Tiempo de llegada hospitalaria y pronóstico funcional después de un infarto cerebral: resultados del estudio PREMIER / Hospital arrival time and functional outcome after acute ischaemic stroke: Results from the PREMIER study

Introducción: La información sobre el tiempo de llegada hospitalaria después de un infarto cerebral (IC) se ha originado en países con unidades especializadas en ictus. Existe poca información en naciones emergentes. Nos propusimos identificar los factores que influyen en el tiempo de llegada hospitalaria a 1, 3 y 6 h y su relación con el pronóstico funcional después del ictus. Métodos: Se analizó la información de pacientes con IC incluidos en el estudio Primer Registro Mexicano de Isquemia Cerebral (PREMIER) que tuvieran tiempo definido desde el inicio de los síntomas hasta la llegada hospitalaria. El desenlace funcional se evaluó mediante la escala modificada de Rankin a los 30 días, 3, 6 y 12 meses. Resultados: De 1.096 pacientes con IC, 61 (6%) llegaron en < 1 h, 250 (23%) en < 3 h y 464 (42%) en < 6 h. Favorecieron la llegada temprana en < 1 h: el antecedente familiar de cardiopatía isquémica y ser migrañoso; en < 3 h: edad 40-69 años, antecedente familiar de hipertensión, antecedente personal de dislipidemia y cardiopatía isquémica, así como la atención en hospital privado; en < 6 h: antecedente familiar de hipertensión, ser migrañoso, ictus previo, cardiopatía isquémica y atención en hospital privado. La llegada hospitalaria tardía se asoció a ictus lacunar y alcoholismo. Solo el 2,4% recibió trombólisis. Independientemente de la trombólisis, la llegada en < 3 h se asoció a menor mortalidad a los 3 y 6 meses, además de menos complicaciones intrahospitalarias. Conclusiones: Una proporción importante de pacientes tuvo un tiempo de llegada hospitalaria temprana; sin embargo, menos del 3% recibió trombólisis. Aunque muchos factores se asociaron a la llegada temprana, es prioritario identificar las barreras intrahospitalarias que obstaculizan la trombólisis

Introduction: Information regarding hospital arrival times after acute ischaemic stroke (AIS) has mainly been gathered from countries with specialised stroke units. Little data from emerging nations is available. We aim to identify factors associated with achieving hospital arrival times of less than 1, 3, and 6 hours, and analyse how arrival times are related to functional outcomes after AIS. Methods: We analysed data from patients with AIS included in the PREMIER study (Primer Registro Mexicano de Isquemia Cerebral) which defined time from symptom onset to hospital arrival. The functional prognosis at 30 days and at 3, 6, and 12 months was evaluated using the modified Rankin Scale. Results: Among 1096 patients with AIS, 61 (6%) arrived in <1 hour, 250 (23%) in <3 hours, and 464 (42%) in <6 hours. The factors associated with very early (<1 hour) arrival were family history of ischemic heart disease and personal history of migraines; in <3 hours: age 40-69 years, family history of hypertension, personal history of dyslipidaemia and ischaemic heart disease, and care in a private hospital; in <6 hours: migraine, previous stroke, ischaemic heart disease, care in a private hospital, and family history of hypertension. Delayed hospital arrival was associated with lacunar stroke and alcoholism. Only 2.4% of patients underwent thrombolysis. Regardless of whether or not thrombolysis was performed, arrival time in <3 hours was associated with lower mortality at 3 and 6 months, and with fewer in-hospital complications. Conclusions: A high percentage of patients had short hospital arrival times; however, less than 3% underwent thrombolysis. Although many factors were associated with early hospital arrival, it is a priority to identify in-hospital barriers to performing thrombolysis

Hospital arrival time and functional outcome after acute ischaemic stroke: results from the PREMIER study.

INTRODUCTION: Information regarding hospital arrival times after acute ischaemic stroke (AIS) has mainly been gathered from countries with specialised stroke units. Little data from emerging nations is available. We aim to identify factors associated with achieving hospital arrival times of less than 1, 3, and 6 hours, and analyse how arrival times are related to functional outcomes after AIS. METHODS: We analysed data from patients with AIS included in the PREMIER study (Primer Registro Mexicano de Isquemia Cerebral) which defined time from symptom onset to hospital arrival. The functional prognosis at 30 days and at 3, 6, and 12 months was evaluated using the modified Rankin Scale. RESULTS: Among 1096 patients with AIS, 61 (6%) arrived in <1 hour, 250 (23%) in <3 hours, and 464 (42%) in <6 hours. The factors associated with very early (<1 hour) arrival were family history of ischemic heart disease and personal history of migraines; in <3 hours: age 40-69 years, family history of hypertension, personal history of dyslipidaemia and ischaemic heart disease, and care in a private hospital; in <6 hours: migraine, previous stroke, ischaemic heart disease, care in a private hospital, and family history of hypertension. Delayed hospital arrival was associated with lacunar stroke and alcoholism. Only 2.4% of patients underwent thrombolysis. Regardless of whether or not thrombolysis was performed, arrival time in <3 hours was associated with lower mortality at 3 and 6 months, and with fewer in-hospital complications. CONCLUSIONS: A high percentage of patients had short hospital arrival times; however, less than 3% underwent thrombolysis. Although many factors were associated with early hospital arrival, it is a priority to identify in-hospital barriers to performing thrombolysis.

Shunting in acute cerebral venous thrombosis: a systematic review.

BACKGROUND AND PURPOSE: The efficacy of cerebrospinal fluid shunting to reduce intracranial hypertension and prevent fatal brain herniation in acute cerebral venous thrombosis (CVT) is unknown. METHOD: From the International Study on Cerebral Vein and Dural Sinus Thrombosis (ISCVT) and a systematic literature review, we retrieved acute CVT patients treated only with shunting (external ventricular drain, ventriculoperitoneal or ventriculojugular shunt). Outcome was classified at 6 months and final follow-up by the modified Rankin Scale (mRS). RESULTS: 15 patients were collected (9 from the ISCVT and 6 from the review) who were treated with a shunt (external ventricular drain in 6 patients, a ventriculoperitoneal shunt in 8 patients or an unspecified type of shunt in another one). Eight patients (53.3%) regained independence (mRS 0-2), while 2 patients (13.3%) were left with a severe handicap (mRS 4-6) and 4 (26.7%) died despite treatment. Five patients with parenchymal lesions were shunted within 48 h from admission deterioration, 4 with an external ventricular drain: 2 (40%) recovered to independence, 2 (40%) had a severe handicap and 1 (20%) died. In contrast, all 3 patients with intracranial hypertension and no parenchymal lesions receiving a ventriculoperitoneal shunt later than 48 h regained independence. CONCLUSION AND IMPLICATIONS: A quarter of acute CVT patients treated with a shunt died, and only half regained independence. With the limitation of the small number of subjects, this review suggests that shunting does not appear to be effective in preventing death from brain herniation in acute CVT. We cannot exclude that shunting may benefit patients with sustained intracranial hypertension and no parenchymal lesions.

Safety of lumbar puncture in patients with cerebral venous thrombosis.

BACKGROUND AND PURPOSE: Lumbar puncture (LP) may precipitate cerebral venous thrombosis (CVT), but it is unclear if LP is deleterious in patients with CVT. We aimed to assess the safety of LP in the International Study on Cerebral Veins and Dural Sinus Thrombosis prospective cohort. METHODS: In 624 patients with CVT, we compared the prognosis of patients submitted or not to LP. The primary outcome was 'death or dependency at 6 months', as evaluated by the modified Rankin Scale (mRS; mRS = 3-6, with adjustment for variables associated with poor prognosis); secondary outcomes were: 'worsening after admission'; 'acute death'; and 'complete recovery at 6 months' (mRS = 0-1). We analyzed the same outcomes in subgroups of patients with brain lesions on the admission computer tomography/magnetic resonance imaging. RESULTS: LP was performed in 224 patients (35.9%). There was no difference in frequency of 'death or dependency at 6 months' between patients with or without LP [13.4% vs. 14.4%; odds ratio (OR) = 0.9, 95% confidence interval (CI) 0.6-1.5; P = 0.739]. LP was not associated with 'worsening after hospitalization' [21.5% vs. 23.5%; OR = 0.9, 95% CI 0.6-1.3; P = 0.577], 'acute death' [3.6% vs. 3.3%; OR = 1.1, 95% CI 0.5-2.7; P = 0.844] or 'complete recovery' [79.9% vs. 76.6%; OR = 1.2, 95% CI 0.8-1.7; P = 0.484]. In the subgroups of patients with brain lesions, the prognoses were not different between patients submitted or not to LP. CONCLUSION: LP was not associated with the functional outcome of patients with CVT, suggesting that LP was not harmful in these patients. These results should not be generalized to patients with large brain lesions and risk of herniation where LP is contraindicated.

Aspirin versus anticoagulation in intra- and extracranial vertebral artery dissection.

BACKGROUND AND PURPOSE: To evaluate the incidence and predictors of ischaemic recurrent stroke and the adverse events of antithrombotic therapy in patients with first intra- or extracranial vertebral artery dissection (VAD) who were treated with aspirin or oral anticoagulation (OA). METHODS: A 21-year database of consecutive patients with confirmed diagnoses of VAD (n = 110, 63% men; mean age 37.9 ± 8.5 years) without intracerebral hemorrhage and who were treated with aspirin or OA were analyzed retrospectively. In all cases, the admission diagnosis was ischaemic stroke. Three groups were defined according to the site of the dissection: (i) extracranial, (ii) intracranial, and (iii) intra-/extracranial. Clinical follow-up was obtained by neurologic examination. Outcome measures were (i) recurrent ischaemic events (ischaemic stroke or transient ischaemic attack) and (ii) intra- and extracranial major bleeding. RESULTS: No difference in age, smoking, or hypertension was found between patients treated with OA (n = 49) and those treated with aspirin (n = 50). Extracranial artery dissection (49%) had preponderance over intracranial (27%) or intra-/extracranial (23%) location. During the follow-up, recurrent ischaemic events were rare (one case). There were no bleeding complications. The treatment that was used did not influence the functional outcome or recanalization. A good functional outcome (modified Rankin score ≤ 2) was observed in 82 patients. CONCLUSIONS: Although this was a non-randomized study, our data suggest that the frequency of recurrent ischaemic stroke in patients with intra- or extracranial VAD is low and most likely independent of the type of antithrombotic treatment.

Aspirina frente a anticoagulación en pacientes jóvenes con infarto cerebral secundario a síndrome antifosfolípido primario / Aspirin versus anticoagulation in young patients with cerebral infarction secondary to primary antiphospholipid syndrome

Introducción. El síndrome antifosfolípido primario (SAP) es un factor de riesgo independiente para infarto cerebral. Objetivo. Evaluar el riesgo de recurrencia, comparar los diferentes tratamientos y determinar los factores de riesgo asociados con recurrencia y complicaciones hemorrágicas en pacientes con infarto cerebral y SAP. Pacientes y métodos. Los datos prospectivamente recogidos de 92 pacientes menores de 45 años (71% mujeres; media de edad: 33,8 ± 8,9 años), con diagnósticos confirmados de infarto cerebral y SAP, tratados con anticoagulantes (n = 54) o aspirina (n = 38), se analizaron restrospectivamente. El seguimiento se realizó con evaluación neurológica cada 6 a 12 meses. Las medidas de pronóstico fueron: recurrencia de infarto cerebral, hemorragia intracerebral sintomática y sangrado menor. Resultados. Durante una mediana de seguimiento de 54 meses (rango: 12-240 meses), ocurrieron ocho (9%) infartos cerebrales recurrentes, sin diferencia entre el tratamiento con aspirina (n = 0) o anticoagulantes (n = 8). La tasa anual de recurrencia fue de 0,014 personas/año de seguimiento. La historia de trombosis previa y de abortos espontáneos fue más habitual en pacientes con recurrencia. Los pacientes tratados con aspirina provenían con mayor frecuencia de medio rural. Cuatro pacientes anticoagulados desarrollaron complicaciones hemorrágicas; dos, hemorragias menores, y dos, hematomas subdurales. El 76% de los casos evolucionó con buen pronóstico funcional (escala de Rankin modificada: 0-2). Conclusión. Con las limitaciones de un estudio no aleatorizado, nuestros datos sugieren que el riesgo de infarto cerebral arterial recurrente en pacientes jóvenes con infarto cerebral secundario a SAP es bajo, no homogéneo y probablemente independiente del tipo de antitrombótico utilizado (AU)

Introduction. The primary antiphospholipid syndrome (PAS) is an independent risk factor for cerebral infarction. Aim. To evaluate the risk of recurrence, to compare different treatments and determine the risk factors associated with recurrence and hemorrhagic complications in patients with cerebral infarction and PAS. Patients and methods. Prospectively collected data from 92 patients under 45 years (71% female, mean age 33.8 ± 8.9 years) with confirmed diagnoses of cerebral infarction and PAS, treated with anticoagulants (n = 54) or aspirin (n = 38) were retrospectively analyzed. Clinical follow-up was obtained by neurological examination every 6 to 12 months. Outcome measures were: recurrence of CI, symptomatic intracerebral hemorrhage, and minor bleeding. Results. During a median follow-up of 54 months (range: 12-240 months), there were 8 (9%) recurrent cerebral infarctions, with no difference between treatment with aspirin (n = 0) or anticoagulants (n = 8). The annual rate of recurrence was 0,014 person-years of follow-up. The history of previous thrombosis and spontaneous abortions were more frequent in patients with recurrence. Aspirin-treated patients more frequently came from rural areas. Four anticoagulated patients developed bleeding complications, two minor bleeding and two subdural hematomas. 76% of the cases evolved with good outcome (modified Rankin scale: 0-2). Conclusion. With the limitations of a nonrandomized study, our data suggest that the risk of recurrent arterial cerebral infarction in young patients with cerebral infarction secondary to PAS is low, probably non-uniform and independent of the type of antithrombotic (AU)

Infarto cerebral criptogénico en pacientes jóvenes. Pronóstico y recurrencia a largo plazo / Cryptogenic stroke in young patients: Long-term prognosis and recurrence

Antecedentes: En menores de 45 años, el infarto cerebral (IC) criptogénico representa hasta el 40% de los casos. El objetivo de la presente serie es determinar la tasa de recurrencia, la evolución clínica funcional a largo plazo y las características de imagen de pacientes menores de 45 años, con IC criptogénico. Métodos: 98 pacientes con diagnóstico confirmado de IC criptogénico fueron seguidos durante una mediana de 54 meses (rango de 12 a 238). Registramos los datos demográficos, factores de riesgo, hallazgos clínicos, de laboratorio y de imagen, así como las complicaciones y la evolución funcional. La evaluación de los casos incluyó estudios de imagen vascular intra y extracraneal, ecocardiograma y dos determinaciones de estudios protrombóticos. Resultados: Esta serie representa el 11% de los casos de IC en jóvenes en nuestro hospital. La edad promedio de los casos fue de 39,5±5, 48 (49%) fueron mujeres, 6 (6%) tenían hipertensión arterial, 11 (11%) hipercolesterolemia, 7 (7%) antecedente de migraña, 32 (33%) de tabaquismo activo y 11 (11%) de alcoholismo. Todos los casos fueron manejados con aspirina. Se observó buen pronóstico funcional (Rankin 0 a 2) en 65 (66%) casos y recurrencia en 4 (4%). La circulación anterior (parcial en 56%, total 12%) fue la más afectada y en 87 (88%) casos el infarto fue único. Conclusiones: En esta serie, los IC criptogénicos fueron mayoritariamente únicos, con baja recurrencia y buen pronóstico funcional a largo plazo. Los infartos totales de circulación anterior se correlacionaron con mal pronóstico (AU)

Background: Around 40% of strokes in young people are labelled as infarcts of undeterminedcause. The aim of this study was to determine the image haracteristics, the long-term functional outcome and recurrence after cryptogenic ischaemic stroke. Methods: We studied ninety-eight patients under 45 years of age during a median follow up of 54 months (range 12-238), with ischaemic stroke of undetermined cause. We registered vascular risk factors, clinical syndrome, laboratory and imaging results. We used Rankin disability score to assess functional outcome. The cases were evaluated with intracranial and extracranialvascular imaging studies, echocardiogram, and at least two determinations of prothromboticstates. Results: In our hospital 11% of the patients with cerebral infarction under 45 years of age were labelled as cryptogenic. The mean age of the cases was 39.5±5, 48 (49%) were women, 6(6%) had arterial hypertension, 7 (7%) prior history of migraine, 32 (33%) were active smokers,11 (11%) had ypercholesterolemia, and 11 (11%) had alcoholism. All cases were treated withaspirin. We observed good functional outcome (Rankin 0-2) in 65 (65%) cases. The anteriorcirculation was the most affected (partial in 56%, total in 12%). Infarction was unique in 87(88%) cases. Recurrence was observed in 4 (4%) cases.Conclusions: In this study cryptogenic cerebral infarctions were mostly single, had lowrecurrence and good functional outcome in the long-term follow-up. Total anterior circulationinfarctions correlated with poor outcome (AU)

Cryptogenic stroke in young patients: long-term prognosis and recurrence.

BACKGROUND: Around 40% of strokes in young people are labelled as infarcts of undetermined cause. The aim of this study was to determine the image characteristics, the long-term functional outcome and recurrence after cryptogenic ischaemic stroke. METHODS: We studied ninety-eight patients under 45 years of age during a median follow up of 54 months (range 12-238), with ischaemic stroke of undetermined cause. We registered vascular risk factors, clinical syndrome, laboratory and imaging results. We used Rankin disability score to assess functional outcome. The cases were evaluated with intracranial and extracranial vascular imaging studies, echocardiogram, and at least two determinations of prothrombotic states. RESULTS: In our hospital 11% of the patients with cerebral infarction under 45 years of age were labelled as cryptogenic. The mean age of the cases was 39.5 ± 5, 48 (49%) were women, 6 (6%) had arterial hypertension, 7 (7%) prior history of migraine, 32 (33%) were active smokers, 11 (11%) had hypercholesterolemia, and 11 (11%) had alcoholism. All cases were treated with aspirin. We observed good functional outcome (Rankin 0-2) in 65 (65%) cases. The anterior circulation was the most affected (partial in 56%, total in 12%). Infarction was unique in 87 (88%) cases. Recurrence was observed in 4 (4%) cases. CONCLUSIONS: In this study cryptogenic cerebral infarctions were mostly single, had low recurrence and good functional outcome in the long-term follow-up. Total anterior circulation infarctions correlated with poor outcome.

Cerebrovascular complications during pregnancy and postpartum: clinical and prognosis observations in 240 Hispanic women.

BACKGROUND AND PURPOSE: Although pregnancy and postpartum have long been associated with stroke, there is a dearth of information in Latino-American populations. The aim of this study was to describe the cerebrovascular complications occurring during pregnancy/postpartum and compare the characteristics amongst stroke types occurring in this period in Hispanic women. PATIENTS AND METHODS: We studied 240 women with cerebrovascular complications during pregnancy and the first 5 weeks postpartum, from our stroke registry. Patients were classified into three groups: cerebral venous thrombosis (CVT), ischaemic stroke (IS), and intracerebral hemorrhage (ICH). For each group, clinical data, timing of the event, and outcome were analyzed. RESULTS: Of the 240 women, 136 had CVT (56.7%), 64 IS (26.7%), and 40 ICH (16.6%). In 72 women (30%), the event occurred during pregnancy, in 153 (64%) during postpartum, and in 15 (6%) closely related to labor. CVT was more common in the first trimester of pregnancy and in the second and third weeks following delivery; whilst IS and ICH were seen mainly during pregnancy and the first 2 weeks following delivery. Pre-eclampsia/eclampsia was more common in patients with ICH (57.5%) and IS (36%) than in those with CVT (9.6%) (P < 0.001). An excellent recovery (modified Rankin Scale: 0-1) was observed amongst women with CVT (64%) and IS (50%) compared to ICH (32%), (P = 0.004). CONCLUSIONS: Pre-eclampsia/eclampsia is a frequent risk factor in patients with ICH and IS, but not in CVT. Stroke types clustered different within the pregnancy-postpartum period. A good prognosis is observed in patients with CVT.

Hemorragia subaracnoidea no aneurismática. Estudio de seguimiento a largo plazo / Nonaneurysmal subarachnoid hemorrhage. Study of long-term follow-up

Introducción. La hemorragia subaracnoidea (HSA) no aneurismática representa del 15 al 20 % del total de casos de HSA. Su pronóstico puede variar de recuperación completa a diferentes y graves complicaciones. Describimos una serie de casos con HSA no aneurismática, sus características clínicas, tomográficas y sus causas, así como el pronóstico a largo plazo. Pacientes y métodos. Cincuenta pacientes con diagnóstico de HSA y dos angiografías cerebrales negativas para aneurisma fueron seguidos durante un tiempo medio de 62 meses. Se registraron los datos demográficos de importancia y factores de riesgo vascular. En la fase aguda se evaluaron mediante la escala clínica de Hunt y Hess y la escala topográfica de Fisher. La distribución de la hemorragia se catalogó como ausente, perimesencefalica, focal, ventricular o difusa. Durante el seguimiento se registró la presencia de resangrado, muerte y la evolución funcional, medida por la escala modificada de Rankin. De acuerdo con esta escala se consideró como pronóstico favorable el Rankin de 0 a 2. Resultados. Esta serie representa el 8,6% de todos los casos de HSA en nuestro hospital. En 6 casos (12%) existió una relación causal entre el uso de fármacos simpaticomiméticos y el desarrollo de la HSA. En el 80% de ellos no se logró documentar la causa de la hemorragia, mientras que en el 20% se encontraron diversas causas (trombosis venosa cerebral en 4 [8 %], disección espontánea de arteria vertebral en 2 [4%], vasculitis secundaria a neurocisticercosis en 2 (4%), angioma cavernoso en 1 (2%) y malformación arteriovenosa espinal en 1). En ninguno de los casos se presentó resangrado y sólo 1 paciente falleció. En 45 pacientes (90%) el pronóstico funcional final fue bueno (Rankin: 0-2). No encontramos diferencias significativas entre el patrón tomográfico de la hemorragia, la condición clínica inicial y el pronóstico a largo plazo. Conclusiones. Nuestros hallazgos muestran una frecuencia baja de HSA no aneurismática en nuestra población y una diversidad de causas mayor a la aportada por otras series. Se confirmó el buen pronóstico funcional en estos casos

Introduction. Nonaneurysmal subarachnoid hemorrhage (SAH) accounts for 15% to 20% of all the cases of SAH. Its prognosis may vary from complete recovery to different and serious complications. We describe a series of cases with nonaneurysmal SAHs, their clinical and tomographic characteristics and causes as well as long term prognosis. Patients and methods. 50 patients diagnosed of SAH and two negative brain angiographies for aneurysm were followed-up for an average period of 62 months. The demographic data of importance, vascular risk factors, were recorded. They were evaluated during the acute phase with the Hunt and Hess clinical scale and Fisher topographic scale. The distribution of the hemorrhage was listed as absent, perimesencephalic, focal, ventricular or diffuse. Presence of rebleeding, death and the functional course, measured by the Rankin modified scale, were recorded during the follow-up. According to this scale, Rankin of 0 to 2 was considered as a favorable prognosis. Results. This series represents 8.6 of all the SAH cases in our hospital. In 6 cases (12%), there was a causal relationship between the use of sympathicomimetic drugs and the development of SAH. In 80% of them, it was not possible to document the cause of the hemorrhage, while different causes (cerebral venous thrombosis in 4 [8%], spontaneous dissection of the vertebral artery in 2 [4%], vasculitis secondary to neurocysticerosis in 2 [4%], cavernous angioma in 1 [2%] and spinal arteriovenous malformation in 1) were found. Rebleeding did not occur in any of the cases and only one patient died. In 45 patients (90 %), the final functional prognosis was good (Rankin 0–2). We found no significant differences between the tomographic pattern of the hemorrhage, initial clinical condition and long term prognosis. Conclusions. Our findings show a low frequency of nonaneurysmal SAH in our population and a diversity of causes greater than those reported by other series. The good functional prognosis in these cases was confirmed

[Nonaneurysmal subarachnoid hemorrhage. Study of long-term follow-up]. / Hemorragia subaracnoidea no aneurismática. Estudio de seguimiento a largo plazo.

INTRODUCTION: Nonaneurysmal subarachnoid hemorrhage (SAH) accounts for 15% to 20% of all the cases of SAH. Its prognosis may vary from complete recovery to different and serious complications. We describe a series of cases with nonaneurysmal SAHs, their clinical and tomographic characteristics and causes as well as long term prognosis. PATIENTS AND METHODS: 50 patients diagnosed of SAH and two negative brain angiographies for aneurysm were followed-up for an average period of 62 months. The demographic data of importance, vascular risk factors, were recorded. They were evaluated during the acute phase with the Hunt and Hess clinical scale and Fisher topographic scale. The distribution of the hemorrhage was listed as absent, perimesencephalic, focal, ventricular or diffuse. Presence of rebleeding, death and the functional course, measured by the Rankin modified scale, were recorded during the follow-up. According to this scale, Rankin of 0 to 2 was considered as a favorable prognosis. RESULTS: This series represents 8.6 of all the SAH cases in our hospital. In 6 cases (12%), there was a causal relationship between the use of sympathicomimetic drugs and the development of SAH. In 80% of them, it was not possible to document the cause of the hemorrhage, while difference causes )cerebral venous thrombosis in 4 [8%], spontaneous dissection of the vertebral artery in 2 [4%], vasculitis secondary to neurocystecerosis in 2 [4%], cavernous angioma in 1 [2%] and spinal arteriovenous malformation in 1) were found. Rebleeding did not occur in any of the cases and only one patient died. In 45 patients (90%), the final functional prognosis was good (Rankin 0-2). We found no significant differences between the tomographic pattern of the hemorrhage, initial clinical condition and long term prognosis. CONCLUSIONS: Our findings show a low frequency of nonaneurysmal SAH in our population and a diversity of causes greater than those reported by other series. The good functional prognosis in these cases was confirmed.

Functional approach to investigate Lp(a) in ischaemic heart and cerebral diseases.

BACKGROUND: Lp(a), a major cardiovascular risk factor, contains a specific apolipoprotein, apo(a), which by virtue of structural homology with plasminogen inhibits the formation of plasmin, the fibrinolytic enzyme. A number of clinical reports support the role of Lp(a) as a cardiovascular or cerebral risk factor, and experimental data suggest that it may contribute to atherothrombosis by inhibiting fibrinolysis. DESIGN: A well-characterized model of a fibrin surface and an apo(a)-specific monoclonal antibody were used to develop a functional approach to detect pathogenic Lp(a). The assay is based on the competitive binding of Lp(a) and plasminogen for fibrin, and quantifies fibrin-bound Lp(a). High Lp(a) binding to fibrin is correlated with decreased plasmin formation. In a transversal case-control study we studied 248 individuals: 105 had a history of ischaemic cardiopathy (IC), 52 had cerebro-vascular disease (CVD) of thrombotic origin, and 91 were controls. RESULTS: The remarkably high apo(a) fibrin-binding in CVD (0.268 +/- 0.15 nmol L-1) compared with IC (0.155 +/- 0.12 nmol L-1) suggests the existence of peculiar and poorly understood differences in pro- or anti-thrombotic mechanisms in either cerebral and/or coronary arteries. CONCLUSIONS: Our results demonstrated that Lp(a) fibrin-binding and small Apo(a) isoforms are associated with athero-thrombotic disease.

Noninvasive cerebrovascular assessment of Takayasu arteritis.

BACKGROUND AND PURPOSE: Despite prominent neurological symptoms reported in Takayasu arteritis (TA), a complete evaluation of the cerebral circulation has not been consistently performed. The purpose of this study is to describe MR angiography (MRA), color Doppler flow imaging, and transcranial Doppler (TCD) findings in the extracranial and intracranial cerebral arteries in TA. METHODS: MRA, color Doppler flow imaging, and TCD were performed in 21 patients with TA. Intima-media thickness was measured in the common carotid artery. The correlation between noninvasive studies and panaorto-arteriography was examined for supraortic vessels. Cerebral angiography findings were compared with the noninvasive methods in 7 patients. Intracranial hemodynamic changes detected by TCD were compared with extracranial circulation lesions assessed by panaorto-arteriography. RESULTS: Noninvasive vascular techniques showed at least 1 abnormality in the extracranial and/or intracranial cerebral arteries in 20 of 21 patients (95%). Both MRA and color Doppler flow imaging showed a substantial correlation in the ability to detect obstructive lesions in supra-aortic vessels compared with panaorto-arteriography. High-resolution ultrasonography displayed common carotid artery wall thickening in 5 vessels that were considered normal by arteriography. In 24% of patients, MRA and TCD showed abnormalities consistent with stenosis of the basal cerebral arteries. In 10 patients with severe extracranial circulation involvement (detected by arteriography), TCD displayed intracranial hemodynamic changes consisting of dampened or blunted waveforms with low pulsatility. CONCLUSIONS: The comprehensive assessment of cerebral circulation in TA patients by noninvasive methods allowed the detection of a high rate of diverse vascular abnormalities in both extracranial and intracranial circulation.

Intracerebral hemorrhage in young people: analysis of risk factors, location, causes, and prognosis.

BACKGROUND AND PURPOSE: The frequency of intracerebral hemorrhages (ICHs) in people aged 31 years (odds ratio, 3.48), and those with ICH that resulted from arteriovenous malformations were aged <20 years (odds ratio, 2.80). The final outcome was considered favorable in 60%. CONCLUSIONS: ICHs in young people are mainly lobar in location and result from vascular malformation. Hypertension causes most cases in which the ICH is located in the basal ganglia. Mortality and morbidity in the acute phase are low and are related to hypertension as the cause of ICH.

Cerebral infarction in young women: analysis of 130 cases.

UNLABELLED: The aim of this study was to determine the risk factors and mechanism of cerebral infarction in young women. METHODS: We evaluated 130 consecutive women younger than 41 years of age with cerebral infarction and compared the risk factors with a control group of 122 healthy, age-matched women. RESULTS: The leading risk factors in patients with cerebral infarction were migraine (15%), tobacco use (15%), and oral contraceptive (OC) use (12%). Cerebral arteriograms were abnormal in 59% of patients (57 of 96). The causes of cerebral infarction were cardiac embolism in 36%, nonatherosclerotic vasculopathy in 25%, hematologic disorders in 8%, and migraine in 8%. The etiology could not be determined in 23% of patients. CONCLUSION: Migraine and OCs are independent risk factors for cerebral infarction in young women. The leading etiologies were rheumatic valve disease and nonatherosclerotic vasculopathy, hematologic disturbances, and migraine were responsible for a few cases.

PIP: This study examines the risk factors and mechanism of cerebral infarction in 130 women younger than 41 years of age with cerebral infarction. A control group of 122 healthy, age-matched women were used for comparison. Each patient underwent the following: complete blood count, biochemical profile, lipid profile, venereal disease laboratory test, erythrocyte sedimentation rate, and rheumatologic profile (rheumatoid factor, antinuclear antibodies, anti-DNA, C-reactive protein). All patients underwent computed tomography or magnetic resonance imaging, transthoracic or transesophageal echocardiography; while transcranial Doppler or sonography of vessels of the neck and cerebral angiography were performed electively. The results of evaluation revealed that the leading factors among patients with cerebral infarction were migraine (15%), tobacco use (15%), and oral contraceptive (OC) use (12%). Cerebral arteriograms were abnormal in 59% of patients. The causes of cerebral infarction were cardiac embolism (36%), nonatherosclerotic vasculopathy (25%), hematologic disorders (8%), and migraine (8%). The etiology could not be determined in 23% of patients. Migraine and OCs were considered as independent risk factors for cerebral infarction in young women.

Recurrent primary cerebral hemorrhage: frequency, mechanisms, and prognosis.

BACKGROUND AND PURPOSE: The frequency of recurrent primary cerebral hemorrhage (RPCH), mainly in cases related to hypertension, has been considered low. This study investigated the frequency, mechanisms, and prognosis of RPCH. METHODS: We evaluated 359 patients with neuroimaging evidence of cerebral hemorrhage and selected 22 with RPCH. RESULTS: Five patients (23%) were older than 70 years at the first cerebral hemorrhage. Mean ages at the first and second hemorrhages were 60 and 63 years, respectively. Risk factors included hypertension (86%), diabetes (27%), and tobacco and alcohol use (each 14%). Hypocholesterolemia was demonstrated in 35% of the patients. The most common pattern of recurrent bleeding was ganglionic-ganglionic, mainly related to hypertension. Overall mortality was 32%. Forty-one percent and 27% of patients, respectively, had incapacitating and nonincapacitating sequelae; 2 of the latter had RPCH with a lobar location. Ganglionic-ganglionic hemorrhage was associated with a poor prognosis; otherwise, this pattern was uncommon in patients with nonincapacitating sequelae. Analysis of the control of risk factors, primarily hypertension after the first cerebral hemorrhage, disclosed that 56% of patients did not gain subsequent control. CONCLUSIONS: Rebleeding after a first primary intracerebral hemorrhage is not uncommon. The main topographic pattern of bleeding, ganglionic-ganglionic, is likely the result of hypertension; the less common lobar-lobar pattern probably results from amyloid angiopathy.

Cerebral cysticercotic arteritis: detection and follow-up by transcranial Doppler.

Intracranial arteritis is a well-known complication of cerebral cysticercosis. The aim of this study was to explore the possible role of transcranial Doppler (TCD) in the evaluation of cysticercotic arteritis in 9 patients with subarachnoid cysticercosis and stroke. Arteritis of main basal vessels was detected by TCD in 7 of 10 arterial lesions that were demonstrated by cerebral angiography. The Doppler pattern was occlusive in 2 cases and stenotic in 5. In the 3 patients with lacunar infarcts, both cerebral angiography and TCD were normal. In 6 arterial lesions followed serially with TCD a stenotic pattern resolved within 4 and 6 months in 3 cases and remained in the stenotic range at 12 months in 1 case, whereas an occlusive pattern persisted at 6 and 18 months in the other 2 cases. In conclusion, TCD may be useful to detect and follow up cerebral vasculitis due to chronic cysticercotic arachnoiditis.

[Prothrombotic states and cerebral ischemia]. / Estados protrombóticos e isquemia cerebral.

INTRODUCTION: Hematological disorders per se represent unusual causes of cerebral ischemia, explaining in young people 4% of strokes. Hematological disorders that induce a thrombotic tendency contribute to overall ischemic stroke risk and may directly cause cerebral ischemia in patients without other risk factors. The frequency of cerebral infarctions caused by prothrombotic states is not known. DEVELOPMENT: This review will focus on disorders such as prothrombotic coagulopaties, including resistance to activated protein C and antiphospholipid syndrome as cause of cerebral infarction. Cerebral venous thrombosis and cerebral infarction from arterial origin are the most common form of neurological involvement. Pathophysiological mechanism of stroke in these patients are multiple and can include as in antiphospholipid syndrome embolism from valves abnormalities related to hematological disturbance, as well as thrombosis of extracranial or intracranial vessels. CONCLUSIONS: Is clear, however, that prothrombotic states could explains a high percentage of cases of those so called cryptogenic cerebral infarction in young people.

Frequency of cerebral arteritis in subarachnoid cysticercosis: an angiographic study.

BACKGROUND AND PURPOSE: Subarachnoid cysticercosis is a well-recognized cause of cerebral infarction. However, few patients with this infection develop cerebral infarction, and the reason for this is not known. The aim of this study was to determine the frequency of cerebral arteritis in these patients. METHODS: Using cerebral arteriography, we studied 28 patients with subarachnoid cysticercosis admitted to our hospital from July 1993 to February 1996. All patients underwent MRI to detect the presence of basal arachnoiditis. We analyzed demographic data, time to cysticercosis since the first symptom onset, mode of onset, stroke syndromes, neuroimaging features of cysticercosis and cerebral infarction, and arteriographic findings for each patient. RESULTS: Of the 28 patients (mean age, 37 years), 15 patients had angiographic evidence of cerebral arteritis (53%); 12 of the 15 had a stroke syndrome (P=.02). Eight of the 15 patients (53%) with cerebral arteritis had evidence of cerebral infarction on MRI, whereas only one patient without cerebral arteritis had cerebral infarction (P=.05). The most commonly involved vessels were the middle cerebral artery and the posterior cerebral artery. CONCLUSIONS: The frequency of cerebral arteritis in subarachnoid cysticercosis is higher than previously reported, and middle-size vessel involvement is a common finding, even in those patients without clinical evidence of cerebral ischemia.

Causes and mechanisms of cerebellar infarction in young patients.

BACKGROUND AND PURPOSE: The incidence of cerebellar infarction in a series of patients with stroke is approximately 1.5%. The average patient age in most reported series is 62 years. The most common etiologies in this age group are atherosclerosis and cardiac embolism. The aim of this study was to determine the causes and mechanisms of cerebellar infarction in patients younger than 40 years. METHODS: We analyzed retrospectively the clinical and radiological data from 21 men and 16 women with cerebellar infarction admitted to our hospital from January 1986 to December 1996. The patients had been studied extensively to determine the etiology of the cerebellar infarction. RESULTS: In the 37 patients (mean age, 30 years), 29 infarcts were limited to one territory (15 in the posteroinferior cerebellar artery [PICA]; 14 in the superior cerebellar artery); 8 had nonterritorial infarctions. The most common stroke mechanisms in each territory were as follows: PICA: nonatherosclerotic vasculopathic (67%), cardioembolic (20%), and hematologic and cryptogenic (each 7%); superior cerebellar artery: cardioembolic (42%), cryptogenic (31%), migrainous (21%), and nonatherosclerotic vasculopathic and hematologic (each 7%); and mixed territory: nonatherosclerotic vasculopathic (50%), cryptogenic (25%), cardioembolic (12%), and hematologic (12%). CONCLUSIONS: The most common mechanism of cerebellar infarctions was arterial occlusion as a result of intracranial vertebral artery dissection (40%), mainly with PICA involvement. Embolism from a cardiac source resulted primarily from patent foramen ovale and rheumatic valvular disease. Hematologic disturbances and migraine were responsible for a few cases.