Movement disorders in ischemic stroke: clinical study of 22 patients

Movement disorders (bemichorea-hemiballismus, hemidystonia and isolated tremor) are an uncommon clinical manifestation in ischemic stroke (IS), and their anatomical basis is poorly understood. We analyzed the clinical and neuroimaging characteristics of 22 consecutive patients who bad movement disorders associated with cerebral infarction (MDCI), studied at four institutions over 8 years. In one institution (from the La Alianza-Central Hospital of Barcelona Stroke Registry) nine patients with MDCI were identified among 1099 consecutive first ever stroke patients (0.8%) (908 with IS, 1%). Fifteen out of 22 patients (68%) had hemichorea-hemiballismus, five (23%) hemidystonia and two (9%) isolated tremor. MDCI were more often left sided (n = 15, 68%), being bilateral in one patient (4.5%). A lesion was found on neuroimaging (CT and/or MRI) in 15 patients (68%), in the territory of the posterior cerebral artery (n = 8) and middle cerebral artery (six deep and one superficial). The most commonly involved structure was the thalamus (n = 8, 36.5%). IS subtypes were; presumed lacunar infarcts in 14 patients (64%), atherothrombotic infarcts in two patients (9%), cardioembolic infarcts in two patients (9%) and infarcts of unknown etiology in four patients (18%). Hemichorea-hemiballismus was the most common type of MDCI in our study, usually being the result of a thalamic infarction. The thalamus was the most frequently damaged structure underlying all types of MDCI. There was a striking propensity of MDCI which resulted from nondominant deep hemispheric small vessel infarctions.

Diagnosis of CADASIL disease in normotensive and non-diabetics with lacunar infarct

BACKGROUND

CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is characterized by recurrent cerebral ischemic episodes of the lacunar subtype usually without traditional vascular risk factors. We investigated the frequency of CADASIL among selected patients with cerebral ischemia of the lacunar subtype.

METHODS

we studied patients under 65 years old who presented cerebral ischemia of the lacunar subtype without hypertension, diabetes mellitus or other causes that explained the cerebral ischemia. On the skin biopsies, we performed immunostaining analysis on 5μm frozen sections with monoclonal antibody anti-Notch 3 (1E4). We also performed a genetic analysis of the Notch 3 gene (exons 3,4,5,6,11 and 19).

RESULTS

of 1.519 patients analyzed, only 57 (3.7%) fulfilled the selection criteria, and 30 of them accepted to participated in the study. We studied 30 patients, mean age was 53 years (range 34 to 65), 50% were men and all patients suffered a lacunar stroke. Immunostaining analysis was positive in two patients (6.6%) and the genetic analysis confirmed a mutation characteristic of CADASIL in exon 4 nt 622C/T (Arg 182 Cys) and 694 T/C (Cys206Arg) respectively.

CONCLUSIONS

CADASIL disease was present in 6.6% of patients younger than 65 years with a lacunar stroke and without hypertension or diabetes mellitus. Screening for CADASIL should be considered in these patients.

Diagnostic yield of prothrombotic state studies in cryptogenic stroke

OBJECTIVES

Around 30% of ischemic strokes are considered cryptogenic. We analyzed the diagnostic yield of prothrombotic state (PS) studies in patients with an initial cryptogenic stroke (CS).

MATERIAL AND METHODS

We prospectively included consecutive CS patients according to the TOAST criteria. PS included plasmatic determinations of antiphospholipid (APL) antibodies and lupus anticoagulant (LA), S (SPd) and C (CPd) protein deficiencies, and genetic analysis of the prothrombin gene mutation (PT G20210A) and the factor V Leiden mutation (FV G1691A). We recorded age, sex and vascular risk factors.

RESULTS

From a total of 89 patients (mean age 56.9 +/- 14.3 years, 53% men), we identified 16 PS in 15 patients (16.85%): APL-6, LA-2, SPd-2, CPd-1, PT G20210A -3 and FV G1691A -2. One patient presented an association (APL and PT G20210A).

CONCLUSIONS

One of every six patients with initial CS present a PS. Age or sex and conventional cardiovascular risk factors were not related to PS study findings, supporting the relevance of such studies in all patients with an initial CS.

[Percutaneous transluminal angioplasty of the subclavian artery in Takayasu disease: results of long-term follow-up]

Takayasu arteritis is a chronic inflammatory arteriopathy of unknown etiology affecting the aorta and proximal portion of its main branches. Although it was initially reported in young women of Oriental descent, its current worldwide distribution is known to affect both sexes. In the last decade, percutaneous transluminal angioplasty (PTA) has emerged as a viable alternative in its treatment. However, the percentage of restenosis is more common in Takayasu disease than atherosclerotic lesions (21% vs 10%), probably due to diffuse inflammatory vascular involvement. Since the introduction of stent, this technique has emerged as a viable alternative to treatment of atherosclerotic stenotic lesions, although its efficacy and safety in Takayasu disease is still unclear. Herein, we report our experience in a woman with subclavian steal syndrome in whom Takayasu disease was diagnosed and treated with subclavian artery angioplasty and stent, with a good outcome during four years of follow-up.

Stroke and pulmonary thromboembolism after a long flight

In the economy class syndrome (ECS) the patient presents a deep venous thrombosis (DVT) with or without pulmonary thromboembolism (PTE) during or after a long trip as a result of prolonged immobilization. Economy class stroke syndrome is an infrequent ECS variant in which ischemic stroke is associated with a patent foramen ovale (PFO). Few cases have been published in the literature to date. We present a patient who suffered a PTE and an ischemic stroke immediately after a transoceanic flight. A 36-year-old woman with no significant medical or familial history flew economy class from Lima, Peru, to Madrid, Spain. On disembarkation she presented sudden dyspnea and a depressed level of consciousness, global aphasia, and right hemiparesis. A pulmonary scintigraphy showed a PTE and a cranial MRI revealed an ischemic infarct in the left middle cerebral artery territory. We simultaneously performed a transesophageal echocardiography and a transcranial Doppler and observed a massive right-to-left shunt through a PFO. The patient was a heterozygous carrier of the C46T mutation of coagulation factor XII. The appearance of a stroke following a long trip is suggestive of paradoxical embolism through a PFO, mainly if it is associated with a DVT and/or a PTE. The cause of the initial event, the DVT, could be a prothrombotic state.

[Intracerebral haemorrhage by cerebral hyperperfusion after carotid angioplasty in a tandem lesion. A case report]

Intracerebral hemorrhage (ICH) by hyperperfusion after carotid angioplasty has a frequency of 1.2 % - 4.4% in the literature. Until now no case of ICH after carotid angioplasty in a tandem lesion has been reported. We present the case of a patient who suffered an ICH due to the hyperperfusion syndrome, after carotid angioplasty of two stenotic lesions of the left internal carotid artery (ICA) (intracranial and extracranial). He was a 58 year old man who suffered repetitive left carotid TIA despite being treated with antiplatelet therapy. An angiogram showed 76 % extracranial stenosis and 96 % intracranial stenosis of the left ICA as well as 59 % extracranial stenosis of right ICA. Angioplasty with stenting of the two stenosis of the left ICA was performed. After 48 hours of the angioplasty, the patient presented a massive ICH and died a few hours later. ICH by hyperperfusion is an infrequent complication of the carotid angioplasty. The risk factors of the ICH should be evaluated in order to decrease their incidence as well as to maintain an intensive control of the arterial pressure during and after the procedure. This case is the first one published after angioplasty of a tandem lesion. It is possible that the pathophysiologic mechanism involved was an excessively rapid restitution of the normal arterial size.

New concepts in lacunar stroke etiology: the constellation of small-vessel arterial disease

OBJECTIVE

To update the less frequent etiologies causing lacunar infarcts (LIs). To highlight recent advances in risk factors, clinical syndromes, topography, complementary tests and long-term prognosis in this subtype of ischemic stroke.

PATIENTS AND METHODS

The most important studies are analyzed, from CM Fisher works, selecting those referring to LIs of unusual etiology, and recent advances and controversies in the clinical management of LI are discussed.

RESULTS

LIs are found in approximately 11% of patients admitted with stroke. The pure motor hemiparesis (55%) constitutes the most usual lacunar syndrome. However, lacunar syndromes may not be caused by LIs in 10-20% of cases. LIs caused by microembolism and cholesterol embolism from the aortic arch are reviewed. Hematological diseases can also cause LI, such as polycythemia rubra vera, essential thrombocythemia and primary antiphospholipidic antibody syndrome. Other etiologies are carotid plaque embolism, severe stenosis of a perforated arteriole and amyloid angiopathy. Infectious arteritis by neurolues, neurocysticercosis, neuroborreliosis, by AIDS or Helicobacter pylori infection have also been associated with the presence of LIs. Likewise, inflammatory arteritis in systemic lupus erythematosus or granulomatous angiitis, cocaine abuse and panarteritis nodosa have been related to LI, although in the latter LI would be caused by a thrombotic microangiopathy and not by vasculitis.

CONCLUSIONS

LI is an ischemic stroke subtype with a characteristic clinical presentation and a short-term favorable prognosis. Although high blood pressure constitutes the main risk factor and the main etiology, LIs may be caused, in less than 5% of cases, by various etiologies, mainly hematological diseases and infectious or inflammatory arteritis. It is essential to make a correct etiological diagnosis for LI as treatment will be different according to its etiology.

[Asystolias in the acute phase of brain stroke. Report of a case]

Brain areas involved in heart autonomic control are not well characterized. Insulae have been proposed as control centers. A lesion in these areas may induce a cardiac autonomic dysfunction (arrhythmias, atrioventricular conduction abnormalities). Asystolia has not been previously reported. A 65-year-old man suffered an acute ischemia of the right middle cerebral artery (MCA) territory. NIHSS score was 19 points. Brain CT scan was normal. Transcranial Doppler (TCD) showed occlusion of the right MCA. Fibrinolysis was initiated 135 minutes after stroke onset with TCD monitoring. Twenty minutes later he suffered cardiac arrest with asystolia trace in the ECG monitor. Fibrinolysis was stopped during resuscitation. Four minutes later, he recovered with the same NIHSS score. Aggressive resuscitation maneuvers were not necessary. A repeated brain CT scan showed infarct signs in the whole MCA territory and a new TCD did not show any change. Serial blood analyses including cardiac nzymes were normal. The patient experienced four brief cardiac arrests in the next nine hours, so a temporary cardiac pacemaker was placed for four days. He was treated with aspirin and was discharged 14 days after admission. He has not experienced recurrences during a 6-month follow-up. We could not diagnose the etiology of the cardiac arrests. All the episodes occurred in the acute stroke stage and arrhythmia, atrioventricular block, myocardial ischemia or structural lesions were not found in the cardiac study. We propose that ischemia in the right insula induced sudden and transitory interruptions of the sympathetic cardiac tone.

[Leukoaraiosis. Clinical importance and prognosis]

Advance in the health care systems, in medical knowledge and improvements in quality of life have contributed to the fact that life expectancy of the persons in developed countries exceeds 80 years of age. This has made it possible to observe the increase in frequency of common diseases of the elderly, one of the most relevant of which is dementia. The two most frequent etiologies of dementia are the degenerative one, with Alzheimer's disease (AD) as the main cause, and those of vascular etiology or vascular dementia, within which subcortical arteriosclerotic encephalopaty or Binswanger's disease (BD) are found with low prevalence. Since, on one hand, diagnosis of the dementias is not enough or definitive by clinical means, and on the other hand, the pathological diagnosis does not modify the evolution of disease, emphasis is presently placed on diagnosis by neuroimaging studies. In recent years, with the coming of the computerized tomography (CT) and the magnetic resonance (MR), it has been possible to observe lesions in the white matter of the brain hemisphere in patients with these two etiologic groups of dementias, that is, degenerative and vascular, as well as in elderly patient without cognitive deterioration, with or without vascular risk factors.

Blood pressure variability and leukoaraiosis amount in cerebral small-vessel disease

OBJECTIVES

To analyze the correlation between blood pressure (BP) variability and leukoaraiosis (LA) amount in patients with symptomatic cerebral small-vessel disease.

MATERIALS AND METHODS

We included 25 hypertensive patients: 13 with Binswanger's disease (BD) and 12 with a first-ever lacunar infarction (LI). Baseline office BP was obtained for 3 consecutive weeks. From a 24-h ambulatory BP monitoring performed 1 week later we obtained average systolic (SBP) and diastolic (DBP) BP for daytime, nighttime and 24-h periods. SBP and DBP variability was defined as the within-subject standard deviation of all readings. A standardized cerebral MR was performed in each patient and an LA score was calculated.

RESULTS

No statistically significant correlation was obtained between the LA score and any of the following BP values: 1) Baseline SBP and DBP; 2) 24-h, daytime or nighttime SBP and DBP, and 3) 24-h, daytime or nighttime SBP and DBP variability.

CONCLUSION

Increased BP variability is not associated with greater amounts of leukoaraiosis.

Cerebral perfusion and haemodynamics measured by SPET in symptom-free patients with transient ischaemic attack: clinical implications

Transient ischaemic attacks (TIAs) are heterogeneous from the clinical, physiopathological, aetiological and prognostic points of view. Single-photon emission tomography (SPET) may influence patient management by helping to define the vascular topography and by suggesting the probable mechanism (embolic or haemodynamic). However, the variables predicting focal regional cerebral blood flow (rCBF) and cerebrovascular reserve (CVR) abnormalities on SPET and their clinical correlation are poorly known. Our objective in this study was to assess the value of rCBF and CVR measured by SPET in a prospective series of 42 patients with recent (within the preceding 30 days) first-ever TIA Two SPET examinations [baseline and post-acetazolamide (ACZ)] were consecutively performed, and region/reference ratios were obtained using an irregular region of interest (ROI) method. Percentages of interhemispheric asymmetry between homologous brain regions were used to identify abnormalities on baseline SPET, and the percentage changes in asymmetry between the baseline and post-ACZ SPET studies were used to identify abnormal responses to the vasodilator stimulus. Mean baseline and test-retest values previously obtained in normals were used as a reference. The relationship of SPET findings with clinical data and results of complementary examinations was assessed. Most patients (98%) had abnormal findings on either baseline (43%), post-ACZ (19%) or both SPET studies (36%). Thus, 33 patients had hypoperfusion on baseline SPET (78.5%, symptom related in 45%). In 23 patients, a poor response to ACZ was found (55%, symptom related in 21.5%). No predictors for rCBF or CVR impairment were found. Most patients with a first-ever TIA episode present focal hypoperfusion on SPET, either with or without correlation with TIA symptoms. Post-ACZ SPET increases the probability of finding cerebrovascular abnormalities, and orients attention towards an haemodynamic compromise. Focal hypoperfusion on SPET should not be viewed as clinically insignificant because it probably reflects previous or ongoing clinical and/or subclinical episodes of cerebral ischaemia.

Blood pressure variability in Binswanger's disease and isolated lacunar infarction

To determine whether blood pressure (BP) variability is increased in hypertensive patients with Binswanger's disease (BD), we studied two samples of consecutive treated hypertensive patients: (1) 11 with BD (mean age 71.3 +/- 5.2 years); (2) 16 with lacunar infarction (mean age 65.2 +/- 8.3 years) without cognitive impairment. An averaged baseline office BP was obtained for 3 consecutive weeks. Ambulatory BP monitoring was then carried out to obtain the averaged mean systolic (SBP) and diastolic BP, and BP variability was defined as the standard deviation of consecutive BP values.

RESULTS

Diurnal SBP variability was significantly increased in the BD group (p = 0.04). However, with the analysis of covariance for age and baseline office BP, the difference was no longer significant (p = 0.17 and p = 0.09, respectively). We conclude that increased BP variability in BD patients is probably due to older age and increased baseline office BP. Increased BP variability may be a risk factor for small-vessel disease, but not for cognitive impairment.

The effect of medial frontal and posterior parietal demyelinating lesions on stroop interference

Functional imaging has consistently shown that attention-related areas of medial frontal and posterior parietal cortices are active during the attentional conflict induced by color naming in the presence of distracting words (Stroop task). Such studies, however, have provided few details of the correlational nature between observed regional brain activations and reaction time delay occurring in this situation. We analyzed the effect of medial frontal and posterior parietal lesions on the Stroop response in a group of patients with multiple sclerosis, a neurological disorder in which Stroop response speed is affected to varying degrees. Forty-five patients were assessed using a computer-presented verbal version of the Stroop task and specific MRI protocol. Demyelination areas were measured on five anatomical divisions of the medial frontal white matter and on white matter of the posterior parietal lobe. We found that a combination of frontal and parietal lesion measurements accounted for 45% of the Stroop interference time variance. Patients with more right frontal than left parietal demyelination showed slowed Stroop responses, whereas the predominance of lesions in the left posterior parietal region was associated with a reduced Stroop interference. These results may contribute to defining the specific participation of these attention-related brain areas in the conflict of attention represented by the Stroop paradigm. They also help to explain the variability of the Stroop effect in multiple sclerosis patients and suggest that the Stroop test does not assess just a single cognitive operation, but rather the combined effect of anatomically segregated neural processes.

Beck Depression Inventory factors related to demyelinating lesions of the left arcuate fasciculus region

This study was conducted to further establish the significance of the previously reported association between depressive symptoms and demyelinating lesions in the region of the left arcuate fasciculus in multiple sclerosis patients. The Beck Depression Inventory (BDI) was broken down into its main symptom categories on the basis of well-established factor analyses from the literature, and the correlation pattern between the resulting BDI subscores and lesion measurements was analyzed. We found that lesions of the left arcuate fasciculus region were selectively associated with BDI items expressing patients' Affective Symptoms and Somatic Complaints. Specifically, lesion measurements from this brain location accounted for 26% of symptom score variance of the BDI part that includes only these two factors. Performance Difficulties and Cognitive Distortions were not consistently associated with the lesion measurement. Performance Difficulties, however, showed a high correlation with the neurologic deficit detected in the physical examination. These results show that lesions in the left arcuate fasciculus region are associated with the core of the depressive syndrome rather than marginal symptoms and, thus, further suggest that this left suprainsular brain region involves white matter tracts relevant to mood regulation.

The Barcelona Stroke Registry

The Barcelona Stroke Registry was established to collect clinical data of hospitalized patients with stroke, in order to study their clinical characteristics and outcome. Data were collected over a 17-year period in 3,577 consecutive patients with first-ever stroke admitted to a stroke unit in two university hospitals in the city of Barcelona (Catalonia, Spain). Patients were generally admitted within 48 h from stroke onset, were evaluated by a neurologist, and clinical data were collected using a standardized protocol. All subjects underwent computerized tomography (CT) examination. Data on the 3,577 patients revealed the following stroke subtypes: cerebral infarction (81%), corresponding to the varieties of atherothrombotic (39.5%), cardioembolic (17.5%), lacunar (11%), unusual (5%), or unknown (8%); and cerebral hemorrhage. We analyzed age distribution (mean age 66 years); risk factors (the most frequent being hypertension, present in 54% of cerebral infarctions and in 65% of hemorrhages); clinical manifestations (the most salient being abrupt onset in one half of the cases; high frequency of decreased consciousness in cardioembolic infarction; headache, seizures and nuclear palsy in 'unusual' cerebral infarctions; vomiting and coma in hemorrhage); localizations by vascular territories; mechanisms of the various stroke subtypes; complications (present in one third of patients, with a mortality of 14%), and outcome. Two out of 3 hospitalized stroke patients are first-ever stroke sufferers. Neuroimaging shows a cerebral infarct in 86.5% of cases. Clinical and laboratory investigations cannot determine the mechanism of 8% of infarcts and of 23% of hemorrhages. The high frequency of medical complications, mortality, and disability highlights the need to establish stroke units and stroke registries in order to perform further research into the diagnosis and management of patients with cerebrovascular disease.

[Primary ventricular hemorrhage]

INTRODUCTION

Primary intraventricular hemorrhage is non-traumatic cerebral hemorrhage limited to the ventricular system which presents on rare occasions, forming 3% of the spontaneous cerebral hemorrhages.

DEVELOPMENT

The diagnosis may be suspected when there is sudden onset of headache, nausea and vomiting with reduced level of consciousness. On examination there are signs of meningism, bilateral positive Babinski signs and absence of localizing neurological signs. However, cases of more subacute onset or with a normal state of consciousness are also seen. Therefore, in spite of clinical suspicion, diagnosis is made on cerebral computerized tomography. The aetiology is varied and it should be emphasized that vascular malformations cause 34% and in 21-47% no cause is found. Probably arterial hypertension is a major cause of primary intraventricular haemorrhage (38.5% in one series). Arteriography is necessary as well as computerized tomography for diagnosis of the aetiology. The prognosis is relatively good. The mortality is 29% and most survivors become asymptomatic or are left with only minor sequelae, often characterized by memory problems. In elderly patients there is a worse prognosis if there is an initial alteration in consciousness and if hydrocephaly occurs, but the prognosis does not appear to be affected by the volume of the hemorrhage. There is no specific treatment, but promising results have been obtained with intrathecal administration of fibrinolytic agents followed by external drainage.

[The phenomenon of diaschisis in cerebral vascular disease]

INTRODUCTION AND OBJECTIVE

Diaschisis is a physiological phenomenon based on reversible depression of functions anatomically or functionally connected to the damaged area. Its study has become more interesting over the past twenty years, due to the advances made in functional neuroimaging techniques and their possible participation in the recovery of function. Our objective is to review the main types of diaschisis and their clinical contribution.

DEVELOPMENT

At present it has mainly been described in cerebrovascular pathology, and been classified according to the connecting fibres involved. When the connecting fibres are intra-hemispheric, the phenomenon of ipsilateral thalamic or subcortical-cortical diaschisis may be seen; when they are interhemispheric, there is transcallosal diaschisis, and if they are cerebellar, the diaschisis is of the contralateral cerebellum or crossed cerebellar diaschisis. Ipsilateral thalamic and crossed cerebellar diaschisis are phenomena which are frequently observed, but have no clinical significance. Regression of the subcortical-cortical and transcallosal diaschisis might explain the neuropsychological and functional neuroimaging changes observed over the first few months after the vascular incident.

CONCLUSION

Study of the different types of diaschisis should be considered in patients with cerebrovascular disease since it is potentially reversible, and to differentiate it from focalization due to the lesion.

[Hospital mortality in subarachnoid hemorrhage. Experience of the "Barcelona Registry of Cerebrovascular Diseases"]

OBJECTIVES

To determine clinical predictors of in-hospital mortality in patients with non-traumatic subarachnoid hemorrhage.

PATIENTS AND METHODS

Data de 184 patients with subarachnoid hemorrhage were obtained from consecutive stroke included in the prospective "Barcelona Stroke Registry". Demographic, anamnestic, clinical, neuroimaging and outcome variables in the subgroup of patients who died were compared with those in the surviving subgroup. The independent predictive value of each variable on the development of death was assessed with a logistic regression analysis. Three predictive models were constructed. A first model was based on demographic and clinical variables (total 10 variables). A second model was based on demographic, clinical and neuroimaging variables (total 17). A third model was based on demographic, clinical, neuroimaging and outcome variables (total 21).

RESULTS

In-hospital death was observed in 44 patients (24%). Transient neurological deficit (OR = 13.92; 95% CI: 1.01-191.95), progressive deficit (OR = 4.21; 95% IC: 1.28-13.86), limb weakness (OR = 3.24; 95% IC: 1.49-7.08) and age (OR = 1.05; 95% CI: 1.02-1.09) appeared to be independent prognostic factors of in-hospital mortality in the first predictive model. In addition to these variables, intraventricular hemorrhage (OR = 5.51; 95% CI: 1.94-16.04) was selected in the second predictive model. Transient neurological deficit (OR = 41.2; 95% CI: 1.61-1056.2), neurological complications (OR = 11.04; CI del 95%: 3.85-31.74), carotid aneurysm (OR = 6.61; 95% CI: 1.23-35.43), intraventricular hemorrhage (OR = 5.51; 95% CI: 1.65-18.4), progressive deficit (OR = 5.35; 95% CI: 1.11-25.90) and hemispheric intracerebral hemorrhage (OR = 4.32; 95% CI: 1.35-13.90), appeared to be independent prognostic factors of in-hospital mortality in the third model.

CONCLUSIONS

Clinical features easily obtained at the patient's bedside in addition to neuroimaging data easily obtained in routine neuroimaging studies help clinicians to predict in-hospital mortality in patients with subarachnoid hemorrhage. Transient neurological deficit prior to definitive subarachnoid hemorrhage was the main clinical predictor of in-hospital mortality.

Alien hand sign after a right parietal infarction

Involuntary movements are unusual during or after acute stroke, and alien hand sign has not been reported after single parietal infarction. We report on a woman who presented with involuntary movements and a sense of alienness of her left upper limb following a right parietal infarction. This combination, that can meet the criteria for the 'alien hand syndrome', is rarely seen after acute lesions sparing the corpus callosum and the mesial frontal areas.

[The developing profile of cerebral ischemia]

Cerebral ischemia, which may be silently manifested as transitory ischemia attacks or cerebral infarction, is not a stable, but rather, a moving process. In cerebral infarctions the initial ischemic area may change or move in a high percentage of patients and may involve a significant volume (mean of 32%) of neuronal tissue. The negative changes of initial cerebral ischemia which produce a worsening of the same may be due to the progression of the thrombus, appearance of new embolisms, cerebral edema, hemorrhage, blood reperfusion and systemias causes. These changes may determine the conversion of the shaded ischemic area into a definitive, irreversible infarction. The negative changes may also be produced some distance from the initial ischemic area, either because of microthromboembolisms or diaschisis. The positive changes of initial cerebral ischemia which produce as improvement of the same, may be due to collateral circulation, lysis or fragmentation of the embolism and a decrease in cerebral edema. Clinical changes with no evident clinical manifestations may also be produced and may be diagnosed with the use of clinical scales, imaging techniques, ultrasound and hematological and biochemical markers. Acknowledgement of these cerebral ischemia changes in the acute phase may determine the salvation of a part of the brain, and thereby modify the future clinical situation of the patient.

[The latency of hospital admission in an acute cerebral accident]

Variable time is the main limiting factor of the current possibilities of treatment of patients with acute cerebral attack. Different authors have demonstrated the need for prompt hospital arrival: the concept of therapeutic window, the possibility of treatment with thrombolytic and neuroprotector drugs, the possibility of receiving adequate support therapy, treatment in an ictus unit, the need for appropriate differential diagnosis and the socioeconomic consequences which all of the above represent. However, at present the arrival of patients to hospital is excessively delayed due to different demographic, organizational, educational and medical factors and, in addition, intrahospital delays are produced in the diagnosis and treatment of these patients. The main factor for these delays is the indecision of the patient in going to the hospital and the best way of forwarding the latency of arrival is rapid request of emergency transportation. To shorten the time of patient care different factors related to the detection, transportation, emergency unit screening, attainment of complementary tests, protocols of diagnostic and therapeutic decision and the administration of specific treatments should be attended. Fortunately, recent contributions have demonstrated the efficacy of treatments in the first hours of evolution and therefore special emphasis should be given to the variable time since, in cases of acute cerebral attack, "time is brain".

[Non pharmacological treatments in cerebral vascular diseases]

Non pharmacological treatments are useful in cerebral vascular diseases. An adequate diet, physical exercise and avoidance of modificable risk factors associated with lifestyle (smoking, obesity and alcohol abuse) are recommended as primary prevention against these diseases. In the early treatment, on initiation of the neurologic focalization, hyperthermia and hyperglycemia should be avoided and adequate nutrition must be achieved. The cephalic position of the patient should be adequate and physiotherapy should be initiated early. Urinary dysfunction, fecal incontinence and cutaneous complications should be prevented and appropriately controlled.

[Cerebral venous thrombosis. Study of 17 cases]

BACKGROUND

We undertook this study to determine the clinical, neuroimaging findings, etiologies and final outcome of 17 patients with cerebral venous thrombosis diagnosed in a single center.

PATIENTS AND METHODS

In this retrospective study we analyzed the clinical and neuroimaging findings of patients with cerebral venous thrombosis collected at our hospital from 1980 to 1997. The diagnosis of cerebral venous thrombosis was made by angiography and/or magnetic resonance imaging. Final outcome was assessed with the modified Rankin scale and patients were included in two groups. Differences between groups were tested using uni and multivariate analysis.

RESULTS

Seventeen patients (10 women) with a mean age of 41.9 years were analyzed. The most frequent clinical pattern was focal cerebral signs (70.5%) followed by symptoms/signs of increased intracranial pressure (12%) and diffuse encephalopathy (12%). The diagnosis of cerebral venous thrombosis was made by conventional angiography in 12 cases (70.5%) and by magnetic resonance imaging in 5 (29.5%). The most frequent site of venous occlusion was superior sagittal sinus (47%) followed by lateral sinus (35%). Etiologies were hematologic disease (29%), neoplasms (23.5%), oral contraceptives (12%), infection (12%) and unknown in 18%. The majority of the patients (59%) had minor neurological sequelae during follow-up. A decreased level of consciousness and neoplasm were associated with a worse functional outcome.

CONCLUSIONS

In our series the most frequent clinical pattern was focal cerebral signs and the main etiology was hematologic disease. A relatively good prognosis was observed in those patients. A decreased level of consciousness and presence of neoplasm were the factors associated with a bad prognosis in these cases.

Predictive clinical factors of very early in-hospital mortality in subarachnoid hemorrhage

This study was conducted to determine clinical predictors of very early in-hospital mortality (within the first 72 h) in patients with non-traumatic subarachnoid hemorrhage. Data of 184 patients with subarachnoid hemorrhage were obtained from consecutive stroke patients included in the prospective Barcelona Stroke Registry. Demographic, anamnestic, clinical, neurological and neuroimaging variables in the subgroup of patients who died within 72 h after the onset of symptoms were compared with those in the subgroup of patients that had survived this initial period. The independent predictive value of each variable on the development of very early death was assessed with a logistic regression analysis. Very early in-hospital death was observed in 18 patients (9.8%). These patients were significantly more likely to have progressive deficit, seizures, altered consciousness, limb weakness, sensory involvement and basal ganglia hematoma than patients without very early death. After multivariate analysis, only progressive deficit (odds ratio (OR) 6.90; 95% confidence interval (95% CI) 2-23.80) and limb weakness (OR 5.46; 95% CI 1.78-16.77) were independent clinical predictors of very early mortality. Progressive neurological deficit and limb weakness at the onset of stroke was independent predictive factors of very early death in patients with non-traumatic subarachnoid hemorrhage. These results further emphasize the need to establish an early etiological diagnosis and to manage these patients aggressively including early surgery in selected cases.

[Atherosclerosis and cerebral ischemia. A systemic process]

INTRODUCTION

Atherosclerosis is a systemic process involving all the arteries of the body. It is often silent, until its progression affects an organ causing a cerebral infarct, myocardial infarct or peripheral vascular disease.

DEVELOPMENT

We consider three distinct aspects of this systemic involvement: the risk factors which are common to atherosclerosis at any site; previous alterations of other vascular regions apart from the current disorder, and the frequent presentation of a new site of vascular disorder, mainly coronary. The authors discuss the evolution of our understanding of cerebral ischaemia and the process of atherosclerosis. Atherosclerosis of the intracranial arteries leading to thrombosis was considered for many years to be the main cause of cerebral infarcts. However, this has been shown to be an unusual cause. The commonest cause has been found to be atheromatosis of the extracranial arteries leading to stenosis, ulceration or thrombosis. The aorta, the artery which is the first and most severely altered by the process of atherosclerosis, is often the cause of a cerebral infarct of unknown aetiology. The embolic etiology of cardiac origin is generally due to valvulopathies and disorders of rhythm and, less frequently, to myocardial ischaemia.

CONCLUSION

Atherosclerosis of arteries of the limbs is an indicator of systemic atherosclerosis but not a common etiological factor of cerebral infarct.

Spontaneous primary intraventricular hemorrhage: clinical data, etiology and outcome

The clinical features, etiology, and neurological outcome in patients with primary intraventricular hemorrhage (PIVH) have rarely been reported. We retrospectively reviewed the clinical data, complementary examinations, outcome, computed tomography (CT) blood amount, and ventricle size of 13 patients (mean age 60 years, five men). We defined PIVH as hemorrhage detected by CT in the ventricular system only. The major symptoms included headache (n = 13), decreased level of consciousness (n = 9), and nausea/vomiting (n = 7). The cause was unknown in five patients; and was associated with arterial hypertension in five, vascular malformations in two, and tumor in one, although arteriography was performed in only five patients. Outcomes were death in three, asymptomatic in six, mild disability in three, and moderate disability in one. Prognosis was not related to clinical or CT data. Clinical features can suggest the diagnosis of PIVH, but cerebral CT is required for confirmation.

[A study of lacunar infarcts based on analysis of the main anatomopathological series in the literature]

INTRODUCTION

There are few clinico-anatomopathological studies of lacunar infarcts (LI), because of the excellent functional prognosis and unlikelihood of death occurring whilst in hospital.

MATERIAL AND METHODS

We reviewed the 10 main anatomopathological series of LI in the literature. A personal contribution was made based on analysis of the LI analyzed in 50 consecutive autopsies of patients with cerebrovascular disease. A descriptive clinico-anatomopathological assessment was done. Cerebrovascular risk factors, associated neurological syndromes and causes of death were analyzed.

RESULTS

A total of 1,200 cases were analyzed in the 11 anatomopathological series. The most usual number of LI was between 2 and 5 per brain (6 series). The commonest topographical lesions found, in order of frequency, were: In the lenticular nucleus (9 series), thalamus (4 series) and frontal white matter (4 series). The main risk factor was arterial hypertension (AHT), which occurred in between 58% and 90%. The main clinical findings were: Pseudobulbar syndrome (6 series), pure motor hemiparesia (3 series) and clinically silent ischemia (2 series). The causes of death were mainly non-neurological and due to ischemic cardiopathy, sepsis and pulmonary embolism.

CONCLUSIONS

LI are usually multiple, and topographically they are found at the level of the basal ganglia. AHT is the main cerebrovascular risk factor. The causes of death are usually non-neurological.

[Circadian rhythm and lacunar syndromes]

BACKGROUND

There is scarce knowledge on the mode of onset of disease related to circadian rhythm in lacunar syndromes.

METHODS

A prospective clinical analysis was conducted in 181 patients with lacunar infarcts (LI) and 47 patients with lacunar syndromes not due to lacunar infarcts. In every patient the onset of the disease was recorded for each of the four 6-hour equal periods of the day. The injure volume of the LI was measured by means of a computer and image analyzer. A descriptive analysis of the hour of onset of the disease and a comparative analysis of clinical differences and injure size for each day period, relating to circadian rhythm were made.

RESULTS

For LI, the onset occurred during nocturnal sleep in 32.5% and during wakening hours in 67.5%. The morning onset of the disease was significantly more frequent in lacunar syndromes by cerebral hemorrhage (55.5%) than in LI (24.5%) (p < 0.001). For LI, the mean injure volume was significantly larger when associated with a morning onset (2,574 mm3), during the afternoon (1,678 mm3) or during the night (1,328 mm3) (p < 0.04). At discharge, no significant differences were documented between hospital stay length and also between functional disability, when compared with disease onset and circadian rhythm.

CONCLUSIONS

A third of patients with LI had their onset of symptoms during nocturnal sleep. The morning onset of the disease regarding circadian rhythm in LI is associated with a larger injure volume.

Lesions in the left arcuate fasciculus region and depressive symptoms in multiple sclerosis

Depression is a common mood disturbance in multiple sclerosis (MS) patients. Epidemiologic data suggest a causative relationship between depressive symptoms and cerebral demyelination, although a specific lesion site responsible for depressed mood has not been identified. Given that depression in neurologic disease is closely related to frontal and temporal lobe damage, we focused our study on investigating the extent to which lesions in the white matter connecting both cerebral lobes may account for depressive symptoms in MS. Forty-five patients were assessed using the Beck Depression Inventory and an MRI protocol conceived to quantify lesions separately in the basal, medial, and lateral frontotemporal white matter. The presence of lesions in the left suprainsular white matter, the region that mainly includes the arcuate fasciculus, was specifically associated with depressive symptoms, accounting for a significant 17% of the depression score variance. Although a multifactorial origin is suspected for depression in MS, this finding gives support to the existence of a direct negative effect of demyelination on mood.

Neurospectroscopic alterations and globus pallidus hyperintensity as related magnetic resonance markers of reversible hepatic encephalopathy

In patients with chronic hepatic encephalopathy, proton magnetic resonance spectroscopy can be used to detect specific metabolic abnormalities in the brain; MRI shows a hyperintense globus pallidus on T1-weighted sequences. We investigated the relationship between these two MR findings in a series of 25 patients with the use of quantitative data and a multiple regression analysis model. The cerebral increase in glutamine compounds and the decrease in myoinositol and choline correlated separately with globus pallidus hyperintensity, and each was complementary in accounting for this imaging finding. Such as association suggests that spectroscopic and imaging alterations are two different expressions of the reversible events that occur in the brain of patients with hepatic encephalopathy in that both disappear after liver transplantation. Globus pallidus hyperintensity seems to be a global indicator of the cerebral metabolic disorder, and the spectroscopic pattern denotes the specific metabolic alterations.

Isolated dysarthria caused by a right paravermal infarction

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Pentosan polysulfate-induced thrombocytopenia: a case diagnosed with an ELISA test used for heparin-induced thrombocytopenia

We report a patient who developed severe thrombocytopenia and ischemic stroke following pentosan polysulfate treatment. An ELISA test employed in type-II heparin-induced thrombocytopenia was highly positive. To our knowledge, this is the first case in which this test has been performed in a pentosan polysulfate-induced thrombocytopenia (PIT). Our data suggest that the antibody against pentosan polysulfate-platelet complex also cross-reacts with heparin-platelet factor 4 complex. Due to its greater sensitivity and wider availability, this ELISA test should be used in cases where PIT is suspected.

Frontal lobe activation during word generation studied by functional MRI

AIMS

To further delimit the specific verbal operations occurring in the dorsolateral frontal cortex during the generation of words.

METHODS

Different verbal fluency tasks guided by distinct specifications (phonological, semantic, or automatic production of words) were used in a functional magnetic resonance study. The study group comprised 10 right-handed normal subjects ranging in age from 23 to 27 years. Functional magnetic resonance images were obtained in a 1.5-Tesla magnet using a spoiled GRASS sequence.

RESULTS

Noticeable activation was found during the word generation tasks in the dorsolateral frontal cortex. The region showing the most prominent activation was the posterior part of the left middle frontal gyrus. Nevertheless, the different tasks each had a different activation effect. The phonologically guided generation of words produced the most consistent activation of the middle frontal gyrus, which mainly involved the premotor cortex.

CONCLUSION

The results suggest that operations concerned with the generation of sound sequences, rather than the amount of produced words or their semantics, are responsible for sustained focal activity observed in the frontal lobes during verbal fluency tasks.

[Clinico-anatomopathologic analysis of 25 patients with lacunar infarction]

BACKGROUND

Lacunar infarctions (LI) are associated with an excellent functional prognosis and mortality is exceptional during hospital stay. Therefore, clinico-pathological studies on LI are scarce.

METHODS

A retrospective analysis was made of 50 consecutive necropsies of patients with cerebrovascular disease (CVD) from the brain archive of the Pathology Department performed from 1976 and 1985. A macroscopic and microscopic study was carried out of visualized LI which were classified in old or cystic, recent and through perivascular dilation. A clinico-pathologic evaluation was made by analyzing cerebrovascular risk factors, the associated neurological syndromes and mortality causes.

RESULTS

Fifty percent of brains with CVD analyzed (25 out of 50) had LI. The total of LI was 107, with a mean of 4.2 +/- 3.4 LI per brain. The main location was at the basal ganglia (54.7%), mainly the putamen (35.8%). The most common lesional diameters ranged from 1 to 4 mm (68.5%). Arterial hypertension was the main cerebrovascular risk factor (84%). Fifty-two percent of brains with LI (n = 13) were asymptomatic (clinically silent LI) Twenty-four percent had a clinical course consistent with a pseudobulbar syndrome (n = 6). Twenty percent had a pure motor hemiparesis (n = 5) and the remaining 4% had a transient ischemic attack associated with the LI topography (n = 1). Mortality causes in LI were non-neurological in nature in 88% (n = 22), whereas in non-lacunar CVD they were neurological in nature in 60% (n = 15) (p < 0,0007).

CONCLUSIONS

LI are usually multiple, with a small lesional diameter (from 1 to 4 mm) and clinically silent. Arterial hypertension was associated with 84% of cases and mortality causes are usually non-neurological in nature (88%).

[Latent period before hospital admission in cerebrovascular pathology: determining factors]

OBJECTIVE

Establish the factors determining the latent period before hospital admission of patients with cerebrovascular disorders.

MATERIAL AND METHOD

One hundred patients with cerebrovascular disorders admitted to the Hospital de la Santa Creu i Sant Pau, Barcelona were analyzed. All patients were systematically interviewed, evaluating: age, sex, place of residence, initial condition, type of transport to hospital, vascular risk factors, past history of cerebrovascular disorders, time of onset of symptoms, sleeping-wakefulness state, initial symptom, accompanying symptoms, initial course of illness, complications whilst in hospital, clinical condition and functional ability on leaving hospital, and duration of stay in hospital. All these factors were compared according to the latent period before admission (6 hours or less, or more than 6 hours).

RESULTS

Patients with a latent period before admission of 6 hours or less more frequently had: changes in the level of consciousness (p = 0.04), motor disorders (p < 0.01), stable course (p = 0.04), systemic complications (p = 0.02) and were severely affected (p > 0.01). Patients with a latent period of more than 6 hours before admission more frequently: were smokers (p > 0.01), had a clinical course in stages (p < 0.01) and no limitation (p = 0.02). The stay in hospital lasted longer in the first group of patients. No differences were found when comparing: age, sex, place of residence, state at onset, type of transport to the hospital, vascular risk factors apart from smoking, past history of cerebrovascular illness, time of onset of symptoms, state of sleeping-wakefulness, initial symptoms and accompanying symptoms apart from changes in level of consciousness and motor defect.

CONCLUSIONS

Factors determining delay in the hospital admission of patients with cerebrovascular disorders are: smoking, the clinical picture (alteration of consciousness, motor disorders) and the initial course of symptoms.

[Contralateral hyperhidrosis secondary to the pontine infarct]

Unilateral hyperhydrosis due to a cerebral infarct is a clinical sign rarely described in the literature, the significance of which is unknown and may be due to a lesion of the crossed sympathetic inhibitory tract. We describe the case of a patient with contralateral hyperhydrosis due to a hemipontine infarct.

[Neuropsychological disorders due to left fronto-striatal lesions: a longitudinal study of an adolescent]

Relatively little is known of the neuropsychological consequences of isolated frontal-striatal lesions in children. We study the case of an adolescent boy who suffered a stroke in the left hemisphere at the age of 11. In addition to the expected frontal dysfunctions, the patient at first suffered lowered IQ and attention disorder with hyperactivity. Four years after the stroke, only frontal lobe dysfunctions (difficulties in planning, anticipating, responding, generating words, attending, and sequencing with loss of mental flexibility) persisted. The functional recovery might have come about because the right hemisphere striate assumed functions of the left hemisphere. The persistence of frontal dysfunctions favors specialization of the left frontal lobe and the relatively early maturity of this cortical structure.

[A retrospective study of potential benefits of thrombolytic drugs in a stroke]

We carried out a retrospective analysis into the possible uses of thrombotic drugs on 190 consecutive patients with ischaemic stroke who had been admitted to the Neurological Service of the Barcelona 'Hospital de la Santa Creu i Sant Pau' in accordance with exclusion criteria commonly accepted for the use of this type of medication. We thus analyzed the initial symptoms, type of instauration, etiological diagnosis and topographical diagnosis. In those patients who could be possible candidates for such treatment with these drugs we assessed their disability variations (on the Rankin scale) at the end of two weeks using currently available therapeutic means. 70% of patients would subsequently be excluded from our study. Among reasons for exclusion were especially minor neurological deficiencies, age and latency time. As for patients included, most predominant factors were immediate instauration, cardioembolic etiological mechanism and severe onset symptomatology (motor disorder, awareness and language abnormalities). We observed a substantial spontaneous improvement in 7% of patients. This fact is especially clear in cardioemboligenic etiology patients. Bearing the spontaneous improvement cases in mind, we concluded that some 23% of patients with ischaemic cerebrovascular pathology could benefit from thrombotic drugs in our milieu.

Presurgical identification of the primary sensorimotor cortex by functional magnetic resonance imaging

The ability of functional magnetic resonance (MR) imaging to detect a selective sensorimotor cortex activation in healthy subjects and the feasibility of motor activation in patients with lesions around the central sulcus were investigated. Twenty-five healthy volunteers performed 100 motor activation trials, using a variety of motor tasks, which were monitored by several image analysis methods. The functional images were obtained using a 1.5-tesla standard MR imaging system magnet with blood oxygenation level-dependent contrast. Four patients were assessed using functional MR imaging and invasive cortical mapping. Rolandic cortex activation was observed in 98% of the trials performed on healthy subjects in which no head motion occurred. Nevertheless, the cortical response was not selective in a task-rest analysis due to concurrent activation of neighboring regions. Across-task comparison analyses were useful in cancelling nonrelevant activity in most cases (86%). In the patient group, the region identified as the sensorimotor cortex by invasive means corresponded accurately to the area that was activated in functional MR imaging. Present data support the feasibility of detecting selective activation of the rolandic cortex, even in the clinical setting, leading the authors to suggest the usefulness of this widely available technique in surgical planning.

Hemorrhagic stroke as a complication of bacterial meningitis in adults: report of three cases and review

We describe three adults who had hemorrhagic strokes during the acute phase of bacterial meningitis (BM). We also report the results of a literature review and a review of the charts of 296 adults treated at our hospital for acute BM. The diagnosis of hemorrhagic stroke was made based on the results of cerebral computed tomography (CT) for two of 92 patients with BM who had CT performed and by means of lumbar puncture and a postmortem study in one other case. Two patients died of cerebral bleeding. Although the frequency of hemorrhagic stroke was only 2.1% among adults with acute BM, it is a major determinant of prognosis for such patients.

[Hematological changes and cerebrovascular disorders]

Stroke is due to abnormalities in the vascular wall, heart disease or hematological abnormalities. This last cause has a low causal rate in stroke but despite this its importance is self evident given that there still exists a number of stroke patients where etiology cannot be established. An exhaustive check was carried out on the different hematological phenomena which may play a part in the etiology of ischaemic or hemorrhagic strokes. We analyzed abnormalities in the red series, white series and blood cells; coagulapathies; discrasias of the plasmic cells and antiphospholipid antibodies. For each of the hematological entities, conceptual criteria, their role in brain hemorrhage or ischaemia, and therapeutic measures were established.