Antonio Saiz

Antiphospholipid Syndrome of Late Onset: A Difficult Diagnosis of a Recurrent Embolic Stroke.

A 77-year-old woman with atrial fibrillation (AF) treated with warfarin had a cortical left middle cerebral artery (MCA) stroke (October 2009, international normalized ratio [INR], 1.6) and a cortical left frontal stroke (October 2011, INR, 1.9). Anticoagulation was adjusted. In October 2011, she had a right frontal stroke (INR, 2.3). Acetylsalicylic acid (ASA) was temporally added to the treatment. In June 2013, she had a left occipital stroke (INR, 2.3). Warfarin was changed to rivaroxaban. In August 2013, she had a right occipital stroke. ASA 100 was added to the treatment. On all occasions, repeated neurovascular studies and echocardiography were normal. Diagnoses were cardioembolic stroke. In November 2013, she was admitted because of a left MCA stroke. A complete blood analysis showed the presence of anticardiolipin, anti-b2-glycoprotein antibodies, and lupus anticoagulant. Primary antiphospholipid syndrome (APS) was later confirmed. APS should be considered in young stroke patients, however is not frequent in stroke patients older than 70 years with several cerebrovascular risk factors. The existence of AF in our patient with several embolic strokes made the cardiembolic etiology likely. Uncommon causes of stroke were not considered despite the repetition of the ischemic events. Thus, a wider etiological study should be made in all patients with a recurrent stroke regardless of age, such as a complete blood analysis including immunology study in order to exclude an APS of late onset.

CADASIL: how to avoid the unavoidable?

All three siblings (one female/two males) of a family presented successively with cerebrovascular events at the ages of 55, 63 and 65. The first one manifested extensive left subcortical haemorrhage and both the second and third patient, showed left lacunar ischemic stroke. Their mother had died from vascular dementia at the age of 60 after several subcortical ischaemic strokes. Their maternal grandfather had died in his fifties from haemorrhagic stroke. All of them showed extensive white matter involvement. The genetic study revealed a mutation in exon 11 of the Notch3 gene in two family members. They were diagnosed with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Although CADASIL is a well-established disease, little is known about this disorder. The fact that all three siblings presented with CADASIL successively may appear disheartening, further studies are needed in order to control the clinical course of this devastating and unavoidable disorder.

Chronic migraine does not increase posterior circulation territory (PCT) infarct-like lesions

UNLABELLED Two population-based studies have found an increased prevalence of posterior circulation territory (PCT) infarct-like lesions in migraine, which seemed to increase with attack frequency. OBJECTIVE To determine whether chronic migraine (CM) patients are at increased risk of PCT infarct-like lesions. METHODS We prospectively obtained brain MRIs from adult women fulfilling CM criteria. To keep radiologists blinded we also obtained brain MRIs in 15 episodic migraine (EM) patients. MRIs were acquired on a 1.5 T unit. Protocol included whole brain weighted images in sagittal T1 (5 mm slices), axial FLAIR T2 (3 mm) and combined proton density and T2 fast spin echo (3 mm). Two independent neuroradiologists carefully analyzed all the images. RESULTS One hundred women with CM participated. Their ages ranged from 18 to 68 years (mean 43.7) and the length of CM ranged from 0.5 to 38 years (mean 9.8). Sixty-three patients (63%) had at least one vascular risk factor. Thirty-three met analgesic overuse criteria. Fifty-one had a history of migraine with aura attacks, though aura frequency was below one per month in all patients except one. Eleven were not on preventatives. We found PCT infarct-like lesions in only 6 CM patients aged 42-64 years (mean age 54 years) who had at least two vascular risk factors. CONCLUSIONS As frequency of PCT infarct-like lesions in our CM patients was in the low range than that found for EM in general population studies, we conclude that frequency of migraine attacks itself is not a factor increasing PCT infarct-like lesion risk.

Endovascular treatment in the acute and non-acute phases of carotid dissection: a therapeutic approach

Background Carotid dissection (CD) may, in certain cases, lead to significant stenosis, occlusion, or pseudoaneurysm formation, causing embolic stroke or hemodynamic failure, despite medical therapy. Objective To evaluate the results of endovascular treatment and clinical outcomes of patients with CD. Methods A four-hospital retrospective study of endovascular treatment of extracranial CD in which medical treatment had failed or patients presented with a National Institute of Health Stroke Scale (NIHSS) score ≥8. Results Thirty-eight patients (mean age 46.6±13.5 years, 78.9% male, 84.2% spontaneous CD, 44.7% left CD and 26.3% bilateral CD) were analyzed. In 24 patients (63.2%) treatment was undertaken in the acute-phase CD (APCD). IV recombinant tissue plasminogen activator was administered in 7 (29.2%) APCD cases. The patients with APCD exhibited a high rate of successful revascularization (Thrombolysis In Cerebral Infarction ≥2b; 19 patients (79.2%)), a low risk of symptomatic intracranial hemorrhage (n=2 (8.3%)), and good global functional outcomes (modified Rankin Scale (mRS) ≤2; n=17 (70.8%)). Good recanalization correlated (p=0.001) with good clinical evolution (mRS ≤2) in the patients with APCD. Of the 14 patients with non-acute phase CD (NAPCD), seven were treated for pseudoaneurysm with multiple stents (six patients) or covered prostheses, with stenosis being treated in the remaining seven patients. Conclusions Endovascular treatment of selected cases of patients with CD associated with thromboembolic events and hemodynamic failure after unsuccessful medical therapy is a safe and effective method of restoring vessel lumen integrity, with good short-term clinical evolution.

Fluctuating neurological symptoms in demyelinating disease mimicking an acute ischaemic stroke

Fluctuating neurological symptoms in an older patient most often point towards a cerebral ischaemic pathology. The authors present a 66-year-old male patient suffering from a fluctuating right hemiparesis, with an initial diagnosis of ischaemic stroke. The brain and cervical MRI showed demyelinating lesions with abnormal cerebrospinal fluid (CSF) and visual evoked potentials and the patient was successfully treated with intravenous corticosteroids. Demyelinating disease in older patients could be more frequent than expected. It should be considered even in older patients with fluctuating neurological symptoms. MRI and CSF analysis are critical to provide an accurate diagnosis.

Parkinson’s Disease Database Analysis of Stereotactic Coordinates Related to Clinical Outcomes

Parkinson’s Disease is one of the leading movement disorder diseases. It is the fourth most common neurological disease, after migraine, stroke and epilepsy. The motor symptoms of the disease significantly impair daily living and quality of life and exact a high burden on both patients and their caregivers. Deep Brain Stimulation is a proven therapy for this disease, getting positive outcomes while reducing medication. In this paper, stereotactic system used for Deep Brain Stimulation (DBS) procedures will be described. Different planning methods will be observed and compared to the gold standard normally used, neurophysiological coordinates recorded intra-operatively. MRI, CT scan and direct calculation of stereotactic coordinates will be compared and group in three different groups, according to DBS therapy outcomes: “very good DBS therapy”, “good DBS therapy” and “not major improvement”.

Long-Term Results of Deep Brain Stimulation of the Mamillotegmental Fasciculus in Chronic Cluster Headache

Background: Deep brain stimulation (DBS) and the proper target for chronic cluster headache (CCH) are still subjects of controversy. Objectives: We present our long-term results of analysis of the target and its structural connectivity. Methods: Fifteen patients with drug-resistant CCH underwent DBS in coordinates 4 mm lateral to the III ventricular wall and 2 mm behind and 5 mm below the intercommissural point. The clinical parameters recorded were the number of weekly attacks, pain intensity, and duration of the headache. Structural connectivity was studied using 3-T MR diffusion tensor imaging (DTI). Results: All of our patients improved from a mean of 39 attacks/week to 2; pain intensity decreased from 9 to 3 out of 10, and the mean cephalalgia duration decreased from 53 to 8 min. The mean stereotactic coordinates of the effective contact location were 6.1 mm lateral to the midcommissural point and 1.2 mm behind and 4.0 mm below the intercommissural point. DTI analysis showed that this target was connected to tracts and nuclei of the posterior mesencephalic tegmentum, specifically the dorsal longitudinal and mamillotegmental fasciculi. Conclusions: Our data showed DBS to be a safe and useful procedure for the treatment of drug-resistant CCH; the rate of improvement was higher than those found in other series. Although these are promising results, larger series targeting those fasciculi with a longer follow-up are needed.

Analysis of endovascular treatment of ruptured microaneurysms compared with ruptured larger aneurysms

Objective To retrospectively analyze the complications and outcome of the endovascular treatment of ruptured microaneurysms compared with the treatment of ruptured larger aneurysms. Methods 40 ruptured cerebral microaneurysms treated by endovascular techniques were selected retrospectively and compared with 207 larger ruptured cerebral aneurysms treated by endovascular techniques during the same time period. Medical charts and imaging studies were reviewed to analyze baseline clinical and epidemiologic characteristics, procedural complications, and clinical outcomes Results Cerebral microaneurysms had a higher incidence of intraoperative technical ruptures (13.5% vs 2.9%, p<0.005). The number of thromboembolic complications was not increased. Patient prognosis was similar for the two groups (mean modified Rankin Scale score 1.81 vs 2.09, p>0.1). Conclusions Coiling of cerebral microaneurysms has a reasonable safety profile with good clinical outcomes, similar to coiling of larger aneurysms. In our experience, the systematic use of remodeling balloons, operator experience, and the ability to manage complications are the reasons for the satisfactory results.

Neuropsychiatric Systemic Lupus Erythematosus and Cognitive Impairment: A Complex Issue with a Dark Prognosis

Aims: Neuropsychiatric systemic lupus erythematosus (NPSLE), may present as a wide range of symptomatology where cognitive impairment could play a key role in the prognosis of SLE patients. Presentation of Case: A 24 year-old female was admitted in 1999 in unconsciousness. Cranial MRI showed two thalamo-mesencephalic lesions and the patient was discharged home with a diagnosis of metabolic and/or toxic encephalopathy. One year later systemic lupus erythematosus was diagnosed. Following up showed memory disturbance with several strokes and atrophy in neuroimaging, and positivity of antiphospholipid antibodies. Anticoagulation was indicated with an irregular compliance. In March 2010 the patient was admitted due to generalized articular pain and hemoptoic sputum due to bad control of the anticoagulation. One month later she was admitted to Intensive Care Unit due to acute pulmonary edema and acute renal failure. In June 2010, the

Progressive back pain due to epidural hygroma: an infrequent complication of lumbar puncture in adults

A 25-year-old woman was admitted to the emergency department with orthostatic headache, nausea and dorsal stabbing pain not relieved with decubitus. Two days prior, she had undergone lumbar puncture after consulting for malaise, fever and headache. After admission, the pain progressed to the cervical and lumbar areas, though neurological examinations were normal. A spinal MRI showed an epidural cerebrospinal fluid (CSF) collection, which extended from D1 to S1 vertebral levels, displacing the spinal cord forward and surrounding the thecal sac (figure 1). During the following 48 h, the pain worsened, such that lying prone was the only position the patient tolerated. Analgaesia with NSAIDs, opioids, corticoids and caffeine failed to provide relief, so 5 days after admission an epidural blood patch (EBP) was decided on. Twenty cubic centimetres of autologous blood were injected into the epidural space within the L4–L5 level. After the procedure, the back pain subsided …