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.

Encefalopatía subaguda en una paciente con policondritis recidivante: caso clínico / Subacute encephalopathy associated with relapsing polychondritis: report of one case

Relapsing polychondritis (RP) is a rare multisystemic autoimmune disorder characterized by the inflammation and destruction of cartilages, with preference for auricular, nasal and laryngotracheal cartilages. RP may also affect proteoglycan-rich structures, such as, blood vessels, eyes, kidneys, and heart. The central nervous system (CNS) is involved in less than 3% of patients. We report a 32-year-old female with RP associated with a progressive subacute encephalopathy characterized by behavioral disturbances, auditory and visual hallucinations. The EEG showed generalized slow activity and a mononuclear pleocytosis with increased protein was found in the cerebrospinal fluid. The brain magnetic resonance imaging showed multiple supra and infratentorial nodular inflammatory lesions. After initiating treatment with corticosteroids and cyclophosphamide, a significant improvement in chondritis and neurological status was observed.

Experiencia en el tratamiento endovascular del accidente cerebrovascular isquémico agudo en un centro chileno / Emergency endovascular management of ischemic stroke: experience in 104 patients

Background: Recently, five randomized controlled trials confirmed the efficacy and safety of endovascular treatment with or without intravenous thrombolysis in acute ischemic stroke with large-vessel occlusion. Aim: To report patients with ischemic stroke treated with endovascular methods. Material and Methods: Retrospective analysis of 104 patients aged 61 ± 15 years (54% males) with ischemic stroke who received endovascular treatment at a single medical center between 2009 and 2017. Results: Sixty one percent were treated with intravenous thrombolysis plus endovascular procedures and 39% with endovascular procedures alone. The median door-to needle time was 61 minutes and door-to femoral puncture was 135 minutes. The median National Institute of Health Stroke Scale (NIHSS) scores on admission, 24 hours later and at discharge were 12,4 and 1 points, respectively. Middle cerebral artery was occluded in 60% of cases. Other frequent localizations where distal carotid artery in 17% and vertebro-basilar artery in 14%. Thrombolysis in cerebral infarction (TICI) scale flow score after the procedure was 3 or 2b in 58% of cases and significantly correlated with NIHSS scores at 24 hours and discharge. Fifty percent of patients had a mRankin score < = 1 and ten patients died (9.6%). Eight percent had a symptomatic intracerebral hemorrhage. Conclusions: The clinical improvement of these patients 24 hours after the procedure and at discharge demonstrate the effectiveness of endovascular treatment in ischemic stroke. The presence neurologists able to interpret multimodal images at the emergency room, the use of local guidelines, the availability of an experienced neuro-interventional team engaged with the workflow and the use of stent retrievers are strongly associated with good outcomes.

Evento cerebro vascular isquémico / Ischemic vascular brain event

Las enfermedades vasculares cerebrales son la tercera causa de muerte en el mundo occidental y el ictus isquémico sigue siendo una causa importante de morbilidad y mortalidad, pues representa un tercio de las muertes en Norteamérica. Los pacientes con mayor riesgo de desarrollar un Evento Cerebro Vascular Isquémico (ECVI) son aquellos que presentan fibrilación auricular, estenosis arterial sintomática de una de las arterias carótidas internas o vertebrales, amaurosis fugaz u otros eventos isquémicos. La tomografía computada de cerebro inicial resulta normal en un tercio de los pacientes. Existe evidencia de que el ingreso a unidades especializadas en el manejo del ictus disminuye su riesgo de muerte, incapacidad y cuidados crónicos institucionalizados. A pesar de todo, muchos pacientes fallecen en muerte cerebral. Aunque no existen estudios clínicos sobre la mejor forma de proteger la vía aérea en pacientes con ECVI, cuando hay compromiso de conciencia e incapacidad de protegerla se utiliza de preferencia la intubación endotraqueal. Se recomienda ser prudente en el manejo de la HTA en la fase aguda del ictus isquémico. La administración intravenosa o intraarterial de agentes trombolíticos puede lograr la re-permeabilización del vaso ocluido y mejorar el resultado neurológico de los pacientes con un infarto cerebral. Sólo el rt-PA tiene clara evidencia de su beneficio. Se revisan el tratamiento del EVCI y de sus complicaciones.

Brain vascular diseases are the third leading cause of death in the Western world, while ischemic ictus continues to be a major cause of morbimortality, accounting for one third of all deaths in North America. Patients with a higher risk of developing an Ischemic Cerebrovascular Event (ICE) are those presenting auricular fibrillation, symptomatic arterial stenosis in one of the vertebral or internal carotids, amaurosis fugax or other ischemic events. Initial brain computed tomography is found to be normal in a third of all patients. It has been evidenced that timely admission to Centers specialized in ictus treatment reduces death risk rates, handicaps, and residential health care for chronically ill patients. Nevertheless, many patients die from brain death. Despite the non-existence of clinical studies on how to best protect aerial pathway in ICE patients, when there is consciousness compromise and no possibility of protecting it, endotracheal intubation is performed preferably. During acute stage of ischemic ictus a sensible management of AHT is recommended. Intravenous or intraarterial administration of thrombolytic agents may produce repermeabilization of the occluded vessel and improve neurological outcome in patients with brain infarction. Only rt-PA has proved to be clearly beneficial. Management of ICE and its complications are revised.