCCT or magnetic resonance imaging - MRI) 24 hours after admission. ASPECTS evaluation was performed by three neuroradiologists, three neurologists, and three neurology residents, all blinded to the symptoms and the injury side. The scores were compared to the ground truth, and an ASPECTS score was provided by two independent non blinded evaluators. Sensitivity and specificity were analyzed, and receiver operating characteristic curves, Bland-Altman plots with mean error score, and Matthews correlation coefficients (MCCs) were obtained for ASPECTS scores, assuming values equal to 10 for images without injury and values other than 10 for images with ischemic injury. Results: e-ASPECTS demonstrated similar performance to that of neuroradiologists and neurologists, with an area under the curve of 0.78 and an MCC value of 0.48 in the dichotomous analysis. The sensitivity and specificity of e-ASPECTS were 75% and 73%, respectively. Conclusion: e-ASPECTS is a validated and reliable tool for determining early signs of ischemia in NCCT.

RESUMO Introdução: A avaliação rápida da tomografia de crânio sem contraste (TCSC) em pacientes com AVC de circulação anterior economiza tempo e permite um tratamento rápido e otimizado. O e-ASPECTS é um software que calcula automaticamente os valores do ASPECTS e permite uma avaliação da imagem mais precisa e ágil. Objetivo: Determinar a habilidade do e-ASPECTS em diferenciar imagens com e sem lesão. Métodos: Cento e dezesseis pacientes admitidos em uma unidade de AVC de um hospital terciário brasileiro foram submetidos a uma TCSC na admissão e pelo menos uma imagem de controle (TC ou Ressonância de Crânio) 24 horas após a admissão. A avaliação do ASPECTS foi realizada por três neurorradiologistas, três neurologistas e três residentes em neurologia, todos cegados para os sintomas e para o lado da lesão. Os valores foram comparados ao ground truth (GT) e uma pontuação ASPECTS foi obtida por dois avaliadores independentes não cegos. Análise da sensibilidade e especificidade, características das curvas ROC, gráficos de Bland-Altman com média de escore de erro e coeficientes de correlação de Matthews (CCM) foram realizados para os valores de ASPECTS, assumindo valores iguais a 10 como imagens sem lesões e valores diferentes de 10 como imagens com alguma lesão isquêmica. Resultados: o e-ASPECTS demonstrou uma performance similar aos neurorradiologistas e neurologistas, com uma área sob a curva de 0,78 e um valor de CCM de 0,48 na análise dicotômica. Sensibilidade e especificidade do e-ASPECTS foram, respectivamente, 75 e 73%. Conclusão: O e-ASPECTS é uma ferramenta confiável e validada para determinar sinais precoces de isquemia nas TCSC.

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.

Ischemic stroke related to HIV and SARS-COV-2 co-infection: a case report

Abstract A 56-year-old male with human immunodeficiency virus required hospitalization due to the onset of both dyspnea and asthenia. A computed tomography of the chest exam showed the radiological pattern of coronavirus SARS-CoV-2 pulmonary involvement. Based on immunochromatographic analysis, the patient evolved as a reagent for immunoglobulin M (IgM) and immunoglobulin G (IgG) anti-SARS-CoV-2 antibodies. The individual developed complete hemiparesis with a predominance in the right arm and conduction aphasia. T1-weighted magnetic resonance sequence of the brain showed an area of hypointensity with a high intrinsic cortical signal and hyperintensity in the T2-sequence. A Doppler velocimetric examination showed total/critical sub occlusion, suggesting an ischemic stroke.

Establishment and evaluation of a monkey acute cerebral ischemia model

OBJECTIVES: Cerebral ischemia seriously threatens human health and is characterized by high rates of incidence, disability and death. Developing an ideal animal model of cerebral ischemia that reflects the human clinical features is critical for pathological studies and clinical research. The goal of this study is to establish a local cerebral ischemia model in rhesus macaque, thereby providing an optimal animal model to study cerebral ischemia. METHODS: Eight healthy rhesus monkeys were selected for this study. CT scans were performed before the operation to exclude cerebral vascular and intracranial lesions. Under guidance and monitoring with digital subtraction angiography (DSA), a microcatheter was inserted into the M1 segment of the middle cerebral artery (MCA) via the femoral artery. Then, autologous white thrombi were introduced to block blood flow. Immediately following embolization, multisequence MRI was used to monitor cerebrovascular and brain parenchymal conditions. Twenty-four hours after embolization, 2 monkeys were sacrificed and subjected to perfusion, fixation and pathological examination. RESULTS: The cerebral ischemia model was established in 7 rhesus monkeys; one animal died during intubation. DSA and magnetic resonance angiography (MRA) indicated the presence of an arterial occlusion. MRI showed acute local cerebral ischemia. HE staining revealed infarct lesions formed in the brain tissues, and thrombi were present in the cerebral artery. CONCLUSION: We established a rhesus macaque model of local cerebral ischemia by autologous thrombus placement. This model has important implications for basic and clinical research on cerebral ischemia. MRI and DSA can evaluate the models to ensure accuracy and effectiveness.

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.

Mecanismos de lesión cerebral en niños prematuros / Mechanisms of brain injury of the premature baby

Los nacimientos prematuros son uno de los principales indicadores de salud de un país. Están asociados a una alta mortalidad e importante morbilidad en niños con parálisis cerebral y otros trastornos del neurodesarrollo, incluyendo problemas cognitivos y del aprendizaje. Los principales tipos de lesión encefálica en los recién nacidos prematuros son: a) las lesiones de la sustancia blanca, generalmente asociadas a alteraciones neuronales y axonales en la corteza cerebral y otras zonas de sustancia gris; b) hemorragias intracraneanas que incluyen las de la matriz germinal, intraventriculares e intraparenquimatosas y c) del cerebelo. Las lesiones de sustancia blanca incluyen la leucomalacia periventricular quística, no quística (con focos de necrosis microscópicos) y lesiones difusas de sustancia blanca, no necróticas. Estas lesiones tienen múltiples factores etiológicos. Las características anatómicas y fisiológicas de las estructuras vasculares periventriculares predisponen a la sustancia blanca a ser muy vulnerable a las situaciones de isquemia cerebral y, en interacción con factores infecciosos/inflamatorios, activan a las microglías generando estrés oxidativo (por liberación de radicales libres del oxígeno y del nitrógeno), liberación de citoquinas proinflamatorias, liberación de glutamato, fallo energético y alteración de la integridad vascular. Todo lo anteriormente mencionado genera una particular vulnerabilidad de los pre-oligodendrocitos que termina alterando la mielinización. La hipoxia-isquemia también puede producir necrosis neuronal selectiva en diferentes regiones encefálicas. La matriz germinal es un área altamente vascularizada en la región subependimaria periventricular con una estructura capilar muy frágil que la predispone a las hemorragias.

Preterm birth is one of the main country health indicators. It is associated with high mortality and significant morbidity in preterm newborns with cerebral palsy and potential long-term neurodevelopmental disabilities like cognitive and learning problems. The main lesions could be: a) white matter injuries, generally associated with cortical and other regions of grey matter neuronal-axonal disturbances; b) intracranial hemorrhage that includes germinal matrix, intraventricular and parenchymal, c) cerebellum injuries. The white matter lesions include cystic and non-cystic (with microscopic focal necrosis) periventricular leukomalacia and non-necrotic diffuse white matter injury. Multiple etiologic factors are associated with these injuries. Anatomical and physiological characteristics of periventricular vascular structures predispose white matter to cerebral ischemia and, interacting with infection/inflammation factors, activate microglia, generating oxidative stress (mediated by free oxygen and nitrogen radicals), pro-inflammatory cytokine and glutamate toxicity, energetic failure and vascular integrity disturbances. All these factors lead to a particular vulnerability of pre-oligodendrocytes that will affect myelination. Hypoxia-ischemia also may produce selective neuronal necrosis in different cerebral regions. Germinal matrix is a highly vascularized zone beneath ependymal or periventricular region that constitutes a capillary bed with a particular structural fragility that predispose it to hemorrhage.

Comparison of different types of endovascular mechanical embolectomy in acute ischemic stroke

SUMMARY Background: To compare the treatment efficacy of different types of endovascular mechanical embolectomy in acute ischemic stroke (AIS). Material and Methods: A total of 89 patients with AIS were selected in our hospital from January 2014 to January 2016 and divided into tPA group (n=27), tPA+Trevo group (n=30) and tPA+Solitaire FR group (n=32) for different treatments. Treatment effectiveness was evaluated using NIHSS and mRS system. The NIHSS score, vascular recanalization rate and postoperative complications were compared among groups. Results: The NIHSS score of the tPA group was significantly lower than that of other two groups at 1 d after the operation (p < 0.05), but it was significantly higher than that of other two groups at 3 d and 3 w after the operation (p < 0.05). After the treatment, no significant difference in NIHSS score was found between the tPA+Trevo and tPA Solitaire FR groups. The revascularization rate was significantly higher, but the mortality rate in 90 d was significantly lower in the tPA+Trevo and tPA+Solitaire FR groups than that in the tPA group (p < 0.05), and no significant difference was found between the tPA+Trevo and tPA+Solitaire FR groups. The incidence rate of symptomatic intracranial hemorrhage was significantly lower in the tPA+Solitaire FR group than that in tPA+Trevo group (p < 0.05) or tPA group (p < 0.01). Significantly more patients with mRS no higher than 2 points were found in the tPA+Trevo and tPA+Solitaire FR groups than those in tPA group (p < 0.05), and no significant difference was found between the tPA+Trevo and tPA+Solitaire FR groups. Conclusion: TPA+Solitaire FR is a type of thrombectomy that is superior to tPA and tPA+Trevo in the treatment of patients with AIS.

RESUMO OBJETIVO Comparar a eficácia do tratamento de diferentes tipos de embolectomia mecânica endovascular em acidente vascular cerebral isquêmico agudo (AIS). MATERIAL E MÉTODOS Um total de 89 pacientes com AIS foi selecionado em nosso hospital de janeiro de 2014 a janeiro de 2016, e os pacientes foram divididos em: grupo tPA (n = 27), tPA + grupo Trevo (n = 30) e grupo tPA + Solitaire FR (n = 32) para diferentes tratamentos. A eficácia do tratamento foi avaliada usando NIHSS e sistema mRS. Escore NIHSS, taxa de recanalização vascular e complicações pós-operatórias foram comparados entre os grupos. RESULTADOS A pontuação NIHSS do grupo tPA foi significativamente menor do que a dos outros dois grupos em um dia após a operação (p < 0,05), mas foi significativamente maior do que nos outros dois grupos em três dias e três semanas após a operação (p < 0,05). Após o tratamento, não houve diferença significativa no escore NIHSS entre o grupo tPA + Trevo e o grupo tPA Solitaire FR. A taxa de revascularização foi significativamente maior, mas a taxa de mortalidade em 90 dias foi significativamente menor nos grupos tPA + Trevo e tPA + Solitaire FR do que no grupo tPA (p < 0,05) e não houve diferença significativa entre os grupos tPA + Trevo e tPA + Solitaire FR. A taxa de incidência de hemorragia intracraniana sintomática foi significativamente menor no grupo tPA + Solitaire FR do que no grupo tPA + Trevo (p < 0,05) ou no grupo tPA (p < 0,01). Significativamente mais pacientes com mRS não maiores que 2 pontos foram encontrados no grupo tPA + Trevo e tPA + Solitaire FR do que no grupo tPA (p < 0,05), e nenhuma diferença significativa foi encontrada entre os grupos tPA + Trevo e tPA + Solitaire FR. Conclusão O tPA + Solitaire FR é um tipo de trombectomia superior ao tPA e tPA + Trevo no tratamento de pacientes com EIA.

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.

Arteritis de células gigantes en el sistema vertebrobasilar, isquemias cerebelo-occipitales y parálisis III par: caso clínico / Giant cell arteritis of the vertebrobasilar system, posterior ischemia and palsy of the third nerve: report of one case

Giant cell arteritis is the most common vasculitis in patients aged over 50 years. We report an 89-year-old woman with significant weight loss and persistent frontal-occipital headaches lasting two months. The neurological examination at admission identified a decrease in visual acuity of the left eye, paralysis of the third cranial nerve of the right eye and alterations of body motility without objective signs of damage of the motor or sensitive pathways. Magnetic resonance imaging showed changes of the temporal artery wall and in both vertebral arteries, as well as bilateral cerebellar and occipital ischemic lesions. The Doppler ultrasound of the temporal arteries was compatible with Giant cell arteritis. Treatment with steroids was started. While receiving oral prednisone, the patient suffered new infarcts of the posterior territory, documented with a CAT scan.