RESUMEN
BACKGROUND AND PURPOSE: The study aims to compare lipid profiles among ischemic stroke patients in a predominantly Caribbean-Hispanic population in Miami and a Mestizo Hispanic population in Mexico City. METHODS: We analyzed ischemic stroke Hispanic patients with complete baseline fasting lipid profile enrolled contemporaneously in the prospective registries of two tertiary care teaching hospitals in Mexico City and Miami. Demographic characteristics, risk factors, medications, ischemic stroke subtype, and first fasting lipid profile were compared. Vascular risk factor definitions were standardized. Multiple linear regression analysis was performed to compare lipid fractions. RESULTS: A total of 324 patients from Mexico and 236 from Miami were analyzed. Mexicans were significantly younger (58 · 1 vs. 67 · 4 years), had a lower frequency of hypertension (53 · 4% vs. 79 · 7%), and lower body mass index (27 vs. 28 · 5). There was a trend toward greater prevalence of diabetes in Mexicans (31 · 5 vs. 24 · 6%, P = 0 · 07). Statin use at the time of ischemic stroke was more common in Miami Hispanics (18 · 6 vs. 9 · 4%). Mexicans had lower total cholesterol levels (169 · 9 ± 46 · 1 vs. 179 · 9 ± 48 · 4 mg/dl), lower low-density lipoprotein (92 · 3 ± 37 · 1 vs. 108 · 2 ± 40 · 8 mg/dl), and higher triglyceride levels (166 · 9 ± 123 · 9 vs. 149 · 2 ± 115 · 2 mg/dl). These differences remained significant after adjusting for age, gender, hypertension, diabetes, body mass index, smoking, ischemic stroke subtype, and statin use. CONCLUSION: We found significant differences in lipid fractions in Hispanic ischemic stroke patients, with lower total cholesterol and low-density lipoprotein, and higher triglyceride levels in Mexicans. These findings highlight the heterogeneity of dyslipidemia among the Hispanic race-ethnic group and may lead to different secondary prevention strategies.
Asunto(s)
Isquemia/epidemiología , Trastornos del Metabolismo de los Lípidos/epidemiología , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/metabolismo , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Hispánicos o Latinos , Hospitales de Enseñanza/estadística & datos numéricos , Humanos , Isquemia/complicaciones , Metabolismo de los Lípidos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Accidente Cerebrovascular/etiologíaRESUMEN
OBJECTIVE: To evaluate the types and mechanisms of stroke in a large population of HIV-infected patients. METHODS: We reviewed records of consecutive HIV-infected patients with acute stroke admitted to a large metropolitan hospital between 1996 and 2004. Stroke mechanism was defined by consensus between two cerebrovascular neurologists using TOAST classification. RESULTS: A total of 82 patients were included, 77 with ischemic stroke and 5 with intracerebral hemorrhage. Mean age was 42 years and 89% were African American. Previous diagnosis of HIV infection was documented in 91% and AIDS diagnosis in 80%. Mean CD4 count was 113 cells/mm(3) and 85% had CD4 count <200 cells/mm(3). A total of 61% of patients had received combination antiretroviral treatment (CART). The mechanism of ischemic stroke was large artery atherosclerosis in 12%, cardiac embolism in 18%, small vessel occlusion in 18%, other determined etiology in 23%, and undetermined in 29% (including 19% with incomplete evaluation). Vasculitis was deemed responsible for the stroke in 10 patients (13%) and hypercoagulability in 7 (9%). Protein S deficiency was noted in 10/22 (45%) and anticardiolipin antibodies in 9/31 (29%) tested patients. When comparing patients with large or small vessel disease (atherothrombotic strokes) vs the rest of the population, there were no differences in exposure to CART or CD4 count, but patients with non-atherothrombotic strokes were younger (p = 0.04). Recent cocaine exposure was less common among patients with atherothrombotic strokes (p = 0.02). Strokes were fatal or severely disabling in 35% of cases. CONCLUSIONS: Stroke mechanisms are variable in HIV-infected patients, with a relatively high incidence of vasculitis and hypercoagulability. In our population of severely immunodepressed patients, exposure to combination antiretroviral treatment did not significantly influence the mechanism of stroke.
Asunto(s)
Isquemia Encefálica/epidemiología , Infecciones por VIH/epidemiología , Accidente Cerebrovascular/epidemiología , Adolescente , Adulto , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Asparaginasa/efectos adversos , Isquemia Encefálica/fisiopatología , Recuento de Linfocito CD4/estadística & datos numéricos , Cardiolipinas/inmunología , Hemorragia Cerebral/epidemiología , Niño , Preescolar , Trastornos Relacionados con Cocaína/epidemiología , Comorbilidad , Citarabina/efectos adversos , Daunorrubicina/efectos adversos , Femenino , Humanos , Incidencia , Arteriosclerosis Intracraneal/epidemiología , Embolia Intracraneal/epidemiología , Masculino , Persona de Mediana Edad , Deficiencia de Proteína S/epidemiología , Estudios Retrospectivos , Accidente Cerebrovascular/fisiopatología , Tioguanina/efectos adversos , Trombofilia/epidemiología , Vasculitis/epidemiologíaRESUMEN
The WASID trial showed no advantage of warfarin over aspirin for preventing the primary endpoint of ischemic stroke, brain hemorrhage, or vascular death. In analyses of selected subgroups, there was no definite benefit from warfarin. Warfarin reduced the risk of the primary endpoint among patients with basilar artery stenosis, but there was no reduction in stroke in the basilar artery territory or benefit for vertebral artery stenosis or posterior circulation disease in general.
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Aspirina/uso terapéutico , Enfermedades Arteriales Cerebrales/tratamiento farmacológico , Enfermedades Arteriales Cerebrales/mortalidad , Medición de Riesgo/métodos , Warfarina/uso terapéutico , Anciano , Anciano de 80 o más Años , Antiinflamatorios no Esteroideos/uso terapéutico , Anticoagulantes/uso terapéutico , Enfermedades Arteriales Cerebrales/diagnóstico , Constricción Patológica/diagnóstico , Constricción Patológica/tratamiento farmacológico , Constricción Patológica/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Análisis de Supervivencia , Tasa de Supervivencia , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Necropsy studies have shown that nonbacterial thrombotic endocarditis (NBTE) may be associated with cerebral infarctions and antemortem diagnosis is now possible. However, the best treatment for patients with NBTE presenting with stroke is not known. We describe three patients presenting with an acute embolic stroke secondary to large,mobile vegetations detected by transthoracic (one case) or transesophageal echocardiography (two cases). All patients underwent surgery for removal of the vegetations to prevent recurrent embolic events; valve replacement was necessary in two cases. The sterile nature of the vegetations was confirmed by pathological examination and negative stains and cultures of the surgical samples. A previously unrecognized hypercoagulable condition was diagnosed in all patients (antiphospholipid antibody syndrome in two cases and disseminated adenocarcinoma in one case). CONCLUSION: NBTE should be considered among the possible causes of embolic stroke even in the absence of history of cancer, hypercoagulability, or previous embolic manifestations. If NBTE is diagnosed, the possibility of underlying thrombophilia should be thoroughly investigated. Valvular surgery represents a valuable therapeutic alternative in patients with large mobile vegetations, valvular dysfunction or recurrent embolic events despite anticoagulation.
Asunto(s)
Embolia/cirugía , Endocarditis/cirugía , Accidente Cerebrovascular/cirugía , Adulto , Ecocardiografía Transesofágica/métodos , Embolia/complicaciones , Embolia/diagnóstico , Endocarditis/complicaciones , Endocarditis/diagnóstico , Femenino , Humanos , Masculino , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/diagnósticoAsunto(s)
Acetazolamida/uso terapéutico , Demencia por Múltiples Infartos/tratamiento farmacológico , Trastornos Migrañosos/tratamiento farmacológico , Adulto , Encéfalo/irrigación sanguínea , Demencia por Múltiples Infartos/diagnóstico , Demencia por Múltiples Infartos/genética , Diagnóstico Diferencial , Femenino , Homeostasis/efectos de los fármacos , Humanos , Trastornos Migrañosos/diagnóstico , Trastornos Migrañosos/genética , Migraña con Aura/diagnóstico , Migraña con Aura/tratamiento farmacológico , Migraña con Aura/genéticaRESUMEN
BACKGROUND: Microembolic signals (MES) have been demonstrated by transcranial Doppler (TCD) in cases of internal carotid artery dissection. The influence of treatment on MES in arterial dissection is uncertain. The authors here present a case of internal carotid artery dissection in which we detected a reduction of MES after the initiation of intravenous heparin. METHODS: A 37-year-old woman developed a right temporal headache 10 days prior to admission. This was followed by episodes of left arm numbness and weakness. Magnetic resonance imaging (MRI) showed a right frontal and deep subcortical ischemic infarct. Catheter angiography confirmed a right internal carotid artery dissection with intracranial extension. She was then monitored with TCD for MES before and after intravenous heparin was started. RESULTS: The first TCD, performed 12 days after symptom onset, showed 39 MES during 60 minutes of insonation of the right middle cerebral artery. Treatment with intravenous heparin resulted in a decline in MES by 50% after 96 hours. This decline continued and no further MES were detected after 11 days of anticoagulation. CONCLUSION: The authors were able to demonstrate a decline of MES with heparin anticoagulation in a case of internal carotid artery dissection.
Asunto(s)
Anticoagulantes/uso terapéutico , Disección de la Arteria Carótida Interna/diagnóstico , Embolia/diagnóstico , Heparina/uso terapéutico , Adulto , Disección de la Arteria Carótida Interna/complicaciones , Disección de la Arteria Carótida Interna/tratamiento farmacológico , Embolia/tratamiento farmacológico , Femenino , Humanos , Imagen por Resonancia Magnética , Ultrasonografía Doppler TranscranealRESUMEN
OBJECTIVES: To review techniques and the most important clinical applications of microembolus detection with transcranial Doppler. DEVELOPMENT: Technical aspects of microembolus detection are discussed initially; clinical circumstances in which embolus detection is currently used follow, such as carotid stenosis, cardiac pathology, monitoring during neuroangiography, coronary revascularization surgery and endarterectomy. Lastly, the potential clinical applications of this technique are reviewed: localization of an embolic source, risk of recurrent ischemia in patients with unstable atherosclerotic plaques, intraoperative monitoring and potential surgical technique modifications based on this information, contributions to the understanding of the pathophysiology of the fat embolism syndrome, and monitoring therapeutic efficacy of antithrombotics and thrombolytics. CONCLUSIONS: The ability to detect cerebral emboli with transcranial ultrasound has increased significantly our understanding about the pathogenesis of cerebral ischemia. Microembolus detection with transcranial Doppler is a powerful and novel diagnostic technique that allows to study the embolic process in vivo and in real time, instead of using indirect indicators of embolism (clinical and radiological features, possible embolic sources, etc.).
Asunto(s)
Isquemia Encefálica/etiología , Embolia Intracraneal/diagnóstico por imagen , Ultrasonografía Doppler Transcraneal , Isquemia Encefálica/diagnóstico por imagen , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico , Infarto Cerebral/diagnóstico por imagen , Infarto Cerebral/etiología , Embolia Grasa/complicaciones , Embolia Grasa/diagnóstico , Endarterectomía Carotidea , Humanos , Cirugía TorácicaRESUMEN
BACKGROUND AND PURPOSE: The fat embolism syndrome (FES) is characterized by the simultaneous occurrence of pulmonary and neurological symptoms as well as skin and mucosal petechiae in the setting of long-bone fractures or their surgical repair. Its pathophysiology is poorly understood, and effective treatments are lacking. We present 5 patients with long-bone fractures in whom in vivo microembolism was detected by transcranial Doppler. METHODS: Five patients with long-bone fractures were monitored with transcranial Doppler for microembolic signals (MESs) after trauma. Two patients also had intraoperative monitoring. A TC-2020 instrument equipped with MES detection software was used. Detected signals were saved for subsequent review. Selected signals satisfied criteria defined previously and were categorized as large or small. RESULTS: Cerebral microembolism was detected in all 5 patients and was transient, resolving within 4 days of injury. Intraoperative monitoring revealed an increase in MESs during intramedullary nail insertion. The characteristics of MESs after injury varied among patients, with large signals being more frequent in the only patient with a patent foramen ovale. CONCLUSIONS: Cerebral microembolism after long-bone fractures can be detected in vivo and monitored over time. These findings may have potential diagnostic and therapeutic implications.
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Traumatismos del Brazo/complicaciones , Embolia Grasa/diagnóstico por imagen , Fracturas Óseas/complicaciones , Embolia Intracraneal/diagnóstico por imagen , Traumatismos de la Pierna/complicaciones , Ultrasonografía Doppler Transcraneal , Accidentes de Tránsito , Adulto , Embolia Grasa/etiología , Femenino , Fracturas del Fémur/complicaciones , Peroné/lesiones , Humanos , Embolia Intracraneal/etiología , Masculino , Persona de Mediana Edad , Fracturas del Radio/complicaciones , Fracturas de la Tibia/complicaciones , Fracturas del Cúbito/complicacionesRESUMEN
Transcranial ultrasonography was performed in a patient with a persistent trigeminal artery, a remnant of fetal cerebral circulation that bridges the carotid and basilar territories. The study revealed low flow and reversal of flow in the vertebral and basilar arteries, respectively. The interpretation and significance of these findings are discussed.
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Arterias Cerebrales/anomalías , Arterias Cerebrales/diagnóstico por imagen , Ultrasonografía Doppler Transcraneal , Adulto , Arteria Basilar/anomalías , Arteria Basilar/diagnóstico por imagen , Velocidad del Flujo Sanguíneo , Arteria Carótida Interna/anomalías , Arteria Carótida Interna/diagnóstico por imagen , Humanos , MasculinoRESUMEN
OBJECTIVE: To examine the autonomic nervous system functions in patients with Huntington disease. BACKGROUND: Although patients with Huntington disease frequently experience vegetative symptoms, it is not clear if there is dysfunction of the autonomic nervous system. METHODS: Sympathetic skin response (SSR) latency and amplitude from both palms and soles and R-R (heart rate) interval variation (RRIV) at rest and during the Valsalva maneuver were examined in 22 patients and 21 age-matched controls. Unified Huntington's Disease Rating Scale scores were determined in all the patients. RESULTS: Our data are reported as means +/- SEMs. The SSR latencies in patients (mean palm latency, 1835.8+/-110.7 milliseconds; mean sole latency, 2625.3+/-226.9 milliseconds) were prolonged compared with controls (mean palm latency, 1359.5+/-28 milliseconds [P<.01]); mean sole latency, 2038.1+/-44.9 milliseconds [P<.01]) and amplitudes in patients (mean amplitude, 1063.1+/-237.7 microV) were smaller compared with controls (mean amplitude, 1846.3+/-251.2 microV [P<.05]). The RRIV in patients both at rest (mean RRIV in patients, 3.7%+/-0.4% vs. controls, 9.7%+/-0.6% [P<.01]) and during the Valsalva maneuver (mean RRIV in patients, 6.3%+/-1.6% vs. controls, 14.5%+/-1.2% [P<.01]) was lower compared with controls. Furthermore, the prolonged SSR latencies, smaller amplitudes, and lower RRIV in patients compared with controls closely correlated with the various components of the Unified Huntington's Disease Rating Scale scores (total behavior score and SSR latency, R = 0.6 [P<.01]; total behavior score and SSR amplitude, R = -0.5 [P<.05]; total behavior score and RRIV, R = -0.4 [P<.05]; verbal fluency and SSR latency, R = -0.5 [P<.05]; verbal fluency and SSR amplitude, R = 0.5 [P<.05], verbal fluency and RRIV, R = 0.5 [P<.05]; total functional capacity and SSR latency, R = -0.6 [P<.01]; total functional capacity and SSR amplitude, R = 0.5 [P<.05]). CONCLUSION: These results suggest that there is autonomic nervous system dysfunction in patients with Huntington disease.
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Sistema Nervioso Autónomo/fisiopatología , Respuesta Galvánica de la Piel , Frecuencia Cardíaca , Enfermedad de Huntington/fisiopatología , Adulto , Anciano , Femenino , Humanos , Enfermedad de Huntington/diagnóstico , Masculino , Persona de Mediana Edad , Conducción Nerviosa , Nervio Peroneo/fisiología , Tiempo de Reacción , Nervio Sural/fisiología , Maniobra de ValsalvaRESUMEN
INTRODUCTION: Over the last 10 years the diagnosis of chronic and acute cerebrovascular disorders has been greatly improved. We have available now not only better anatomical imaging methods that allow a more precise localization and subtyping of the problem, but also physiological methods that look at the function and interaction between the brain's parenchyma and its perfusion. DEVELOPMENT: In this article the utility and clinical indications of ultrasonography (duplex and Transcranial Doppler) including the modern techniques of embolus detection are described. Also discussed are Magnetic resonance angiography, perfusion-diffusion magnetic resonance, computed tomographic angiography (angio-CT), single photon emission tomography (SPECT). Clinical examples of real cases exemplify the use of these techniques.
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Encéfalo , Trastornos Cerebrovasculares/diagnóstico , Encéfalo/diagnóstico por imagen , Encéfalo/patología , Angiografía Cerebral , Ecoencefalografía , Humanos , Imagen por Resonancia Magnética , Tomografía Computarizada de Emisión de Fotón Único , Ultrasonografía Doppler TranscranealRESUMEN
Retinal ischemia is often caused by emboli arising from the cardiac chambers or the common carotid artery bifurcation; the latter are often composed of cholesterol. However, in many patients no lesions are identified after evaluation of these sources of emboli. Two patients were observed who had retinal ischemia and emboli originating from aortic atheromatous plaques that were visualized by transesophageal echocardiography. Cardiac, carotid, and intracranial sources of emboli were excluded. The embolic nature of retinal ischemia was further corroborated by the presence of microembolic signals during transcranial Doppler insonation of the middle cerebral artery on the side ipsilateral to the symptomatic retina. In patients with Hollenhorst plaques the aortic arch can be a potential source of emboli. Transesophageal echocardiography should be considered in these patients when the initial evaluation does not identify a cardiac or carotid lesion.
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Síndromes del Arco Aórtico/diagnóstico , Arteriosclerosis/diagnóstico , Embolia/diagnóstico , Isquemia/diagnóstico , Vasos Retinianos/patología , Anciano , Anciano de 80 o más Años , Síndromes del Arco Aórtico/diagnóstico por imagen , Arteriosclerosis/diagnóstico por imagen , Embolia/diagnóstico por imagen , Humanos , Isquemia/diagnóstico por imagen , Imagen por Resonancia Magnética , Masculino , UltrasonografíaRESUMEN
To clarify the question of whether Guillain-Barré syndrome (GBS) patients treated with intravenous immune globulin (i.v.IG) relapse at a higher frequency than those treated with plasma exchange (PE), 54 patients with GBS were studied retrospectively. A higher frequency of relapses was noted in the PE-treated patients than in those receiving i.v.IG. The presence of an associated medical condition correlated with an increased risk of relapses, while earlier onset of treatment resulted in a decrease of relapses of GBS. This study found no support for prior suggestions of increased relapses in patients with GBS treated with i.v.IG as opposed to those treated with PE.
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Inmunoglobulinas Intravenosas/uso terapéutico , Intercambio Plasmático , Polirradiculoneuropatía/terapia , Adulto , Femenino , Humanos , Masculino , Registros Médicos , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
Acute bilateral tongue palsy is a rare clinical presentation. We report one such case caused by skull base metastases from prostate cancer. There were no other cranial nerves involved or associated neurological deficit. Mild improvement was seen following radiation therapy. We review the anatomy of the nerve and differential diagnosis of its disfunction.
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Trastornos de la Articulación/etiología , Nervio Hipogloso/fisiopatología , Neoplasias de la Base del Cráneo/secundario , Trastornos de la Articulación/diagnóstico por imagen , Trastornos de la Articulación/fisiopatología , Deglución , Humanos , Nervio Hipogloso/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Neoplasias de la Base del Cráneo/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Enfermedades de la Lengua/etiología , Enfermedades de la Lengua/fisiopatologíaRESUMEN
We report two patients with numb clumsy hands due to cervical spondylotic spinal cord compression. It is proposed that arterial insufficiency in the watershed area between the central and radial arterial systems of the cervical cord explains the sensory findings in the upper extremities with preservation of motor function. Although this is a rare conditions, its recognition is important since the prognosis is improved by early surgical decompression.