[Outcome of intraarterial procedures in acute ischemic stroke]

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]

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.

[Topographic disorientation associated with infarction in the territory of the right posterior cerebral artery]

INTRODUCTION

Topographic disorientation is defined as the difficulty to find one s way in familiar surroundings. It can be due to an amnesic or agnostic like defect, which is known as topographic amnesia or agnosia. This disorder can give rise to disability in the life of the patient and may well go undetected unless a suitable neuropsychological study is conducted.

CASE REPORTS

We report the cases of two patients with infarction in the territory of the right posterior cerebral artery who began with hemianopsia and topographic disorientation. One of the cases was due to a disorder affecting spatial memory and the other was caused by errors in visuospatial perception. The battery of tests for studying visuospatial perception VOSP was administered.

CONCLUSIONS

Occipital lesions are often associated with topographic disorientation, especially when it is the right hemisphere that is injured. It is important to detect this alteration, which makes the patient totally dependent on others even in his or her own home. The appearance of an amnesic or agnostic type disorientation can be related with a disorder affecting one of the two systems that play a part in the processing of visual data. A guided neuropsychological study can provide us with a great deal of information about the type of disorder presented by the patient.

[Bilateral hemifacial spasm: eight personal case reports]

INTRODUCTION

Hemifacial spasms consist in tonic clonic, involuntary, asymmetrical and asynchronous contractions in the territory innerved by the facial nerve. Several different causes may give rise to this disorder, the most frequent of which are vascular abnormalities in the cerebellopontine angle. Its clinical features and electrophysiological studies are commonly used in diagnosis and its etiological diagnosis is most frequently performed by means of magnetic resonance imaging. Symptoms are treated using local injections of Botulinum toxin Type A in the affected muscles.

AIMS

To review our experience in the handling of this pathological condition and to determine the results of employing Botulinum toxin.

PATIENTS AND METHODS

We describe the cases of bilateral hemifacial spasms that have been diagnosed in the Virgen Macarena Hospital in Seville and La Fe in Valencia since 1980, as well as the follow up after treatment with Botulinum toxin.

RESULTS

We describe eight cases of this pathological condition in which patients were treated with Botulinum toxin, and in all cases there was an improvement in the symptoms.

CONCLUSIONS

Treatment with Botulinum toxin is considered to be satisfactory and provides a marked improvement in the patients quality of life.

[Time analysis of mortality from cerebrovascular diseases in Andalucia (1975-1999)]

INTRODUCTION

In previous publications we analysed the tendency of mortality from cerebrovascular diseases (CVD) in Andalusia over the period 1975-1992, and we observed a marked decrease in the mortality rates in both sexes. AIMS. To describe the evolution of mortality from CVD in Andalusia throughout the period 1975-1999.

PATIENTS AND METHODS

Deaths from CVD over the period 1975 1999 were obtained from the Instituto Andaluz de Estadística. We employed the direct method of standardisation of rates (world standard population). The rates were subjected to logarithmic transformations and the regression lines were adjusted.

RESULTS

A considerable decrease was found in the rates: 3.9% in males and 4.0% in females. The drop in truncated rates (35 64 years old) was greater in women ( 5.9%) than in men ( 4.3%).

CONCLUSIONS

Our work shows a marked and continuous decrease in mortality from CVD in Andalusia (1975-1999). In accordance with the process of aging of the population, the magnitude of CVD measured in terms of deaths, invalidity and health costs still represents a great challenge for preventative and health care policies.

[Spontaneous cerebral calcium embolism]

INTRODUCTION

Calcium embolism is an uncommon cause of stroke which may not be diagnosed in cases which do not involve cardiac surgery or catheterization. The emboli may come from cardiac valves or calcified atheroma of the aortic or carotid arteries.

CASE REPORTS

Two patients with cerebral infarcts secondary to spontaneous calcium embolism confirmed by neuro imaging. In both cases on CT scans there were dense points corresponding to calcified material within the middle cerebral artery or one of its branches. In the first case migration of the calcified point following the course of the artery was observed.

CONCLUSIONS

Cranial CAT scans are essential for diagnosis of calcium embolism. Migration of the calcified point confirms the diagnosis. It is still not clear whether valve replacement is necessary in these patients and treatment with antiaggregants and/or anticoagulants is controversial.

Mitochondrial disease and stroke

BACKGROUND AND PURPOSE

It is well known that some mitochondrial disorders are responsible for ischemic cerebral infarction in young patients. Our purpose was to determine, in this prospective ongoing study, whether ischemic stroke is the only manifestation of a mitochondrial disorder in young patients.

METHODS

Patients aged </=50 years, admitted to the Stroke Unit from January 1999 to May 2000 with a diagnosis of ischemic stroke of unknown origin, were included in the study. All of them had full biochemical and hematologic tests, neuroimaging studies, transesophageal echocardiography, and extracranial and transcranial Doppler sonography. Patent foramen ovale was ruled out. Lactic acid concentrations were measured after anaerobic exercise of the forearm, and a morphological, biochemical, and molecular study after biceps muscle biopsy was performed.

RESULTS

Of the 18 patients so far included, 3 (17%) presented lactic acid hyperproduction after physical exercise, and 6 (33%) showed deficit of the mitochondrial respiratory chain complexes. The molecular analyses have confirmed mitochondrial mutations at base pairs 3243 (characteristic of mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes [MELAS]), 4216, and 15 928.

CONCLUSIONS

These results suggest that ischemic stroke may be the only manifestation or the initial manifestation of a mitochondrial disorder.

Statuslike SUNCT in two young women

OBJECTIVE

To describe the statuslike pattern of SUNCT (short-lasting unilateral neuralgiform pain with conjunctival injection and tearing) in two young women.

BACKGROUND

SUNCT syndrome is a rare condition characterized by a short-lasting periocular pain associated with marked autonomic symptoms. Twenty-five cases have been reported in the literature with a high preponderance of males and a mean age of 51 years. The frequency of episodes shows a wide variability, not just among individuals but also in the same patient, and a statuslike pattern of almost continuous attacks has been described.

METHODS

We report the cases of two young women (aged 26 and 23 years) with typical SUNCT features who suffered bouts of up to 60 paroxysms of pain per hour. Paraclinical investigations showed no abnormalities.

CONCLUSIONS

Although unusual, paroxysms in SUNCT may overlap into a clinical status. A strong relationship with hormonal changes was noted in one patient. In both cases, the pain was refractory to treatment with indomethacin, carbamazepine, and hypnotics, and only intravenous methylprednisolone with oral carbamazepine may have been partially effective in one case.

[Repeated strokes in a patient with a basilar artery aneurysm]

INTRODUCTION

The estimated prevalence of basilar dolichoectasia in the healthy general population is 50 per 100,000 inhabitants. The treatment of symptomatic cases is controversial. Strokes caused by it may be due to thrombosis of the perforating arteries, arterio-arterial emboli or a compressive mechanism.

CLINICAL CASE

We present the case of a 68 year old woman with repeated stokes in which the vertebrobasilar territory was involved. On neuroimaging there was basilar dolichoectasia associated with aneurismal dilatation of both internal carotid arteries. The patient died of massive subarachnoid hemorrhage after starting heparin treatment. At necropsy the aneurysmic dilatation was confirmed together with signs of arteriosclerosis of the arteries of the circle of Willis.

CONCLUSIONS

Since subarachnoid hemorrhage secondary to rupture of a dolichoectasia is exceptional, some authors support the use of permanent anticoagulation rather than platelet antiaggregation in patients with conditions due to ischemia, in which dilatation is limited to the basilar artery. However, this is not suitable for cases with associated fusiform aneuryms, or cases such as ours in which the dolichoectasia extends beyond the basilar artery, to become generalized throughout all the arteries of the circle of Willis.