Short-term atorvastatin therapy improves arterial stiffness of middle-aged systemic lupus erythematosus patients with pathological pulse wave velocity.

Objectives Statins have been proposed as a potential treatment for systemic lupus erythematosus (SLE) due to their immunomodulatory properties, their role restoring endothelial function and preventing atherosclerosis. We evaluate the effect of a short period treatment with a low dose of atorvastatin and its withdrawal on early stage subclinical atherosclerosis. Methods Thirty-seven SLE females received 20 mg/day atorvastatin during eight weeks. At baseline, at the end of treatment and six months after atorvastatin withdrawal, disease activity, subclinical atherosclerosis -assessed by measuring carotid-femoral pulse wave velocity (PWV) - and quantification of circulating endothelial progenitor cells (EPC) - as a surrogate biological marker of subclinical atherosclerosis - were carried out. Results The group of SLE patients with baseline pathological arterial stiffness showed a significant decrease of PWV after atorvastatin therapy (8.43 ± 1.45 m/s vs 7.42 ± 1.06 m/s; p = 0.002) that is maintained six months after treatment finished. Only patients of the middle-aged group showed a nearly significant decrease in the PWV measured along the study (7.16 ± 1.23 m/s vs 6.76 ± 0.82 m/s; p = 0.05). Atorvastatin induced a significant decrease in the circulating EPC percentage (0.65 ± 0.67 vs 0.40 ± 0.31; p = 0.023) as well as a downward trend of disease activity that it is observed by a decrease in SLE disease activity index simultaneously with an increase in C3 complement and significant decrease in serum concentration of vascular endothelial grow factor (VEGF) and sVCAM-1. Conclusions Short-term atorvastatin therapy reduces arterial stiffness of SLE patients with baseline pathological PWV, who are mainly in the group of middle-aged patients. Further studies are needed to determine whether these patients would benefit from statin therapy in preventing cardiovascular events.

Metabolic syndrome is associated with decreased circulating endothelial progenitor cells and increased arterial stiffness in systemic lupus erythematosus.

OBJECTIVES: Metabolic syndrome (MetS) is highly prevalent in patients with systemic lupus erythematosus (SLE) and it has been associated with increased cardiovascular risk. We examined the contribution of MetS to inflammatory markers, arterial stiffness and circulating endothelial progenitor cells (EPCs) as surrogates of subclinical atherosclerosis. METHODS: Cardiovascular risk factors, SLE-specific factors and peripheral blood EPCs were assessed in 50 female SLE patients. MetS was defined according to the National Cholesterol Education Program Adult Treatment Panel III. Simultaneously, atherosclerosis was assessed by measuring the carotid-femoral pulse wave velocity (PWV) by doppler velocimetry. RESULTS: Beyond the factors included in the definition, SLE patients with MetS have a significantly higher serum level of uric acid (6.88 ± 2.20 vs 4.45 ± 1.17, p < 0.001) and some inflammatory biomarkers such as homocysteine, IL-8, sICAM-1 or complement molecules. The presence of MetS in our patients was closely linked with a significantly increased patient organ damage score (3.20 ± 1.97 vs 1.60 ± 1.67, p = 0.008), a decreased percentage of circulating EPCs (0.53 ± 0.24 vs 0.85 ± 0.57, p = 0.007) and an increased arterial stiffness (9.89 ± 2.40 vs 7.13 ± 1.51, p < 0.001). CONCLUSIONS: MetS may contribute to the development of atherosclerosis by significantly increasing inflammation levels and arterial stiffness and decreasing circulating EPCs. This finding would justify close monitoring of these patients.

Increased arterial stiffness is independently associated with metabolic syndrome and damage index in systemic lupus erythematosus patients.

OBJECTIVES: We evaluated whether traditional or non-traditional cardiovascular (CV) risk factors and systemic lupus erythematosus (SLE)-related risk factors were associated with pathological arterial stiffness measured by pulse wave velocity (PWV) adjusted for patients' age and blood pressure. METHOD: CV risk factors were measured in the 46 SLE female patients studied. Activity and organ damage were assessed by the SLE Disease Activity Index (SLEDAI) and the Systemic Lupus International Collaborative Clinics/American College of Rheumatology (SLICC/ACR) Damage Index, respectively. Other lupus-related parameters and information concerning treatment were recorded. Subclinical atherosclerosis was assessed by PWV calculated from pulse wave recording by Doppler, a non-invasive method to measure arterial stiffness. Multivariate logistic regression analysis was used to identify independent determinants of increased PWV. RESULTS: PWV was categorized as normal or pathological arterial stiffness following the reference values adjusted by age and blood pressure recently published by the European Society of Cardiology. Pathological PWV was associated with CV risk factors including homocysteine (p = 0.01), high-sensitivity C-reactive protein (hs-CRP; p = 0.03), uric acid (p = 0.01), and metabolic syndrome (p = 0.007). With regard to SLE-specific risk factors, a significant association was found between PWV and SLICC/ACR score (p = 0.006). Multivariate analysis showed that increased PWV was independently associated with metabolic syndrome [odds ratio (OR) 6.6, 95% confidence interval (CI) 1.2-38, p = 0.03] and SLICC/ACR score (OR 1.5, 95% CI 1-2.32, p = 0.05). CONCLUSIONS: We have found a close link between metabolic syndrome and SLICC/ACR score with increased aortic stiffness. These variables might be an indicator of subclinical atherosclerosis in SLE women without clinical evidence of atherosclerotic cardiovascular disease (CVD).

[Essential mixed cryoglobulinemia as a cause of ischemic cerebrovascular accident]. / Crioglobulinemia mixta esencial como causa de accidente cerebrovascular isquémico.

INTRODUCTION: Involvement of the central nervous system in patients with essential mixed cryoglobulinaemia is rare, and there are few cases described in the medical literature. Moreover, the mechanism by which lesions are produced in the central nervous system is still not clear. CLINICAL CASE: We describe the case of a 35 year old woman who presented with dysarthria, weakness and paraesthesia of her left limbs and left central facial paralysis of sudden onset. Vascular studies showed the presence of IgG-IgM polyclonal positive cryoglobulins and polymerase chain reaction (PCR) showed hepatitis C virus to be present. Cerebral magnetic resonance showed ischemic lesions in the tail of the right caudate nucleus and right corona radiata and the posteromedial part of the right putamen. Other investigations were negative or normal. CONCLUSIONS: In young patients with cerebral vascular pathology the possibility of hepatitis C and essential mixed cryoglobulinemia should be considered, especially when the transaminases are raised as in our patient. We consider that the physiopathological mechanisms must be related to factors which determine a prothrombotic state in the arterial bed involved.

[Transient global amnesia and vascular risk factors]. / Amnesia global transitoria y factores de riesgo vascular.

INTRODUCTION: Transient global amnesia (TGA) is a clinical syndrome determined by an episode of less than 24 hours consisting of temporo-spatial disorientation with retrograde and anterograde amnesia followed by complete recovery. OBJECTIVES: To determine whether the presence or absence of vascular risk factors (VRF) in patients with TGA is associated with different clinical data and/or examination findings. PATIENTS AND METHODS: A retrospective study was made of two groups of 13 and 12 patients with TGA, who presented with and without VRF, respectively. The following variables were determined: VRF, age, a previous history of migraine, triggering factors, duration and repetition of the episodes, associated neurological symptoms and findings obtained by neuroimaging, eco-Doppler of the supra-aortic trunks and transcranial Doppler. The data were subjected to statistical analysis by univariate analysis with Fischer's exact probability test. RESULTS: The statistical studies showed no significant differences between the variables obtained in the two groups of patients. CONCLUSIONS: Transient global amnesia has been particularly related to migraine, epilepsy and cerebral vascular pathology, although its aetiology has not been fully determined. In this study we compare clinical data between the two groups of patients with and without VRF who have had TGA. The lack of significant differences between them tends to rule out a vascular aetiology as the sole cause of this syndrome. Recently Leao's propagated depression has been suggested as the physiopathological mechanism involved. According to this theory, the vascular pathology might act as the trigger but probably not as the aetiological factor. The findings of our study may support this thesis.

Amnesia global transitoria y factores de riesgo vascular / Transient global amnesia and vascular risk factors

Introducción. La amnesia global transitoria (AGT) es un síndrome clínico determinado por un episodio de duración inferior a 24 horas consistente en desorientación temporospacial, amnesia retrógrada y anterógrada, con total recuperación posterior. Objetivos. Determinar si la presencia o ausencia de factores de riesgo vascular (FRV) en pacientes con AGT se asocia con datos clínicos y/o exploratorios diferentes. Pacientes y métodos. Estudio retrospectivo de dos grupos de 13 y 12 pacientes con AGT, que presentaban o no FRV, respectivamente. Se determinaron las variables: FRV, edad, antecedentes de migraña, factores desencadenantes, duración y repetición de los episodios, síntomas neurológicos asociados y hallazgos obtenidos mediante neuroimagen, eco-Doppler de troncos supraórticos y Doppler transcraneal. Los datos obtenidos fueron sometidos a estudio estadístico mediante análisis univariante con el test de probabilidad exacta de Fisher. Resultados. Los estudios estadísticos no mostraron diferencias significativas de las variables obtenidas entre los grupos de pacientes. Conclusiones. La AGT se ha relacionado preferentemente con la migraña, epilepsia y con la patología vascular cerebral, aunque su etiología no ha sido totalmente determinada. En el presente estudio se comparan los datos clínicos entre dos grupos de pacientes con y sin FRV que han sufrido AGT. La ausencia de diferencias significativas entre ambos inclina a desestimar la etiología vascular como único origen de este síndrome. Se ha propuesto recientemente como mecanismo fisiopatológico la depresión propagada de Leao. Según esta teoría, la patología vascular podría actuar como desencadenante, pero no probablemente como factor etiológico. Los hallazgos del presente estudio podrían apoyar esta tesis (AU)

Introduction. Transient global amnesia (TGA) is a clinical syndrome determined by an episode of less than 24 hours consisting of temporo-spatial disorientation with retrograde and anterograde amnesia followed by complete recovery. Objectives. To determine whether the presence or absence of vascular risk factors (VRF) in patients with TGA is associated with different clinical data and/or examination findings. Patients and methods. A retrospective study was made of two groups of 13 and 12 patients with TGA, who presented with and without VRF, respectively. The following variables were determined: VRF, age, a previous history of migraine, triggering factors, duration and repetition of the episodes, associated neurological symptoms and findings obtained by neuroimaging, eco-Doppler of the supra-aortic trunks and transcranial Doppler. The data were subjected to statistical analysis by univariate analysis with Fischer’s exact probability test. Results. The statistical studies showed no significant differences between the variables obtained in the two groups of patients. Conclusions. Transient global amnesia has been particularly related to migraine, epilepsy and cerebral vascular pathology, although its aetiology has not been fully determined. In this study we compare clinical data between the two groups of patients with and without VRF who have had TGA. The lack of significant differences between them tends to rule out a vascular aetiology as the sole cause of this syndrome. Recently Leao’s propagated depression has been suggested as the physiopathological mechanism involved. According to this theory, the vascular pathology might act as the trigger but probably not as the aetiological factor. The findings of our study may support this thesis (AU)

Crioglobulinemia mixta esencial como causa de accidente cerebrovascular isquémico / Essential mixed cryoglobulinaemia as a cause of ischemic cerebrovascular accident

Introduction. Involvement of the central nervous system in patients with essential mixed cryoglobulinaemia is rare, and there are few cases described in the medical literature. Moreover, the mechanism by which lesions are produced in the central nervous system is still not clear. Clinical case. We describe the case of a 35 year old woman who presented with dysarthria, weakness and paraesthesia of her left limbs and left central facial paralysis of sudden onset. Vascular studies showed the presence of IgG- IgM polyclonal positive cryoglobulins and polymerase chain reaction (PCR) showed hepatitis C virus to be present. Cerebral magnetic resonance showed ischemic lesions in the tail of the right caudate nucleus and right corona radiata and the posteromedial part of the right putamen. Other investigations were negative or normal. Conclusions. In young patients with cerebral vascular pathology the possibility of hepatitis C and essential mixed cryoglobulinemia should be considered, especially when the transaminases are raised as in our patient. We consider that the physiopathological mechanisms must be related to factors which determine a prothrombotic state in the arterial bed involved (AU)

Introducción. La afectación del sistema nervioso central en pacientes con crioglobulinemia mixta esencial es rara, y son escasos los casos descritos en la literatura médica. Asimismo no se ha podido establecer de manera concluyente los mecanismos de lesión del sistema nervioso central. Caso clínico. Presentamos el caso de una mujer de 35 años que presentó un cuadro de disartria, debilidad y parestesias en las extremidades izquierdas, y paresia facial central izquierda de instauración brusca. En el estudio vascular se hallaron crioglobulinas positivas policlonales IgG- IgM y la reacción en cadena de la polimerasa (PCR) para el virus de la hepatitis C fue positiva. La resonancia magnética cerebral puso de manifiesto lesiones isquémicas en la cola del núcleo caudado y corona radiada derechas, y en la porción posteromedial del putamen derecho. El resto del estudio fue negativo o dentro de la normalidad. Conclusiones. En pacientes jóvenes con patología vascular cerebral habrá que considerar la hepatitis C y la crioglobulinemia mixta esencial, sobre todo si existe elevación de las transaminasas como en nuestro caso. Nosotros planteamos que el mecanismo fisiopatológico debe estar en relación con factores (AU)

Extended Willis circle model to explain clinical observations in periorbital arterial flow.

A fluid-dynamic model of the circle of Willis and its periorbital links with the external carotid arteries has been established and tested. It is based on anatomic data and takes Doppler measurements as flow input conditions. The model explains, on fluid-dynamic grounds, the clinical observations of periorbital reverse flow and arrival pulse time delay. It also obtains the velocity and pressure pulse at any point of the studied area. This allows the comparison between the normal or healthy condition and the flow distribution when an internal carotid is externally or pathologically occluded. Several combinations of the communicating artery sizes are explored to obtain the reduced cerebral flow. The combination of the communicating diameters can lead to insufficient irrigation which can be hydrodynamically assessed. No other physiological response is included, and the results must be considered as a minimum assured. These results show the need for a common evaluation of the alternative paths and explain some paradoxes found in literature.

[Phenomena and syndrome of subclavian steal. Two cases]. / Fenómeno y síndrome del robo de la subclavia. A propósito de dos casos.

INTRODUCTION: The phenomenon of subclavian steal is a frequent haemodynamic phenomenon which rarely causes symptoms in the vertebrobasilar territory. When this does occur, it is known as the subclavian steal syndrome. CLINICAL CASES: We describe two patients with the syndrome of left subclavian steal diagnosed by doppler. In one of them, symptoms appeared after exercise of the left arm. Various aspects of the syndrome are discussed in relation to diagnosis and indications for treatment. CONCLUSIONS: The subclavian steal syndrome is a condition which can be reliably diagnosed using doppler and the treatment of which should be decided individually in each case.

Gadolinium-DTPA MRI in the diagnosis of a patient with leptomeningeal metastasis produced by uvular carcinoma.

A patient with uvular cancer presented with lower limb weakness and paresthesiae, headache, neck stiffness and multiple cranial palsies. No malignant cells were found on lumbar puncture. CT, and MRI were normal. Gadolinium-DTPA MRI disclosed multiple enhancing lesions consistent with leptomeningeal metastases. Gd-DTPA MRI is the best technique to demonstrate tumoral meningeal infiltration in cytology-negative patients suspected of having leptomeningeal metastases.