Effect of CYP2C19 Polymorphisms on the Platelet Response to Clopidogrel and Influence on the Effect of High Versus Standard Dose Clopidogrel in Carotid Artery Stenting.

OBJECTIVES: Genetic background has been identified to be a major predictor of post-clopidogrel platelet inhibition in patients undergoing coronary stenting. However, there is a lack of data on clopidogrel response regarding genotype in patients undergoing carotid artery stenting (CAS). The influence of the most common allelic variants of CYP2C19 phenotypes and genotypes on response to baseline clopidogrel and on the pharmacodynamic effect of dose adjustment (high or standard dose of clopidogrel) in patients with high on-treatment reactivity after CAS was investigated. METHODS: Platelet reactivity was assessed before and 30 days after carotid stenting using the VerifyNow P2Y12 assay to obtain P2Y12 reactivity unit (PRU) values. RESULTS: A total of 209 patients (79.4% male, 44.1% currents smokers) were treated by CAS. Smokers improved responsiveness to clopidogrel (p = .034). With respect to CYP2C19 enzymatic function, 61 subjects (29.1%) were ultra-rapid metabolizers, 95 patients (45.5%) were extensive metabolizers, 51 (24.4%) were intermediate metabolizers, and two (0.96%) were poor metabolizers. Baseline PRU was significantly higher among intermediate-poor metabolizers compared with ultra-rapid (p = .001) or extensive metabolizers (p = .005). At 30 days follow up, in non-responding patients with the intermediate-poor metabolizer phenotype, the PRU value and inhibition percentage were significantly reduced with standard dose (p = .008; p = .0029) and high dose of clopidogrel (p = .00 0; p = .000). However, high dose clopidogrel did not achieve a more intense pharmacodynamic effect at 30 days (p = .994) compared with standard dose. CONCLUSIONS: In patients undergoing carotid stenting, those with the CYP2C19*2 allele had increased basal PRU values and in fact clopidogrel non-responders increased significantly among intermediate-poor metabolizers. Although high dose and standard dose clopidogrel therapy was effective in lowering the 30 day PRU values in patients with high on-treatment reactivity who are intermediate-poor metabolizers, the use of high dose clopidogrel did not result in statistically significantly greater reductions in reactivity compared with the standard dose.

[Cardioembolic stroke in atrial fibrillation and new anticoagulation criteria: a therapeutic dare]. / Ictus cardioembolico por fibrilacion auricular y nuevos criterios de anticoagulacion: un reto terapeutico.

INTRODUCTION: Atrial fibrillation (AF) increases five times the risk of stroke. The new risk stratification scheme for establishment of oral anticoagulation CHA2-DS2-VASc performs better in risk stratification of stroke compared to the prior CHADS2 scale. AIM: To evaluate in patients with known AF and cardioembolic stroke, the indication of oral anticoagulation under previous risk embolism according to the CHADS2 scale and new classification CHA2-DS2-VASc, assessing the risk of bleeding with HAS-BLED scale. PATIENTS AND METHODS: We included 164 patients with atrial fibrillation and cardioembolic stroke, 87 of them with known AF. It was recorded previous anticoagulant treatment and criteria for prior anticoagulation taking into account CHADS2 scales and CHA2-DS2-VASc, including hemorrhagic risk scale HAS-BLED. In anticoagulated patients INR level was recorded in acute stroke phase. RESULTS: There were no significant differences in baseline patients characteristics according to previous anticoagulation, except higher percentage of previous stroke in anticoagulated patients (47%). 41.3% were anticoagulated with known AF prior to stroke. From 52 non-anticoagulated patients, 61.5% met criteria for anticoagulation prior to stroke as CHADS2. Using CHA2-DS2-VASc, this percentage increased to 94.2% (p <0.001). 78.8% of non-anticoagulated had a low risk of bleeding according to the scale HAS-BLED. In anticoagulated patients, 67.6% had suboptimal INR at the time of stroke. CONCLUSION: In our study, we found low compliance scales of thromboembolic risk stratification in patients with AF for an optimal treatment strategy. It should be increased its use for primary prevention of stroke and optimization of anti-coagulant therapy in patients with AF.

Contenido en filtros tras angioplastia y colocación de stent carotídeo: relación con lesiones isquémicas en la resonancia magnética de difusión / Filter content after carotid angioplasty and stenting: relation to ischemic lesions in diffusion-weighted imaging

Objetivos. Evaluar la relación entre el material recogido en filtros distales tras angioplastia y colocación de stent carotídeo (ASC) y la aparición de lesiones isquémicas cerebrales en la RM potenciada en difusión (RMD). Determinar la influencia que tienen variables demográficas, clínicas y del procedimiento en el proceso embolígeno y en la isquemia post-ASC. Material y método. Se analizó histológicamente el contenido de los filtros de 76 pacientes sometidos a ASC por estenosis grave de la arteria carótida interna (ACI) (60 hombres; edad media 68,39 años; rango: 46-82), valorándose el volumen (< 1 λ=0,001 ml=1μl; 1-10 λ; y > 10 λ) y la composición de las partículas. Se realizó RMD previa y 24h después del procedimiento, recogiéndose la aparición de lesiones, número, tamaño y distribución. Se correlacionaron estadísticamente los datos anteriores y con variables demográficas, clínicas y del procedimiento. Resultados. Cincuenta y ocho pacientes (76,3%) presentaron sintomatología previa al procedimiento. El 64,5% de los filtros (49) presentó partículas, la mayoría menores de 1 λ (77,5%), predominando los agregados fibrinoplaquetarios, restos celulares y cristales de colesterol. Doce pacientes (15,8%) demostraron lesiones en la RMD post-ASC, sin relación con el contenido en los filtros. No se encontró correlación estadística entre la presencia de material en los filtros y otras variables. Conclusiones. La isquemia post-ASC no depende únicamente de la carga embolígena y su naturaleza. La menor prevalencia de lesiones post-ASC en nuestra serie en comparación con otras indica que la adecuada selección de pacientes y la experiencia minimizan la influencia negativa de algunas variables, como la edad, en su aparición (AU)

Objectives. To evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting and the development of ischemic brain lesions in diffusion-weighted imaging (DWI). To determine the influence of demographic, clinical, and procedural variables in the pathogenesis of emboli and in ischemia after carotid angioplasty and stenting. Material and methods. We submitted the contents of the filters of 76 patients (60 men; mean age, 68.39years; range, 46-82) who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery for histologic analysis evaluating volume (< 1 λ=0.001ml = 1μl; 1-10 λ; and > 10 λ) and the composition of the particles. All patients underwent DWI before and 24hours after the procedure; we recorded whether lesions appeared and their number, size, and distribution. We correlated the findings with demographic, clinical, and procedural variables. Results. Symptoms were present before the procedure in 58 (76.3%) patients. Particles were present in 49 (64.5%) of the filters; most particles (77.5%) were 1 λ with a predominance of fibrin-platelet aggregates, cell remnants, and cholesterol crystals. DWI after the procedure detected lesions in 12 (15.8%) patients. We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables. Conclusions. Ischemia after carotid angioplasty and stenting does not depend solely on the embolic load and its nature. We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development(AU)

[Filter content after carotid angioplasty and stenting: relation to ischemic lesions in diffusion-weighted imaging]. / Contenido en filtros tras angioplastia y colocación de stent carotídeo: relación con lesiones isquémicas en la resonancia magnética de difusión.

OBJECTIVES: To evaluate the relation between the material retrieved from distal filters after carotid angioplasty and stenting and the development of ischemic brain lesions in diffusion-weighted imaging (DWI). To determine the influence of demographic, clinical, and procedural variables in the pathogenesis of emboli and in ischemia after carotid angioplasty and stenting. MATERIAL AND METHODS: We submitted the contents of the filters of 76 patients (60 men; mean age, 68.39 years; range, 46-82) who had undergone angioplasty and stenting for severe stenosis of the internal carotid artery for histologic analysis evaluating volume (< 1 λ = 0.001 ml = 1 µl; 1-10 λ; and > 10 λ) and the composition of the particles. All patients underwent DWI before and 24 hours after the procedure; we recorded whether lesions appeared and their number, size, and distribution. We correlated the findings with demographic, clinical, and procedural variables. RESULTS: Symptoms were present before the procedure in 58 (76.3%) patients. Particles were present in 49 (64.5%) of the filters; most particles (77.5%) were 1 λ with a predominance of fibrin-platelet aggregates, cell remnants, and cholesterol crystals. DWI after the procedure detected lesions in 12 (15.8%) patients. We found no statistically significant correlation between filter contents and lesion detection after the procedure or between filter contents and other variables. CONCLUSIONS: Ischemia after carotid angioplasty and stenting does not depend solely on the embolic load and its nature. We consider that the lower prevalence of postprocedural lesions in our series compared to others suggests that appropriate patient selection and experience minimize the negative influence of some variables like age in their development.

Early treatment of obstructive apnoea and stroke outcome: a randomised controlled trial.

The aim of the present study was to assess the impact of nasal continuous positive airway pressure (nCPAP) in ischaemic stroke patients followed for 2 yrs. Stroke patients with an apnoea-hypopnoea index ≥ 20 events·h⁻¹ were randomised to early nCPAP (n = 71; 3-6 days after stroke onset) or conventional treatment (n = 69). The Barthel Index, Canadian Scale, Rankin Scale and Short Form-36 were measured at baseline, and at 1, 3, 12 and 24 months. The percentage of patients with neurological improvement 1 month after stroke was significantly higher in the nCPAP group (Rankin scale 90.9 versus 56.3% (p < 0.01); Canadian scale 88.2 versus 72.7% (p < 0.05)). The mean time until the appearance of cardiovascular events was longer in the nCPAP group (14.9 versus 7.9 months; p = 0.044), although cardiovascular event-free survival after 24 months was similar in both groups. The cardiovascular mortality rate was 0% in the nCPAP group and 4.3% in the control group (p = 0.161). Early use of nCPAP seems to accelerate neurological recovery and to delay the appearance of cardiovascular events, although an improvement in patients' survival or quality of life was not shown.

Internal carotid artery stenting in patients with near occlusion: 30-day and long-term outcome.

BACKGROUND AND PURPOSE: The natural history of the carotid NO is poorly characterized, and the management of patients remains controversial. We report the results and complications associated with CAS and follow-up. MATERIALS AND METHODS: Between March 2000 and March 2009, 116 of 836 CAS procedures were performed in patients with carotid NO (13.9%). A total of 99 men (85.3%) and 17 women (14.7%) with a mean age of 65.8 years were included. Presenting symptoms were TIA in 44 patients (37.9%) and minor stroke or noninvalidating stroke in 61 (52.6%). One hundred five patients (90.5%) were symptomatic. RESULTS: A distal filter was used for cerebral protection in 92 patients (79.3%). Transient hemodynamic alterations were frequent during balloon inflation: hypotension (37.1%), bradycardia (48.3%), and asystole in 24.1%. Four patients (3.4%) developed a TIA after CAS. Stroke in progression was arrested in the 1 patient (0.9%). The median follow-up period for patients was 36 months. Asymptomatic restenosis >70% occurred in 5 patients (4.3%); asymptomatic occlusion occurred in 3 patients (2.6%). During follow-up, 3 patients (2.6%) experienced a stroke, 1 ipsilateral (at 19 months) and 2 contralateral (at 6 and 30 months, respectively). Thirteen patients (11.2%) died, 7 from vascular causes. CONCLUSIONS: Our study showed that carotid NO is an under-recognized condition, and CAS would seem to be beneficial when performed by an experienced neurointerventional team.

Parálisis del hipogloso como forma de presentación de una disección espontánea de múltiples arterias cervicales / Hypoglossal paralysis as a form of presentation of a spontaneous multiple cervical artery dissection

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Volume and composition of emboli in neuroprotected stenting of the carotid artery.

BACKGROUND AND PURPOSE: Periprocedural microembolization is a major and permanent risk for patients treated by angioplasty and stent placement of high-grade carotid stenoses. Little is known however about the characteristics and significance of these embolized particles. Our aim was to assess the volume and composition of debris captured by filters during carotid angioplasty and stent placement (CAS) of severe internal carotid artery (ICA) stenoses. MATERIALS AND METHODS: Institutional review board approval and informed consent from all subjects were obtained. Two hundred one patients (mean age, 66.2 years; range, 35-82 years) with > or = 70% stenosis of the ICA underwent filter-protected CAS. Ultrastructural and semiquantitative analysis of the volume of filters was obtained. Multifactorial statistical analysis was performed to determine factors related to debris volume and composition. RESULTS: Transient ischemic attack occurred in 6 patients (3%), and a major stroke, in 1 (0.5%). Debris was found in 117 filters (58.2%), with volume <1 lambda (0.001 mL) in 71%. The number of balloon dilations, age older than 65 years, and calcified plaques in pre-CAS angiography were significantly associated with the presence of particulates inside the filters (P < .03, P < .004, and P < .05, respectively). CONCLUSIONS: Vessel wall and atheromatous plaques are the main source of microemboli during CAS. Embolization is mainly related to the number of balloon dilations during CAS. Planning a proper and individualized strategy for the procedure in each patient is essential to minimize the potential effects of manipulation during CAS.

[Outcome of intraarterial procedures in acute ischemic stroke]. / Resultados del intervencionismo en el ictus isquémico agudo.

INTRODUCTION: In addition to the thrombolytic agents, mechanical devices are being used in intraarterial procedures in acute stroke patients. The intervention protocol and outcomes of intraarterial procedures performed in the Hospital Virgen del Rocío in 2003-2004 are described. METHODS: The results in each arterial occlusion site and case-control study of the middle cerebral artery (MCA), the placebo group in PROACT II study (Prolyse in Acute Cerebral Thromboembolism II) as historic control group, are described. RESULTS: A total of 32 procedures were performed: 18 MCA occlusions, 8 basilar thrombosis and 6 intracranial carotid occlusions. Urokinase, abciximab and mechanical devices were used in 60%, 26% and 60% of the cases, respectively. MCA occlusions: 60% of the cases improved in 24 hours (25% remained asymptomatic). Only 25% controls remained independent versus 55% of the treated patients (p=0.001). Recanalization and complete recanalization rates were 95 % and 45 %, respectively (18% and 2% in the control group). Symptomatic intracranial hemorrhage (SICH) rate was 18% vs 4% in cases and controls. Basilar thrombosis: only one patient died and 57% of the remaining patients were independent. Carotid occlusions: no complete recanalization was achieved and only one patient was independent. Evolution time in SICH patients was longer (p=0.04), with increased international normalized ratio (INR) for thromboplastin time (p=0.06) and old ischemic lesions in brain CT scan (p=0.02) and they were more dependent at three months (p=0.01). CONCLUSIONS: Intraarterial procedures in MCA occlusions achieve high rates of recanalization and better clinical outcomes than those described in isolated intraarterial thrombolysis. Long-term outcomes in basilar thrombosis were also excellent. Nevertheless, the natural evolution of carotid occlusions was not modified.

[Financial analysis of intraarterial procedures in acute stroke]. / Análisis económico del intervencionismo en el ictus agudo.

INTRODUCTION: Since the most decisive factor related to the cost of stroke is disability, any acute phase intervention to reduce disability will probably be cost-effective. The present acute stroke phase analysis is the first cost-benefit study on intraarterial procedures in acute stroke phase. METHOD: Case-control study focusing on the cost of stroke including acute stroke patients subjected to interventionism in Hospital Virgen del Rocío in 2003-2004 was conducted. The data obtained was subsequently extrapolated to the number of patients who would have been treated if intraarterial procedures could be performed on a 24 hour-day basis. RESULTS: 32 patients were treated in 2003-2004. Direct cost (devices and human resources) of each treated patient was 10,502 euros and global saving in hospital stay and rehabilitation was 11,069 euros, resulting in 567 euros net saving per patient. Nevertheless, 92 patients would have been treated if intraarterial procedures could have been performed on a 24 hour-day basis, resulting in better financial results with 5,792 saving for each treated patient. CONCLUSIONS: Intracraneal procedures in acute stroke has been shown to be cost-effective since cost of material and human resources is greatly exceeded by the saving in hospitalization and rehabilitation as a result of reduction in patient disability.

Análisis económico del intervencionismo en el ictus agudo / Financial analysis of intraarterial procedures in acute stroke

Introducción. El determinante más importante del coste del ictus es el estado de discapacidad, por lo que cualquier intervención en fase aguda que reduzca la discapacidad será probablemente coste-efectiva. El presente análisis es el primer estudio de coste-beneficio del intervencionismo en fase aguda del ictus. Métodos. Se ha realizado un estudio de casos y controles de costes de los pacientes con ictus agudo tratados mediante intervencionismo en el Hospital Virgen del Rocío en los años 2003-2004 y posteriormente se han extrapolado los datos obtenidos al supuesto del número real de pacientes que habrían sido tratados si hubiera estado organizado el intervencionismo como atención continua. Resultados. En los años 2003-2004 se han tratado a 32 pacientes. El coste directo (material fungible + recursos humanos) por cada paciente tratado fue de 10.502 euros y el ahorro global en estancia hospitalaria más rehabilitación resultó de 11.069 euros por paciente, resultando, por tanto, en un ahorro neto de 567 euros por paciente. Sin embargo, si el intervencionismo hubiese estado organizado de forma continua se habrían tratado a 92 pacientes, resultando la evaluación económica más favorable con un ahorro de 5.792 euros por cada paciente tratado. Conclusiones. El tratamiento intervencionista ha demostrado ser coste-efectivo, ya que el gasto derivado del material y los recursos humanos necesarios es superado con creces por el ahorro en tiempos de hospitalización y rehabilitación que se deriva de la reducción de la discapacidad de los pacientes

Introduction. Since the most decisive factor related to the cost of stroke is disability, any acute phase intervention to reduce disability will probably be cost-effective. The present acute stroke phase analysis is the first cost-benefit study on intraarterial procedures in acute stroke phase. Method. Case-control study focusing on the cost of stroke including acute stroke patients subjected to interventionism in Hospital Virgen del Rocío in 2003-2004 was conducted. The data obtained was subsequently extrapolated to the number of patients who would have been treated if intraarterial procedures could be performed on a 24 hour-day basis. Results. 32 patients were treated in 2003-2004. Direct cost (devices and human resources) of each treated patient was 10,502 euros and global saving in hospital stay and rehabilitation was 11,069 euros, resulting in 567 euros net saving per patient. Nevertheless, 92 patients would have been treated if intraarterial procedures could have been performed on a 24 hour-day basis, resulting in better financial results with 5,792 saving for each treated patient. Conclusions. Intracraneal procedures in acute stroke has been shown to be cost-effective since cost of material and human resources is greatly exceeded by the saving in hospitalization and rehabilitation as a result of reduction in patient disability

Resultados del intervencionismo en el ictus isquémico agudo / Outcome of intraarterial procedures in acute ischemic stroke

Introducción. Además de los agentes trombolíticos, se están empleando dispositivos mecánicos en el intervencionismo en pacientes con ictus agudo. Se describe el protocolo y resultados del intervencionismo en el Hospital Virgen del Rocío durante los años 2003-2004. Métodos. Descripción de resultados en cada tipo de oclusión y estudio caso-control de oclusiones de arteria cerebral media (ACM) tratadas empleando como control histórico el grupo placebo del estudio PROACT II (Prolyse in Acute Cerebral Thromboembolism II). Resultados. Se realizaron 32 procedimientos: 18 oclusiones ACM, 8 trombosis basilares y 6 carótidas intracraneales. Se empleó urocinasa, abciximab y disrupción mecánica en un 60, 26 y 60% de pacientes, respectivamente. Oclusiones ACM: el 60% mejoraron en 24 h (25% quedaron asintomáticos). Sólo el 25% de controles quedaron independientes frente a un 55 % de los tratados (p=0,001). La tasa de recanalización y recanalización completa fue del 95 y 45%, respectivamente (18 y 2% en el grupo control). La tasa de hemorragia intracraneal sintomática (HICS) fue del 18% en el grupo tratado y del 4% en el control. Trombosis basilares: un paciente falleció y el 57% de los restantes alcanzó la independencia. Oclusiones carotídeas: en ningún caso se consiguió la recanalización completa y sólo alcanzó la independencia un paciente. Los pacientes con HICS tenían un tiempo de evolución más prolongado (p=0,04), un international normalized ratio (INR) mayor para el tiempo de tromboplastina (p=0,06) e infartos antiguos en la tomografía computarizada cerebral (p=0,02) y quedaban más dependientes al tercer mes (p=0,01). Conclusiones. El intervencionismo en oclusiones de ACM consigue altas tasas de recanalización y mejores resultados clínicos que los descritos para la fibrinólisis intraarterial aislada. Los resultados a largo plazo en las trombosis basilares fueron también excelentes. Sin embargo, no se modificó la evolución natural de las oclusiones carotídeas

Introduction. In addition to the thrombolytic agents, mechanical devices are being used in intraarterial procedures in acute stroke patients. The intervention protocol and outcomes of intraarterial procedures performed in the Hospital Virgen del Rocío in 2003-2004 are described. Methods. The results in each arterial occlusion site and case-control study of the middle cerebral artery (MCA), the placebo group in PROACT II study (Prolyse in Acute Cerebral Thromboembolism II) as historic control group, are described. Results. A total of 32 procedures were performed: 18 MCA occlusions, 8 basilar thrombosis and 6 intracranial carotid occlusions. Urokinase, abciximab and mechanical devices were used in 60%, 26% and 60% of the cases, respectively. MCA occlusions: 60% of the cases improved in 24 hours (25% remained asymptomatic). Only 25% controls remained independent versus 55% of the treated patients (p=0.001). Recanalization and complete recanalization rates were 95 % and 45 %, respectively (18% and 2% in the control group). Symptomatic intracranial hemorrhage (SICH) rate was 18% vs 4% in cases and controls. Basilar thrombosis: only one patient died and 57% of the remaining patients were independent. Carotid occlusions: no complete recanalization was achieved and only one patient was independent. Evolution time in SICH patients was longer (p=0.04), with increased international normalized ratio (INR) for thromboplastin time (p=0.06) and old ischemic lesions in brain CT scan (p=0.02) and they were more dependent at three months (p=0.01). Conclusions. Intraarterial procedures in MCA occlusions achieve high rates of recanalization and better clinical outcomes than those described in isolated intraarterial thrombolysis. Long-term outcomes in basilar thrombosis were also excellent. Nevertheless, the natural evolution of carotid occlusions was not modified

Clinical and electroencephalographic features of carotid sinus syncope induced by internal carotid artery angioplasty.

BACKGROUND AND PURPOSE: Carotid sinus syncope may occur acutely during internal carotid artery angioplasty (CA). We performed this study to investigate the clinical, electroencephalographic (EEG), and hemodynamic features of carotid sinus syncope induced by CA. MATERIALS AND METHODS: Between 1992 and 2003, clinical, EEG, and cardiovascular monitoring was performed in 359 consecutive patients undergoing CA. RESULTS: Carotid sinus reaction (CSR) and syncope occurred in 62.7% and 18.6% of the procedures, respectively. CSR and syncopal spells were classified into cardioinhibitory, vasodepressor, and mixed type. Syncope occurred more frequently in patients with cardioinhibitory CSR (P < .001). The odds ratios for the risk of syncope in patients with cardioinhibitory CSR and vasodepressor/mixed CSR were 6.9 and 1.4, respectively. Sixty-one patients had cardioinhibitory syncope; 7 had the vasodepressor/mixed type. Thirteen spells were not related to cardiovascular disturbances. This last syncope subtype was significantly associated with brain hemodynamic disturbances, including a decrease in cerebral vasoreactivity (P = .04) and the absence of function of both communicating arteries (P = .03). Convulsive movements resembling supplementary sensorimotor seizures occurred in 79% of patients who experienced syncopal spells. EEG changes were more prominent in patients with cardioinhibitory syncope. CONCLUSIONS: Syncope occurs frequently in patients undergoing CA and can be misdiagnosed as seizures. The most frequent mechanism was a cardioinhibitory response. Cerebral hemodynamic disturbances may play a crucial role in the pathophysiology of syncope with normal sinus rhythm and normotension. Moreover, direct depression of the CNS following carotid sinus distension is likely to be involved.

[Multiple myeloma as a treatable cause of stroke: clinical case and review of the literature]. / El mieloma múltiple como causa tratable de ictus. Caso clínico y revisión de la literatura.

Monoclonal and polyclonal immunoglobulinemia, including lymphoma, Waldenström's macroglobulinemia and less commonly multiple myeloma (MM), are considered as infrequent causes of ischemic stroke. Hyperviscosity states, as well as procoagulant disturbances, both potentially treatable, have been implicated in its etiopathogenesis. The so-called "hyperviscosity syndrome" is a clinical syndrome consisting of headache, visual, auditory and vestibular disturbances, confusion and decreased level of consciousness, and is caused by extreme hypervolemia with a high degree of erythrocyte aggregation caused by paraproteinemia. However, in addition to this global cerebral ischemia syndrome, increase in blood viscosity (BV) can also be a cause of focal ischemia. We report a case of a patient diagnosed with IgG type MM, who suffered multiple vertebrobasilar transient ischemic attacks and minor ischemic strokes concurrent with a reactivation of his hematological disease. He became completely asymptomatic after specific treatment with dexamethasone of the paraproteinemia associated with MM. We discuss its pathophysiology in this report.

El mieloma múltiple como causa tratable de ictus. Caso clínico y revisión de la literatura / Multiple myeloma as a treatable cause of stroke. Clinical case and review of the literature

Las inmunoglobulinemias mono y policlonales, incluyendo el linfoma, la macroglobulinemia de Waldenström y, menos comúnmente, el mieloma múltiple (MM), se consideran causas inhabituales de ictus isquémicos. En su etiopatogenia se han implicado tanto estados de hiperviscosidad como alteraciones procoagulantes, ambas potencialmente tratables. El llamado «síndrome de hiperviscosidad» es un cuadro clínico formado por cefalea, alteraciones visuales, auditivas y vestibulares, confusión y disminución del nivel de conciencia y causado por una hipervolemia extrema con una gran agregación eritrocitaria producida por la paraproteinemia. Pero junto a este síndrome de isquemia cerebral global el aumento de la viscosidad sanguínea (VS) puede también ser causa de isquemia focal. Se presenta el caso de un paciente diagnosticado de un MM tipo IgG que sufrió múltiples ataques isquémicos transitorios e ictus isquémicos menores vertebrobasilares coincidiendo con una reactivación de su enfermedad de base y quedó completamente asintomático tras la instauración del tratamiento específico con dexametasona frente a la paraproteinemia asociada al MM. En el presente trabajo se discute su fisiopatología

Monoclonal and polyclonal immunoglobulinemia, including lymphoma, Waldenström's macroglobulinemia and less commonly multiple myeloma (MM), are considered as infrequent causes of ischemic stroke. Hyperviscosity states, as well as procoagulant disturbances, both potentially treatable, have been implicated in its etiopathogenesis. The so-called «hyperviscosity syndrome» is a clinical syndrome consisting of headache, visual, auditory and vestibular disturbances, confusion and decreased level of consciousness, and is caused by extreme hypervolemia with a high degree of erythrocyte aggregation caused by paraproteinemia. However, in addition to this global cerebral ischemia syndrome, increase in blood viscosity (BV) can also be a cause of focal ischemia. We report a case of a patient diagnosed with IgG type MM, who suffered multiple vertebrobasilar transient ischemic attacks and minor ischemic strokes concurrent with a reactivation of his hematological disease. He became completely asymptomatic after specific treatment with dexamethasone of the paraproteinemia associated with MM. We discuss its pathophysiology in this report

Silent ischemia after neuroprotected percutaneous carotid stenting: a diffusion-weighted MRI study.

BACKGROUND AND PURPOSE: To assess by diffusion-weighted MR imaging (DWI) the efficacy of cerebral protection devices in avoiding embolization and new ischemic lesions in patients with severe internal carotid artery (ICA) stenosis undergoing carotid artery stent placement (CAS). METHODS: One hundred sixty-two CASs in the extracranial ICA were performed with the use of distal filters. Mean age of the patients was 68.5 years (range, 33-86) and 122 patients (75.3%) were symptomatic. MR imaging was performed in all patients during the 3-day period before CAS, and DWI was obtained within 24 hours after the procedure. Ninety-five patients (58.6%) were monitored by transcranial Doppler ultrasonography for microemboli detection in the territory of the middle cerebral artery (MCA), ipsilateral to the vessel being treated. RESULTS: Twenty-eight patients (17.3%) showed 58 new ischemic foci in DWI, and 13 patients (46.4%) had multiple foci. Location of new lesions was mainly in the vascular territory supplied by the treated vessel (19 patients; 67.9%), but also in the contralateral MCA (1 patient; 3.6%), and the posterior fossa (4 patients; 14.3%). A significant relationship (P < .03) was found between occurrence of transient ischemic attack (TIA) and appearance of new lesions. Microembolic signals (MES) were detected in 88 patients (92.6%), with no relationship between number of MES and the appearance of new ischemic foci. CONCLUSION: New ischemic foci were observed in 17.3% of the patients undergoing neuroprotected CAS. Appearance of new ischemic lesions were only significantly related to the occurrence of TIA but not to the number of MES registered or other variables. Despite the encouraging results, the incidence of new ischemic lesions should promote research for safer techniques and devices.

Hemianopsia homónima aislada debida a infarto en el territorio de la arteria coroidea anterior / Pure homonymus hemianopia due to anterior choroidal artery territory infarction

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