David Sáez M

Caracterización clínica de 450 pacientes con enfermedad cerebrovascular ingresados a un hospital público durante 1997

Background: In Chile, cerebrovascular diseases are the fifth cause of death among men and the third cause among women. Aim: To assess the clinical features and management of patients with cerebrovascular disease admitted to a public hospital during 1997. Patients and methods: A retrospective analysis of clinical records of patients discharged with a diagnosis of cerebrovascular disease. Those records in which there was discordance between the discharge diagnosis and the clinical picture were not considered in the analysis. Results: Of the 563 discharges from the hospital with the diagnosis of cerebrovascular disease, 487 records were located and 450 were considered in the analysis. Fifty four percent of patients were male and ages ranged from 17 to 96 years old. Fifty one percent of patients had an ischemic stroke, 34% a cerebral hemorrhage, 12% a subaracnoidal hemorrhage and 3% a transient ischemic attack. There was a history of hypertension in 64% patients and 20% had an adequate treatment. Eighteen percent were diabetics, 34% had a heart disease and 20% had a previous episode of stroke. Mean hospital stay was 6.3 days in the emergency room and 11 days in the neurology ward. Hospital infections appeared in 21% of patients (respiratory in 68% and urinary in 22%), lethality was 30.5% and a CAT scan was done in 94%. At the moment of admission, 10% of patients had an evolution of less than 2 hours, 27% had an evolution between 2 and 6 hours and nine cases were potential eligible for thrombolysis. Conclusion: This is a picture of the local features of patients with cerebrovascular diseases that can be used as a reference for future studies. (Rev Med Chile 2000; 128: 1227-36)

Mielopatía por déficit de vitamina B12: caracterización clínica de 11 casos

: A risk factor was identified in 10 cases and themost common was an age over 60 years old. The main presenting symptom was the presence ofparesthesias. On admission, sphincter dysfunction, posterior column and pyramidal syndromescoexisted in nine patients. A level of sensitive deficit was detected in six. Ten patients had macro-cytosis and eight were anemic. Serum vitamin B12 was measured in ten and in nine, it was be-low 200 pg/ml. The mean lapse between onset of symptoms and treatment was eight months. Allreceived intramuscular vitamin B12 in doses on 1,000 to 10,000 IU/day. Sphincter dysfunctionand propioception were the first symptoms to improve.

Plasmaféresis indicada por enfermedad neurológica: Experiencia de 140 procedimientos en 47 pacientes

One hundred fifty nine procedures were reviewed. One hundred forty (88%) were indicated forneurological diseases (44% for Guillain Barre syndrome and 29% for myasthenia gravis).Clinical improvement or eventual complications were avoided in 70% of patients with GuillainBarre syndrome and 100% of patients with myasthenia gravis. Hypotension in 10% andparesthesias in 7% were observed. All complications were successfully controlled with crystalloid orfresh plasma infusions or citrate management. In 11 cases, the procedure was interrupted due toobstruction of the venous access, that was peripheral in eight of these. The most commondifficulties of the procedure were delay in performing it in 50% of patients and insufficientexchange volumes in 30%.

Experiencia de trombolisis sistematizada en infarto cerebral agudo en un hospital público de Chile

BACKGROUND The only accepted treatment for acute ischemic stroke is thrombolysis with recombinant tissue plasminogen activator (t-PA). It was implemented in Chile in 1996, although its use was mainly restricted in Chile to private clinics. Recently, at year 2009, we have implemented this treatment in a public hospital. AIM To describe the results of treatment of acute ischemic stroke with t-PA in a public hospital in Chile. MATERIAL AND METHODS Prospective analysis of all eligible patients with acute ischemic stroke that were admitted within 4 hours of its onset and had no contraindications for thrombolysis. RESULTS In an eight months period, a total of 19 intravenous thrombolyses were performed in 12 males and seven females aged 28 to 79 years old. The mean lapse between onset of symptoms and onset of thrombolysis was 190 ± 57 min. Results were favorable, according to Rankin and National Institute of Health Stroke scales. Ninety days after treatment, 63% of patients had minimal or absent disability, 26% had moderate disability and only one (5%) had severe disability. One patient had a clinically not significant intracranial hemorrhage and one patient died six days after thrombolysis. CONCLUSIONS These results indicate that thrombolysis can be successfully implemented in Chilean public hospitals. The limitations for its use in this setting are mostly administrative.Background: The only accepted treatment for acute ischemic stroke is thrombolysis with recombinant tissue plasminogen activator (t-PA). It was implemented in Chile in 1996, although its use was mainly restricted in Chile to private clinics. Recently, at year 2009, we have implemented this treatment in a public hospital. Aim : To describe the results of treatment of acute ischemic stroke with t-PA in a public hospital in Chile. Material and Methods : Prospective analysis of all eligible patients with acute ischemic stroke that were admitted within 4 hours of its onset and had no contraindications for thrombolysis. Results : In an eight months period, a total of 19 intravenous thrombolyses were performed in 12 males and seven females aged 28 to 79 years old. The mean lapse between onset of symptoms and onset of thrombo- lysis was 190 ± 57 min. Results were favorable, according to Rankin and National Institute of Health Stroke scales. Ninety days after treatment, 63% of patients had minimal or absent disability, 26% had moderate disability and only one (5%) had severe disability. One patient had a clinically not significant intracranial hemorrhage and one patient died six days after thrombolysis. Conclusions : These results indicate that thrombolysis can be successfully implemented in Chilean public hospitals. The limitations for its use in this setting are mostly administrative

MIASTENIA GRAVIS: EMBARAZO E IMPACTO PERINATAL

SUMMARY A total of 19 pregnancies in 9 patients with myasthenia gravis are analyzed. Two exacerbations of myasthenia gravis were observed. One associated to the use of aminoglycosides to treat an acute pyelonephritis. A debut of myasthenia gravis occurred during the 24th week of gestation. There were three cases of neonatal myasthenia gravis that appeared in the same patient, two newborn died after 29 and 25 days respectively, in spite of treatment. One case of preterm childbirth was observed and six cases (35%) of intrauterine growth retardation.

Neurología y embarazo

El embarazo provoca una serie de cambios en la fisiologia de la mujer lo que puede desencadenar diferentes patologias, entre ellas neurologicas y/o descompensar enfermedades previas. Existen cuadros como complicaciones neurologicas de embarazos patologicos: encefalopatia de Wernicke, la encefalopatia posterior reversible que corresponde a una forma de manifestacion de eclampsia, enfermedades previas como epilepsias que conllevan un alto riesgo obstetrico; por un lado por la posibilidad de presentar embriopatias asociadas al uso de farmacos antiepilepticos (FAE) y por otro el riesgo que representa una crisis convulsiva en el feto, enfermedades cerebrovasculares, complicacion rara pero con una alta mortalidad materna, enfermedades extrapiramidales, infrecuentes, salvo el corea gravidico y el sindrome de piernas inquietas, esclerosis multiple, en que el embarazo previene la aparicion de brotes, debido al predominio de la inmunidad celular, neoplasias intracerebrales en que por los cambios hemodinamicos que ocurren al final del segundo trimestre y el aumento del estrogeno y progesterona, muchos tumores pueden aumentar su masa, y alteraciones perifericas como miastenia gravis (MG), hernias discales y aparicion de neuropatias por atrapamiento como el sindrome del tunel del carpo y la meralgia parestesica.

Síndrome de restauración inmune asociado a tratamiento antirretroviral y criptococosis meníngea: Caso clínico

The objective of high activity antiretroviral therapy (HAART) in patients with AIDS, is to obtain immune restoration. This means a reduction of the viral load and restitution of the CD4 cell count. A decreased rate of HIV replication improves both the number and function of CD4 cells. Nevertheless, this treatment sometimes results in the reappearance of previous symptoms from treated conditions due to opportunistic infections (ie: tuberculosis, criptococcosis, hepatitis, Pneumocystis jirovesi, toxoplasmosis, etc) or non infectious condition such as sarcoidosis, Graves disease or Kaposi sarcoma. This is known as Inflammatory Reconstitution Immune Syndrome (IRIS). We report a 37 year-old woman in stage C3-AIDS with a previous criptococcal meningitis. She was treated, achieving a marked improvement with treatment and subsequent suppressive therapy with fluconazole 200 mg/day. IRIS appeared after 8 months of ongoing antiretroviral therapy with immune restoration with the development of aseptic meningitis and intracranial hypertension. The opportunistic agent could not be identified by cultures. Additional laboratory tests excluded toxoplasmosis, tuberculosis, bacterial cerebral abscesses, syphilitic cerebral gummas, and lymphoma. Brain CT and magnetic resonance studies were compatible with brain vasculitis and leptomeningitis. The patient condition improved with general measures, such as a repeated lumbar punctures and non steroidal anti-inflammatory drugs. We conclude that this patient had an IRIS due to a Cryptococcus neoformans antigen

Aspergilosis meningovascular: Caso clínico

Resumen es: El diagnostico precoz de la infeccion por Aspergillus del Sistema Nervioso Central (SNC) es un gran desafio, donde la sospecha clinica fundamentada es cl...

Neurosífilis meningovascular y gomatosa cerebral concomitante, en paciente seronegativo para virus de inmunodeficiencia humana

Resumen es: La Neurosifi lis (NS) es causada por la invasion del Sistema Nervioso Central (SNC) por la espiroqueta Treponema Pallidum (TP), afectando primariamente l...

Muerte encefálica: la necesidad de una causa suficiente y necesaria: A propósito de un caso de deseferentación completa por síndrome de Guillain Barré

La muerte encefalica es una causa valida en la certificacion del deceso de un paciente, especialmente en condiciones de donacion de organos. Existen escasas situaciones en las que el legislador ha propuesto la realizacion de examenes complementarios para su certificacion. Presentamos el caso de un paciente con un sindrome de Guillain Barre, que llego a simular un estado de muerte encefalica, debido al compromiso motor completo, incluyendo musculatura ocular intrinseca. La falta de una condicion suficiente y necesaria para declarar la muerte del paciente lleva a la solicitud de examenes complementarios, en este caso un electroencefalograma, los que determinan la normalidad de la actividad electrica cerebral. Se recalca la necesidad de cumplir estrictamente los criterios para determinar la muerte encefalica y el no inhibirse de solicitar examenes complementarios en condiciones de duda, aun cuando la ley no siempre lo contemple.