ABSTRACT
Objetivo. Estudiar la frecuencia, seguridad y eficacia de la trombólisis intravenosa guiada por tomografía computarizadade perfusión (TCP) mediante la identificación de tejido cerebral rescatable en ictus isquémicos a priori excluidos por criteriostradicionales (SITS-MOST y ECASS-3). Pacientes y métodos. Incluimos ictus isquémicos no lacunares consecutivos. Tras tomografía convencional, se realizó TCP en los siguientes supuestos: inicio 4,5-6 h, desconocido o al despertar, signos precoces de infarto extenso, ictus menoro grave, e inicio con crisis epiléptica o pérdida de conciencia. Se indicó alteplasa intravenosa 0,9 mg/kg si: ausencia de infarto establecido en tomografía simple, core en mapa de volumen sanguíneo cerebral menor de un tercio del territorio de la arteria cerebral media, mismatch > 20% entre mapas de tiempo de tránsito medio y volumen sanguíneo cerebral, y consentimiento informado. Las variables pronósticas fueron parámetros de seguridad-eficacia del SIST-MOST.Resultados. De mayo de 2009 a abril de 2010, 66 pacientes con ictus isquémico a priori no candidatos para trombólisis intravenosa fueron estudiados con TCP. Las indicaciones fueron: > 4,5 h en 18 pacientes, ictus del despertar o inicio desconocido en 25, signos precoces extensos en 6, inicio con crisis epilépticas en 11, e ictus menor (escala del ictus del NationalInstitute of Health < 4) en seis. Veintinueve (44%) recibieron trombólisis intravenosa de acuerdo con los hallazgos de la TCP. De ellos, 2 (6,9%) sufrieron transformación hemorrágica sintomática y 18 (62,1%) alcanzaron un Rankin igual o menor a 2 al tercer mes. Conclusión. Una alta proporción de pacientes con ictus isquémico, excluibles a priori según criterios tradicionales, podríarecibir trombólisis intravenosa de manera eficaz-segura utilizando protocolo de TCP. No obstante, estos hallazgos necesitaríanconfirmación en ensayos clínicos aleatorizados (AU)
Aim. To study the frequency, safety and efficacy of perfusion computed tomography (PCT), through identification of brain tissue-at-risk, to guide intravenous thrombolysis in stroke patients with regulatory exclusion criteria (SITS-MOST andECASS-3). Patients and methods. We studied consecutive acute non-lacunar ischemic stroke patients. After conventional CT wasconsidered eligible, PCT was performed in the following circumstances: 4.5 to 6 h window, wake-up stroke or unknowntime of onset; extent early infarct signs on CT; minor or severe stroke; seizures or loss of consciousness. Intravenous 0.9 mg/kg alteplase was indicated if: cerebral blood volume lesion covered < 1/3 of middle cerebral artery territory;mismatch > 20% between mean transit time and cerebral blood volume maps existed; and informed consent. SITS-MOST safety-efficacy parameters were used as endpoint variables. Results. Between May 2009-April 2010, 66 hyperacute ischemic stroke patients a priori not eligible for intravenous thrombolysis underwent PCT. Indications were: > 4.5 h in 18 patients, wake up stroke or unknown onset in 25, extentinfarct signs in 6, seizures at onset in 11, and minor stroke (NIHSS < 4) in 6. Twenty-nine (44%) of them finally received intravenous thrombolysis. Symptomatic hemorrhagic transformation occurred in 2 (6.9%) patient and 18 (62.1%) achieved a modified Rankin scale score equal or less than 2 on day 90. Conclusion. A high proportion of acute stroke patients with SITS-MOST and ECASS-3 exclusion criteria can be safely andefficaciously treated with intravenous thrombolysis using a PCT selection protocol. However randomized control trials willbe needed to confirm our results (AU)
Subject(s)
Humans , Tomography, X-Ray Computed/methods , Thrombolytic Therapy/methods , Stroke/therapy , Patient Selection , Infusions, Intravenous/methods , Fibrinolytic Agents/administration & dosageABSTRACT
INTRODUCTION: A severe form of acute encephalitis associated to antibodies against the N-methyl D-aspartate (NMDA) receptor has recently been reported. This clinical picture occurs in young people, not always with an underlying tumour and, despite the initial severity, if identified and treated at an early stage, complete recovery without any kind of sequelae can be achieved. We report on a new case and review the body of knowledge currently available on this recently identified condition. CASE REPORT: A 22-year-old female who visited our centre due to a progressive conduct disorder. Over the days that followed, deterioration in the level of consciousness made it necessary to put her on assisted respiration. Magnetic resonance imaging of the head showed hyperintense lesions mainly in deep temporal regions. A study of the cerebrospinal fluid revealed pleocytosis with a predominance of lymphocytes and antibodies against the NMDA receptor. In the complementary study no underlying tumour was observed. Treatment with corticosteroids and immunoglobulins brought about a slow but steady improvement. After a one-year follow-up there have been no recurrences, no tumours have appeared and the patient has gone back to her usual day-to-day activities. Even a significant temporal atrophy that developed at the beginning of the clinical picture has gradually been seen to resolve itself in neuroimaging studies performed as a control measure. CONCLUSION: Encephalitis due to anti-NMDA antibodies is a disease that has only recently been characterised, but which, according to currently available data, is relatively frequent. Clinically well defined, suspicion of this condition will make it possible to reach a definitive diagnosis and to establish early treatment.
Subject(s)
Antibodies/adverse effects , Antibodies/immunology , Limbic Encephalitis/etiology , Receptors, N-Methyl-D-Aspartate/immunology , Female , Humans , Limbic Encephalitis/immunology , Limbic Encephalitis/physiopathology , Young AdultABSTRACT
Introducción. Recientemente se ha descrito una forma grave de encefalitis aguda asociada a anticuerpos contra el receptor N-metil-D-aspartato (NMDA). Este cuadro ocurre en jóvenes, no siempre con un tumor subyacente y, pese a la gravedad inicial, su identificación y tratamiento precoz pueden llevar a recuperaciones sin secuelas. Presentamos un nuevo caso y revisamos los conocimientos disponibles acerca de esta nueva entidad. Caso clínico. Mujer de 22 años de edad que acudió a nuestro centro como consecuencia de un trastorno progresivo del comportamiento. Durante los días siguientes, un deterioro del nivel de conciencia hizo necesario el soporte respiratorio. Una resonancia magnética craneal mostró lesiones hiperintensas principalmente en regiones temporales profundas. El estudio de líquido cefalorraquídeo reveló pleocitosis con predominio linfocitario y anticuerpos contra el receptor NMDA. En el estudio complementario no se apreció tumor subyacente. El tratamiento con corticoesteroides e inmunoglobulinas dio lugar a una lenta pero continua mejoría. Al cabo de un año de seguimiento no ha presentado recidivas, no ha aparecido tumor alguno y la paciente se ha reintegrado a sus actividades habituales. Incluso una atrofia temporal llamativa desarrollada al inicio del cuadro se ha ido resolviendo en estudios de neuroimagen de control. Conclusión. La encefalitis por anticuerpos anti-NMDA es una enfermedad recientemente caracterizada, pero, de acuerdo con los datos disponibles hasta la fecha, relativamente frecuente. Clínicamente bien definida, la sospecha de esta entidad hará posible un diagnóstico definitivo y la instauración de un tratamiento precoz (AU)
Introduction. A severe form of acute encephalitis associated to antibodies against the N-methyl D-aspartate (NMDA) receptor has recently been reported. This clinical picture occurs in young people, not always with an underlying tumour and, despite the initial severity, if identified and treated at an early stage, complete recovery without any kind of sequelae can be achieved. We report on a new case and review the body of knowledge currently available on this recently identified condition. Case report. A 22-year-old female who visited our centre due to a progressive conduct disorder. Over the days that followed, deterioration in the level of consciousness made it necessary to put her on assisted respiration. Magnetic resonance imaging of the head showed hyperintense lesions mainly in deep temporal regions. A study of the cerebrospinal fluid revealed pleocytosis with a predominance of lymphocytes and antibodies against the NMDA receptor. In the complementary study no underlying tumour was observed. Treatment with corticosteroids and immunoglobulins brought about a slow but steady improvement. After a one-year follow-up there have been no recurrences, no tumours have appeared and the patient has gone back to her usual day-to-day activities. Even a significant temporal atrophy that developed at the beginning of the clinical picture has gradually been seen to resolve itself in neuroimaging studies performed as a control measure. Conclusion. Encephalitis due to anti-NMDA antibodies is a disease that has only recently been characterised, but which, according to currently available data, is relatively frequent. Clinically well defined, suspicion of this condition will make it possible to reach a definitive diagnosis and to establish early treatment (AU)
