Calcified Neurocysticercosis and Headache in an Endemic Village: A Case-Control Study Nested to a Population-Based Cohort.

Headache in patients with calcified neurocysticercosis (NCC) is probably common but has been largely overlooked. We aimed to assess the presence, characteristics, and diagnosis of headache across patients with calcified NCC and their matched controls. In this case-control study nested to a population-based cohort, Atahualpa residents aged ≥ 20 years with calcified NCC were identified as case patients and paired 1:1 to age- and gender-matched randomly selected controls. A culturally adapted questionnaire was derived from the EUROLIGHT. Headache diagnosis was established according to the International Classification of Headache Disorders, 3rd edition. Conditional logistic regression models for matched paired data were fitted to assess the independent association between calcified NCC (as the exposure) and headache variables, after adjusting for education, alcohol intake, depression, and epilepsy. The selection process generated 106 case patients and their matched controls. Lifetime headache prevalence (odds ratio [OR]: 4.18; 95% Confidence Interval [CI]: 1.79-9.75; P = 0.001), current headaches (OR: 4.19; 95% CI: 1.92-9.16; P < 0.001), and intense headaches (OR: 9.47; 95% CI: 2.88-31.19; P < 0.001) were more frequent among cases than in controls. In addition, migraine (but not other forms of headache) was more frequent among subjects with calcified NCC (OR: 4.89; 95% CI: 2.36-11.39; P < 0.001). This study shows a robust epidemiological association between headache-particularly migraine-and calcified NCC.

Sub-estudio de neuroimagen del Proyecto Atahualpa / Neuroimaging substudy of the Atahualpa Project

RESUMEN Como parte del Proyecto Atahualpa se diseñó el sub-estudio de neuroimagen, el cual incluye la práctica de IRM y angio-resonancias a toda la población ≥60 años, así como a participantes con padecimientos que ameriten estos exámenes. De igual manera, toda la población de ≥20 años ha sido invitada para la práctica de TC de cerebro. Las IRMs y angio-resonancias han sido realizadas en un equipo marca Philips, modelo Intera, de 1.5 Tesla, y las TC en un equipo helicoidal marca Philips, modelo Brilliance 64, siguiendo protocolos de investigación internacionalmente establecidos. Todos los exámenes han sido interpretados de manera independiente por un neurólogo y un neuroradiólogo. Hasta el momento, la mayoría de lecturas han tenido coeficientes de correlación (kappa) satisfactorio (excelente o muy bueno) y las discrepancias se han solucionado por consenso. Los estudios de IRM se han enfocado en estimación de atrofia cortical global, atrofia parietal posterior, atrofia de núcleo caudado, índice de Evans, atrofia de hipocampo, marcadores de enfermedad de pequeño vaso cerebral, y en la búsqueda de lesiones compatibles con infartos y hemorragias cerebrales. Utilizando angio-resonancia hemos valorado la presencia de estenosis de arterias intracraneales, dolicoectasia basilar y configuración del polígono de Willis. En TC, nos hemos enfocado en el diagnóstico de calcificaciones cisticercosas, en la presencia y severidad de las calcificaciones de la glándula pineal, en las variaciones en grosor, heterogeneidad de los huesos del diploe, en la atrofia de cerebelo, y en la estimación del grado de calcificación de los sifones carotideos. En el presente artículos se describen los protocolos básicos utilizados para la valoración de cada una de las lesiones of interés mencionadas previamente.

ABSTRACT The Atahualpa Project includes a Neuroimaging sub-study, which consists in the practice of MRIs and MRAs to all participants aged ≥60 years, as well as those presenting with specific neurological complains. Likewise, all participants aged ≥20 years have been invited for the practice of a head CT. MRIs and MRAs have been performed with the use of a Philips Intera 1.5T MRI machine, and TCs with the use of a Philips Brilliance 64 CT scanner, following established protocols. All exams have been independently reviewed by a neurologist and a neuroradiologist, with adequate kappa coefficients for inter-rater agreement. MRIs studies have been focused on the evaluation of global cortical atrophy, posterior parietal atrophy, bicaudate index, Evans index, hippocampal atrophy, signatures of cerebral small vessel disease, and lesions consistent with ischemic or hemorrhagic strokes. By the use of MRI, we have assessed the prevalence of intracranial artery stenosis, intracranial dolichoectasia and variations in the configuration of the circle of Willis. Using CT, we have focused on the diagnosis of neurocysticercosis, pineal gland calcifications, as well as in variations and characteristics of skull bones, cerebellar atrophy, and severity of carotid siphon calcifications. In the present study, we focused on the description of basic protocols used for assessment of previously mentioned lesions of interest.

Enfermedad cerebrovascular en Atahualpa: prevalencia e incidencia / Cerebrovascular disease in Atahualpa: prevalence and incidence

RESUMEN El impacto de la enfermedad cerebrovascular (ECV) está en aumento en las regiones rurales de América del Sur. Evaluamos la prevalencia, subtipos y mecanismos patogénicos de la ECV en Atahualpa. En un estudio de tres fases, los casos sospechosos fueron detectados por una encuesta puerta-a-puerta. Luego, los neurólogos evaluaron casos sospechosos y seleccionaron al azar personas negativas, y los pacientes confirmados se sometieron a exámenes. Se encontraron 20 pacientes con ECV entre 642 personas ≥40 años. La prevalencia fue 31,15‰ y aumentó con la edad. La arteriolopatía hipertensiva fue el mecanismo más probable de los ECV (55% de los pacientes). En ningún caso se encontraron lesiones ateroscleróticas extracraneales o fuentes cardíacas de embolia. La comparación de nuestros hallazgos con una encuesta anterior realizada en Atahualpa mostró un aumento alarmante en la prevalencia de ECV (14,08‰ en 2003 a 31,15‰ en 2012, p=0,03). Posteriormente, se realizó un estudio de incidencia. Para ello, todos los eventos nuevos ocurridos a lo largo de cuatro años se identificaron. De 807 individuos sin ECV ingresados prospectivamente en el Proyecto Atahualpa, el seguimiento se logró en 718 (89%), contribuyendo con 2.499 años de seguimiento (promedio de 3,48 ± 0,95 años). La incidencia de ECV fue de 2,97 por 100 años-persona de seguimiento (95% C.I.: 1,73-4,2), que aumentó a 4,77 (95% C.I.: 1,61-14,1) cuando se consideraron las personas mayores de 57 años. Los modelos de regresión de Poisson, ajustados para los factores de confusión relevantes, mostraron que la presión arterial alta (IRR: 5,24; 95% C.I.: 2,55-7,93) y el edentulismo (IRR: 5,06; 95% C.I.: 2,28-7,85). La incidencia de ECV en Atahualpa es comparable a la reportada en el mundo desarrollado. Además de la edad y la presión arterial alta, el edentulismo es un factor importante que predice independientemente los ECV.

ABSTRACT Stroke burden is on the rise in rural regions of South America. We evaluated prevalence, pattern of subtypes and pathogenetic mechanisms underlying stroke in Atahualpa. In a three-phase epidemiologic study, suspected cases were detected by a door-to-door survey. Then, neurologists evaluated suspected cases and randomly selected negative persons, and confirmed patients underwent complementary exams. We found 20 stroke patients among 642 persons aged ≥ 40 years. Stroke prevalence was 31.15‰ that increased with age. Hypertensive arteriolopathy was the most likely mechanism underlying strokes (55% patients). Extracranial atherosclerotic lesions or cardiac sources of emboli were not found in any case. Comparison of our findings with a previous survey performed in the same village showed an alarming increase in stroke prevalence (from 14.08‰ in 2003 to 31.15‰ in 2012, p=0.03). Thereafter, we conducted an incidence study. For this, first-ever strokes occurring over four years were identified from yearly door-to-door surveys and other overlapping sources. Of 807 stroke-free individuals prospectively enrolled in the Atahualpa Project, follow-up was achieved in 718 (89%), contributing 2,499 years of follow-up (average 3.48±0.95 years). Stroke incidence rate was 2.97 per 100 person-years of follow-up (95% C.I.: 1.73-4.2), which increased to 4.77 (95% C.I.: 1.61-14.1) when only persons aged ≥57 years were considered. Poisson regression models, adjusted for relevant confounders, showed that high blood pressure (IRR: 5.24; 95% C.I.: 2.55-7.93) and severe edentulism (IRR: 5.06; 95% C.I.: 2.28-7.85) were the factors independently increasing stroke incidence. Stroke incidence in Atahualpa is comparable to that reported from the developed world. Besides age and high blood pressure, severe edentulism is a major factor independently predicting incident strokes.

The Association Between Neurocysticercosis and Hippocampal Atrophy is Related to Age.

Neurocysticercosis (NCC) has been associated with hippocampal atrophy, but the prevalence and pathogenic mechanisms implicated in this relationship are unknown. Using a population-based, case-control study design, residents in a rural village (Atahualpa) aged ≥ 40 years with calcified NCC were identified as cases and paired to NCC-free individuals (control subjects) matched by age, sex, and level of education. Cases and control subjects underwent magnetic resonance imaging for hippocampal rating according to the Scheltens' scale for medial temporal atrophy and were interviewed to identify those with a clinical seizure disorder. The prevalence of hippocampal atrophy was compared between cases and control subjects by the use of the McNemar's test for correlated proportions. Seventy-five individuals with calcified NCC and their matched control subjects were included in the analysis. Hippocampal atrophy was noted in 26 (34.7%) cases and nine (12%) control subjects (odds ratio: 4.4; 95% confidence interval: 1.6-14.9, P < 0.0021). Stratification of pairs according to tertiles of age revealed an age-related trend in this association, which became significant only in those aged ≥ 68 years (P = 0.027). Only five cases and one control had recurrent seizures (P = 0.221); three of these five cases had hippocampal atrophy, and the single control subject had normal hippocampi. This study confirms an association between NCC and hippocampal atrophy, and shows that this association is stronger in older age groups. This suggests that NCC-related hippocampal atrophy takes a long time to develop.

Intracranial arterial stenosis in Ecuadorian Natives/Mestizos. A population-based study in older adults (The Atahualpa Project).

BACKGROUND: Intracranial arterial stenosis (IAS) is more prevalent among Asians, Blacks and Caribbean Hispanics than in Whites. However, there is no information on the importance of this common cause of stroke among Mestizo/Native populations of Latin America. We aimed to assess prevalence and correlates of IAS in an indigenous Ecuadorian population of older adults. METHODS: Atahualpa residents aged ≥60 years were identified during door-to-door surveys and invited to undergo brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of intracranial vessels for identification of stroke lesions and arterial stenosis. Prevalence of IAS was assessed in patients with strokes as well as in stroke-free individuals. A logistic regression model was constructed with stroke as the outcome, IAS as the exposure, and confounders (demographics and cardiovascular risk factors) as independent variables. RESULTS: Out of 267 participants (mean age 71 ± 8 years, 57% women), 15 (5.6%) had intracranial arterial stenosis, including 10 out of 52 (19.2%) persons with stroke and five out of 215 (2.3%) without. The multivariate logistic regression model showed significant association of IAS with stroke after adjusting for demographics and cardiovascular risk factors (OR: 7.9, 95% C.I.: 2.2-27.8, p=0.001). Mechanisms underlying stroke in patients with IAS included perforator occlusion, artery-to-artery embolism and hypoperfusion. CONCLUSIONS: Prevalence of IAS in Ecuadorian Natives/Mestizos is similar to that in Asians. Individuals aged ≥60 years with IAS are almost eight times more likely to have a stroke after adjusting for confounding variables.

Cognitive performance in community-dwelling older adults with stroke and the contribution of age and diffuse subcortical damage: a population-based study in rural Ecuador (The Atahualpa Project).

BACKGROUND: Cognitive impairment is common among stroke survivors. However, there is controversy on the role of the stroke itself or the associated subcortical damage in post-stroke cognitive decline. AIM: To assess the independent contribution and the interaction of age, the stroke itself and diffuse subcortical damage in the poor cognitive performance observed in patients with stroke. METHODS: Atahualpa residents aged ≥60 years were identified during a door-to-door survey and invited to undergo brain MRI for identification of stroke lesions and white matter hyperintensities (WMH) of presumed vascular origin. Cognitive performance was evaluated by the use of the Montreal Cognitive Assessment (MoCA). Using a generalized linear model, we examined the association between MoCA score, stroke and WMH, after adjusting for demographics, education, vascular risk factors, depression and edentulism. RESULTS: Out of 311 persons aged ≥60 years, 242 (78 %) were enrolled. MRI showed strokes in 39 (16 %) and moderate-to-severe WMH in 52 (22 %) cases. Mean MoCA score was 18.5 ± 4.7 in the entire population. When participants were stratified according to the median age of the population (67 years), the generalized linear model showed that MoCA scores were not different in younger persons irrespective of the presence of stroke or WMH. In contrast, increased age associated with lower MoCA scores in persons with WMH (p = 0.002) or with both stroke and WMH (p = 0.003), but not in those with stroke without WMH (p = 0.087). CONCLUSIONS: Interaction of age and diffuse subcortical damage are major determinants for poor cognitive performance among stroke patients.

Poor sleep quality and silent markers of cerebral small vessel disease: a population-based study in community-dwelling older adults (The Atahualpa Project).

BACKGROUND/OBJECTIVES: Evidence of a relationship between non-breathing-related sleep symptoms and silent markers of cerebral small vessel disease (SVD) is scarce. The present study aimed to evaluate this association in older people living in rural Ecuador, where the burden of stroke is on the rise. METHODS: A group of Atahualpa residents, aged ≥60 years, were interviewed with a validated Spanish version of the Pittsburgh Sleep Quality Index, and underwent magnetic resonance imaging (MRI) for identification of silent markers of SVD. Using multinomial logistic regression analysis, after adjusting for demographics and cardiovascular health status, it was evaluated whether sleep quality is associated with the severity of white matter hyperintensity (WMH), lacunar infarcts, and deep microbleeds. RESULTS: Out of 311 people aged ≥60 years, 237 (76%) were enrolled into the study. Mean age was 70 ± 8 years, 59% were women, 83% had primary school education only, and 73% had a poor cardiovascular health status. Seventy-eight (33%) had poor sleep quality. The MRI showed: WMH in 154 (65%) participants (moderate-to-severe in 52); silent lacunar infarcts in 28 (12%); and deep microbleeds in 17 (7%). Poor sleep quality was associated with WMH presence (OR 2.44, 95% CI 1.26 to 4.71, p = 0.008) and severity (ß coefficient 0.77, SE 0.37, p = 0.037), but not with silent lacunar infarcts or deep microbleeds. CONCLUSIONS: The present study showed an association between poor sleep quality and WMH severity. Further longitudinal studies would help to elucidate the cause and effect of this relationship.

The association of ankle-brachial index with silent cerebral small vessel disease: results of the Atahualpa Project.

BACKGROUND: An abnormal ankle-brachial index has been associated with overt stroke and coronary heart disease, but little is known about its relationship with silent cerebral small vessel disease. AIM: To assess the value of ankle-brachial index as a predictor of silent small vessel disease in an Ecuadorian geriatric population. METHODS: Stroke-free Atahualpa residents aged ≥60 years were identified during a door-to-door survey. Ankle-brachial index determinations and brain magnetic resonance imaging were performed in consented persons. Ankle-brachial index ≤0.9 and ≥1.4 were proxies of peripheral artery disease and noncompressible arteries, respectively. Using logistic regression models adjusted for age, gender, and cardiovascular health status, we evaluated the association between abnormal ankle-brachial index with silent lacunar infarcts, white matter hyperintensities, and cerebral microbleeds. RESULTS: Mean age of the 224 participants was 70 ± 8 years, 60% were women, and 80% had poor cardiovascular health status. Ankle-brachial index was ≤0.90 in 37 persons and ≥1.4 in 17. Magnetic resonance imaging showed lacunar infarcts in 27 cases, moderate-to-severe white matter hyperintensities in 47, and cerebral microbleeds in 26. Adjusted models showed association of lacunar infarcts with ankle-brachial index ≤ 0.90 (OR: 3.72, 95% CI: 1.35-10.27, P = 0.01) and with ankle-brachial index ≥ 1.4 (OR: 3·85, 95% CI: 1.06-14.03, P = 0.04). White matter hyperintensities were associated with ankle-brachial index ≤ 0.90 (P = 0.03) and ankle-brachial index ≥ 1.4 (P = 0.02) in univariate analyses. There was no association between ankle-brachial index groups and cerebral microbleeds. CONCLUSIONS: In this population-based study conducted in rural Ecuador, apparently healthy individuals aged ≥60 years with ankle-brachial index values ≤0.90 and ≥1.4 are almost four times more likely to have a silent lacunar infarct. Ankle-brachial index screening might allow recognition of asymptomatic people who need further investigation and preventive therapy.

Stroke and pineal gland calcification: lack of association. Results from a population-based study (The Atahualpa Project).

OBJECTIVE: It has been suggested that pineal gland calcifications (PGC) represent a risk factor for stroke; however, information comes from a single retrospective hospital-based registry. We aimed to validate this association in a population-based study conducted in rural Ecuador. METHODS: Atahualpa residents aged ≥60 years were identified during a door-to-door survey and invited to undergo neuroimaging studies (CT/MRI) for identification and rating PGC and lesions consistent with cerebral infarcts and hemorrhages. Cardiovascular health (CVH) status was assessed according to the American Heart Association criteria, and clinical strokes were identified by the use of a validated field instrument and confirmed by neurologists. RESULTS: Out of 248 participants (mean age 70±8 years, 59% women, 73% with poor CVH), 137 (55%) had PGC and 39 (16%) had strokes (silent in 28 cases). PGC were noted in 61% versus 54% persons with and without stroke, respectively. After adjusting for age, sex and cardiovascular health, logistic and ordinal logistic regression models showed no association between any evidence (p=0.916) or severity (p=0.740) of PGC and stroke. CONCLUSION: PGC is not associated with stroke in this population of community-dwelling elders, where prevalence of PGC and stroke are similar to those found in other regions.

Incompleteness of the Circle of Willis correlates poorly with imaging evidence of small vessel disease. A population-based study in rural Ecuador (the Atahualpa project).

BACKGROUND: Studies looking for an association between incompleteness of the Circle of Willis (CoW) and small vessel disease (SVD) markers are scarce and conflicting. We aimed to evaluate this association in an unbiased population-based study conducted in Atahualpa (rural Ecuador). METHODS: Atahualpa residents 60 years of age or more were identified during a door-to-door survey and invited to undergo magnetic resonance imaging for identification of SVD markers, including white matter hyperintensities (WMHs), strokes, and deep microbleeds. Magnetic resonance imaging (MRA) was used for classifying the CoW according to the presence or absence of one A1 segment of the anterior cerebral artery or one or both P1 segments of posterior cerebral arteries. RESULTS: Of 311 eligible persons, 258 were enrolled. Mean age was 70 ± 8 years, 59% were women, and 74% had a poor cardiovascular health (CVH) status. Of these, 172 patients (67%) had WMH, 40 patients (16%) had SVD-related strokes, and 23 patients (9%) had deep microbleeds. MRA revealed a complete CoW in 157 persons (61%). Persons with SVD markers were older than those without markers (P < .0001). A poor CVH status was noted in 79% of persons with at least 1 SVD marker and in 65% of those with no markers (P = .02). Logistic regression models showed no association of incompleteness of the CoW with any marker of SVD-alone or in combination-after adjusting for age, sex, and CVH status. CONCLUSIONS: Lack of association between incompleteness of CoW and SVD markers suggest that genetically determined variants in the intracranial vasculature are not responsible for the high prevalence of SVD among native South American populations.

Global cortical atrophy (GCA) associates with worse performance in the Montreal Cognitive Assessment (MoCA). A population-based study in community-dwelling elders living in rural Ecuador.

BACKGROUND/OBJECTIVE: Increasing numbers of individuals with cognitive impairment are posing economic threads to the developing world. Proper assessment of this condition may be complicated by illiteracy and cross-cultural factors. We conducted a population-based study in elders living in rural Ecuador to evaluate whether the MoCA associated with structural brain damage in less-educated populations. METHODS: Atahualpa residents aged ≥60 years were identified during a door-to-door survey and invited to undergo MRI for grading GCA. Using a multivariate generalized linear model, we evaluated whether MoCA scores correlates with GCA, after adjusting for demographics, education, cardiovascular health (CVH) status, depression and edentulism. RESULTS: Out of 311 eligible persons, 241 (78%) were enrolled. Mean age was 69.2±7.5 years, 141 (59%) were women, 199 (83%) had primary school education, 175 (73%) had poor CVH status, 30 (12%) had symptoms of depression and 104 (43%) had edentulism. Average MoCA scores were 18.5±4.7 points. GCA was mild in 108, moderate in 95, and severe in 26 persons. Total and most domain-specific MoCA scores were significantly worse in persons with moderate to severe GCA. In the multivariate model, mean MoCA score was associated with GCA severity (ß=2.38, SE=1.07, p=0.027). CONCLUSIONS: MoCA scores associate with severity of GCA after adjusting for potential confounders, and may be used as reliable estimates of structural brain damage. However, a lower cut-off than that recommended for developed countries, would be better for recognizing cognitive impairment in less educated populations.

White matter hyperintensities of presumed vascular origin: a population-based study in rural Ecuador (The Atahualpa Project).

BACKGROUND: Cerebral small vessel disease is probably one of the most common pathogenetic mechanisms underlying stroke in Latin America. However, the importance of silent markers of small vessel disease, including white matter hyperintensities of presumed vascular origin, has not been assessed so far. AIM: The study aims to evaluate prevalence and correlates of white matter hyperintensities in community-dwelling elders living in Atahualpa (rural Ecuador). METHODS: Atahualpa residents aged ≥ 60 years were identified during a door-to-door survey and invited to undergo brain magnetic resonance imaging for identification and grading white matter hyperintensities and other markers of small vessel disease. Using multivariate logistic regression models, we evaluated whether white matter hyperintensities is associated with demographics, cardiovascular health status, stroke, cerebral microbleeds, and cortical atrophy, after adjusting for the other variables. RESULTS: Out of 258 enrolled persons (mean age, 70 ± 8 years; 59% women), 172 (67%) had white matter hyperintensities, which were moderate to severe in 63. Analyses showed significant associations of white matter hyperintensities presence and severity with age and cardiovascular health status, as well as with overt and silent strokes, and a trend for association with cerebral microbleeds and cortical atrophy. CONCLUSIONS: Prevalence and correlates of white matter hyperintensities in elders living in rural Ecuador is almost comparable with that reported from industrialized nations, reinforcing the concept that the burden of small vessel disease is on the rise in underserved Latin American populations.

Variants in the circle of Willis and white matter disease in Ecuadorian Mestizos.

BACKGROUND AND PURPOSE: Studies on Whites and Asians have shown contradictory results on the association between an incomplete circle of Willis (CoW) and white matter disease (WMD). We evaluated such relationship in Ecuadorian Mestizos. METHODS: Ecuadorian Mestizos aged ≥40 years were evaluated with MRI and MRA. WMD was graded according to the modified Fazekas' scale, and the CoW was classified as complete or incomplete according to the presence or absence of one A1 segment of the anterior cerebral artery or one or both P1 segments of posterior cerebral arteries. RESULTS: A total of 315 persons (mean age 64.7 ± 13.4 years, 56.5% women) were prospectively enrolled over 6 months. MRAs revealed a complete CoW in 65.1%, and MRIs showed WMD in 62.5% of cases. Irrespective of age and sex, incompleteness of the CoW was not associated with a higher prevalence or severity of WMD. In contrast, age was an independent risk factor for the occurrence of WMD. CONCLUSIONS: In the Ecuadorian Mestizo population, WMD occurrence and severity do not seem to be related to incompleteness of the CoW.

Calcified neurocysticercosis associates with hippocampal atrophy: a population-based study.

Calcified neurocysticercosis has been associated with hippocampal atrophy in patients with refractory epilepsy, but the relevance of this association in the population at large is unknown. We assessed calcified cysticerci and its association with hippocampal atrophy in elderly persons living in Atahualpa, an Ecuadorian village endemic for neurocysticercosis. All Atahualpa residents ≥ 60 years of age were invited to undergo computed tomography/magnetic resonance imaging for neurocysticercosis detection. Twenty-eight (11%) out of 248 enrolled persons had calcified cysticerci (case-patients) and were matched 1:1 by age, sex, and years of education to individuals without neurocysticercosis on computed tomography/magnetic resonance imaging (controls). Four case-patients and none of the controls had epilepsy (P = 0.134). Cognitive performance was similar across both groups. The Scheltens' medial temporal atrophy scale was used for hippocampal rating in case-patients and matched controls without neurocysticercosis. Mean score in the Scheltens' scale was higher in case-patients than in controls (P < 0.001). Atrophic hippocampi were noticed in 19 case-patients and five controls (P = 0.003). Atrophy was bilateral in 11 case-patients and unilateral in eight. All case-patients with unilateral hippocampal atrophy had at least one ipsilateral calcification. This study shows an association between calcified cysticerci and hippocampal atrophy and raises the possibility of an inflammation-mediated hippocampal damage as the responsible mechanism for these findings.

The Leganés cognitive test correlates poorly with MRI evidence of global cortical atrophy in an underserved community: A population-based and nested case-control study in rural Ecuador (The Atahualpa Project) / O teste cognitivo Leganés tem baixa correlação com atrofia cortical global avaliada por RM em uma comunidade socialmente desprovida. Um estudo de base populacional e caso-controle no Equador Rural (Projeto Atahualpa)

We aimed to evaluate whether the Leganés cognitive test (LCT) correlates with global cortical atrophy (GCA) and can be used as a surrogate for structural brain damage. Methods: Atahualpa residents aged greater 60 years identified during a door-to-door survey underwent MRI for grading GCA. Using multivariate generalized linear models, we evaluated whether continuous LCT scores correlated with GCA, after adjusting for demographics, education, cardiovascular health (CVH) status, depression and edentulism. In a nested case-control study, GCA severity was assessed in subjects with LCT scores below the cutoff level for dementia (? 22 points) and in matched controls without dementia. Results: Out of 311 eligible subjects, 241(78%) were enrolled. Mean age was 69.2±7.5 years, 59% were women, 83% had primary school education, 73% had poor CVHstatus, 12% had symptoms of depression and 43% had edentulism. Average LCT score was 26.7±3, and 23 (9.5%) subjects scored ? 22 points. GCA was mild in 108, moderate in 95, and severe in 26 individuals. On the multivariate model, mean LCT score was not associated with GCA severity (?=0.06, SE=0.34, p=0.853). Severe GCA was noted in 6 / 23 case-patients and in 8/23 controls (OR: 0.67, 95% CI: 0.14-2.81, p=0.752, McNemar?s test). Conclusion: The LCT does not correlate with severity ofGCA after adjusting for potential confounding variables, and should not be used as a reliable estimate of structural brain damage.

O teste cognitivo Leganés (TCL) é um instrumento para o rastreio rápido de demência em idosos com baixo nível educacional. Objetivo: Tivemos como objetivo avaliar se o TCL associa-se com medidas de atrofia cortical global (ACG) e pode ser usado como um substituto para a lesão cerebral estrutural. Métodos: Residentes de Atahualpa com idade maior ou igual 60 anos identificados durante um levantamento porta-a-porta foram submetidos a ressonância magnética para avaliar a intensidade da ACG. Usando modelos lineares generalizados multivariados, avaliamos se escores TCL contínuos correlacionavam com a intensidade da ACG após ajustes para a dados demográficos, educação, saúde cardiovascular (CVH), depressão e edentulismo. Em um estudo caso-controle aninhado, avaliamos a gravidade da ACG em pessoas com escores no TCL abaixo do nível de corte para demência (? 22 pontos) e em pessoas pareados sem demência. Resultados: Dentre as 311 pessoas elegíveis, 241 (78%) foram selecionadas. A média de idade foi de 69,2±7,5 anos, 59% eram mulheres,83% tinham o ensino primário, 73% tinham mau estado CVH, 12% apresentaram sintomas de depressão e 43% tinham edentulismo. Pontuações médias no TCL foram 26,7±3 e 23 (9,5%) pessoas tinham 22 pontos. ACG foi leve em 108, moderada em 95 e grave em 26 pessoas. No modelo multivariado, a média de pontuação no TCL não foi associada com a gravidade da ACG (B=0,06, SE=0,34, p=0,853). ACG grave foi observada em 6 de 23 pacientes e em 8 de 23 controles (OR:0,67; IC 95%: 0,14-2,81, p=0,752, teste de McNemar). Conclusão: O TCL não se associa com a gravidade da ACG após o ajuste para possíveis fatores de confusão e não deve ser usado como uma estimativa confiável de dano cerebral estrutural.

Neurocysticercosis is a neglected microbleed mimic. a cautionary note for stroke neurologists.

BACKGROUND: Calcified cysticerci share the morphology and signal properties with true cerebral microbleeds, but this condition is neglected at the time of evaluating MRIs for clinical or research purposes. We report our experience with the MRI reading obtained from the Atahualpa Project, a population-based stroke study, conducted in a village endemic for cysticercosis. METHODS: Neuroimaging studies were performed in Atahualpa residents aged ≥60 years identified during a door-to-door survey. Lesions of interest included neuroimaging markers of small vessel disease. Out of 311 residents, 248 (80%) agreed to participate. Two internal readers independently reviewed MRIs blinded to CT findings. RESULTS: Internal readers achieved good-to-very-good inter-rater agreements for all types of investigated lesions, with the exception of cortical microbleeds (κ = 0.53). After reviewing CTs, six of eight conflicting lesions were cysticercus. Five external experts blinded to CT findings also read those images, reporting conflicting results. Cysticercosis was recognized only in 26% of readings. CONCLUSION: Calcified cysticercotic lesions should be included in the list of microbleed mimics. CT should be performed in doubtful cases to avoid overdiagnosis of cerebral microbleeds in large-scale stroke studies and in the clinical practice. Proper recognition of this neglected microbleed mimic may have important therapeutic implications.

The Leganés cognitive test correlates poorly with MRI evidence of global cortical atrophy in an underserved community: A population-based and nested case-control study in rural Ecuador (The Atahualpa Project).

OBJECTIVE: We aimed to evaluate whether the Leganés cognitive test (LCT) correlates with global cortical atrophy (GCA) and can be used as a surrogate for structural brain damage. METHODS: Atahualpa residents aged > 60 years identified during a door-to-door survey underwent MRI for grading GCA. Using multivariate generalized linear models, we evaluated whether continuous LCT scores correlated with GCA, after adjusting for demographics, education, cardiovascular health (CVH) status, depression and edentulism. In a nested case-control study, GCA severity was assessed in subjects with LCT scores below the cutoff level for dementia (< 22 points) and in matched controls without dementia. RESULTS: Out of 311 eligible subjects, 241 (78%) were enrolled. Mean age was 69.2±7.5 years, 59% were women, 83% had primary school education, 73% had poor CVH status, 12% had symptoms of depression and 43% had edentulism. Average LCT score was 26.7±3, and 23 (9.5%) subjects scored < 22 points. GCA was mild in 108, moderate in 95, and severe in 26 individuals. On the multivariate model, mean LCT score was not associated with GCA severity (ß=0.06, SE=0.34, p=0.853). Severe GCA was noted in 6 / 23 case-patients and in 8 / 23 controls (OR: 0.67, 95% CI: 0.14-2.81, p=0.752, McNemar's test). CONCLUSION: The LCT does not correlate with severity of GCA after adjusting for potential confounding variables, and should not be used as a reliable estimate of structural brain damage.

O teste cognitivo Leganés (TCL) é um instrumento para o rastreio rápido de demência em idosos com baixo nível educacional. OBJETIVO: Tivemos como objetivo avaliar se o TCL associa-se com medidas de atrofia cortical global (ACG) e pode ser usado como um substituto para a lesão cerebral estrutural. MÉTODOS: Residentes de Atahualpa com idade > 60 anos identificados durante um levantamento porta-a-porta foram submetidos a ressonância magnética para avaliar a intensidade da ACG. Usando modelos lineares generalizados multivariados, avaliamos se escores TCL contínuos correlacionavam com a intensidade da ACG após ajustes para a dados demográficos, educação, saúde cardiovascular (CVH), depressão e edentulismo. Em um estudo caso-controle aninhado, avaliamos a gravidade da ACG em pessoas com escores no TCL abaixo do nível de corte para demência (< 22 pontos) e em pessoas pareados sem demência. RESULTADOS: Dentre as 311 pessoas elegíveis, 241 (78%) foram selecionadas. A média de idade foi de 69,2±7,5 anos, 59% eram mulheres, 83% tinham o ensino primário, 73% tinham mau estado CVH, 12% apresentaram sintomas de depressão e 43% tinham edentulismo. Pontuações médias no TCL foram 26,7±3 e 23 (9,5%) pessoas tinham < 22 pontos. ACG foi leve em 108, moderada em 95 e grave em 26 pessoas. No modelo multivariado, a média de pontuação no TCL não foi associada com a gravidade da ACG (ß=0,06, SE=0,34, p=0,853). ACG grave foi observada em 6 de 23 pacientes e em 8 de 23 controles (OR: 0,67; IC 95%: 0,14-2,81, p=0,752, teste de McNemar). CONCLUSÃO: O TCL não se associa com a gravidade da ACG após o ajuste para possíveis fatores de confusão e não deve ser usado como uma estimativa confiável de dano cerebral estrutural.

The importance of neurocysticercosis in stroke in rural areas of a developing Latin American country.

There is limited information on the prevalence of neurocysticercosis (NCC) among stroke patients, and no community-based survey has addressed this issue. We performed a 3-Phase, population-based study, to assess the prevalence and pathogenesis of stroke in a rural village of coastal Ecuador, where cysticercosis is highly endemic. Twenty stroke patients were found among 642 individuals ≥ 40 years of age. Eighteen of these patients underwent neuroimaging studies and no patient had evidence of NCC or angiitis of intracranial vessels. The serum immunoblot test for the detection of anticysticercal antibodies, performed in 15 of these 20 patients during a previous survey, were negative in 13 cases and the remaining two had a normal computed tomography of the head. This study suggests that NCC is not responsible for the increasing burden of stroke in rural areas of developing countries.