Grace Under Pressure: Resiliency of Quality Monitoring of Stroke Care During the Covid-19 Pandemic in Mexico City.

Stroke is one of the leading causes of death and disability among adults worldwide. The World Health Organization (WHO) officially declared a COVID-19 pandemic on March 11, 2020. The first case in Mexico was confirmed in February 2020, subsequently becoming one of the countries most affected by the pandemic. In 2020, The National Institute of Neurology of Mexico started a Quality assurance program for stroke care, consisting of registering, monitoring and feedback of stroke quality measures through the RES-Q platform. We aim to describe changes in the demand for stroke healthcare assistance at the National Institute of Neurology and Neurosurgery during the pandemic and the behavior of stroke quality metrics during the prepandemic and the pandemic periods. For this study, we analyzed data for acute stroke patients registered in the RES-Q platform, in the prepandemic (November 2019 to February 2020) and pandemic (March-December 2020) periods in two groups, one prior to the pandemic. During the pandemic, there was an increase in the total number of assessed acute stroke patients at our hospital, from 474 to 574. The average time from the onset of symptoms to hospital arrival (Onset to Door Time-OTD) for all stroke patients (thrombolyzed and non-thrombolyzed) increased from 9 h (542 min) to 10.3 h (618.3 min) in the pandemic group. A total of 135 acute stroke patients were enrolled in this registry. We found the following results: Patients in both groups were studied with non-contrast computed tomography (NNCT), computed tomography angiography (CTA), magnetic resonance angiography (MRA), digital subtraction angiography (DSA) or more frequently in the pandemic period (early carotid imaging, Holter monitoring) as needed. Treatment for secondary prevention (antihypertensives, antiplatelets, statins) did not differ. Frequency of performing and documenting the performance of NIHSS scale at arrival and early dysphagia test improved. There was an increase in alteplase use from 21 to 42% (p = 0.03). There was a decrease in door to needle time (46 vs. 39 min p = 0.30). After the implementation of a stroke care protocol and quality monitoring system, acute stroke treatment in our institution has gradually improved, a process that was not thwarted during the COVID-19 pandemic.

Survival After Ischemic and Hemorrhagic Stroke: A 4-Year Follow-Up at a Mexican Hospital.

BACKGROUND: Overall, 75.2% of deaths from stroke occur in low- and middle-income countries. Mexico is a middle-income country with little information about the prognosis of early and late postischemic and hemorrhagic stroke. OBJECTIVE: To evaluate the factors associated with post-stroke survival in the Mexican population. METHODS: Observational study of consecutive stroke cases involving a first-ever hemorrhagic or ischemic stroke, with patients who received care at the National Institute of Neurology and Neurosurgery, in Mexico City, between 2009 and 2012. Patients were followed for up to 4 years after the index event. Exploratory analysis of survival was carried out with Kaplan-Meier and log-rank tests. Factors associated with survival time were determined using Cox models. RESULTS: A total of 300 out of 544 (55.15%) patients had a hemorrhagic stroke, 135 of 544 (24.82%) patients died during the entire follow-up period, and 56 of 544 (10.29%) died in the first 30 days post-stroke (early mortality). Early mortality after stroke was associated with age ≥ 65 years (Adjusted Hazard Ratio - AHR = 2.07, P = .02) and ≥ 2 in-hospital medical complications (AHR = 46.13, P < .01). Late mortality was associated with age ≥ 65 years (AHR = 3.43, P < .01), ≥2 in-hospital medical complications (AHR = 2.55, P < .01), high comorbidity (AHR = 5.43, P < .01), and recurrence (AHR = 1.90, P = .01). CONCLUSIONS: Patients with hemorrhagic and ischemic stroke who presented in-hospital medical complications, high comorbidity, and were over 65 years old had higher rates of early and late mortality.

Exquisite response to intravenous immunoglobulin in Susac syndrome during pregnancy.

INTRODUCTION: From its initial report on two female patients in 1979 by J.O. Susac, Susac syndrome (SuS) or SICRET (small infarctions of cochlear, retinal and encephalic tissue) has persisted as an elusive entity. To date the available evidence for its treatment is based on case reports and case series. The largest systematic review described only 304 reported cases since the 1970s. Here we presented the first reported case to our knowledge in Mexican population and the unusual presentation in a pregnant patient. CASE PRESENTATION: A 34-year-old Hispanic woman was brought to the ER in our hospital for apathy and behavioral changes. Upon arrival at the ER, her husband described a one-month history of behavioral changes with apathy, progressive abulia, visuospatial disorientation, and gait deterioration. The initial lab test shows no significance except by a positive qualitative hCG. An MRI was obtained and showed hyperintense periventricular white matter lesions in T2 and FLAIR sequences also involving bilateral basal ganglia and with predominant affection of the corpus callosum, in addition to infratentorial cerebellar lesions. After treatment with intravenous immunoglobulins a marked and prompt clinical and radiological improvement was observed. CONCLUSION: SuS is still an elusive disease. To date, no definitive score or clinical feature can predict the outcome of the disease. The presentation during pregnancy is also rare and therefore the optimal treatment and the prognosis is unknown. We hope that this article will serve as a foundation for future research.

Bilateral Third Nerve Palsy in Mirror Aneurysms of the Posterior Communicating Arteries.

BACKGROUND: Bilateral third cranial nerve palsy has only been reported in a handful of conditions including some with inflammatory, tumoural and vascular causes. An urgent imaging study is mandatory to rule out vascular aetiology, mainly aneurysmal subarachnoid haemorrhage (aSAH). CASE PRESENTATION: A 28-year-old Hispanic woman presented to the emergency department with a 21-day history of a sudden-onset and severe headache that on three occasions was accompanied by transient loss of awareness, the last episode occurring a week previously. The simple CT image showed minimal bleeding at the level of the perimesencephalic cisterns, with evidence of SAH. An angioCT revealed a 5×6 mm bilobed saccular aneurysm of the right posterior communicating artery and a 2×2 mm saccular aneurysm in the posterior left communicating artery. CONCLUSIONS: A mirror aneurysm is found in 2-25% of aSAH cases. To date there is no consensus about the optimal management of patients with these findings. LEARNING POINTS: The presence of third cranial nerve palsy should always raise the suspicion of an aneurysm.Subarachnoid haemorrhage is the most common cause of a thunderclap headache.Aneurysmal subarachnoid haemorrhage requires surgical management in all cases.

Temporal Trends in Mortality from Ischemic and Hemorrhagic Stroke in Mexico, 1980-2012.

BACKGROUND: Over the past decades, the decline in mortality from stroke has been more pronounced in high-income countries than in low- and middle-income countries. We evaluated changes in temporal stroke mortality trends in Mexico according to sex and type of stroke. METHODS: We assessed stroke mortality from Mexico's National Health Information System for the period from 1980 to 2012. We analyzed age-adjusted mortality rates by sex, type of stroke, and age group. The annual percentage change and the average annual percentage change (AAPC) in the slopes of the age-adjusted mortality trends were determined using joinpoint regression models. RESULTS: The age-adjusted mortality rates due to stroke decreased between 1980 and 2012, from 44.55 to 33.47 per 100,000 inhabitants, and the AAPC (95% confidence interval [CI]) was -.9 (-1.0 to -.7). The AAPC for females was -1.1 (-1.5 to -.7) and that for males was -.7 (-.9 to -.6). People older than 65 years showed the highest mortality throughout the period. Between 1980 and 2012, the AAPC (95% CI) for ischemic stroke was -3.8 (-4.8 to -2.8) and was -.5 (-.8 to -.2) for hemorrhagic stroke. For the same period, the AAPC for intracerebral hemorrhage (ICH) was -.7 (-1.6 to .2) and that for subarachnoid hemorrhage (SAH) was 1.6 (.4-2.8). CONCLUSIONS: The age-adjusted mortality rates of all strokes combined, ischemic stroke, hemorrhagic stroke, and ICH, decreased between 1980 and 2012 in Mexico. However, the increase in SAH mortality makes it necessary to explore the risk factors and clinical management of this type of stroke.

[Anti-N-Methyl-D-aspartate receptor encephalitis (anti-NMDAR): a case report]. / Encefalitis por anticuerpos antirreceptor de N-metil-D-aspartato (anti-NMDAR): reporte de un caso.

Anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDAR) is an autoimmune disorder characterized by neuropsychiatric symptoms, hyperkinetic movements, and even central hypoventilation. Anti-NMDAR encephalitis is a recently described disease, but is already considered one of the most frequent etiologies of noninfectious encephalitis. We report the case of 16-year-old man in which it the presence of anti-NMDAR antibodies in the absence of a neoplasm was identified. Disease course and gradual recovery, as well as a brief review of the syndrome, is presented. To our knowledge this is the first proven case of anti-NMDAR encephalitis in Mexico.

Chronic deep brain stimulation of the hypothalamic nucleus in wistar rats alters circulatory levels of corticosterone and proinflammatory cytokines.

Deep brain stimulation (DBS) is a therapeutic option for several diseases, but its effects on HPA axis activity and systemic inflammation are unknown. This study aimed to detect circulatory variations of corticosterone and cytokines levels in Wistar rats, after 21 days of DBS-at the ventrolateral part of the ventromedial hypothalamic nucleus (VMHvl), unilateral cervical vagotomy (UCVgX), or UCVgX plus DBS. We included the respective control (C) and sham (S) groups (n = 6 rats per group). DBS treated rats had higher levels of TNF-α (120%; P < 0.01) and IFN-γ (305%; P < 0.001) but lower corticosterone concentration (48%; P < 0.001) than C and S. UCVgX animals showed increased corticosterone levels (154%; P < 0.001) versus C and S. UCVgX plus DBS increased IL-1ß (402%; P < 0.001), IL-6 (160%; P < 0.001), and corsticosterone (178%; P < 0.001 versus 48%; P < 0.001) compared with the C and S groups. Chronic DBS at VMHvl induced a systemic inflammatory response accompanied by a decrease of HPA axis function. UCVgX rats experienced HPA axis hyperactivity as result of vagus nerve injury; however, DBS was unable to block the HPA axis hyperactivity induced by unilateral cervical vagotomy. Further studies are necessary to explore these findings and their clinical implication.