New England Medical Center Posterior Circulation registry.

Among 407 New England Medical Center Posterior Circulation registry patients, 59% had strokes without transient ischemic attacks (TIAs), 24% had TIAs then strokes, and 16% had only TIAs. Embolism was the commonest stroke mechanism (40% of patients including 24% cardiac origin, 14% intraarterial, 2% cardiac and arterial sources). In 32% large artery occlusive lesions caused hemodynamic brain ischemia. Infarcts most often included the distal posterior circulation territory (rostral brainstem, superior cerebellum and occipital and temporal lobes); the proximal (medulla and posterior inferior cerebellum) and middle (pons and anterior inferior cerebellum) territories were equally involved. Severe occlusive lesions (>50% stenosis) involved more than one large artery in 148 patients; 134 had one artery site involved unilaterally or bilaterally. The commonest occlusive sites were: extracranial vertebral artery (52 patients, 15 bilateral) intracranial vertebral artery (40 patients, 12 bilateral), basilar artery (46 patients). Intraarterial embolism was the commonest mechanism of brain infarction in patients with vertebral artery occlusive disease. Thirty-day mortality was 3.6%. Embolic mechanism, distal territory location, and basilar artery occlusive disease carried the poorest prognosis. The best outcome was in patients who had multiple arterial occlusive sites; they had position-sensitive TIAs during months to years.

Stroke in Patients with Systemic Lupus Erythematosus and Antiphospholipid Antibody Syndrome.

Primary prevention of strokes in patients with antiphospholipid antibodies (APLs) with or without systemic lupus erythematosus (SLE) is not well known. The same applies to patients with SLE and valvular heart disease. The decision should be made on an individual basis until further studies become available. Special consideration for preventive antithrombotic treatment should be given to patients with persistent high titers of immunoglobulin G APLs, which require protein cofactor for detection, presence of lupus anticoagulant, or left-sided cardiac valve lesions. High-level oral anticoagulation with warfarin is still the preferred treatment for secondary prevention of strokes in patients with antiphospholipid antibody syndrome (APS) with or without SLE or with cardiac valvular lesions. Immunosuppression should only be used in patients with active SLE disease. There is no evidence so far to support its use in patients with primary APS. Advances in identifying unique APL features that are associated with increased risk for thrombosis will hopefully allow a more rational treatment for primary and secondary prevention of strokes in these patients in the near future.

Patterns of perfusion-weighted imaging in patients with carotid artery occlusive disease.

BACKGROUND: The importance of hemodynamic factors in the pathophysiology of stroke and transient ischemic attacks in patients with internal carotid artery (ICA) stenosis or occlusion remains controversial. OBJECTIVE: To investigate whether perfusion-weighted imaging (PWI) could identify pathophysiologically meaningful categories in patients with symptomatic and asymptomatic ICA occlusive disease. METHODS: Thirty-eight consecutive patients with occlusion (22 patients) or severe stenosis (16 patients) of the ICA, determined by ultrasonography or magnetic resonance angiography, were identified from the Beth Israel Deaconess Medical Center Stroke Database, Boston, Mass. Thirty-five patients were symptomatic (29 who had strokes and 6 who had transient ischemic attacks) and 3 were asymptomatic. All symptomatic patients underwent PWI within the first 24 hours after symptom onset. The patterns of PWI were analyzed according to the degree of ICA stenosis and the clinical presentation. RESULTS: Three patterns of perfusion abnormalities were identified: extensive hypoperfusion involving the middle cerebral arterial and/or anterior cerebral arterial territories (25 patients), localized perfusion deficits involving predominantly the ipsilateral border zone areas (8 patients), and normal perfusion (5 patients). All 3 patterns were found whether or not the ICA was occluded. Patients who had acute stroke most frequently had extensive perfusion deficits involving 1 or 2 territories while patients who had transient ischemic attacks often had hypoperfusion affecting the border zone regions. All asymptomatic patients had normal perfusion. CONCLUSIONS: In our sample the pattern of PWI related to the clinical presentation but not to the degree of ICA disease (occlusive vs severe stenosis). Our study findings add further support to the hypothesis that hypoperfusion is a major contributing factor in the pathophysiology of carotid artery occlusive disease.

Parkinsonismo associado a tumor cerebral: relato de caso / Parkinson disease associated to brain tumors: a case report

Descreve-se o caso de paciente com síndrome parkinsoniana à direita, associada a disfunçöes cognitivas e síndrome de hipertensäo intracraniana. A tomografia de crânio e o estudo angiográfico de vasos intracranianos demonstraram a presença de volumoso processo expansivo fronto-temporal esquerdo. A eletromiografia revelou tremor de repouso com frequência de 4 a 6 ciclos por segundo. A paciente foi submetida a ressecçäo cirúrgica da massa tumoral, cujo exame histológico revelou tratar-se de maningioma. A evoluçäo pós-operatória foi excelente e após dois meses todas as anormalidades neurológicas haviam desaparecido. Um ano após a remoçäo do tumor a paciente permanecia assintomática sem uso de qualquer medicaçäo. Säo discutidos aspectos fisiopatológicos do parkinsonismo por processo expansivo e as particularidades do presente caso säo analisadas em confronto a dados da literatura

HTLV-I associated myelopathy in Brazil: a preliminary report

Neste relato preliminar os autores registram a constataçäo de alta prevalência do soropositividade para anticorpos dirigidos ao HTLV-I detectados pelo método de Westernblot (37,5%) em amostra de 16 pacientes brasileiros com mielopatias crônicas de causa näo determinadas