Effect of Size and Location of Unruptured Intracranial Aneurysms on Self-Reported Headache.

AIM: To describe the relationship between aneurysm size and location with the prevalence of headache at diagnosis and three- and six-month follow-up in a sample of patients with UIA. MATERIAL AND METHODS: In this cohort study, patients were diagnosed with UIAs by digital subtraction angiography (DSA). Follow-up visits occurred three and six months after the diagnosis. Headache presence was registered, and headache was further classified by phenotypes. After DSA, the recorded variables were aneurysm number, morphology, location, and size (diameter [W], neck [N], and dome-neck distance [H]). The aspect ratio (H/N) and the dome/neck ratio (W/N) were calculated. The outcome of this study was the self-reported headache status at follow-up. RESULTS: Data from 42 patients and 46 aneurysms were available; 81.0% of patients were women, with a mean age of 57.4±14.3 years. Headache was reported by 61.9% of the patients. The pain phenotype was tension-type in 38.1%, migraine in 11.9%, neuralgia in 2.4%, and unclassifiable in 9.5%. The median (min-max) measurements were W=5.05 (0.89-22.9); N=3.02 (0.52-17.9); H=5.08 (0.92-23.0); aspect ratio 1.59 (0.68-17.69) and W/N ratio 1.65 (0.62-16.92). Thirty-three patients (37 aneurysms) received treatment, 47.8% by surgical clipping and 32.6% by endovascular occlusion. In the treated patients, headaches had persisted in 14.3% until the first visit and in 9.5% until the second visit. There were no differences in any registered variables between patients with and without headaches at follow-up. CONCLUSION: In this study, data was found that support that headaches in patients with UIAs improve after treatment and that such improvement is probably unrelated to the size and shape of the UIAs.

Neurological Disorders in Literary Fiction: A Single Author Case Series.

Background: Across literary fiction, allusions to medical ailments are common. However, in the bibliography of Stephen King, neurological disorders appear to be present disproportionately. Objective: The objective of this study is to describe the epidemiology of neurologic disorders depicted in the writings of Stephen King. Methods: This study presents data from Stephen King's 60 published novels. The frequency, prevalence, lethality, and mortality of each neurological diagnosis found in the characters that appear in the novels are reported. Results: Forty-eight novels portrayed at least one character with a neurological diagnosis, and in total, 150 characters exhibited a neurological condition. The overall prevalence was 111.2 per 1,000 characters. Their median age was 20 years (range 76), and 61.7% were males. Headache was the most common symptom (35.3%), followed by stroke symptoms in 28.7%. Prevalence was 24.5, 17.8 for headache and epilepsy, respectively. Lethality was 28.7%. The overall mortality rate was 31.9. Conclusions: The epidemiology described in Stephen King's novels parallels that of the real world. The depiction of neurological disorders found in his novels showcases the elevated contribution of neurological disorders to the global burden of the disease, an important message for the readers of his fiction and interest to all neurologists.

Extended time window mechanical thrombectomy for pediatric acute ischemic stroke.

Endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) remains an off-label procedure seldom utilized in the pediatric population; this holds especially true for patients presenting outside the standard 6-hour time window. In this review we describe the published literature regarding usage of the extended time window EVT in pediatric stroke. We searched PubMed for all pediatric AIS cases and case series that included patients treated with extended time window EVT. We found data from 38 cases found in 27 publications (15 case reports and 12 case series). The median age was 10 years; 60.5% males. The median NIHSS before EVT was 13 with a median time-to-treatment of 11 hours. The posterior circulation was involved in 50.0%. Stent retrievers were used in 68.5%, and aspiration in 13.2%. Angiographic outcome TICI ≥2B was achieved in 84.2%, whereas TICI˂2B was reported in 10.6%. A favorable clinical outcome (NIHSS score ≤4, modified Rankin score ≤1, or Pediatric Stroke Outcome measure score ≤1) occurred in 84.2%. Eight cases that did not report the clinical outcome employing a standardized scale described mild to absent neurological residual deficits. This study found data that supports that extended window EVT produces high recanalization rates and good clinical outcomes in pediatric patients with AIS. Nevertheless, the source materials are indirect and contain substantial inconsistencies with an increased risk of bias that amount to low evidence strength.

Correlation between optic nerve sheath diameter and extracorporeal life support time.

INTRODUCTION: The objective of the study was to analyse the correlation between extracorporeal life support (ECLS) and aortic cross-clamp times and optic nerve sheath diameter (ONSD). PATIENTS AND METHODS: Study in a cohort of patients aged 0-15 years that underwent ECLS for cardiac surgery after obtention of signed informed consent. We calculated a sample size of 23 participants. First, we obtained 3 vertical and 3 horizontal measurements of the ONSD for each eye and calculated the mean of both eyes for each measurement to be used in the analysis. The measurements were made at admission and at 6 and 24 h post surgery. We retrieved the ECLS time and the aortic cross-clamp time were from the operative report. RESULTS: We analysed data for 23 participants, 52.2% female, with a median age of 14 months. The median ECLS time was 60 min; the median aortic cross-clamp time was 32 min. The median baseline ONSD was 3.1 mm. ONSD values had increased a median of 0.015 mm at 6 h post surgery (P = .03). We found a positive correlation between ECLS time and ONSD values (r = 0.476, P < 0,05). The ONSD values returned to baseline by 24 h post surgery. None of the patients developed signs or symptoms of increased intracranial pressure. CONCLUSION: Our study found a correlation between ECLS time and ONSD at 24 h post surgery. We found variations in the ONSD even in patients without signs or symptoms of increased ICP. Further research is required to identify the factors related to these variations.

Correlación del diámetro de la vaina del nervio óptico y el tiempo de circulación extracorpórea / Correlation between optic nerve sheath diameter and extracorporeal life support time

Introducción: El objetivo de este estudio es establecer la correlación entre los tiempos de circulación extracorpórea (CEC) y pinzamiento aórtico y el diámetro de la vaina del nervio óptico (DVNO). Pacientes y métodos: Se estudió una cohorte de pacientes con edad de 0 a 15 años, sometidos a cirugía cardíaca con CEC. Se calculó un tamaño muestral de 23 participantes. Primero se obtuvo el promedio de tres mediciones verticales y tres horizontales del DVNO. Después, se utilizó para los análisis la media de los valores de ambos ojos. Las mediciones ocurrieron al ingreso y a las 6 y 24 horas poscirugía. Los tiempos de CEC y pinzamiento aórtico se obtuvieron del informe quirúrgico. Resultados: Se analizaron datos de 23 participantes, el 52,2% mujeres, con edad mediana de 14 meses. La mediana del tiempo de CEC fue 60 minutos; la mediana de tiempo de pinzamiento aórtico fue 32 minutos. La mediana del DVNO basal fue 3,1mm. Los valores de DVNO aumentaron por una mediana de 0,015mm a las 6 horas poscirugía (p=0,03). Encontramos una correlación positiva entre el tiempo de CEC y los valores de DVNO (r=0,476; p<0,05). Los valores de DVNO regresaron al valor basal a las 24 horas poscirugía. Ningún paciente desarrolló signos o síntomas de incremento de la presión intracraneal. Conclusión: El estudio encontró una correlación entre el tiempo de CEC y el DVNO medido 24 horas poscirugía. Hubo variaciones del DVNO incluso en pacientes sin signos o síntomas de incremento de la presión intracraneal. Se requiere más investigación para identificar los factores relacionados con estas variaciones. (AU)

Introduction: The objective of the study was to analyse the correlation between extracorporeal life support (ECLS) and aortic cross-clamp times and optic nerve sheath diameter (ONSD). Patients and methods: Study in a cohort of patients aged 0 to 15 years that underwent ECLS for cardiac surgery after obtention of signed informed consent. We calculated a sample size of 23 participants. First, we obtained 3 vertical and 3 horizontal measurements of the ONSD for each eye and calculated the mean of both eyes for each measurement to be used in the analysis. The measurements were made at admission and at 6 and 24hours post surgery. We retrieved the ECLS time and the aortic cross-clamp time were from the operative report. Results: We analysed data for 23 participants, 52.2% female, with a median age of 14 months. The median ECLS time was 60minutes; the median aortic cross-clamp time was 32minutes. The median baseline ONSD was 3.1mm. ONSD values had increased a median of 0.015mm at 6hours post surgery (P=.03). We found a positive correlation between ECLS time and ONSD values (r=0.476, p<,05). The ONSD values returned to baseline by 24hours post surgery. None of the patients developed signs or symptoms of increased intracranial pressure. Conclusion: Our study found a correlation between ECLS time and ONSD at 24hours post surgery. We found variations in the ONSD even in patients without signs or symptoms of increased increased intracranial pressure. Further research is required to identify the factors related to these variations. (AU)

[Correlation between optic nerve sheath diameter and extracorporeal life support time]. / Correlación del diámetro de la vaina del nervio óptico y el tiempo de circulación extracorpórea.

INTRODUCTION: The objective of the study was to analyse the correlation between extracorporeal life support (ECLS) and aortic cross-clamp times and optic nerve sheath diameter (ONSD). PATIENTS AND METHODS: Study in a cohort of patients aged 0 to 15 years that underwent ECLS for cardiac surgery after obtention of signed informed consent. We calculated a sample size of 23 participants. First, we obtained 3 vertical and 3 horizontal measurements of the ONSD for each eye and calculated the mean of both eyes for each measurement to be used in the analysis. The measurements were made at admission and at 6 and 24hours post surgery. We retrieved the ECLS time and the aortic cross-clamp time were from the operative report. RESULTS: We analysed data for 23 participants, 52.2% female, with a median age of 14 months. The median ECLS time was 60minutes; the median aortic cross-clamp time was 32minutes. The median baseline ONSD was 3.1mm. ONSD values had increased a median of 0.015mm at 6hours post surgery (P=.03). We found a positive correlation between ECLS time and ONSD values (r=0.476, p<,05). The ONSD values returned to baseline by 24hours post surgery. None of the patients developed signs or symptoms of increased intracranial pressure. CONCLUSION: Our study found a correlation between ECLS time and ONSD at 24hours post surgery. We found variations in the ONSD even in patients without signs or symptoms of increased increased intracranial pressure. Further research is required to identify the factors related to these variations.

Role of the physical examination in the determination of etiology of ischemic stroke.

The actual investigation of the body of a patient by the clinician in search for the signs of the disease beginning with the primary vital signs and continues with the careful and attentive observation of the patient. This article reviews the key findings in the physical examination of patients with ischemic stroke that have the potential to indicate the etiology of the infarct and to help to choose the use of ancillary tests. Through a systematic search of articles published in English related to the physical examination of patients with stroke, we identified key findings in the vital signs and classic components of the physical exam (appearance of the patient, auscultation, and eye examination) that have shown clinical significance when determining ischemic stroke etiology. We further suggest that the prompt identification of such findings can translate into better use of diagnostic tools and selection of ancillary confirmatory tests, thus, reducing the time to etiology based treatment and secondary prevention of ischemic stroke. in this manuscript, we aim to show that even though nowadays the clinical skills tend to be overlooked due to the overreliance on technology, the physical exam continues to be a valuable tool in the clinician armamentarium when facing the challenge of a patient with ischemic stroke.

[Topiramate in monotherapy or in combination as a cause of metabolic acidosis in adults with epilepsy]. / Topiramato en monoterapia o en combinación como causa de acidosis metabólica en adultos con epilepsia.

AIM: To determine the frequency of metabolic acidosis and its related factors in outpatients taking topiramate in monotherapy or as an adjuvant for the treatment of epilepsy. PATIENTS AND METHODS: Cross-sectional analysis of arterial blood gas test of epileptic patients who received topiramate during 2010 in the Epilepsy Clinic at the National Medical Center '20 de Noviembre' in Mexico. Clinical data regarding epilepsy history and management and the common symptoms of metabolic acidosis were recorded. RESULTS: We studied 32 adults with epilepsy at an outpatient epilepsy clinic who were treated with topiramate in monotherapy or in combination for at least one month. Metabolic acidosis was found in all patients (HCO3<22 Eq/L); nine were taking topiramate in monotherapy, and 23 were taking at least two antiepileptic drugs (AEDs). All of the patients were asymptomatic. We found no correlation between bicarbonate levels and the dose of the drug or the duration of treatment. The dose was significantly higher in the monotherapy group, and the bicarbonate level was lower in the patients taking more than one AEDs. CONCLUSIONS: The use of concomitant AEDs increases the known effects of topiramate on serum bicarbonate levels and the presence of metabolic acidosis, and these effects appear to be independent of the number of AEDs used.

TITLE: Topiramato en monoterapia o en combinacion como causa de acidosis metabolica en adultos con epilepsia.Objetivo. Determinar la frecuencia de acidosis metabolica y sus factores relacionados en pacientes tratados con topiramato solo o como adyuvante para el tratamiento de epilepsia. Pacientes y metodos. Analisis transversal de la gasometria arterial de pacientes epilepticos que recibieron topiramato durante 2010 en la clinica de epilepsia del Centro Medico Nacional 20 de Noviembre en Mexico. Se registraron datos clinicos concernientes a la epilepsia y su tratamiento, asi como de los sintomas comunes de acidosis metabolica. Resultados. Se estudiaron 32 adultos con epilepsia, quienes recibieron topiramato en monoterapia o en combinacion por lo menos durante un mes. Se encontro acidosis metabolica en todos los pacientes (HCO3 < 22 Eq/L); nueve tomaron solo topiramato y 23 tomaron por lo menos dos farmacos antiepilepticos (FAE). Todos los pacientes fueron asintomaticos. No se encontro correlacion entre los niveles de bicarbonato y la dosis del medicamento o la duracion del tratamiento. La dosis fue significativamente mayor en el grupo de monoterapia y el nivel de bicarbonato fue mas bajo en los pacientes que tomaban mas de un FAE. Conclusiones. El uso concomitante de FAE incrementa los efectos conocidos del topiramato sobre los niveles sericos de bicarbonato y la presencia de acidosis metabolica; estos efectos parecen ser independientes del numero de FAE utilizados.

The burden of stroke in México.

Regrettably, stroke has been scarcely studied in México, and the available data suffer from great variability in diagnostic testing, risk factor definitions, and poor generalizability. The current cumulative incidence of stroke in Mexico is 232.2 per 100,000, whereas prevalence among people aged 60 years or older is 18.2 per 1000. Hypertension and diabetes are the main risk factors. Ischemic stroke is the most frequent sub-type. Stroke mortality has been increasing during last years, and 30-day case fatality rate doubles at one-year follow-up. A remarkable finding of a hospital-based registry was that most of ischemic stroke cases are of undetermined etiology and even when a quarter of patients arrive on time for thrombolysis, less than 1% received this management.

Endovascular treatment: balloon angioplasty versus nimodipine intra-arterial for medically refractory cerebral vasospasm following aneurysmal subarachnoid hemorrhage.

Cerebral vasospasm (CV) accounts significant morbimortality after aneurysmal subarachnoid hemorrhage. The objective of this study was to compare the clinical outcome of patients with CV treated by 2 endovascular procedures: intra-arterial nimodipine angioplasty (IANA) and balloon angioplasty (BA). Between 2008 and June 2011, we performed 22 IANA and 8 BA in 30 patients. The mean age was 44 years and 60% was female. In 17 patients, the treatment was clipping, whereas 13 underwent coil treatment. The CV was severe in 63%, moderate in 30%, and mild in 7%. Good outcome between 2 groups was similar (P = .36). The clinical outcome according to the subgroups of CV severity and modality treatment was equivalent (P = .22). Mortality at 3 months was 16% and 20% at 1 year. We did not find differences in the clinical outcome despite the fact that both techniques produce adequate angiographic resolution of CV.