Araceli Alonso-Cánovas

Off-label intravenous thrombolysis in acute stroke.

Background and purpose: Therapy for stroke with intravenous tissue plasminogen activator (IV‐tPA) is hampered by tight licensing restrictions; some of them have been discussed in recent literature. We assessed the safety and effectiveness of off‐label IV‐tPA in the clinical settings.

Stroke mimics treated with thrombolysis: further evidence on safety and distinctive clinical features.

Background: Patients who present with symptoms mimicking ischaemic stroke (IS), but have a different diagnosis, are known as stroke mimics (SM). The necessity for rapid administration of intravenous thrombolysis in patients with acute IS may lead to treatment of patients with conditions mimicking stroke. A variable proportion of patients with SM (1.4–14%) are currently treated with intravenous tissue plasminogen activator therapy (IV-tPA). The outcome of these patients is generally favourable and complications are rather infrequent. We aimed to determine the frequency, clinical features and prognosis of SM patients treated with IV-tPA in an experienced stroke centre. Methods: A prospective registry was assembled with patients treated with IV-tPA at our stroke unit from January 2004 to December 2011. We recorded age, gender, baseline National Institutes of Health Stroke Scale (NIHSS) score, treatment delay, vascular risk factors, clinical syndrome and aetiology. We retrospectively analysed the clinical characteristics of SM, safety (symptomatic intracranial haemorrhage and mortality) and outcome measures (modified Rankin Scale at 3 months, mRS) and compared them with IS patients. Results: 621 patients were treated with IV-tPA during the study period, 606 (97.5%) were IS and 15 (2.4%) were SM. The aetiology of SM was somatoform disorders (5), headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) syndrome (3), herpetic encephalitis (2), glial tumours (2), and migraine with aura, focal seizure and cortical vein thrombosis in single cases. SM were younger (72 ± 14 vs. 53.7 ± 16 years, p < 0.05), had a lower baseline deficit [NIHSS 13 (9–18) vs. 8 (5–10), p < 0.05], fewer vascular risk factors, and left hemisphere symptoms were predominant (80 vs. 52.4%, p < 0.05). Global aphasia without hemiparesis (GAWH) was the presenting symptom in 8 (54%) SM and 44 (7%) IS (p < 0.05). Multimodal computed tomography was performed in 3 SM patients and showed perfusion deficits in 2 of them. No intracranial haemorrhage or disability (functional outcome at 3 months, mRS >2) was recorded in any SM patient. Conclusions: The use of intravenous thrombolysis appears to be safe in our SM patients, and prognosis is universally favourable. Somatoform disorder and HaNDL syndrome were prominent causes, and GAWH the most common presentation. The safety of thrombolysis in SM suggests that delaying or withholding treatment may be inappropriate: the benefit of thrombolysis in case of IS may outweigh the risks of treating an SM. Further studies may assess the future role of multimodal computed tomography in the differential diagnosis between IS and SM.

Successful intravenous thrombolysis in acute ischaemic stroke in a patient on rivaroxaban treatment

Successful intravenous thrombolysis in acute ischaemic stroke in a patient on rivaroxaban treatment -

Neurology at the airport

Objectives Neurological problems are reported to be common in air travellers. The authors aimed to study neurological problems which might be associated with air traffic in a systematic way. Methods The authors analysed a prospective registry of all the patients referred from Madrid-Barajas International Airport to the emergency department of their tertiary university hospital (Hospital Universitario Ramón y Cajal), for whom a neurological consultation was required, during a period of 21 months. Results 77 patients with a history of air travel presented with neurological problems and were included in the analysis. Fifty-nine (76.6%) were male, and the mean age was 45.9 (range 8–89, SD 17.5). Onset of symptoms was after landing in 44 subjects (58.7%), during the flight in 31 (41.3%), and unknown in two (5.1%). Thirty-nine (50.9%) had seizures, 18 (23.4%) had a stroke, and 20 (26%) other diagnosis. Sixty-one per cent of the patients with seizures had no previous history of epilepsy. Seizures on presentation were significantly associated with the use of drugs (p=0.0008), and most of the cases with known epilepsy admitted non-adherence to treatment. Three ‘body packers’ were admitted with seizures secondary to intra-abdominal cocaine pack rupture. Of eight ischaemic strokes, five had high-grade carotid stenosis, and one case had economy-class stroke syndrome. Six patients with stroke were eligible and treated with intravenous thrombolysis. Conclusion In our series of neurological problems among air travellers, drug-induced seizures and ischaemic strokes due to large-artery atherosclerosis were the commonest observed diagnoses.

The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis mimicking an acute stroke

The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) can present as sudden onset of focal neurological deficits which are clinically and radiologically indistinguishable from an ischaemic stroke. Its diagnosis requires a lumbar puncture (LP), which contraindicates intravenous thrombolytic therapy (IV‐tPA).

Primary cerebral lymphomatoid granulomatosis as an immune reconstitution inflammatory syndrome in AIDS

First described by Liebow [1, 2], lymphomatoid granulomatosis (LG) is an infrequent B-cell multisystemic proliferation related to Epstein–Barr Virus (EBV) [3]. The lungs are the principal location, but the central nervous system (CNS) may also be affected [4]. Primary cerebral LG is rare [5]. In human immunodeficiency virus (HIV) infected patients, four cases have been reported, only once related to an immune reconstitution inflammatory syndrome (IRIS) after highly active antiretroviral therapy (HAART) [6–9]. Histological findings are essential for diagnosis [10]. We report here a case of primary CNS LG after starting HAART. A 44-year-old woman with a colorectal adenocarcinoma treated with surgery and chemotherapy was admitted to our hospital because of Pneumocystis Jirovecii pneumonia and diagnosed with HIV infection. CD4? count was five cells/ ll and HIV viral load 5.17log. HAART was initiated with efavirenz 600 mg, emtricitabine 200 mg and tenofovir 300 mg daily. She progressively developed confusion, disorientation, memory loss and mild aphasia. Magnetic resonance imaging (MRI) showed a diffuse, periventricular leukoencephalopathy with multiple hypointense nonenhancing areas in T1-weighted sequences. Cerebrospinal fluid (CSF) contained proteins of 1.12 g/l, 3 cells/mm and normal glucose (51 mg/dl). CSF polymerase chain reaction (PCR) for herpes viruses and polyomaviruses, serology for toxoplasma and syphilis, CSF and urine PCR and culture for Mycobacterium tuberculosis were negative. A total body tomography did not reveal other lesions. One month later she developed a right arm paresis and her aphasia worsened, presenting difficulties in understanding verbal commands and in repeating short sentences, a nomination deficit and frequent paraphasias. MRI showed leukoencephalopathy progression with a left frontal mass lesion (Fig. 1). CSF examination yielded two cells/mm, glucose of 45 mg/dl, and proteins of 2 g/l. CSF PCR for herpes viruses, polyomaviruses and Mycobacterium tuberculosis, rapid plasma reagin, cryptococcal antigen, and cytology

Substantia Nigra Echogenicity Predicts Response to Drug Withdrawal in Suspected Drug-Induced Parkinsonism

Response to drug withdrawal in patients with suspected drug‐induced parkinsonism (DIP) is of prognostic and therapeutic importance, but cannot be predicted solely on clinical information. The aim of this study was to validate SN hyperechogenicity (SN+) assessed by transcranial sonography as a predictor of response to drug withdrawal in this group of patients.