Héctor Jorge Villarreal-Velázquez

Posterior reversible leukoencephalopathy syndrome (PRES) associated with severe eclampsia: Clinical and biochemical features

OBJECTIVES Posterior Reversible Encephalopathy Syndrome (PRES) and eclampsia share clinical characteristics and patients may present with a combination of these two entities. Our aim was to study the proportion of patients with eclampsia having evidence of PRES in their brain imaging. METHODS Retrospective study of pregnant patients diagnosed as having eclampsia that underwent brain magnetic resonance imaging (MRI) during their hospitalization. MRI diagnosis of PRES was assessed by 2 investigators blinded to group. RESULTS We included a total of 29 patients with eclampsia, out of which 17 (58.6%) had MRI evidence of PRES. When patients with eclampsia and eclampsia/PRES were compared, there was no difference in demographic characteristics such as age, weight or multiparity. Patients with eclampsia/PRES had higher levels of creatinine, liver enzymes, mean platelet volume and there was a trend towards higher proteinuria. Infants of mothers with eclampsia/PRES also had worse 1min APGAR scores. CONCLUSION PRES appears to accompany eclampsia in over half of all cases. The clinical picture of patients with eclampsia with or without associated PRES is similar, but certain biochemical characteristics suggest that PRES might be indicative of a more severe disease process.

Alterations in balance and mobility in people with epilepsy

PURPOSE People with epilepsy (PWE) are burdened by physical disability and side effects of antiepileptic drugs (AED) such as drowsiness and blurred vision. These factors place them at risk for reduced mobility and falls. The purpose of this study was to evaluate mobility and balance in PWE. METHODS This was a cross-sectional study of PWE and age- and sex-matched controls. We evaluated mobility and balance using the Timed Up and Go Test (TUG) and the Tinetti Mobility Test (TMT). Self-reported confidence in balance was assessed using the Activities-Specific Balance Confidence Scale (ABC). Clinical and demographic characteristics and particularly epilepsy-related variables were recorded. RESULTS We included 33 PWE and 33 controls. PWE had a mean age of 36.7years, and 61% were male. They had a mean of 1.52 of seizures per month and used a mean of 1.6 anti-epileptic drugs (AEDs). PWE scored significantly worse in all measures (TUG, TMT, ABC) when compared with controls. PWE had poor performance in 60.6% of cases in the TUG and in 48.5% of cases in the TMT, compared to none in the control group. There was good correlation between the three instruments. TUG scores were correlated with epilepsy duration, but not age, seizure control or AED use. On multivariate logistic regression, poor performance TMT was significantly associated with poor confidence in balance, according to the ABC. CONCLUSIONS PWE have significant alterations in balance and mobility, independently of AED use or seizure control. These alterations are reflected in a poor self-reported confidence in carrying out daily activities.

Difference in Stroke Knowledge between Rural and Urban Communities in a Developing Country after Community-Based Stroke Educational Campaigns: Results from a Cross-Sectional Study

Background: Ischemic stroke is a leading cause of disability and death in Mexico. Poor ability to identify signs and symptoms of ischemic stroke leads to longer hospital arrival times and precludes prompt treatment. The knowledge of stroke risk factors and warning signs in rural population is scarce. Since 2010, Stroke Education Campaigns are performed with a community-based approach. The aim of this study was to assess and compare stroke knowledge in rural and urban communities. Methods: During World Stroke Campaign, a standardized questionnaire to assess knowledge of stroke risk factors and warning signs was applied in urban and non-urban communities of Nuevo Leon, Mexico. Results: A total of 4,144 surveys were collected. Mean age was 44.2 ± 16.1 and 75.9% were women. People from rural and semi-urban areas mentioned > 3 risk factors (p < 0.001) and warning signs (p < 0.001) compared to the urban area. After logistic regression analysis, having received previous information about stroke remained significant for the knowledge of > 3 stroke risk factors and warning signs (p < 0.001; 95% CI 1.997–2.727; p < 0.001; 95% CI 1.880–3.787) respectively. Conclusions: Rural and semi-urban regions performed better than the urban population. Receiving stroke information is a determinant factor for stroke knowledge. Stroke Educational Campaigns are a cost-effective method for raising stroke awareness, thus reducing stroke burden.

Septo-optic dysplasia plus diagnosed in adulthood

Dear editor: Septo-optic dysplasia (SOD), previously termed de Morsier syndrome, is a rare congenital anomaly. It can be diagnosed (clinically) when two or more features of the classical triad of optic nerve hypoplasia, pituitary hormone abnormalities and midline brain defects are present. Seizures, developmental delay and cerebral palsy are the most frequent neurological associations [1]. Its rarity and heterogeneity often make early diagnosis difficult and it is sometimes made well into adulthood. The associated cortical malformations with SOD (SOD-plus) include a spectrum of disorders of cortical development such as schizencephaly, cortical dysplasia and polymicrogyria. A 19-year-old woman presented to the emergency department after presenting three generalized tonic-clonic seizures the previous night. She had been diagnosed with epilepsy (presenting mainly absence seizures) at age 13 and treated with valproic acid. She had no relevant perinatal or maternal history. Other relevant history included a mild delay in psychomotor development (started walking at 2 years), but she successfully completed secondary education. At age 3, she was intervened surgically to correct bilateral congenital strabismus. At age 9, she was diagnosed with panhypopituitarism after complaining of weakness and short stature and was started on hormone replacement therapy. Her seizures were under control until a year before her admission, when they started changing in phenotype, now including simple partial seizures of the left limbs. The episodes that prompted the visit to the emergency department were the first generalized tonicclonic seizures she had ever presented. Upon examination, the patient was found alert and responsive. Her speech was slow but coherent. Ophthalmoscopic examination revealed bilaterally atrophied optic nerves. She also had lateral-gaze-induced bilateral nistagmus. There were no pyramidal, sensitive or cerebellar signs. There was no fever or meningismus. Standard biochemical parameters including glucose, electrolytes and liver function tests were normal. All pituitary hormone levels were within normal range. A brain MRI revealed hypoplasia of the optic nerves and optic chiasm, agenesis of the septum pellucidum and a frontal region of cortical dysplasia and agyria (Fig. 1). Electroencephalogram showed right-sided frontal spikes and slow waves but no ictal activity. The patient was diagnosed with SOD-plus. Levetiracetam was added to her antiepileptic treatment and seizures were controlled. SOD has a reported incidence in 1/10,000 live births and can appear in either sex [1]. It has been associated with a young maternal age [2]. It can present at birth in association wi th mul t ip le congeni ta l abnormal i t ies such as microcephallus, cleft palate and undescended testes [1, 2]. Ophthalmologic findings such as strabismus, nystagmus and blurred vision are common. Pituitary hormone abnormalities might manifest as hypoglycaemia or adrenal crises. The most common midline brain defects described in the literature are agenesis of the septum pellucidum and/or corpus callosum. Neuroradiological anomalies are present in up to 90% in those with associated neurological deficits [3]. Cortical malformations in SOD-plus are usually accompanied by psychomotor developmental delay, motor deficits or seizures [4]. * Carlos R. Camara-Lemarroy crcamara83@hotmail.com

Pure lupus podocytopathy first presenting as thrombotic thrombocytopenic purpura-like syndrome

Lupus podocytopathy (LP) is an uncommon proteinuric disorder in the spectrum of lupus nephropathy. Its histological features are similar to those described in minimal change disease (MCD) with or without mesangial immune deposits. Although infrequent, a close relationship between systemic lupus erythematosus (SLE) and thrombotic thrombocytopenic purpura (TTP) is well accepted. Proteinuria in the setting of SLE has previously been associated with the development of TTP-like syndrome. As far as we know, LP first presenting as a TTP-like syndrome has never been reported. Here, we describe the case of a previously healthy 45-year-old woman who developed simultaneously these two conditions and then we briefly review the literature on the topic, emphasizing the previous cases of concurrent initial diagnosis of both SLE and MCD (n = 7) and SLE and TTP (n = 72). In conclusion, renal biopsy is central to the management of SLE patients with nephrotic syndrome. Furthermore, in a SLE patient with anemia and thrombocytopenia, TTP should be part of the differential diagnosis, even when no schistocytes were detected in peripheral blood smear.