Alexandre Pieri

Guidelines for acute ischemic stroke treatment: part II: stroke treatment

The second part of these Guidelines covers the topics of antiplatelet, anticoagulant, and statin therapy in acute ischemic stroke, reperfusion therapy, and classification of Stroke Centers. Information on the classes and levels of evidence used in this guideline is provided in Part I. A translated version of the Guidelines is available from the Brazilian Stroke Society website (www.sbdcv.com.br).

Stroke in Latin America: Burden of Disease and Opportunities for Prevention.

The epidemiological transition in Latin America toward older urban dwelling adults has led to the rise in cardiovascular risk factors and an increase in morbidity and mortality rates related to both stroke and myocardial infarction. As a result, there is an immediate need for effective actions resulting in better detection and control of cardiovascular risk factors that will ultimately reduce cardiovascular disease burden. Data from case-control studies have identified the following risk factors associated with stroke: hypertension; smoking; abdominal obesity; diet; physical activity; diabetes; alcohol intake; psychosocial factors; cardiac causes; and dyslipidemia. In addition to its high mortality, patients who survive after a stroke present quite frequently with marked physical and functional disability. Because stroke is the leading cause of death in most Latin American countries and also because it is a clearly preventable cause of death and disability, simple, affordable, and efficient strategies must be urgently implemented in Latin America.

Dissecção espontânea das artérias carótidas e vertebrais em uma população multiétnica

Spontaneous dissection of the carotid and vertebral arteries (SDCVA) is considered a rare cause of stroke, particularly in countries with multiethnic population. The objective was to evaluate the clinical and neuroimaging features of patients with SDCVA from a multiethnic population. Sixty-six patients diagnosed with SDCVA were studied at two tertiary hospitals at Sao Paulo. An initial questionnaire was completed and patients were followed prospectively. Among the patients studied, 82% were caucasian, 53% were male and the average age was 41.7 years old. The most frequent cardiovascular risk factors found were systemic hypertension and tobacco use. Other aspects evaluated were history of previous migraine, initial treatment and prognosis. In conclusion, although the population studied was multhiethnic, there was a marked predominance of caucasians. The analysis of clinical and neuroimaging data from patients with SDCVA allows a better understanding of the disease, leading to an earlier diagnosis and more appropriate treatment.

Internal carotid artery dissection presenting as cluster headache

Dr. Clecio Godeiro-Junior – Rua Dr. Diogo de Faria 650 / 33 04037-002 São Paulo SP Brasil. E-mail: cleciojunior@yahoo.com.br Cluster headache (CH) is a clinical entity characterized by strictly unilateral head pain attacks accompanied by ipsilateral autonomic phenomena. The attacks are severe, short-lasting (15–180 minutes), and may occur several times a day. Symptomatic CH cases have been described in association with different kind of lesions located in the middle fossa, near the sellar or parasellar structures although lesions of the internal carotid artery (ICA) were also described: aneurysma of ICA and internal carotid artery dissection (ICAD). We report a patient with symptomatic CH secondary to ICAD, and complete remission of his symptoms with usual treatment for CH. We obtained informed constent from the patient for publication.

Prevalence of cardiovascular risk factors among elderly Brazilians over eighty with ischemic stroke

INTRODUCTION An ischemic stroke is usually a catastrophic event, mostly in the elderly. Cardiovascular involvement is the leading cause of ischemic stroke in this age population and hence the knowledge about its risk factors is important for the definition of specific policies of prevention. PURPOSE To evaluate the prevalence of cardiovascular risk factors in patients with age equal to or above 80 in a hospital population with ischemic stroke. METHOD Retrospective study of consecutive patients diagnosed with ischemic stroke admitted to a tertiary health facility. RESULTS From September 2004 to March 2006, 215 patients were studied. There was a female preponderance (p<0.01). Among patients over eighty, 72% had hypertension and atrial fibrillation was more common among the oldest old (p<0.01). CONCLUSION Hypertension and atrial fibrillation should be treated aggressively in the elderly. Anticoagulants should be considered more often in these patients.

Spontaneous carotid dissection with hypoglossal nerve palsy as residual deficit: the importance of magnetic resonance evaluation.

Dr. Marcio Luiz Escorio Bezerra – Rua Dr. Diogo de Faria 671 / 106 04037-002 São Paulo SP Brasil. E-mail: marciobzrra@gmail.com Spontaneous dissection of the carotid artery was once considered uncommon, but nowadays neuroimaging progress has lead to an increased recognition of the pathology. It is an important cause of stroke in young patients, representing 10 to 25% of the cases. Most patients affected are in the fifth decade of life. It is not definitely established whether the cardiovascular risk factors are important in spontaneous carotid dissection; however, tobacco use, migraine and respiratory tract infections have been shown to be relevant in different studies. In spite of the term spontaneous dissection, minor precipitating events, such as rotation or hyperextension of the neck, are frequently found. The most frequent initial symptom is headache, which is reported in up to 90% of the cases, usually preceding the neurological deficit. Few patients present the classical triad of headache, ischemic stroke and Horner syndrome. Cranial nerve palsy is found in about 12% of the cases, but unusually it is the sole manifestation. We report a case of carotid artery dissection presenting as lower cranial nerve palsy and headache. The diagnosis was made through magnetic resonance imaging (MRI), using fat suppression technique, highlighting its importance in such cases.

Avaliação clínica da relação entre postura, respiração e deglutição em paciente pós-acidente vascular cerebral na fase crônica: relato de caso

The Stroke is a neurological disorder that disables more adults. The breathing, posture and swallowing have a direct relationship in this disease, thus requiring a multidisciplinary approach. The goal of this study was to conduct a clinical evaluation integrated to analyze the relationship between these disorders. This case is a female patient aged 37 with six years of diagnosis of ischemic stroke with right hemiparesis complete predominantly crural, hypertension, dysphagia and dysarthrophonia. In history, reported symptoms related to dyspnea, pain in the lumbar spine, the presence of coughing and choking and drooling to food, especially during the speech. The patient has scoliosis, thoracic kyphosis and abdominal weakness. The evaluation showed a respiratory expiratory force below the expected range. The peak cough flow is lower than expected, demonstrating not have the strength to cough. The research revealed changes in speech increased time to eat, need to drink to help swallow solid food before any leaks, the need for multiple swallows due to the sense of stasis in laryngeal-pharyngeal cavity and decreased taste and thick and viscous saliva. Using physical and speech therapy evaluations, we concluded that a patient with stroke in chronic respiratory presents alterations that may prevent it from effectively protecting the lower airways, which, added to postural changes and swallowing show the importance of integrated assessment for future therapeutic interventions more effective.

Spontaneous artery dissection in a patient with Human Immunodeficiency Virus (HIV) infection.

BACKGROUND The relationship between human immunodeficiency virus infection and stroke may be attributed in some cases to an underlying vasculopathy such as in spontaneous cervical arteries dissections. CASE REPORT We report the case of an HIV-infected patient who developed a Wallembergs syndrome due to a vertebral artery dissection. Screening laboratory exams showed hyperhomocysteinemia and also high C-reactive protein plasma levels. CONCLUSIONS This is the first case describing the association between arterial dissection (AD) and HIV-infection. We suggest that AD should also be remembered as a possible mechanism of ischemic stroke in HIV-infected patients.