Fábio Iuji Yamamoto

European Stroke Initiative Recommendations for Stroke Management

This article summarises recommendations for acute management of stroke by the European Stroke Initiative (EUSI), on behalf of the European Stroke Council (ESC), the European Neurological Society (ENS), and the European Federation of Neurological Societies (EFNS).

Stroke as the First Manifestation of Calcific Aortic Stenosis

Heart valve calcifications are rarely recognized as a potential source for cerebral embolism. Previous studies have identified mitral, but not aortic, valve calcifications to be risk factors for stroke. Based on these studies, heart surgery is unlikely to be indicated in patients who present with a stroke and an ‘incidental’ aortic valve calcification. We report a case of a 46-year-old man presenting with acute onset of left-sided weakness and numbness. A previous smoking history was the only cardiovascular risk factor found. Head CT scan revealed a right middle cerebral artery territory infarct and an adjacent high-density lesion. CT angiography demonstrated the presence of calcific embolic material in the middle cerebral artery. A search for embolic sources revealed a calcific aortic stenosis (CAS). Initially placed on coumadin, the patient developed silent myocardial infarction 2 months later, presumed to be also embolic in origin from the CAS. After aortic valve replacement, the patient has been symptom-free during a 2-year follow-up. In conclusion, CT angiography may be the method of choice for detecting calcific cerebral emboli, and demonstration of a causal relationship between CAS and an embolic stroke by CT angiography may be an important adjunct in surgical decision-making.

Dissecção espontânea cervical carotídea e verbal: estudo de 48 pacientes

OBJECTIVE To report a Brazilian series of spontaneous cervical arterial dissections, risk factors, warning symptoms, clinical manifestations, diagnostic tests, treatment and prognosis. METHOD We performed the retrospective analysis of clinical and neuroradiological records (MRI, A-MRI and Angiography) of patients with this diagnosis who were evaluated in a tertiary hospital for the period of 1997-2003. RESULTS 48 patients (24 men) with median age 37.9 years: 26 patients with unilateral internal carotid dissection (ICAD), 15 with unilateral vertebral artery dissection (VAD) and 7 with multivessel dissections. All patients presented neurological deficits. Hypertension, smoking and dyslipidemia were the main risk factors. More than 80% of patients presented at least one initial symptom, most of them temporoparietal headache. 44% of patients with VAD and only 3.4% of patients with ICAD had neck pain. The median interval between the onset of symptom and the appearance of neurological deficit was 5.4 days for ICAD and 13.5 days for VAD. Five patients with ICAD presented preceding TIA. Angiography was performed in 93% of patients. In 42% of these patients, MRI and A-MRI were associated. In three patients the diagnosis was made just through cervical MRI. 75% of patients received anticoagulation. Two patients received intravenous thrombolytic therapy with no complications. Prognosis was good for all patients but two patients with bilateral ICAD died. CONCLUSION Our results are similar to the literature, except for the low frequency of neck pain in ICAD patients and predominance of temporoparietal headache in cervical artery dissection patients. Vascular risk factors were commonly found.

Spontaneous cervical artery dissection: an update on clinical and diagnostic aspects

Disseccao arterial cervical espontânea (DACE) e uma laceracao ou ruptura na parede de arterias cervicais responsaveis pela irrigacao sanguinea cerebral: arterias carotidas internas e arterias vertebrais. E responsavel por cerca de 25% dos acidentes vasculares cerebrais isquemicos em pacientes abaixo de 45 anos de idade. Ao longo das duas ultimas decadas, com a maior conscientizacao sobre suas manifestacoes clinicas e o avanco das tecnicas de neuroimagem, a DACE tem sido diagnosticada mais precocemente, tornando-se o tipo de lesao vascular mais comumente identificado nas arterias cervicais, sendo superada apenas pelas lesoes ateroscleroticas. Esta revisao e uma atualizacao sobre a epidemiologia, segmentos arteriais mais vulneraveis, fatores de risco, manifestacoes clinicas, diagnostico, tratamento e prognostico da DACE.Spontaneous cervical arterial dissection (SCAD) is a non-traumatic tear or disruption in the wall of the internal carotid arteries or the vertebral arteries. It accounts for about 25% of strokes in patients aged under 45 years. Awareness of its clinical features and advances in imaging over the last two decades have contributed to earlier identification of this condition. SCAD has become the commonest form of vascular lesion identified in the cervical carotid and vertebral arteries, second only to atherosclerosis. This review is an update on the epidemiology, vulnerable arterial segments, risk factors, clinical features, diagnosis, current treatment and prognosis of SCAD.

Bilateral occipital infarcts associated with carotid atherosclerosis and a persistent hypoglossal artery

The persistent hypoglossal artery (PHA) is the second most common persistent embryological carotid-basilar connection and usually represents an incidental finding in cerebral arteriograms. The hypoglossal artery connects the primordial carotid artery with the longitudinal neural arteries, which later form the basilar artery. The PHA leaves the internal carotid artery as an extracranial branch, enters the skull through the anterior condyloid foramen, the hypoglossal canal and joins the caudal portion of the basilar artery. We report magnetic resonance and digital subtraction angiography findings in the first case of bilateral occipital infarctions associated with PHA and carotid atherosclerosis. The probable mechanism underlying bilateral occipital infarcts was embolism from the carotid territory to the posterior cerebral arteries. PHA may present a challenge in diagnosis and management of patients with carotid atherosclerosis and vertebrobasilar ischemia.

Stroke management in a university hospital in the largest South American city

OBJECTIVE To describe characteristics and provision of care for patients admitted with cerebrovascular disorders (CVD), focusing on ischemic stroke (IS), in a large, public, academic hospital in São Paulo, Brazil. METHOD We retrieved information about 357 patients with CVD admitted to the Neurology Emergency Department (NED) and Neurology Ward (NW) of our institution. We described patient characteristics and management of IS in NED and in NW. RESULTS IS was diagnosed in 79.6% of CVD patients admitted to NED; 2.7% were submitted to thrombolysis. Extent of IS investigation and management were significantly different in NED and NW. CONCLUSION IS patients in our center were younger than in developed countries. IS management was significantly influenced by patient characteristics. This information can aid in planning strategies to decrease stroke burden.

Methylenetetrahydrofolate reductase gene polymorphism is not related to the risk of ischemic cerebrovascular disease in a Brazilian population

PURPOSE Data are conflicting concerning the risk for ischemic stroke associated with a common polymorphism in the gene encoding 5,10-methylenetetrahydrofolate reductase C677T, which predisposes carriers to hyperhomocysteinemia. A meta-analysis study suggested that the 5,10-methylenetetrahydrofolate reductase 677TT genotype might have a small influence in determining susceptibility to ischemic stroke. METHODS We analyzed the 5,10-methylenetetrahydrofolate reductase 677TT genotype polymorphism in Brazilian subjects with ischemic stroke, using a case-control design. RESULTS We compared 5,10-methylenetetrahydrofolate reductase genotypes in groups of subjects presenting ischemic stroke (n = 127) and normal control (n = 126) and found an odds ratio of 1.97 (95% CI, 0.84-4.64) in a multivariate analysis in which results were adjusted to baseline clinical characteristics of study participants. CONCLUSION We found that the homozygous 5,10-methylenetetrahydrofolate reductase C677T genotype was not a risk factor for ischemic stroke in these Brazilian subjects.

Acidente vascular cerebral isquêmico em uma enfermaria de neurologia: complicações e tempo de internação

INTRODUCTION: Purposes of this study were: evaluate complications and length of stay of patients admitted with diagnosis of ischemic stroke (IS) in the acute or subacute phase, in a general Neurology ward in Sao paulo, Brazil; investigate the influence of age, risk factors for vascular disease, arterial territory and etiology. METHODS: Data from 191 IS patients were collected prospectively. RESULTS: Fifty-one patients (26.7%) presented at least one clinical complication during stay. pneumonia was the most frequent complication. Mean length of stay was 16.8+-13.8 days. Multivariate analysis revealed a correlation between younger age and lower complication rates (OR=0.92-0.97, p < 0.001). presence of complications was the only factor that independently influenced length of stay (OR=4.20; CI=1.928.84; p<0.0001). CONCLUSION: These results should be considered in the planning and organization of IS care in Brazil.

Intracranial vertebral artery dissection presenting as subarachnoid hemorrhage: successful endovascular treatment

Introduction– Intracranial vertebral artery dissection is a rare condition which may present as subarachnoid hemorrhage. In this situation, treatment is controversial. Case report– A case of intracranial right vertebral artery dissection in a 55‐year‐old woman presenting with subarachnoid hemorrhage is reported. The patient underwent therapeutic occlusion of the dissected artery through microcatheterization using pushing detachable platinum microcoils and had a good outcome. At this moment, the patient has a normal neurologic examination and a control digital subtraction angiography 1 year after the procedure showed an occluded right vertebral artery at V3; there was retrograde flow in the right intracranial vertebral artery up to the origin of a meningeal branch; the artery was thin and had mural irregularities, without any evidence of aneurismatic dilatation. Discussion– We review the literature and discuss the role of endovascular therapy and other therapeutic options in the treatment of this condition.

Treatment of subclavian steal syndrome with percutaneous transluminal angioplasty and stenting: case report.

Subclavian steal syndrome refers to the association of neurological symptoms related to vertebrobasilar insufficiency and the phenomenon of subclavian steal. We report the case of a 63 year-old male patient that presented subclavian steal syndrome and severe proximal (80%) stenosis of the left subclavian artery. The patient was submitted to percutaneous transluminal angioplasty and stenting on the left SA. The procedure was well tolerated and immediately afterwards, there was complete remission of the symptoms and of the phenomenon of subclavian steal evaluated by angiography and transcranial doppler. We propose that percutaneous transluminal angioplasty with stenting placement is a good therapeutic option for subclavian steal syndrome.