Isidro Huete

Mechanical Fragmentation and Pharmacologic Thrombolysis in Massive Pulmonary Embolism

PURPOSE To evaluate the usefulness of mechanical fragmentation associated with intrapulmonary thrombolysis in acute massive pulmonary embolism (PE). PATIENTS AND METHODS Sixteen cases of massive PE treated with mechanical fragmentation associated with pharmacologic thrombolysis were retrospectively studied. Severity of PE was assessed with the angiographic index according to the Urokinase Pulmonary Embolism Trial (maximum value of 18; score according to whether obstruction was central or peripheral, complete or partial). Mechanical fragmentation of the emboli was performed with angiographic catheters and angioplasty balloons. Urokinase was infused directly into the thrombus during the course of 8-24 hours. The effect of therapy was measured with direct pulmonary artery pressure (PAP) and blood O2 values. RESULTS Pre- and postinfusion angiographic index mean values (+/- standard deviation) were 13.7 +/- 1.4 and 6.1 +/- 2.2 (P < .0001). Mean pre- and postinfusion PAPs were 48.2 +/- 13.4 and 18.5 +/- 7.2 mm Hg (P < .0001). PaO2 increased from 60.1 +/- 12.1 to 88.7 +/- 23.4 mm Hg (P = .01). Fourteen patients (87.5%) completely recovered. One patient died during treatment despite improvement in PAP and PaO2 parameters. There were no major hemorrhagic complications. CONCLUSIONS The data support the efficacy of mechanical fragmentation associated with pharmacologic thrombolysis in the treatment of acute massive PE, resulting in improved hemodynamics and-blood oxygenation and in decreased PAP, with low morbidity.

Massive Pulmonary Embolism: Treatment with the Hydrolyser Thrombectomy Catheter

PURPOSE To assess the efficacy of clot removal with use of the Hydrolyser thrombectomy catheter in acute massive pulmonary embolism (PE). MATERIALS AND METHODS Eleven patients (eight women, three men) with a mean age of 61 (range, 37-79) years with acute massive PE underwent percutaneous mechanical thrombectomy (PMT) with use of the Hydrolyser. In four patients with no contraindication, fibrinolysis was performed with use of urokinase at low doses after thrombectomy. RESULTS Ten patients (90.91%) recovered from massive PE and were discharged within 11 days. The Urokinase Pulmonary Embolism Trial angiographic severity indexes (mean +/- SD) were 14.7 +/- 2.6 and 7.5 +/- 2.7, respectively, before and after thrombectomy (P < .001). Partial arterial pressures of O2 increased from 72.8 mm Hg +/- 16.4 to 93.5 mm Hg +/- 5.6 (P < .005). Pulmonary artery pressure decreased from 45.5 mm Hg +/- 14.2 to 29.5 mm Hg +/- 13.6 after thrombectomy (P < .0001). Calculated by semiquantitative computed analysis, PMT with use of the Hydrolyser removed 74.06% of thrombus +/- 13.46%. One patient developed self-limited hemoptysis immediately after thrombectomy. One patient died during the procedure secondary to PE. CONCLUSION PMT with use of the Hydrolyser is effective and safe in massive PE, resulting in improved hemodynamics and blood oxygenation and decreased pulmonary artery pressure. It offers an alternative to fibrinolysis and surgical thrombectomy.

Intracranial metastasis or meningioma? An uncommon clinical diagnostic dilemma.

BACKGROUND Cerebral metastases are the most frequent brain tumors in adults and they may occasionally present as an isolated meningeal mass, suggesting a meningioma. Because of the prognostic relevance in discriminating both tumors, we review the literature and analyze four patients in whom the diagnosis of meningioma was initially made. CASE DESCRIPTION Four cases of isolated meningeal metastases are presented and in all of them a meningioma was considered as the main preoperative diagnosis. Only one patient had a history of previous cancer. The primary tumors found after pathological testing of the lesions were thyroid carcinoma, prostate adenocarcinoma, breast adenocarcinoma, and hypernephroma. The clinical and neuroimaging features as well as the differential diagnoses are discussed. The literature regarding these forms of meningeal metastases was reviewed. CONCLUSIONS Although they are uncommon, dural metastases can be mistaken for meningiomas. Our experience in these cases has led us to consider ordinary metastases as a differential diagnosis even when a meningioma is suspected. The definitive diagnosis of a meningioma should be established only after the histopathological report has been analyzed.

Risk factors for systemic embolism in patients with paroxysmal atrial fibrillation

The purpose of this study was to define the risk factors for systemic embolism in patients with recently diagnosed paroxysmal atrial fibrillation. We therefore studied 63 consecutive patients with symptomatic nonvalvular paroxysmal atrial fibrillation and performed a clinical and noninvasive cardiac, peripheral vascular, and neurologic evaluation that included two-dimensional echocardiography, 24-hour Holter monitoring, and computed tomographic brain scan. Patients with predisposing clinical conditions for systemic embolism (valvular heart or coronary artery disease) or paroxysmal atrial fibrillation (sick sinus disease, preexcitation, or thyroid dysfunction) were excluded. At entry 34 patients had idiopathic paroxysmal atrial fibrillation and 29 had hypertension. Fourteen patients had a recent systemic embolic complication: nine had a recent occlusive nonlacunar cerebrovascular accident, two had transient ischemic attacks, and three had peripheral systemic emboli that required surgery. In addition, five patients had evidence of old cerebrovascular accident on the computed tomographic scan (group 1). Forty-four patients had no systemic embolism (group 2). Results of univariate analysis showed that patients in group 1 were older (72 +/- 9 vs 63 +/- 13 years, p less than 0.05), had a higher incidence of hypertension (70% vs 35%, p less than 0.01), and had an increased left atrial diameter (4.1 +/- 0.7 vs 3.6 +/- 0.5 cm, p less than 0.05). Multiple stepwise logistic regression analysis showed that a history of hypertension and left atrial enlargement on two-dimensional echocardiography were significant independent risk factors for systemic embolism in patients with symptomatic nonvalvular paroxysmal atrial fibrillation.

Carotid artery dissection: endovascular treatment. Report of 12 patients.

The purpose of this article is to report our experience with endovascular treatment of internal carotid artery (ICA) dissection with the use of stents.

Stroke Patterns in Neonatal Group B Streptococcal Meningitis

Neonatal group B streptococcus meningitis causes neurologic morbidity and mortality. Cerebrovascular involvement is a common, poorly studied, and potentially modifiable pathologic process. We hypothesized that imaging patterns of focal brain infarction are recognizable in neonatal group B streptococcal meningitis. A consecutive case series included term neonates with the following: (1) bacterial meningitis, (2) acute group B streptococcal infection (positive cerebrospinal fluid/blood culture), (3) brain magnetic resonance imaging within 14 days, and (4) acute intraparenchymal focal infarctions (restricted diffusion). Lesions within known arterial territories were classified as arterial ischemic stroke. Clinical presentations, investigations, and neurologic outcomes were recorded. Eight newborns (50% female) with focal infarction were identified. Five presented early (<1 week), and all manifested clinical shock and elevated acute-phase reactants. Less than 50% had prenatal group B streptococcal screening, while 2 of 3 screened were negative. Two distinct patterns of focal infarction were identified: (1) deep perforator arterial stroke to basal ganglia, thalamus, and periventricular white matter (7/8, 88%), and (2) superficial injury with patchy, focal infarctions of the cortical surface (6/8, 75%). Outcomes (mean 23.8 months) were poor, with severe disability or death in 6/8 (75%). Recognizable stroke patterns contribute to severe neurologic outcomes and represent a potentially modifiable pathophysiologic process in neonatal group B streptococcal meningitis.

Limbus lumbar and sacral vertebral fractures

Abstract e evaluated the fractures of the lumbar and sacral vertebral limbus by disc impingement at the peripheral ring apophysis in 23 adults associated with trauma in 16 of them. Lumbalgia, radicular pain and narrow canal symptoms are the presenting forms of this underdiagnosed pathology. CT is the best method of examination, while plain roentgenograms and MR are usually negative. Accurate diagnosis and surgical technique with larger exposure are needed to resect the fractured fragments and protruded disc material for decompressing the roots and the dural sac. Our results were very good on the majority of cases. [Neurol Res 2002; 24: 139-144]

Hipercoagulabilidad en fibrilación auricular y su relación con factores de riesgo para embolia sistémica

Background: Atrial fibrillation is associated to a high risk of systemic embolism and to hypercoagulability. Aim: To evaluate the activation of the coagulation cascade through determinations of the thrombin-antithrombin complex in patients with atrial fibrillation and to correlate this data with the clinical and echocardiographic risk factors for systemic embolism. Patients and Methods: In 53 patients with atrial fibrillation plasma levels of the thrombin-antithrombin complex were determined on admission to a coronary care unit and 30 days later. Using a univariate and multiple regression analysis, the association basal thrombin-antithrombin with the duration of the arrhythmia, age over 70 years, previous use of antiplatelet agents, history of hypertension, mitral valve disease, diabetes, heart failure, previous systemic embolism, left atrial diameter and the presence of spontaneous contrast echo or thrombus in the left atrial appendage, was studied. Results: Basal thrombin-antithrombin values were 40.1±69 mg/L (Median 8.34 [3.0-47.5]) compared to 2.7±3.3 mg/L in healthy controls (p <0.001). No significant correlation was found between activation of the coagulation cascade and risk factors for systemic embolism. There were no significant differences in thrombin-antithrombin values between patients with chronic or paroxysmal atrial fibrillation (29.5±43 mg/L and 49.4±83 mg/L respectively). Mean thrombin-antithrombin values in patients under antiplatelet agents were lower than in those without treatment (17.3±43 vs 66.8±127 mg/L; p=0.018). Conclusions: The activation of the coagulation cascade in patients with atrial fibrillation was confirmed. However, no association of this activation with well known clinical and echocardiographic risk factors for systemic embolism, was found. Previous antiplatelet treatment prevented a higher activation of the coagulation cascade (Rev Med Chile 2002; 130: 1087-94)

Clinical and radiological risk factors for poststroke epilepsy in childhood

BACKGROUND There are few studies evaluating risk factors for poststroke epilepsy (PSE) after an arterial ischemic stroke (AIS) in childhood. This study aimed to evaluate clinical and radiological predictors for PSE in a cohort of children with a first-ever AIS. METHODS A retrospective analysis of a single-center prospective consecutive cohort of children beyond neonatal age with a first-ever AIS admitted at the Pontifical Catholic University of Chiles Clinical Hospital between 2003 and 2013. All participants had a brain magnetic resonance imaging at the time of diagnosis. All children underwent follow-up for at least three years with an annual clinical evaluation. We used the current epilepsy definition of the International League Against Epilepsy. Studied variables include demographics, clinical manifestations at onset, stroke risk factors, and radiological characteristics of AIS. Cox proportional hazards regression analysis was used to evaluate PSE risk adjusted for clinical and radiological variables. RESULTS Among 98 children who met the study criteria, 41 (41.8%) with PSE. Following multivariate analysis, it was determined that the predictors of PSE include young age at AIS (hazard ratio [HR] = 0.91; confidence interval [CI] = 0.84-0.99), the occurrence of acute symptomatic seizures (HR = 3.29; CI = 1.35-8.01), cortical infarction (HR = 5.01; CI = 2.00-12.6), and multifocal infarction (HR = 3.27; CI = 1.01-10.8). CONCLUSION Seizures, young age, cortical lesions, and multiple infarction at the time of stroke are independent risk factors for PSE in children following a first-ever AIS.

Compromiso cerebrovascular agudo en sindrome hemolítico urémico: descripción de dos casos pediátricos

Diarrhea-associated Hemolytic Uremic Syndrome (D+HUS) is a multisystem disorder in which neurological involvement (35 to 50%) is associated to adverse outcome. An important cause of a permanent neurological impairment is the cerebrovascular pathology. OBJECTIVE To report two pediatric cases of D+HUS with severe neurological involvement due to cerebrovascular disease, and review available literature. CLINICAL CASES Two previously healthy 15- and 21-month-old children debuted with seizures and impairment of consciousness within the first week of a D+HUS. Both presented hypertension, severe acute renal failure, and focal motor deficit. One child showed significant improvement in neurologic status after five sessions of plasmapheresis. Brain magnetic resonance showed in the first child multiple bilateral infarcts of small vessels and lesions of white matter. In the second patient, large bilateral infarcts on both middle cerebral arteries territories were identified. One year after the acute event, both children showed functional impairment; The first patient evolved with language delay and spastic hemiparesis; the second patient with spastic quadriparesis, epilepsy with poor seizure control and marked functional impairment. CONCLUSION Although most of the children with D+HUS and brain involvement do not have long-term sequelae, cerebrovascular disease in the acute period causes permanent damage, and in addition to the management of electrolyte disturbances, hypertension, and renal failure, therapies directed at specific pathophysiological mechanisms that trigger vascular compromise may improve prognosis.