Intraventricular hemorrhage as clinical presentation of herpes simplex virus encephalitis. A case report and review of the literature.

OBJECTIVE: Herpes simplex virus encephalitis (HSVE) represents the most common cause of sporadic encephalitis in humans. The development of intracerebral hematomas is rare and late during the course of HSVE. To report a case of a patient with HSVE who initially presented a diffuse intracranial hemorrhage with predominant intraventricular bleeding. CASE REPORT: A 66-year-old man was admitted to the Emergency Department with acute headache. Antecedents: alcohol consumption and ethylic hepatopathy. The brain computed tomography showed acute tetraventricular hemorrhage and hydrocephalus. The blood analysis showed pancytopenia and alteration of all hepatic parameters. After external drainage of cerebrospinal fluid the patient presented a worsening of headache, disorientation, mild left hemiparesis, neck stiffness and temperature of 37.6 °C. The cerebrospinal fluid was hemorrhagic, with 3 lymphocytes/mm3, 60 mg/dL of proteins and PCR positive for Herpes simplex virus type 1. The patient improved with intravenous acyclovir, however he experienced several medical complications which caused his dead. DISCUSSION: The patient presented an atypical cerebral bleeding related to HSVE because the development of hematoma was early and the topography of hemorrhage was basically intraventricular. Probably, both atypical characteristics were related to thrombocytopenia and severe coagulation disorder. This case expands the spectrum of cerebrovascular disorders associated with HSVE.

Frequency and mechanism of ischemic stroke associated with malignancy: a retrospective series.

BACKGROUND: Cerebrovascular disease is the second most common non-metastatic neurological disorder in oncological patients. The aims of this study were to determine the prevalence of cancer in stroke patients and to compare mechanisms of stroke between patients with and without malignancy. PATIENTS AND METHODS: This retrospective study involved patients with ischemic stroke admitted over 1 year to a Neurology Department. Demographic and clinical data, cardiovascular risk factors, and laboratory findings were recorded. The etiology was classified following the TOAST criteria. Participants were classified as stroke and cancer patients (diagnosis of malignancy before stroke or cancer diagnosed after admission) or as control stroke patients. RESULTS: Over 1 year, 291 stroke patients (268 ischemic) were admitted. Sixteen ischemic patients had a malignancy (5.9%), and in 12 patients, malignancy was the only cause found for the stroke; in 4 patients, malignancy was a coexisting condition. Coexistent stroke and cancer was significantly related to higher median levels of fibrinogen, D-dimers, and erythrocyte sedimentation rate (ESR). Logistic regression analysis showed that D-dimer and ESR levels were independently related to cancer, with odds ratios of 1.004 (95% CI 1.001-1.007, p=0.02) and 1.075 (95% CI 1.031-1.121, p=0.001), respectively. CONCLUSIONS: Almost 6% of ischemic stroke patients had a concomitant malignancy. In most of them, cancer was the only cause of stroke found. Patients with stroke and malignancy exhibited raised D-dimer, fibrinogen, and ESR levels, suggesting the prothrombotic state was a principal mechanism underlying stroke. D-dimer and ESR assessments may be useful in identifying underlying disorders in ischemic stroke.

Usefulness of measurement of fibrinogen, D-dimer, D-dimer/fibrinogen ratio, C reactive protein and erythrocyte sedimentation rate to assess the pathophysiology and mechanism of ischaemic stroke.

BACKGROUND: Classification defined in the Trial of Org10172 in Acute Ischaemic Stroke (TOAST) is widely used in trials and practice. Previous studies on pathophysiology suggest a role for endothelial inflammation in atherothrombotic strokes and intracardiac thrombosis in cardioembolic strokes. Data on lacunar and undetermined strokes are limited. The aim of the study was to assess non-specific inflammatory and thrombogenic parameters in patients with ischaemic stroke. METHODS: This was a prospective controlled clinical study involving 200 patients with ischaemic stroke and 50 controls. Patients were classified following the TOAST criteria. Plasma levels of fibrinogen, D-dimer, C reactive protein and values for D-dimer/fibrinogen ratio and erythrocyte sedimentation rate were assessed over 48 h after admission. Clinical severity was measured using the National Institutes of Health Stroke Scale and the Oxfordshire Community Stroke Project classification. Patients with severe systemic disorders were excluded. RESULTS: The assessed parameters were significantly higher in patients versus controls. Cardioembolic stroke patients showed increased D-dimer, fibrinogen and D-dimer/fibrinogen ratio. Patients with atherothrombotic stroke showed raised fibrinogen and erythrocyte sedimentation rate. Patients with lacunar and undetermined stroke showed intermediate values of markers. Total anterior cerebral infarction syndrome was related to D-dimer. DISCUSSION: Patients showed analytical modifications during the acute phase of stroke, both related to acute response and mechanism. The results suggest that the biochemical profile may be prothrombotic in patients with cardioembolism and inflammatory in those with atherothrombotic stroke. Patients with lacunar and undetermined stroke showed intermediate profiles. Assessment of the studied parameters is not expensive, widely available and may proportionate information about pathophysiology in stroke patients without severe systemic conditions.

Albumin level and stroke. Potential association between lower albumin level and cardioembolic aetiology.

BACKGROUND: Lower level of albumin was related to worse prognosis of stroke and clinical trials showed that albumin therapy reduced mortality. However, stroke is heterogeneous and differences in the baseline concentration of albumin among subtypes of stroke were not assessed. The aim was to assess albumin level in patients with ischemic stroke classified by mechanism. METHODS: Prospective controlled clinical study, including 200 patients with ischemic stroke and 50 controls. Patients were classified following Trial of ORG 10172 in Acute Stroke Treatment criteria. Plasma levels of albumin, fibrinogen, D-dimer, and C-reactive protein were assessed during 48 hr after admission. The National Institutes of Health Stroke Scale (NIHSS) on admission, in-hospital mortality, and Rankin score on discharge were recorded. Dependence was defined as mRS > 2. RESULTS: Patients with cardioembolic stroke showed significantly higher D-dimer and lower albumin. Mortality was related to higher NIHSS, higher D-dimer, lower albumin, and cardioembolic aetiology. Dependence was strongly related to lower albumin and higher NIHSS. LOGISTIC REGRESSION: The cardioembolic aetiology (OR 0.101, 95% CI 0.010-1.007, p = .051) and the higher NIHSS score (OR 0.871, 95% CI 0.758-1.002, p = .053) were related to mortality; NIHSS (OR 1.560, 95% CI 1.323-1.838, p < .0001) and older age (OR 1.052, 95% CI 1.012-1.093, p = .010) were independently related to dependence. DISCUSSION: Patients with cardioembolic stroke showed lower albumin and higher risk of mortality than non-cardioembolic ones. Lower mean level of albumin was related to mortality and dependence in all patients. Reduced albumin may be a marker of chronic systemic inflammation, which may be the mechanism for cardiopathy and bad outcome of stroke. In addition, direct effects on ischemic tissue were suggested in experimental models.

[Lipoprotein-associated phospholipase A(2) and stroke]. / Fosfolipasa A(2) asociada a lipoproteínas y patología vascular cerebral.

INTRODUCTION: Lipoprotein-associated phospholipase A2 (Lp-PLA2) is an enzyme member of A2 phosholipases superfamily. The 80% circulates bound to LDL-cholesterol and levels of both parameters are positively correlated. The main function of this enzyme is to hydrolyze oxidized phospholipids contained in LDL-cholesterol forming pro-inflammatory products in atheroma plaque. Several studies related raised Lp-PLA2 and vascular risk. AIM: To review available data relating Lp-PLA2 and stroke. DEVELOPMENT: Different cohorts and cases and controls studies showed an association between higher levels of Lp-PLA2 and the risk of suffering: first cardiovascular event (coronary heart disease, ischemic stroke) or its recurrence; progression of coronary damage evaluated using cardiac computed tomography; or death of cardiovascular cause. Published risk measurements are less than 2 and it has been demonstrated that raised levels of enzyme are risk factor independent of classic cardiovascular risk factors and non-HDL cholesterol and C-reactive protein levels. The clinical data and the knowledge of the role of Lp-PLA2 in plaque destabilization justified the development of inhibitor drugs. CONCLUSIONS: According to current evidence, patients in the higher range of Lp-PLA2 may be considerate at higher risk of suffering a vascular event. The application to stroke needs a better definition of the pathophysiologic role and the knowledge of phase II clinical trials currently under development in coronary heart disease.

[Serotonin syndrome: report of two cases and review of the literature]. / Síndrome serotoninérgico: presentación de dos casos y revisión de la bibliografía.

INTRODUCTION: Serotonin is a neurotransmitter synthesized from tryptophan. It is implied in the regulation of mood, cognition, sleep cycle, synthesis of cerebrospinal fluid, and other processes. Generally, it is implied in human pathology by hypofunction. However, there is a complication of unknown incidence related to treatment with drugs that increase the stimulation of 5-HT1A serotonin receptors, called serotonin syndrome (SS). Clinically, it is characterised by the presence of a triad of mental and autonomic disorders, and motor hyperactivity. This entity has not biological markers and its diagnosis could be done verifying the proposed criteria. CASE REPORTS: Two cases of SS are presented, one of them related to the combination of risperidone and sertraline, as first report in the literature. Both cases had a favourable outcome employing support measures. CONCLUSIONS: The physiopathology, the diagnosis, the differential diagnosis, and the treatment are reviewed. We emphasize the potentially high frequency of this disorder, given the growing use of serotonin activity modifying drugs, and the typically benign course of the SS once the support measures are started.

[The normal values of the haemodynamic reserve (HR) evaluated by the CO2 test]. / Valores de normalidad de la reserva hemodinámica cerebral (RHC) evaluada mediante el test de CO2.

BACKGROUND: The cerebral haemodynamic reserve (HR) is a recognised predictive factor of brain ischaemia in subjects with carotid stenosis. Our objective is to establish normal parameters which may be used for comparison with deficit states. SUBJECTS AND METHOD: The haemodynamic reserve was calculated in healthy subjects who had no evidence of previous carotid, haematological or cardiovascular pathologies. Subjects were asked to inhale CO2. The HR was then calculated as a percentage of the increase in the mean velocity in the Silvian artery for each millimetre of mercury increase of the end-tidal CO2. The median and percentiles 5 and 95 were calculated for each hemisphere, sex and age group. RESULTS: 100 subjects were studied (45 men and 55 women, mean age 51.6 years, range 18-79). Normal HR value was defined as percentile 5, with a value of 2% for men, and 2.5% for women. The only adverse reaction was dyspnea in 2 subjects. CONCLUSIONS: Values for the haemodynamic reserve of healthy subjects, which may serve as a reference for other ultrasonography laboratories, are established from an extensive control group.

Valores de normalidad de la reserva hemodinámica cerebral (RHC) evaluada mediante el test de CO2 / The normal values of the haemodynamic reserve (HR) evaluated by the CO2 test

FUNDAMENTO: El estado de la reserva hemodinámica cerebral (RHC) en los sujetos con estenosis carotídea es un factor predictivo reconocido del riesgo de presentar isquemia cerebral ipsilateral. Nuestro objetivo es establecer valores de referencia procedentes de la población sana que puedan ser aplicados en el estudio de estos pacientes. PACIENTES Y MÉTODO: Se calculó la RHC en sujetos sanos y sin evidencia de patología carotídea, hematológica o cardiovascular previa. El método elegido fue la inhalación de CO2, expresando la RHC como el porcentaje de incremento de la velocidad media en la arteria silviana por cada milímetro de mercurio de aumento en la concentración espiratoria final de CO2 al inducir la hipercapnia. Se calcularon las medianas y percentiles 5 y 95 por hemisferio, sexo y grupo de edad. RESULTADOS: Se estudiaron 100 sujetos (45 varones y 55 mujeres, media de edad 51,6 años, rango 18-79 años). Se consideró como límite de normalidad de la RHC el percentil 5, que fue de un 2 per cent para los varones y de un 2,5 per cent para las mujeres. El único acontecimiento adverso fue sensación disneica en 2 individuos. CONCLUSIONES: Los valores presentados son los primeros parámetros de normalidad procedentes de una serie extensa de controles publicados en la bibliografía y pueden ser de referencia para otros laboratorios de ultrasonografía. (AU)

[Intracranial venous thrombosis: a study of 16 cases and a review of the literature]. / Trombosis venosa intracraneal: estudio de 16 casos y revisión de la bibliografía.

INTRODUCTION: The clinical picture and aetiology of intracranial venous thrombosis are highly variable. Early descriptions reported it as a rare disease with a poor prognosis but the advent of neuroimaging techniques, and a deeper knowledge of the clinical picture, have shown it to have a higher frequency and a better prognosis. OBJECTIVE: To report the clinical and neuroimaging findings in patients diagnosed as having intracranial venous thrombosis in our department and review the state of the literature. PATIENTS AND METHODS: We reviewed all discharge reports from patients admitted to the neurology department of the Juan Canalejo Hospital between 1975 and 2000. Of these, we reviewed the medical records of those patients diagnosed as having intracranial venous thrombosis in order to obtain data relating to the clinical manifestations, complementary tests, etiological and topographical diagnosis, treatment and outcome. RESULTS: Diagnosis of intracranial venous thrombosis was made in 16 patients. The most common symptom was headache. The superior sagittal was the most frequently affected sinus. In almost all patients CT results led to the suspicion, and in some cases the confirmation, of the diagnosis. The most frequently found aetiology was oral contraceptive consumption. Outcome was generally good both with anticoagulation and symptomatic treatments. CONCLUSIONS: The most important difference between the present study and earlier reports is in the frequency of the different aetiologies. Our findings provide further evidence that intracranial venous thrombosis is not an infrequent disease and that the prognosis is generally good.