Manejo avanzado del infarto cerebral en un hospital público chileno: trombectomía mecánica en el Hospital Barros Luco Trudeau / Mechanical thrombectomy in a Chilean public hospital. Experience in 149 patients

BACKGROUND: Mechanical thrombectomy is the accepted treatment for acute ischemic stroke in Large Vessel Occlusion. The Barros Luco Trudeau hospital developed endovenous thrombolysis in 2010, and since 2012, implemented endovascular management, becoming the neurovascular center in the southern area of the metropolitan region. AIM: To describe endovascular management of acute ischemic stroke in a Chilean public hospital. Material and Methods: Analysis of patients with acute ischemic stroke that were treated with mechanical throm-bectomy from 2012 to 2019 in the Barros Luco Hospital. RESULTS: In the study period, a mechanical thrombectomy was carried out in 149 patients aged 61 ± 15 years (46% females). The average National institute of Health Stroke Scale (NIHSS) at presentation was 19 ± 4-5. Anterior or posterior circulation involvement was present in 89.9 and 10.1 % of patients. Twenty-five percent of patients were referred from other public centers. The mean lapse between onset of symptoms and thrombectomy was 266 ± 178 in. Ninety days after the procedure, 58% of patients had minimal or absent disability (Modified Ranson score of 0-2), and 19,2% died. CONCLUSIONS: Mechanical thrombectomy, according to this experience, has favorable clinical outcomes in patients with high NIHSS scores at entry.

Experiencia de trombolisis sistematizada en infarto cerebral agudo en un hospital público de Chile / Thrombolysis for acute ischemic stroke with recombinant tissue plasminogen activator in a Chilean public hospital

Background: The only accepted treatment for acute ischemic stroke is thrombolysis with recombinant tissue plasminogen activator (t-PA). It was implemented in Chile in 1996, although its use was mainly restricted in Chile to private clinics. Recently, at year 2009, we have implemented this treatment in a public hospital. Aim: To describe the results of treatment of acute ischemic stroke with t-PA in a public hospital in Chile. Material and Methods: Prospective analysis of all eligible patients with acute ischemic stroke that were admitted within 4 hours of its onset and had no contraindications for thrombolysis. Results: In an eight months period, a total of 19 intravenous thrombolyses were performed in 12 males and seven females aged 28 to 79 years old. The mean lapse between onset of symptoms and onset of thrombolysis was 190 ± 57 min. Results were favorable, according to Rankin and National Institute of Health Stroke scales. Ninety days after treatment, 63 percent of patients had minimal or absent disability, 26 percent had moderate disability and only one (5 percent) had severe disability. One patient had a clinically not significant intracranial hemorrhage and one patient died six days after thrombolysis. Conclusions: These results indicate that thrombolysis can be successfully implemented in Chilean public hospitals. The limitations for its use in this setting are mostly administrative.

Muerte encefálica: la necesidad de una causa suficiente y necesaria: a propósito de un caso de deseferentación completa por síndrome de Guillain Barré / Brain death: the need for sufficient and necessary cause: apropos of a complete deseferentation case from Guillain Barre syndrome

La muerte encefálica es una causa válida en la certificación del deceso de un paciente, especialmente en condiciones de donación de órganos. Existen escasas situaciones en las que el legislador ha propuesto la realización de exámenes complementarios para su certificación. Presentamos el caso de un paciente con un síndrome de Guillain Barré, que llegó a simular un estado de muerte encefálica, debido al compromiso motor completo, incluyendo musculatura ocular intrínseca. La falta de una condición suficiente y necesaria para declarar la muerte del paciente lleva a la solicitud de exámenes complementarios, en este caso un electroencefalograma, los que determinan la normalidad de la actividad eléctrica cerebral. Se recalca la necesidad de cumplir estrictamente los criterios para determinar la muerte encefálica y el no inhibirse de solicitar exámenes complementarios en condiciones de duda, aún cuando la ley no siempre lo contemple.

Brain death is a valid cause of death certification in a patient, especially in terms of organ donation. There are few situations in which the legislator has proposed further examination for certification. We report the case of a patient with Guillain Barré syndrome, which came to simulate a state of brain death due to motor impairment in full, including intrinsic ocular muscles. The lack of a necessary and sufficient condition for declaring the patient's death led to request additional examinations, in this case an electroencephalogram, which determine the normality of brain electrical activity. It emphasizes the need to comply strictly with the criteria for determining brain death and not to request additional examinations inhibited in a position of doubt, even though the law does not always contemplated.

Neurosífilis meningovascular y gomatosa cerebral concomitante, en paciente seronegativo para virus de inmunodeficiencia humana / Meningovascular neurosyphilis and concomitant syphilitic gummata in hiv-seronegative patients

Neurosyphilis (NS) is caused by the presence of Treponema Pallidum (TP) spirochete within the Central Nervous System (CNS), mainly affecting the meninges and cerebrospinal fluid (CSF). 5 percent to 10 percent of untreated syphilitic patients are deemed to develop symptomatic NSÕ. Its incidence and clinical spectrum have changed over the years with prevalence of early clinical stages of meningitic and meningovascular (MV) NS and exceptional occurrence of late clinical stages (tabes dorsalis, general paresis, and gummata) in the age of antibiotics. The case under analysis deals with aggressive MV and concomitant brain gumma (BG) NS. The case subject is a human inmunodeficiency virus (HIV)-seronegative, 44-year-old woman with 2-year symptomatic latency. Her medical record showed recurrent sensorimotor vascular involvement, fast cognitive damage and chronic, daily cephalea. She met clinical diagnosis, cerebrospinal fluid and serologic criteria for NS. Brain computerized tomography (CT) and magnetic resonance (MR) reported lenticulostriate artery infarction and bilateral ganglionic syphilitic gummata. She underwent Penicillin G-based treatment, making progress with neurological, cognitive-motor sequelae. Although NS has anticipated and speeded up its several clinical stages in connection with HIV/Syphilis co-infection, the peculiarity of this case is the concurrence of early and late NS manifestations in HIV-seronegative patient. The conclusion is that NS is a disease that still prevails and that appropriate diagnosis and treatment prevent irreversible neurological sequelae.

La Neurosífilis (NS) es causada por la invasión del Sistema Nervioso Central (SNC) por la espiroqueta Treponema Pallidum (TP), afectando primariamente las meninges y líquido cefalorraquídeo. Entre 5 a 10 por ciento de los pacientes sifilíticos no tratados desarrollarán una NS sintomáticaÕ. Su incidencia y espectro clínico ha cambiado a lo largo del tiempo, siendo las formas clínicas precoces meníngea y meningovascular (MV) las más prevalentes. En contraste, las formas tardías (tabes dorsal, parálisis general y gomas) son de ocurrencia excepcional en la era antibiótica. Se analiza un caso de NS menigovascular y gomas cerebrales concomitantes, de curso clínico agresivo. En una mujer de 44 años, seronegativa para virus de inmunodeficiencia humana (VIH), con latencia sintomática de dos años. Presentaba una historia de focalidad sensitivo-motor de perfil vascular recurrente, rápido deterioro cognitivo-motor y cefalea crónica diaria. Cumplía criterios diagnósticos clínicos, licuorales y serológicos para NS. La Tomografía computada (TC) y Resonancia Magnética (RM) cerebral mostró infartos arteriolares lentículo-estriados y gomas sifilíticas ganglionares bilaterales. Recibió tratamiento con Penicilina G, evolucionando con secuelas neurológicas cognitivas-motoras. Si bien, la NS actualmente, ha anticipado y acelerado sus diferentes formas clínicas en relación a co-infección VIH/Sífilis. Lo llamativo de este caso, es la presentación concomitante de con manifestaciones precoces y tardías de NS en paciente VIH seronegativo. Se concluye que la NS sigue siendo una enfermedad vigente y su diagnóstico y tratamiento oportuno previene secuelas neurológicas irreversibles.

Neurología y embarazo / Neurology and pregnancy

Pregnancy produces a series of physiological changes in women which may trigger several neurologic pathologies or decompensation in pre-existing diseases. There are neurologic complications in pathological pregnancies such as: Wernicke's encephalopathy; posterior reversible encephalopathy which is a form of eclampsia; previous diseases such as epilepsies that entail a high obstetric risk due to the possibility of presenting embriopathies associated to the use of antiepileptic drugs (AEDs) and also because of the risk of a convulsive crisis in the fetus; cerebrovascular diseases which are rare although with high maternal mortality; extrapyramidal pathologies which are infrequent except for the chorea gravidarum and the restless legs syndrome; cerebral neoplasms in which due to haemodynamic changes at the end of the second quarter and the increase of estrogen and progesterone many tumors may raise their volume; and peripheral alterations like myasthenia gravis (MG); intervertebral disk displacement and entrapment neuropathies like carpal tunnel syndrome and meralgia paresthetica. Anyhow because of cellular immunity in multiple sclerosis pregnancy is protected from new outbreaks.

El embarazo provoca una serie de cambios en la fisiología de la mujer lo que puede desencadenar diferentes patologías, entre ellas neurológicas y/o descompensar enfermedades previas. Existen cuadros como complicaciones neurológicas de embarazos patológicos: encefalopatía de Wernicke, la encefalopatía posterior reversible que corresponde a una forma de manifestación de eclampsia, enfermedades previas como epilepsias que conllevan un alto riesgo obstétrico; por un lado por la posibilidad de presentar embriopatías asociadas al uso de fármacos antiepilépticos (FAE) y por otro el riesgo que representa una crisis convulsiva en el feto, enfermedades cerebrovasculares, complicación rara pero con una alta mortalidad materna, enfermedades extrapiramidales, infrecuentes, salvo el corea gravídico y el síndrome de piernas inquietas, esclerosis múltiple, en que el embarazo previene la aparición de brotes, debido al predominio de la inmunidad celular, neoplasias intracerebrales en que por los cambios hemodinámicos que ocurren al final del segundo trimestre y el aumento del estrógeno y progesterona, muchos tumores pueden aumentar su masa, y alteraciones periféricas como miastenia gravis (MG), hernias discales y aparición de neuropatías por atrapamiento como el síndrome del túnel del carpo y la meralgia parestésica.

Programa piloto para pacientes beneficiarios de Fonasa, que padecen esclerosis multiple: tratamiento con inmunomoduladores en el sistema público de salud de Chile: Informe del primer año, 10 de julio 2008-30 de Junio 2009 / Pilot national treatment program for multiple sclerosis patients belonging to the public health care system of Chile (FONASA) with immunomodulating disease-modifying therapies: first year report from July 2008 to June 2009

Multiple Sclerosis (MS) is a chronic disease of the central nervous system. It is manifested in the young adult who presents at the beginning alternation between transient neurological dysfunction and normality, followed by a progressive level of disability. MS affects the quality of life in the young adults in their full productive and creative age limiting not only in their personal lives but also affects to the whole society in terms of "dreams and life projects". Besides, this illness also influences the family group who has to assume progressively the help and care for the patient. In healthcare aspect MS implies intensive and progressive resources. In Chile, although we don't have epidemiological studies that indicate which is the MS prevalence it exist a projection that states 14 per 100.000 inhabitants. Considering a population of 16.5 million of inhabitants our expectative of patients with MS is of 2310 cases in our country. The MS immunomodulating injectable disease-modifying therapies are of high cost and were not available in a regular way in the state health care system of Chile (FONASA) that attends the 70 percent of the population; the other 30 percent has different private health insurances. In 2008 the ministry of health decided to initiate and pilot (exploratory) program which had a great meaning and impact concerning to start offering immunomodulating therapies to relapsing remitting MS, for patients belonging to FONASA system. The pilot program was thought with a double mission, on the one hand to achieve that a very limited group of MS patients belonging to FONASA system (80 cases) from all over the country had access to immunomodulating injectable disease-modifying therapies of high cost in a regular way. The second objective was to obtain clinical and epidemiological information which let us to evaluate the clinical and administrative obstacles generated by the incorporation of this treatment in the public health...

Introducción El presente documento corresponde al informe del primer año de trabajo operativo del "Programa piloto de tratamiento con inmunomoduladores, para pacientes beneficiarios de Fonasa1, que padecen esclerosis múltiple (EM)", elaborado por el equipo del centro de referencia nacional, para este programa, con sede en el Servicio de Neurología del Complejo Asistencial Barros Luco (CABL) del SSMS2. Dado su origen no incluye antecedentes del proceso de gestión ni toma de decisiones del nivel Minsal3 o Fonasa. Este trabajo, no es ni aspira ser: un ensayo clínico, una guía de práctica clínica, una revisión bibliográfica, ni una puesta al día sobre el tratamiento de la Esclerosis Múltiple (EM), es simplemente el informe anual de un centro de referencia, para una tarea específica, a la autoridad ministerial competente. El informe incluye algunos antecedentes generales y referencias presentadas como "notas al pie", sólo para contextualizar la información presentada4. La EM es una enfermedad crónica del SNC, de origen incierto, inmunológicamente mediada, bien definida en sus características inmunopatogénicas, patológicas, imagenológicas y clínicas. Se expresa en el adulto joven, quien presenta inicialmente alternancia entre disfunción neurológica transitoria y normalidad y cuya progresión determina múltiples efectos discapacitantes. La EM afecta la calidad de vida de adultos jóvenes en plena edad productiva y creativa limitando tanto los "sueños y proyectos de vida" como el desarrollo laboral, social y afectivo. Además trasciende al grupo familiar, cuando deben asumir la asistencia del paciente. En lo sanitario, la EM, genera uso intensivo y progresivo de recursos. Las terapias inmunomoduladores para la EM, que tienen la posibilidad de detener o reducir la evolución de la modalidad recurrente remitente de la EM, no se encontraban disponibles en forma regular en el sector público de salud de nuestro país, por esto el presente programa piloto...

Síndrome cerebeloso secundario a granulomas de fosa posterior y tuberculosis multisistémica en un paciente con SIDA / Cerebelous syndrome by infratentorial brain tuberculornas and mutisystemic tuberculosis in AIDS patient

Presentamos el caso clínico de un paciente que consultó por un síndrome cerebeloso y diplopía, asociados a pérdida de peso de 10 kilos en 6 meses y adenopatías múltiples. El estudio imagenológico cerebral demostró la presencia de lesiones de aspecto granulomatoso a nivel cerebeloso y mesencefálico, sin alteración citoquímica del líquido cefalorraquídeo. Las baciloscopias de orina y de la biopsia ganglionar fueron positivas y permitieron el diagnóstico de tuberculosis (TBC) sistémica. La serología para VIH resultó positiva en sangre con un recuento de linfocitos CD4 de 590 cel/mm3, clasificándose el caso como SIDA etapa Cl. El paciente fue tratado con el esquema antituberculoso según norma nacional, con buena respuesta clínica e imagenológica. La presentación de tuberculomas infratentoriales sin meningitis, como primera causa de pesquisa de TBC y SIDA no es habitual, de allí nuestro interés por comunicar el caso.

We present a clinical case of a patient who consulted for a cerebelous syndrome and diplopia associated to 10 kg weight loss in six months and multiple adenopathies. Cerebral imagenology study evidenced the presence of granulamatous masses at the cerebellum and midbrain level, there were no cerebrospinal fluid abnormalities. Systemic tuberculosis (TB) diagnosis was done based in finding of acid-fast bacilli positive staining in urine and lymph node biopsy. HIV infection was documented by ELISA serology. CD4 cell count was 590 cell/mm3, classifying the case a AIDS Cl stage. TB was treated according to national guidelines leading to good clinical and imagenology evolution. The clinical case scenario of infratentorial tuberculomas without meningitis as a first manifestation of TB and AIDS is unusual, generating our interest in reporting this case.

Síndrome de restauración inmune asociado a tratamiento antirretroviral y criptococosis meníngea: Caso clínico / Inflammatory reconstitution immune syndrome associated to antiretroviral therapy and meningeal cryptococcosis

The objective of high activity antiretroviral therapy (HAART) in patients with AIDS, is to obtain immune restoration. This means a reduction of the viral load and restitution of the CD4 cell count. A decreased rate of HIV replication improves both the number and function of CD4 cells. Nevertheless, this treatment sometimes results in the reappearance of previous symptoms from treated conditions due to opportunistic infections (ie: tuberculosis, criptococcosis, hepatitis, Pneumocystis jirovesi, toxoplasmosis, etc) or non infectious condition such as sarcoidosis, Graves disease or Kaposi sarcoma. This is known as Inflammatory Reconstitution Immune Syndrome (IRIS). We report a 37 year-old woman in stage C3-AIDS with a previous criptococcal meningitis. She was treated, achieving a marked improvement with treatment and subsequent suppressive therapy with fluconazole 200 mg/day. IRIS appeared after 8 months of ongoing antiretroviral therapy with immune restoration with the development of aseptic meningitis and intracranial hypertension. The opportunistic agent could not be identified by cultures. Additional laboratory tests excluded toxoplasmosis, tuberculosis, bacterial cerebral abscesses, syphilitic cerebral gummas, and lymphoma. Brain CT and magnetic resonance studies were compatible with brain vasculitis and leptomeningitis. The patient condition improved with general measures, such as a repeated lumbar punctures and non steroidal anti-inflammatory drugs. We conclude that this patient had an IRIS due to a Cryptococcus neoformans antigen.

Miastenia gravis: embarazo e impacto perinatal / Myasthenia gravis: pregnancy and perinatal impact

Se analizan 19 embarazos en 9 pacientes con miastenia gravis. Hubo 2 exacerbaciones de la enfermedad, una de esta asociada al uso de aminoglicósidos en el tratamiento de pielonefritis aguda. En un caso la enfermedad debutó a las 24 semanas de gestación. Hubo tres casos de miastenia gravis neonatal en la misma gestante, 2 de los recién nacidos fallecieron a los 29 y 25 días respectivamente, pese al tratamiento. Hubo un recién nacido de pretérmino y 6 casos (35 por ciento) de restricción del crecimiento intrauterino.

Aspergilosis meningovascular: caso clínico / Meningovascular aspergillosis: case report

El diagnóstico precoz de la infección por Aspergillus del Sistema Nervioso Central (SNC) es un gran desafío, donde la sospecha clínica fundamentada es clave por la alta letalidad de la entidad aún con tratamiento oportuno. La importante dificultad diagnostica es favorecida por algunas características de la entidad: baja incidencia, compromiso de individuos inmunocomprometidos que presentan múltiples infecciones, manifestaciones neurológicas clínicas e imagenológicas inespecíficas y métodos diagnósticos etiológicos de resultados tardíos. Presentamos el caso de un paciente diabético y alcohólico, con aspergilosis meningovascular precedida en 8 meses por un foco fúngico pulmonar. La presentación clínica fue a la manera de una meningoencefalitis subaguda con: cefalea, vértigo, compromiso de lenguaje, hemiparesia, alteración de conciencia y crisis convulsiva. Se trato con Anfotericina B con recuperación clínica completa. En este artículo revisamos algunos aspectos del compromiso por Aspergillus del SNC: mecanismos patogénicos, formas clínicas, factores de riesgo, principales métodos diagnósticos y alternativas de tratamiento.

Mielopatía por déficit de vitamina B12: caracterización clínica de 11 casos / Subacute combined degeneration of the spinal cord caused by vitamin B12 deficiency: report of 11 cases

Background: Subacute combined degeneration is a clinical manifestation of vitamin B12 deficiency, that we observe with unusual frequency. Aim: To report a series of eleven patients with subacute combined degeneration. Patients and methods: Retrospective analysis of 11 patients hospitalized in a public hospital in Santiago, between March 2001 and February 2003. All had a myelopathy of more than three weeks of evolution with serum vitamin B12 levels of less than 200 pg/ml. Results: A risk factor was identified in 10 cases and the most common was an age over 60 years old. The main presenting symptom was the presence of paresthesias. On admission, sphincter dysfunction, posterior column and pyramidal syndromes coexisted in nine patients. A level of sensitive deficit was detected in six. Ten patients had macrocytosis and eight were anemic. Serum vitamin B12 was measured in ten and in nine, it was below 200 pg/ml. The mean lapse between onset of symptoms and treatment was eight months. All received intramuscular vitamin B12 in doses on 1,000 to 10,000 IU/day. Sphincter dysfunction and propioception were the first symptoms to improve. Conclusions: Subacute combined degeneration must be suspected in patients older than 60 years with a subacute myelopathic syndrome and low serum vitamin B12 levels.

Potenciales evocados somatosensoriales y respuesta sintomática a medicamentos dopaminérgicos en enfermedad de Parkinson / Somatosensory evoked potentials and sintomatic response to dopaminergic drugs in Parkinson's disease

Short latency somatosensory evoked potentials were measured in 10 patients with Parkinson's disease before and after tha administration of Apomorphine 5 mg sc. Eight of these subjects were reassessed after one month of treatment with Levo-dopa. These potentials were measured in other nine subjects before and after one month of treatment with Selegiline 10 mg od. There was a significant increase of frontal potential N30 in nine of 10 subjects that received apomorphine, in seven of 8 patients treated with Levodopa and 7 of 9 patients treated with Selegiline. No changes in N20 parietal potential were observed. During apomorphine test, changes in N30 potential preceded clinical improvement in 6 patients and occurred simultaneously in 3 patients. No changes with apomorphine in N30 potential were observed in 2 healthy males. There was no relationship between electrophysiological changes and duration of disease or motor fluctuations. It is concluded that short latency somatosensory evoked potentials are an objective means of measuring dopaminergic response in patients with Parkinson's disease

Prueba de apomorfina: evaluación de la respuesta dopaminérgica en parkinsonismos / Apomorphine test: evaluation of dopaminergic response in Parkinson's disease

Apomorphine is a potent dopaminergic agonist that quickly and predictably reverts parkinsonian symptomatology. In 32 patients (18 male) aged 45 to 83 years old (22 with idiopathic parkinsonism and 10 with parkinsonism of other causes), the dopaminergic response to apomorphine after domperidone administration was assessed using the digital skill test and Webster scale. Twenty patients with idiopathic parkinsonism and 1 with parkinsonism of other causes had a positive response to apomorphine. In 44 percent apomorphine had adverse effects. All patients with idiopathic parkinsonism and the only patient with parkinsonism of other causes with a positive apomorphine test had a good response to levodopa therapy. It is concluded that apomorphine test has a 95 percent positive value for idiopathic parkinsonism and is useful diagnostic tool

Distonía tardía: complicación tardía y persistente de la terapia neuroléptica: reporte de un caso / Tardive dystonia: late-onset and persistent complication of neuroleptic therapy: a case report

Desde la introducción de los neurolépticos se conoce la presentación de alteraciones de tipo extrapiramidal como reacción adversa. Entre ellos resulta de importancia la diskinesia tardía, siendo menos frecuente pero de peor pronóstico la distonía tardía, a la que algunos autores incluyen como parte de la primera. Presentamos un paciente de 32 años que presenta un cuadro de distonía tardía posterior a tratamiento neuroléptico prolongado. Se analizan algunos aspectos de este síndrome, enfatizándose las diferencias clínicas, farmacológicas y pronósticas con la diskinesia tardía

Estudio comparativo del estado nutricional de un grupo de niños en edad preescolar y escolar / Comparative study of nutritional status in a groups of preschool and school children

A través de nuestra investigación se pretendió evaluar en forma comparativa el estado nutritivo de una muestra de 128 niños en dos etapas de su vida: a) al egresar de la actividad control salud (5 a 6 años de edad) y b) en su etapa escolar (9 a 14 años). La información se obtuvo a través de la Tarjeta Control Salud para el primer grupo y por medición directa a los escolares de la unidad Educativa F. N. 843 de Contulmo. Se utilizaron los criterios Peso/Talla, Peso/Edad y Talla/Edad. Observamos un porcentaje importante de niños con sobrepeso (ñ 20% en escolares) lo que debe ser motivo de preocupación respecto a los riesgos de salud que esto implica a futuro. Por último, es alentador encontrar que el estado nutritivo no se deteriora en la etapa escolar sino que incluso experimenta una mejoría apreciable en el porcentaje de escolares con estado nutritivo normal (73,4% P/E, 79,6% p/T). La magnitud de los desnutridos es bastante mayor empleando el parámetro Peso/Edad (15,6%; 9,4%) que con el Peso/Talla (0,8% en ambos períodos), diferencia explicada por el porcentaje elevado de niños con retraso estatural en las dos etapas (43% y 36,7% respectivamente), consecuencia tanto de déficit nutricional crónico como de factores genéticos implicados en una alta tasa de población indígena en la zona