Screening for cognitive impairment with the Montreal Cognitive Assessment in Spanish patients with minor stroke or transient ischaemic attack.

OBJECTIVE: The symptoms of minor stroke and transient ischemic attack (TIA) are temporary and mild. Despite the transient nature of the focal symptoms and the absence of visible brain lesions in some patients, many experience persistent cognitive problems subsequently. We aimed to establish the discriminant capacity of the Montreal Cognitive Assessment (MoCA) in screening for cognitive impairment (CI) within 90 days of TIA. METHODS: A total of 50 patients with minor stroke or TIA were recruited. Patients were administered the MoCA test and a formal neuropsychological test battery. CI was defined clinically according to neuropsychological test findings. RESULTS: The average age of recruited patients was 57.7±8.0 years; 70.0% were men; all patients had completed at least primary education. Thirty-seven patients (74.0%) presented CI. Receiver operating characteristic curve analysis obtained an optimal MoCA cut-off point of 25 for discriminating between patients with CI and those without, with an area under the curve of 0.835 (95% confidence interval [CI], 0.720-0.949), sensitivity of 78.4% (95% CI, 62.8%-88.6%), specificity of 76.9% (95% CI, 49.7%-91.8%), positive predictive value of 90.6% (95% CI, 81.0%-95.6%), and negative predictive value of 55.6% (95% CI, 39.5%-70.4%). CONCLUSIONS: More than half of the patients presented CI as determined by the formal battery of neuropsychological tests. A MoCA cut-off point of 25 is sufficiently sensitive and specific for detecting CI after minor stroke or TIA, and may be implemented as a screening technique in routine clinical practice.

Detección del deterioro cognitivo con la Evaluación Cognitiva de Montreal en pacientes españoles con ictus minor o ataque isquémico transitorio / Screening for cognitive impairment with the Montreal Cognitive Assessment in Spanish patients with minor stroke or transient ischaemic attack

Objetivo: Los síntomas de un ictus minor o un ataque isquémico transitorio (AIT) son leves y de corta duración. A pesar de la naturaleza pasajera de los síntomas focales y la ausencia de lesiones cerebrales visibles en algunos pacientes, muchos experimentan problemas cognitivos persistentes posteriormente. Nuestro objetivo es establecer el poder discriminativo del Montreal Cognitive Assessment (MoCA, «Evaluación Cognitiva de Montreal») en la detección del deterioro cognitivo (DC) dentro de los 90 días posteriores al AIT. Método: Se incluyeron un total de 50 pacientes con ictus minor y AIT. Se les aplicó la prueba MoCA y una batería neuropsicológica formal. El DC se definió clínicamente según los hallazgos de las pruebas neuropsicológicas. Resultados: La edad promedio de los pacientes seleccionados fue de 57,7 ± 8,0 años, siendo la mayoría de ellos varones (70,0%). Todos los pacientes tenían un nivel educativo igual o superior al primario. Treinta y siete (74,0%) sujetos presentaron DC. Mediante el análisis de la curva característica del receptor se obtuvo un punto de corte del test MoCA de 25 puntos para discriminar entre sujetos con y sin DC, siendo el área bajo la curva de 0,835 (intervalo de confianza del 95% [IC 95%] 0,720 a 0,949), la sensibilidad, del 78,4% (IC 95% 62,8-88,6%), la especificidad, del 76,9% (IC 95% 49,7-91,8%), el valor predictivo positivo, del 90,6% (IC 95% 81,0-95,6%) y el negativo, del 55,6% (IC 95% 39,5-70,4%). Conclusiones: Más de la mitad de la muestra presentaba DC según lo determinado por la batería formal de pruebas neuropsicológicas. Un punto de corte de 25 en el MoCA es lo suficientemente sensible y específico para detectar DC tras un ictus minor o AIT y podría implementarse en la práctica clínica como método de cribado. (AU)

Objective: The symptoms of minor stroke and transient ischemic attack (TIA) are temporary and mild. Despite the transient nature of the focal symptoms and the absence of visible brain lesions in some patients, many experience persistent cognitive problems subsequently. We aimed to establish the discriminant capacity of the Montreal Cognitive Assessment (MoCA) in screening for cognitive impairment (CI) within 90 days of TIA. Method: A total of 50 patients with minor stroke or TIA were recruited. Patients were administered the MoCA test and a formal neuropsychological test battery. CI was defined clinically according to neuropsychological test findings. Results: The average age of recruited patients was 57.7 ± 8.0 years; 70.0% were men; all patients had completed at least primary education. Thirty-seven patients (74.0%) presented CI. Receiver operating characteristic curve analysis obtained an optimal MoCA cut-off point of 25 for discriminating between patients with CI and those without, with an area under the curve of 0.835 (95% confidence interval [95% CI] 0.720-0.949), sensitivity of 78.4% (95% CI 62.8-88.6%), specificity of 76.9% (95% CI 49.7-91.8%), positive predictive value of 90.6% (95% CI 81.0-95.6%), and negative predictive value of 55.6% (95% CI 39.5-70.4%). Conclusions: More than half of the patients presented CI as determined by the formal battery of neuropsychological tests. A MoCA cut-off point of 25 is sufficiently sensitive and specific for detecting CI after minor stroke or TIA, and may be implemented as a screening technique in routine clinical practice. (AU)

Screening for cognitive impairment with the Montreal Cognitive Assessment in Spanish patients with minor stroke or transient ischaemic attack. / Detección del deterioro cognitivo con la Evaluación Cognitiva de Montreal en pacientes españoles con ictus minor o ataque isquémico transitorio.

OBJECTIVE: The symptoms of minor stroke and transient ischemic attack (TIA) are temporary and mild. Despite the transient nature of the focal symptoms and the absence of visible brain lesions in some patients, many experience persistent cognitive problems subsequently. We aimed to establish the discriminant capacity of the Montreal Cognitive Assessment (MoCA) in screening for cognitive impairment (CI) within 90 days of TIA. METHOD: A total of 50 patients with minor stroke or TIA were recruited. Patients were administered the MoCA test and a formal neuropsychological test battery. CI was defined clinically according to neuropsychological test findings. RESULTS: The average age of recruited patients was 57.7±8.0 years; 70.0% were men; all patients had completed at least primary education. Thirty-seven patients (74.0%) presented CI. Receiver operating characteristic curve analysis obtained an optimal MoCA cut-off point of 25 for discriminating between patients with CI and those without, with an area under the curve of 0.835 (95% confidence interval [95% CI] 0.720-0.949), sensitivity of 78.4% (95% CI 62.8-88.6%), specificity of 76.9% (95% CI 49.7-91.8%), positive predictive value of 90.6% (95% CI 81.0-95.6%), and negative predictive value of 55.6% (95% CI 39.5-70.4%). CONCLUSIONS: More than half of the patients presented CI as determined by the formal battery of neuropsychological tests. A MoCA cut-off point of 25 is sufficiently sensitive and specific for detecting CI after minor stroke or TIA, and may be implemented as a screening technique in routine clinical practice.

Determinants of success in treating acute ischemic cerebral and ocular ischemia through carotid revascularization. An observational study of a case series / Determinantes do sucesso no tratamento da isquemia cerebral e ocular aguda por meio da revascularização carotídea. Um estudo observacional de uma série de casos

ABSTRACT Objective: stroke etiology is ischemia in 85%, and in circa 25% of these, the source is the extracranial carotid. Recurrence is frequent and usually more severe. Carotid revascularization prevents new ischemic strokes. The sooner the treatment is undertaken, complete recovery chances are greater with less recurrences. But, historically, intervention in the acute setting was catastrophic. Objective: Identify determinants of success when carotid revascularization after a recent cerebral ischemic event is performed. Materials and Methods: A cohort of 50 subjects underwent carotid revascularization after ischemic symptoms, within a period of 71 months. The currently diagnostic tools were used, and the symptoms stratified by the Rankin scale. The extension of the cerebral lesion and the source location the source of the event was analyzed. Results: indications were based on the Rankin Scale (R0: 35.4%; R1: 45.8%; R2:18.8% and R3: zero), on the location of the source and the absence of ischemic areas greater than 15mm. An early surgical approach was adopted in all patients. Extreme care was applied to control arterial pressure. At discharge, no additional deficits were observed. Conclusions: carotid revascularization after ischemic events can be achieved without additional morbidity and no recurrences, using the most appropriate therapy in the shortest time, in patients with Rankin Scale up to 2, absence of intracranial hemorrhage and single or multiple ischemic intracerebral areas, with 15mm or less in their greater dimension.

RESUMO Introdução: isquemia é a etiologia do acidente vascular cerebral em 85% dos casos e em cerca de 25% destes, a fonte é a carótida extracraniana. Recorrência é frequente e usualmente mais grave que a inicial. A revascularização carotídea previne novos acidentes. Quanto mais cedo for realizado o tratamento, maiores as chances de recuperação e menor o risco de recorrência. Mas, historicamente, os resultados das intervenções precoces eram catastróficos. Objetivos: identificar determinantes de sucesso da revascularização carotídea após um evento isquêmico cerebral recente. Materiais e Métodos: uma coorte de 50 pacientes foi submetida à revascularização carotídea após sintomas isquêmicos, em um período de 71 meses. Foram empregados os métodos de investigação atuais e os sintomas estratificados pela Escala de Rankin. A extensão das lesões cerebrais e a fonte do evento foram estudados e analisados. Resultados: as indicações foram baseadas na escala de Rankin (R0: 35.4%; R1: 45.8%; R2: 18.8% e R3: zero), na localização da fonte e na ausência de áreas isquêmicas com menos de 15mm. Uma abordagem cirúrgica precoce foi empregada em todos os pacientes. Cuidados extremos com a pressão arterial foram aplicados. Na alta hospitalar, nenhum déficit adicional foi observado. Conclusões: a revascularização carotídea após eventos isquêmicos pode ser realizada sem morbidade adicional ou recorrências, empregando a terapêutica mais apropriada no período de tempo mais curto, em pacientes classificados como Rankin até 2, na ausência de hemorragia intracraniana e com áreas isquêmicas intracerebrais únicas ou múltiplas, com menos de 15mm em sua maior dimensão.

Ataque isquémico transitorio por embolia aérea iatrogénica secundaria a inyecciones intracavernosas en procedimiento urológico / Transient ischemic attack due to iatrogenic air embolism secondary to intracavernous injections during an urologic procedure

RESUMEN Se presenta un caso de ataque isquémico transitorio con sintomatología compatible con lesión de la circulación cerebral posterior, secundario a embolia aérea iatrogénica. Se describe la evolución clínica y las consideraciones más relevantes de la atención y el diagnóstico del ataque cerebrovascular de la circulación posterior. En cuanto a la embolia gaseosa, se describen los métodos diagnósticos, las intervenciones clínicas y las opciones de tratamiento disponibles.

SUMMARY Here ia a case of transient ischemic attack with symptoms compatible with injury to the posterior cerebral circulation, secondary to iatrogenic air embolism. Clinical evolution and the most relevant aspects for the care and diagnosis of cerebrovascular stroke of the posterior circulation are described. Regarding air embolism, the diagnostic methods, clinical interventions, and available treatment options are described.

Accidente cerebrovascular isquémico en un adulto joven

RESUMEN Presentamos caso de un varón de 39 años con antecedentes de varios accidentes isquémicos transitorios que siempre resolvieron rápida y espontáneamente. Fue sometido a varios estudios cardiovasculares, neurovasculares y de neuro y angioimagen que resultaron normales. El paciente se presentó a consulta con una paresia facio-braquial derecha y disartria. Sin embargo, el cuadro cedió en el transcurso de horas a pesar de manifestarse una isquemia en los estudios neurovasculares. Por todo lo anterior se decidió estudiar trombofilias presentándose el resultado de una mutación del gen G20210A de la protrombina. Al alta, en tratamiento con anticoagulantes orales, el paciente se presenta asintomático con monitoreo mensual continuo.

ABSTRACT We present the case of a 39-year-old man with a history of several transient ischemic attacks that always resolved quickly and spontaneously. He underwent several cardiovascular, neurovascular, and neuro and angioimaging studies that were normal. The patient presented for consultation with a right faciobrachial paresis and dysarthria. However, the condition subsided within hours despite ischemia manifested in neurovascular studies. For all the above, it was decided to study thrombophilias, finding the prothrombin G20210A mutation. Upon discharge, on treatment with oral anticoagulants, the patient is asymptomatic with continuous monthly monitoring.

Forma clínica indeterminada da doença de Chagas e o risco potencial de evento isquêmico / Indeterminate clinical form of Chagas disease and the potencial risk of ischemic event / Forma clínica indeterminada de la enfermedad de Chagas y potencial riesgo de evento isquémico

Acidentes vasculares cerebrais ou isquêmicos transitórios são eventos raros em pacientes jovens sem fatores de risco clássicos, correspondendo muitas vezes a eventos não definidos etiologicamente e caracterizados como fenômenos tromboembólicos criptogênicos. A doença de Chagas é um fator de risco que deve ser considerado como potencial causa etiológica quando especificamos áreas endêmicas, tanto pelo conhecido mecanismo cardioembólico de acometimento cardíaco como pelas demais formas sem acometimento cardíaco, uma vez que já é descrita como fator de risco independente para doenças cerebrovasculares. Este estudo demonstra, por meio de um relato de caso, o desfecho de uma paciente portadora da doença de Chagas crônica, na forma indeterminada, sem fatores de risco clássicos. A paciente foi acometida por um ataque isquêmico transitório, tendo como etiologia presumida a doença de Chagas, que pode determinar um perfil pró-inflamatório e pró-coagulante, de modo a corroborar a tese de que o prognóstico da forma indeterminada pode não ser benigno. A associação entre a forma indeterminada e as doenças cerebrovasculares incorre na necessidade de anexar ao protocolo de investigação de acidente vascular encefálico (AVE) criptogênicos da doença de Chagas, quando se refere a áreas endêmicas, bem como em alertar as áreas da saúde para essa forma da doença, como forma de ajudar em medidas de prevenção de fenômenos tromboembólicos encefálicos.

Transient strokes or ischemic attacks are rare events in young patients without classic risk factors, often corresponding to events not defined etiologically and characterized as cryptogenic thromboembolic phenomena. Chagas disease is a risk factor that should be considered as a potential etiological cause when specifying endemic areas, both for the cardioembolic mechanism and for other forms without cardiac involvement, since it is described as an independent risk factor for cerebrovascular diseases. This study shows, by means of a case report, the outcome of a patient with chronic indeterminate Chagas disease without classic risk factors. The patient was affected by a transient ischemic attack, with the presumed etiology being Chagas disease, which can determinate a pro-inflammatory and pro-coagulant profile, thus corroborating that the prognosis of the indeterminate form may not be benign. The association between the indeterminate form and stroke incurs in the need to attach to the investigation protocol for cryptogenic stroke of Chagas disease, when referring to endemic areas, as well as to take a better look at this form to help in prevention measures for encephalic thromboembolic phenomena.

Los accidentes cerebrovasculares o accidentes isquémicos transitorios son eventos raros en pacientes jóvenes sin factores de riesgo clásicos, que a menudo corresponden a eventos no definidos etiológicamente caracterizándose como fenómenos tromboembólicos criptogénicos. La enfermedad de Chagas es un factor de riesgo que debe ser considerado como una posible causa etiológica cuando especificamos áreas endémicas, tanto por el conocido mecanismo cardioembólico de afectación cardíaca como por otras formas sin afectación cardíaca, puesto que la enfermedad ya está descrita como factor de riesgo independiente de enfermedades cerebrovasculares. Este estudio demuestra, a partir de un reporte de caso, el desenlace de un paciente con enfermedad de Chagas crónica en forma indeterminada sin factores de riesgo clásicos. La paciente sufrió un ataque isquémico transitorio, con la enfermedad de Chagas como presunta etiología, lo que puede determinar un perfil proinflamatorio y procoagulante, por lo que corroboró con la tesis de que el pronóstico de la forma indeterminada puede no ser tan benigno. La asociación entre la forma indeterminada y las enfermedades cerebrovasculares incurre en la necesidad de adjuntar la enfermedad de Chagas al protocolo de investigación de accidente cerebrovascular (ACV) criptogénico cuando se habla de áreas endémicas, así como de incrementar la visión de las áreas de salud a esta forma de enfermedad, para así contribuir con las medidas preventivas de los fenómenos tromboembólicos cerebrales.

Estenosis bilateral de carótidas internas manifestado por síndrome de Limb-Shaking / Bilateral internal carotid artery stenosis presenting as Limb-Shaking syndrome

Introducción: El síndrome de limb-shaking o sacudida de extremidades como presentación de un ataque isquémico transitorio es raro y suele asociarse con estenosis de las arterias carótidas internas. El principal diagnóstico diferencial es con crisis convulsivas. Presentación del caso: presentamos el caso de un paciente con estenosis carotídea intracraneal bilateral que cursó con sacudidas en extremidades y tuvo mejoría clínica satisfactoria tras un procedimiento con stent.

Limb-shaking syndrome or involuntary shaking movements of the affected limbs as a manifestation of a transient ischemic attack is rare and often is associated with internal carotid artery stenosis. The main differential diagnosis is a convulsive seizure. We present the case of a patient with bilateral intracranial carotid artery stenosis presenting as limb shaking syndrome, showing satisfactory clinical improvement after undergoing stent revascularization.

Ataque isquémico transitorio como manifestación inicial de arteritis de células gigantes: reporte de caso / Transient ischemic attacks initial manifestation of giant cell arteritis: case report

RESUMEN La arteritis de células gigantes es la vasculitis sistémica de medianos y grandes vasos más frecuente en adultos mayores de 50 años. Afecta de manera preferencial a las ramas de las arterias carótidas y vertebrales, pero también se han visto involucradas las arterias axilares, las femorales y las iliacas. Se reporta el caso de un paciente adulto que debutó con clínica de accidente isquémico transitorio asociado con cefalea frontotemporal de moderada intensidad persistente. A la exploración física se encontraba con arterias temporales prominentes y dolorosas, pero no refería síntomas o signos de claudicación mandibular ni de polimialgia reumática. Se confirmó el diagnóstico de arteritis de células gigantes mediante biopsia de arteria temporal y se instauró corticoterapia de forma temprana con buena respuesta al tratamiento. Los eventos isquémicos cerebrovasculares son una presentación relativamente poco frecuente y se han descrito clásicamente cuando ya se han iniciado síntomas de vasculitis. En este caso se presentó como manifestación inicial del periodo activo de la enfermedad, lo cual conlleva un reto diagnóstico que es importante tener en cuenta para iniciar las medidas terapéuticas de manera precoz y disminuir las complicaciones potencialmente graves asociadas. Dentro de tales medidas es preciso destacar el uso de agentes biológicos como el tocilizumab que como terapia adyuvante reduce el riesgo de recaída y la exposición acumulativa de corticoides, en comparación con la monoterapia con corticoides en ciertos casos de arteritis de células gigantes con complicaciones.

SUMMARY Giant cell arteritis is the most common systemic vasculitis of medium and great vessels in adults over 50 years of age. This involvement preferentially the branches of the carotid and vertebral arteries, but the axillary, femoral and iliac arteries have also been involved. The case of an adult patient who debuted with a transient ischemic accident clinic who associated manifestation of moderate persistent frontotemporal headache and the physical examination with prominent and painful temporal arteries is reported. No symptoms or signs of mandibular claudication or polymyalgia rheumatica are reported. The diagnosis of giant cell arteritis was confirmed by temporal artery biopsy and corticosteroid therapy was instituted early with a good response to treatment. Cerebrovascular ischemic events are a relatively rare presentation and have been classically described when symptoms of vasculitis have started, in this case they presented as the initial manifestation of the active period of the disease, which denotes a diagnostic challenge that is important to consider. to initiate therapeutic measures early and reduce associated potentially serious complications. Among these therapeutic measures, the use of biological agents such as Tocilizumab, which as adjuvant therapy reduces the risk of relapse and cumulative corticosteroid exposure compared to corticosteroid monotherapy in cases of giant cell arteritis with complications, should be highlighted.

Association between self-perceived psychological stress and transitory ischaemic attack and minor stroke: A case-control study. / La autopercepción del estrés psicológico se asocia con el ataque isquémico transitorio e ictus minor. Un estudio de casos y controles.

INTRODUCTION: Stroke has a complex aetiopathogenesis influenced by numerous risk factors. There is growing interest in the study of the pathophysiological changes associated with stress and their potential relationship with cerebrovascular disease. The purpose of this paper is to assess the strength of association between exposure to stress and stroke. METHODS: We conducted a case-control study (1:1) to compare exposure to stress in a group of patients with a history of a first transient ischaemic attack (TIA) or minor stroke and in a control group. Participants were asked a subjective question about their perception of stress in the previous months and completed the standardised Effort-Reward Imbalance (ERI) questionnaire. Logistic regression models were used for data analysis. RESULTS: The study included data on 50 cases and 50 controls. There were no significant differences in demographic variables and economic, social, and employment status between cases and controls. Fifty percent of the cases reported moderate to severe stress, compared to 30% of controls (OR: 2.33; 95% CI: 1.02-5.30; P=.041). ERI questionnaire results found that greater effort at work (OR: 1.48; 95% CI: 1.19-1.83) and greater commitment is associated with stroke (OR: 1.34; 95% CI: 1.17-1.54), while higher reward constitutes a protective factor against the disease (OR: 0.71; 95% CI: 0.61-0.82). CONCLUSIONS: There is a strong association between self-perceived psychological stress and TIA. The imbalance between effort and reward at work is also clearly related to TIA.

Complicaciones cerebrovasculares luego de angiografía coronaria en contexto de infarto agudo de miocardio. Estudio de cohorte / Cerebrovascular complications after invasive percutaneous coronary procedure for acute myocardial infarction in a patient cohort / Complicações cerebro-vasculares após procedimento coronário invasivo percutâneo para infarto do miocárdio aguda em um coorte do paciente

Resumen: Introducción: los eventos cerebrovasculares son una complicación grave, pero infrecuente, de los procedimientos coronarios invasivos. La angioplastia coronaria aumenta el riesgo de presentarla en 17 veces. Los pacientes que la sufren tienen más complicaciones agregadas y mayores tasas de mortalidad. Objetivo: determinar las características clínicas y evolutivas de los pacientes que desarrollaron un evento cerebrovascular luego de una angiografía coronaria de urgencia en el contexto de un infarto agudo de miocardio (IAM). Secundariamente, analizar la relación temporal entre ambos eventos e identificar factores previos asociados al desarrollo de la complicación neurológica. Método: cohorte retrospectiva de pacientes que sufrieron un evento cerebrovascular de cualquier tipo dentro de los 30 días posteriores a un procedimiento coronario por IAM en el Centro Cardiovascular Universitario, entre 2008 y 2017. Se analizaron características demográficas, del procedimiento coronario y del evento cerebrovascular. Resultados: 24 pacientes, 54,2% hombres; 1/3 del total tenía ataque cerebrovascular (ACV) previo. El 66,7% sufrió IAM sin elevación del segmento ST. Todos los eventos cerebrovasculares fueron isquémicos; la mayoría sobre la circulación anterior. El 62% ocurrió en las primeras 48 horas luego del procedimiento coronario, asociándose a mayor duración del procedimiento y número de vasos tratados. En tres casos se utilizó activador tisular del plasminógeno recombinante para reperfusión del evento neurológico. La mediana de NIHSS (National Institute of Health Stroke Scale) fue de 4 puntos (IQ 2-8) en IAM sin elevación del ST, y 8 puntos (IQ 3-20) en IAM con elevación del ST (p=0,20). El 79% de los pacientes sufrió complicaciones adicionales durante la hospitalización; cinco fallecieron. Conclusiones: entre quienes sufrieron complicaciones cerebrovasculares luego de angiografía coronaria pos-IAM existió una proporción similar de ambos sexos y un porcentaje elevado de pacientes con antecedentes de ACV. La forma de presentación del evento cardiovascular fue predominantemente IAM sin elevación del ST. Los eventos cerebrovasculares fueron isquémicos, en su mayoría de la circulación cerebral anterior y ocurrieron en las primeras 48 horas. El ACV/AIT (ataque isquémico transitorio) en este contexto podría asociarse a una mayor estancia hospitalaria y mortalidad.

Summary: Introduction: cerebrovascular events are serious but infrequent complications of invasive percutaneous coronary procedure. Coronary angioplasty increases the risk 17 times. Patients suffering this complication have higher morbidity and mortality rates. Objective: to determine the clinical and evolutionary characteristics of the patients who developed a cerebrovascular event after an emergency coronary angiography in the context of an acute myocardial infarction. Secondly, analyze the temporal relationship between both events and identify previous factors associated with the development of neurological complications. Methods: demographic, characteristics of the angiographic procedure, and cerebrovascular features of a population of patients with stroke occurring within 30 days after of invasive percutaneous coronary procedure for myocardial infarctions are described. Data was retrospectively collected from the Cardiovascular University Center (Hospital de Clínicas, Montevideo, Uruguay) between 2008-2017. Results: 24 patients, 54.2% were men; 1/3 had prior stroke; 66.7% presented non ST segment elevation myocardial infarction. All of the cerebrovascular events were ischemic, most were from the anterior circulation. 62% occurred in the first 48 hours after invasive percutaneous coronary procedure, having this group a higher percentage of percutaneous coronary angioplasty and longer procedures. In three patients recombinant tissue plasminogen activator was used for stroke treatment. NIHSS median was 4 points (IQ 2-8) in patients without ST-segment elevation myocardial infarction and 8 points (IQ 3-20) in patients with ST-segment elevation myocardial infarction (p=0.20). 79% of patients had complications during the hospitalization, and 5 died. Conclusions: there was a similar proportion of men and women, and a high percentage of patients with a history of stroke. The presentation of the cardiovascular events was predominantly non ST myocardial infarction. All the cerebrovascular events were ischemic, it occurred for most patients in the first 48 hours after invasive percutaneous coronary procedure, and the anterior brain circulation was most commonly affected. Stroke/transient ischemic attack after invasive percutaneous coronary procedure could be associated with longer hospital stays and death.

Resumo: Introdução: o acidente vascular cerebral é uma complicação séria, mas pouco frequente, da procedimiento coronário invasivo percutâneo. Angioplastia coronariana aumenta o risco 17 vezes. Pacientes que sofrem dessa complicação têm mais complicações e maiores taxas de mortalidade. Objetivo: determinar as características clínicas e evolutivas dos pacientes que desenvolveram um evento cerebrovascular após uma angiografia coronária de emergência no contexto de um infarto agudo do miocárdio. Em segundo lugar, analise a relação temporal entre os dois eventos e identifique os fatores anteriores associados ao desenvolvimento de complicações neurológicas. Métodos: uma coorte retrospectiva dos pacientes que sofreram um acidente vascular cerebral nos primeiros 30 dias de um procedimento coronário para o infarto agudo do miocárdio, e a análise dos seus dados demográficos e características de processo coronária e acidente vascular cerebral é realizada é descrito. Dados do Centro Cardiovascular Universitário do Hospital de Clínicas de Montevidéu, Uruguai, foram obtidos retrospectivamente a partir das datas entre 2008 e 2017. Resultados: 24 pacientes; 54,2% eram homens; 1/3 haviam sofrido um ataque cerebrovascular prévio; 66,7% apresentavam infarto agudo do miocárdio sem supradesnivelamento do segmento ST. Todos os eventos cerebrovasculares foram isquêmicos, a maioria era da circulação anterior. 62% dos eventos cerebrovasculares ocorreram nas primeiras 48 horas após o procedimento coronário, tendo encontrado nesse grupo procedimentos mais longos e com mais angioplastias coronarianas realizadas. Em 3 pacientes, a ativador do plasminogênio tissular recombinante foi usada para tratar o acidente vascular cerebral. O NIHSS mediana foi de 4 pontos (IQ 2-8) no infarto agudo do miocárdio, sem elevação do segmento ST, e 8 pontos (IQ 3- 20) no infarto agudo do miocárdio com elevação do segmento ST (p = 0,20) . 79% dos pacientes sofreram complicações durante a internação e 5 morreram. Conclusões: houve uma proporção semelhante de ambos sexos e uma alta porcentagem de pacientes com história de acidente vascular cerebral. A apresentação do evento cardiovascular foi predominantemente IAM sem supradesnivelamento do segmento ST. O ataque cerebrovascular foi isquêmico, ocorreu mais freqüentemente nas primeiras 48 horas e afetou principalmente a circulação cerebral anterior. Acidente vascular cerebral após intervenção coronária percutânea poderia estar associada a uma permanência hospitalar mais longa e mortalidade.

Stroke and transient ischemic attacks related to antiplatelet or warfarin interruption / Acidente vascular cerebral e ataques isquêmicos transitórios relacionados à interrupção de antiplaquetários ou varfarina

ABSTRACT Patients on anticoagulant or antiplatelet therapy are often required to discontinue these medications before and during surgical or invasive procedures. In some cases, the patient stops the treatment without medical supervision. These situations may increase stroke risk. Objective To identify the ischemic stroke and transient ischemic attack (TIA) prevalence related to length of time of discontinuation of antiplatelet or vitamin K antagonist therapy, in a group of inpatients from a specialized neurological hospital in Brazil. Methods Cross-sectional, retrospective and descriptive study of stroke inpatients for three years. Medical reports were reviewed to find study participants, stroke characteristics, risk factors, reasons and time of drug interruption. Results In three years, there were 360 stroke and TIA inpatients, of whom 27 (7.5%) had a history of antiplatelet or vitamin K antagonist interruption correlated with the time of the event (81% ischemic stroke, 19% TIA). The median time between antiplatelet interruption and an ischemic event was five days, and 62% of events occurred within seven days after drug suspension. For vitamin K antagonists, the average time to the ischemic event was 10.4 days (SD = 5.7), and in 67% of patients, the time between drug discontinuation and the event was 7-14 days. The most frequent reason for drug suspension was patient negligence (37%), followed by planned surgery or invasive examination (26%) and side effects, including hemorrhage (18.5%). Conclusion Antiplatelet or vitamin K antagonist suspension has a temporal relationship with the occurrence of stroke and TIA. Since these events are preventable, it is crucial that healthcare professionals convince their patients that drug withdrawal can cause serious consequences.

RESUMO Pacientes em terapia anticoagulante ou antiagregante plaquetária frequentemente são solicitados a descontinuar essas medicações antes e durante procedimentos cirúrgicos ou invasivos. Se o paciente interromper tratamento sem supervisão médica, poderá aumentar de risco de acidente vascular cerebral (AVC). Objetivo Identificar prevalência de AVC isquêmico e ataque isquêmico transitório (AIT) associados à descontinuação de terapia antiplaquetária ou coumarínicos em pacientes internados em hospital especializado em atendimento neurológico no Brasil. Métodos Estudo transversal, retrospectivo de três anos, descritivo dos pacientes hospitalizados por AVC. A revisão de relatórios médicos determinou características do AVC, fatores de risco, motivos e tempo de interrupção medicamentosa. Resultados Em três anos, foram internados 360 pacientes por AVC ou AIT; destes, 27 interromperam temporariamente terapia antiplaquetária ou coumarínicos relacionando ao evento (81% acidente vascular cerebral isquêmico, 19% AIT). A prevalência foi de 7,5%. O tempo médio entre interrupção antiplaquetária e evento foi cinco dias, com 62% deles ocorrendo até sete dias após suspensão medicamentosa. Para coumarínicos, o tempo médio foi 10,4 dias (d.p.= 5,7), em 67% dos casos o tempo entre a descontinuação medicamentosa e o evento foi 7-14 dias. O motivo mais frequente para suspensão do medicamento foi negligência do paciente (37%), seguido por cirurgia planejada ou exame invasivo (26%) e efeitos colaterais, incluindo hemorragia (18,5%). Conclusão Suspensão de terapia de antiplaquetários ou coumarínicos tem relação temporal com ocorrência de AVC e de AIT. Esses eventos são passíveis de serem evitados, sendo imprescindível que profissionais de saúde convençam seus pacientes das consequências graves da retirada do medicamento.

Get With The Guidelines®-Stroke performance indicators in patients with transient ischemic attack / Indicadores de desempenho do programa "Get With The Guidelines®-Stroke" em pacientes com ataque isquêmico transitório

ABSTRACT Get With The Guidelines®-Stroke is an in-hospital program for improving stroke care by promoting adherence to scientific guidelines. Of the patients with transient ischemic attack (TIA), 10-15% have a stroke within three months, and many patients do not receive the recommended interventions to prevent this outcome. Objective: The goal of this study was to assess the adherence to stroke quality indicators in patients with TIA. Methods: This retrospective observational study evaluated consecutive patients admitted to a primary stroke center with TIA or acute ischemic stroke (AIS) from August 2008 to December 2013. Six quality indicators applicable to both TIA and AIS were analyzed and compared between groups. Results: A total of 357 patients with TIA and 787 patients with AIS were evaluated. Antithrombotic medication use within 48 hours of admission, discharge use of anticoagulation for atrial fibrillation and counseling for smoking cessation were similar between groups. In the TIA group, discharge use of antithrombotic medication (95% versus 98%; p = 0.01), lipid-lowering treatment (57.7% versus 64.1%; p < 0.01) and stroke education (56.5% versus 74.5%; p < 0.01) were all less frequently observed compared with patients with AIS. Conclusions: The adherence to some of the Get With The Guidelines®-Stroke quality indicators was lower in patients with TIA than in patients with AIS. Measures should be undertaken to reinforce the importance of such clinical interventions in patients with TIA.

RESUMO O "Get With The Guidelines®-Stroke (GWTG-S)" é um programa hospitalar criado para melhorar os cuidados em pacientes com AVC ao promover a adesão às diretrizes. Dez a quinze porcento dos pacientes com ataque isquêmico transitório terão um AVC em 3 meses, sendo que muitos não recebem intervenções de prevenção secundária recomendadas. Objetivo: Avaliar a adesão aos indicadores de qualidade do programa GWTG em pacientes com ataque isquêmico transitório. Métodos: Este estudo retrospectivo observacional avaliou pacientes consecutivos admitidos em um centro de AVC com suspeita de ataque isquêmico transitório ou AVC isquêmico agudo de agosto/2008 a dezembro/2013. Seis indicadores de qualidade aplicáveis tanto ao ataque isquêmico transitório quanto ao AVC isquêmico agudo foram analisados e comparados entre os grupos. Resultados: Um total de 357 pacientes com ataque isquêmico transitório e 787 pacientes com AVC isquêmico agudo foram avaliados. O uso de antiagregante dentro das primeiras 48 horas da admissão, liberação na alta com anticoagulante para fibrilação atrial e aconselhamento para cessação do tabagismo foram similares entre os grupos. No grupo com ataque isquêmico transitório, o uso de antiagregante na alta hospitalar, o tratamento com estatina e a educação sobre o AVC foram observados menos frequentemente quando comparados ao grupo de pacientes com AVC isquêmico agudo. Conclusões: A adesão a alguns dos indicadores de qualidade do programa GWTG-S foi mais baixa em pacientes com ataque isquêmico transitório quando compara a pacientes com AVC isquêmico agudo. Medidas devem ser tomadas para reforçar a importância dessas intervenções em pacientes admitidos com ataque isquêmico transitório.

Cryptogenic Acute Ischemic Stroke: Assessment of the Performance of a New Continuous Long-Term Monitoring System in the Detection of Atrial Fibrillation / AVC Isquêmico Agudo Criptogênico: Avaliação do Desempenho de um Novo Sistema de Monitorização Contínua e Prolongada, via Telefonia Celular, na Detecção de Fibrilação Atrial

Abstract Background: Long-term monitoring has been advocated to enhance the detection of atrial fibrillation (AF) in patients with stroke. Objective: To evaluate the performance of a new ambulatory monitoring system with mobile data transmission (PoIP) compared with 24-hour Holter. We also aimed to evaluate the incidence of arrhythmias in patients with and without stroke or transient ischemic attack. Methods: Consecutive patients with and without stroke or TIA, without AF, were matched by propensity score. Participants underwent 24-hour Holter and 7-day PoIP monitoring. Results: We selected 52 of 84 patients (26 with stroke or TIA and 26 controls). Connection and recording times were 156.5 ± 22.5 and 148.8 ± 20.8 hours, with a signal loss of 6,8% and 11,4%, respectively. Connection time was longer in ambulatory (164.3 ± 15.8 h) than in hospitalized patients (148.8 ± 25.6 h) (p = 0.02), while recording time did not differ between them (153.7 ± 16.9 and 143.0 ± 23.3 h). AF episodes were detected in 1 patient with stroke by Holter, and in 7 individuals (1 control and 6 strokes) by PoIP. There was no difference in the incidence of arrhythmias between the groups. Conclusions: Holter and PoIP performed equally well in the first 24 hours. Data transmission loss (4.5%) occurred by a mismatch between signal transmission (2.5G) and signal reception (3G) protocols in cell phone towers (3G). The incidence of arrhythmias was not different between stroke/TIA and control groups.

Resumo Fundamentos: Monitorização prolongada permite maior detecção de fibrilação atrial (FA) em pacientes com acidente vascular cerebral (AVC) isquêmico criptogênico. Não há consenso sobre a duração ideal da monitorização ou o valor prognóstico da FA de curta duração. Objetivos: Avaliar o desempenho de um novo sistema de monitorização ambulatorial (PoIP) com transmissão por telefonia celular, comparado ao Holter 24 horas, e a ocorrência de arritmias comparando pacientes com e sem AVC ou ataque isquêmico transitório (AIT). Métodos: Pacientes consecutivos com e sem AVC/AIT, sem FA, foram pareados pelo escore de propensão. Foi utilizado Holter 24 horas e o PoIP por 7 dias. Resultados: Selecionamos 52 de 84 pacientes (26 com AVC/AIT agudo e 26 controles). O tempo de conexão foi de 156,5 ± 22,5 horas e o de gravação no servidor foi de 148,8 ± 20,8 horas, com perdas de 6,8 e 11,4%, respectivamente. Houve maior tempo de conexão nos pacientes ambulatoriais (164,3 ± 15,8 h) que nos hospitalizados (148,8 ± 25,6h) (p = 0,02) com tempo de gravação semelhante (153,7 ± 16,9 e 143 ± 23,3 h). Detectamos FA pelo Holter em 1 paciente com AVC e pela monitorização prolongada em 7 (1 controle e 6 AVC). Não houve diferença na incidência de outras arritmias entre os grupos. Conclusões: Holter e PoIP tiveram desempenho equivalente nas primeiras 24 horas. O menor tempo de monitorização nos pacientes hospitalizados ocorreu por sinal de baixa intensidade. Perda de dados (4,5%) ocorreu por discrepância entre protocolos de transmissão (2,5G) e recepção pelas antenas (3G). A incidência de arritmias não diferiu entre os grupos AVC/AIT e controle.

Charles Miller Fisher: the 65th anniversary of the publication of his groundbreaking study "Transient Monocular Blindness Associated with Hemiplegia" / Charles Miller Fisher: 65 anos da publicação de seu estudo inovador "Cegueira monocular transitória associada com hemiplegia"

ABSTRACT Charles Miller Fisher is considered the father of modern vascular neurology and one of the giants of neurology in the 20th century. This historical review emphasizes Prof. Fisher's magnificent contribution to vascular neurology and celebrates the 65th anniversary of the publication of his groundbreaking study, "Transient Monocular Blindness Associated with Hemiplegia."

RESUMO Charles Miller Fisher é considerado o pai da neurologia vascular moderna, e um dos gigantes da neurologia no século XX. Esta revisão histórica enfatiza a magnífica contribuição de Miller Fisher na neurologia vascular, particularmente com a celebração dos 65 anos de publicação do seu estudo inovador intitulado "Cegueira monocular transitória associada com hemiplegia".

Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death.

INTRODUCTION: The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. METHODS: Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD(2) score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. RESULTS: We evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD(2) score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. CONCLUSIONS: In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.

Rapid assessment of transient ischaemic attack in a hospital with no on-call neurologist.

BACKGROUND: Risk of stroke soon after a transient ischaemic attack (TIA) is high. Urgent care can reduce this risk. Our aim is to describe and evaluate the efficacy of rapid assessment of TIA patients in a hospital without a neurologist available 24 hours a day. METHODS: In February 2007, we set up a protocol of rapid management of patients with symptoms consistent with acute TIA, with the aim of prioritising urgent care and reducing hospital admissions, without increasing risk of recurrences. We analyse our results since the protocol was implemented with particular focus on the analysis of delay in neurological and neurovascular assessment, percentage and reasons for hospitalisation, and stroke recurrence rates after 3 months. RESULTS: Four hundred and eleven patients were studied, with a final diagnosis of TIA in 282 (68.6%). Among other diagnoses, the most frequent were a vasovagal reaction (5.6%) and confusional syndrome (4.6%). Delay between emergency arrival and neurovascular assessment was <24h in 82% of the cases, and <48 h in 93%. After neurological evaluation, 28.7% of the patients were immediately admitted to hospital (most common causes: severe stenosis of a large artery and crescendo TIA). The incidence of ischaemic stroke in TIA patients was 3.55% after 3 months and 70% of them suffered the recurrence within the first week after the initial TIA. CONCLUSIONS: In a hospital without a neurologist available 24 hours a day, early assessment and management of TIA patients can be carried out in accordance with the guidelines, and may avoid hospitalisation in most cases without increasing recurrence rates.

Estudio de frecuencia de los factores de riesgo asociados al desarrollode enfermedad cerebrovascular isquémica no embólica en un hospitalde tercer nivel / Frecuency study of risk factors for cerebrovascular disease development in tertiary hospital in Colombia

Los factores epidemiológicos y las características clínicas de la Enfermedad Cerebrovascular(ECV) varían de acuerdo a factores ambientales, raciales, de género y socioculturales; por tal razón, el conocimientode dichos factores epidemiológicos de riesgo para ECV en nuestra población tiene gran importanciay aporta elementos claves en términos de salud pública.Objetivos. Determinar la frecuencia de los factores de riesgo para el desarrollo de ECV y su tiempo de evolución,así como el número de pacientes que reciben tratamiento para dichos factores de riesgo, la adherenciaal mismo y el seguimiento de recomendaciones de dieta y actividad física.Materiales y métodos. Se realizó un estudio observacional, tipo serie de casos, en pacientes mayores de 18años que consultaron por ECV isquémico en el periodo comprendido entre enero de 2009 hasta septiembrede 2013. Los pacientes se identificaron a través de los códigos CIE-10 contenidos en la base de datos de lainstitución para obtener los registros que incluyeran un diagnóstico principal o relacionado de EnfermedadCerebrovascular Isquémica.Resultados. El promedio de edad fue de 72.7 (SD 12.7) años. Hubo predominio del sexo masculino (50.4%).Conclusiones. La frecuencia de factores de riesgo para ECV parece haber aumentado respecto a publicacionesprevias, posiblemente por modificaciones no saludables en el estilo de vida de la población. El presente estudio brinda información respecto al tratamiento y adherencia farmacológica, ya que realizar un diagnóstico correctode factores de riesgo es muy importante; así mismo, es fundamental instaurar un tratamiento adecuado y, sobre todo, que los pacientes sean adherentes con la terapia para obtener los resultados esperados...

to environmental racial, gender and cultural factors, for this reason, knowledge of the epidemiology of CVDrisk factors in our population is very important and provides key elements in terms of public health.Objective. To determine the frequency of risk factors for the development of CVD and its development time,as well and the number of patients receiving treatment for these risk factors, their adherence to it, in terms offollowing recommendations of diet and physical activity.Materials and Methods. We performed an observational, case series, in patients over 18 years old whoconsulted for ischemic CVD in the period between January 2009 and September 2013. Patients were identifiedby ICD-10 codes in the database for those records or associated with a diagnosis of Ischemic CerebrovascularDisease. Thus, 220 patients met the inclusion criteria. For data collection, a questionnaire was designed to beapplied to each of the records. The information collected was entered in a database in Excel. Descriptive analysiswas performed using STATA statistical software version 12.0. Measures of central tendency and dispersionfor continuous variables and frequencies and proportions for nominal and ordinal variables were estimated...

Guidelines for the preventive treatment of ischaemic stroke and TIA (II). Recommendations according to aetiological sub-type.

BACKGROUND AND OBJECTIVE: To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and Transient Ischaemic Attack (TIA). METHODS: We reviewed the available evidence on ischaemic stroke and TIA prevention according to aetiological subtype. Levels of evidence and recommendation levels are based on the classification of the Centre for Evidence-Based Medicine. RESULTS: In atherothrombotic IS, antiplatelet therapy and revascularization procedures in selected cases of ipsilateral carotid stenosis (70%-90%) reduce the risk of recurrences. In cardioembolic IS (atrial fibrillation, valvular diseases, prosthetic valves and myocardial infarction with mural thrombus) prevention is based on the use of oral anticoagulants. Preventive therapies for uncommon causes of IS will depend on the aetiology. In the case of cerebral venous thrombosis oral anticoagulation is effective. CONCLUSIONS: We conclude with recommendations for clinical practice in prevention of IS according to the aetiological subtype presented by the patient.

Endarterectomía de carótidas con analgesia acupuntural / Endarterectomy of carotids with acupunctural analgesia

La enfermedad carotídea aumenta significativamente el riesgo de tener el tipo más común de ataque isquémico cerebral (ictus). Son sobradamente conocidos los elevados procesos isquémicos cerebrales que tienen su origen en lesiones estenosantes (ulceradas o no) de las arterias extracraneales, fundamentalmente en la bifurcación carotídea. Dado que estas lesiones tienen acceso quirúrgico, el tratamiento de rutina desde hace años es la endarterectomia carotídea. El efecto analgésico de la acupuntura permite realizar cualquier tipo de operación en la región anatómica seleccionada, conservando el paciente su lucidez mental, algo oportuno para determinar qué pacientes necesitarán de shunt intraluminal después del clampeo de las arterias durante esta operación. Con el objetivo de asociar estos criterios, a un paciente masculino de 76 años que había sufrido cuatro ataques cerebrales de isquemia, producto de placa de ateroma complicada y estenosante de la bifurcación carotidea izquierda, se le realizó una endarterectomía con analgesia acupuntural sin complicaciones transoperatorias ni postoperatorias, por lo que se propone que es una alternativa lógica, económica y segura de realizar la desobstrucción carotídea.

Carotid disease increases the risk of having the most common brain-ischemic stroke significantly. The elevated brain ischemic processes havig their origin in lesions caused by stenosis (ulcerous o non-ulcerous) of the extracranial arteries, mainly in the carotid bifurcation are well-known. As these lesions are surgically accessible, for long years the routine treatment is the Endarterectomy of carotids. The analgesic effect of the acupuncture permits any types of surgery in the chosen anatomic region, preserving mental lucidity in patient, something very significant to determine the patients needing intraluminal shunt after campling the arteries during this surgical procedure. Aimed at associating these criteria, a 76-year-old-male patient who had suffered from four ischemic brain strokes as a consequence of a complicated atheromatous plaque and stenosis of left carotid bifurcation, an Endarterectomy of carotids with acupunctural analgesia was performed without trans-operative or post-operative complications, therefore it is proposed as a logic, economic and secure alternative to remove the carotid obstruction.