Luiz Carlos Porcello Marrone

Thrombolysis in an ischemic stroke patient on dabigatran anticoagulation: a case report.

Case Report We report a case of a 73-year-old man with a history of nonvalvular atrial fibrillation, hypertension, smoking and a prior transient ischemic attack 7 months previously, who had been using 110 mg of dabigatran twice daily since the transient ischemic attack. The patient had excellent adherence to the treatment and there was no precipitating factor for stroke, such as dehydration or nonuse of medication. His CHADS2VASC was 6. He arrived in the emergency room with abrupt onset of left hemiplegia and dysarthria 2 h before the initial evaluation (NIHSS: 14; the onset of neurological deficit occurred 7 h after the last dose of dabigatran). At the time of admission, his temperature was normal and his blood pressure was 160/85 mm Hg, his international normalized ratio was 1.13, activated partial thromboplastin time 38 s (normal 23–32 s), thrombocyte count 170 ! 10 3 mm 3 (normal 140 ! 10 3

Gemcitabine Monotherapy Associated with Posterior Reversible Encephalopathy Syndrome

Posterior reversible encephalopathy syndrome is a clinicoradiologic entity that may present with headaches, altered mental status, seizures and visual loss as well as specific neuroimaging findings. We report a case of a 74-year-old woman receiving adjuvant gemcitabine chemotherapy as monotherapy for a stage IIa pancreatic adenocarcinoma, who developed posterior reversible encephalopathy syndrome.

Risk Factors among Stroke Subtypes in Brazil

Stroke is a leading cause of mortality and disability in Brazil. Among the risk factors for cerebrovascular disease, some have more influence than others in certain stroke subtypes. Little data are available in the literature on the prevalence of stroke subtypes in Latin America. We analyzed data from 688 patients with acute ischemic stroke (52.3% women; mean age, 65.7 years) who were enrolled in a stroke data bank. Standardized data assessment and stroke subtype classification were used. The most common stroke subtype was large-artery atherosclerosis (n = 223; 32.4%), followed by cardioembolism (n = 195; 28.3%), and microangiopathy (n = 127; 18.5%). Stroke risk factors differ among stroke subtypes. The population of South America is ethnically diverse, and few previous studies have describe the distribution of risk factors among stroke subtypes in this population. In this study, the most important risk factors were hypertension and dyslipidemia.

Posterior Reversible Encephalopathy Syndrome Following a Scorpion Sting

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic entity not yet understood, that is present with transient neurologic symptoms and particular radiological findings. The most common imaging pattern in PRES is the presence of edema in the white matter of the posterior portions of both cerebral hemispheres. The cause of PRES is unclear. We report a case of 13‐year‐old male who was stung by a scorpion and developed a severe headche, visual disturbance, and seizures and had the diagnosis of PRES with a good outcome. Numerous factors can trigger this syndrome, most commonly: acute elevation of blood pressure, abnormal renal function, and immunosuppressive therapy. There are many cases described showing the relationship between PRES and eclampsia, transplantation, neoplasia and chemotherapy treatment, systemic infections, renal disease acute, or chronic. However, this is the first case of PRES following a scorpion sting.

Blood–Brain Barrier Breakdown in Reduced Uterine Perfusion Pressure: A Possible Model of Posterior Reversible Encephalopathy Syndrome

BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinical entity characterized by headaches, altered mental status, seizures, and visual disturbances and is associated with white matter vasogenic edema. There are no experimental models to study PRES brain changes. METHODS Twenty-eight pregnant Wistar rats were divided into 4 groups of 7: (1) pregnant-control; (2) reduced uterine perfusion pressure (RUPP); (3) invasive blood pressure (IBP); and (4) reduced uterine perfusion pressure plus invasive blood pressure (RUPP-IBP). The RUPP and RUPP-IBP groups were submitted to a reduction of uterine perfusion pressure at pregnancy days 13 to 15. The invasive mean arterial pressure of the IBP and RUPP-IBP groups was measured on day 20. The blood-brain barriers (BBBs) of all groups were analyzed using 2% Evans Blue dye on day 21. RESULTS RUPP rats had higher blood pressures and increased BBB permeability to Evans Blue dye compared with the control animals. Brain staining occurred in 11 of 14 RUPP rats and in none of the control groups (P < .0001). CONCLUSIONS The physiopathology of PRES remains unclear. Here, we described the use of RUPP rats as a potential model to better comprehend this syndrome.

Posterior Reversible Encephalopathy Syndrome Associated with FOLFOX Chemotherapy

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic entity characterized by headaches, altered mental status, seizures, visual loss, and characteristic imaging pattern in brain MRI. The cause of PRES is not yet understood. We report a case of a 27-year-old woman that developed PRES after the use of FOLFOX 5 (oxaliplatin/5-Fluoracil/Leucovorin) chemotherapy for a colorectal cancer.

Chronic syphilitic aortic aneurysm complicated with chronic aortic dissection.

BACKGROUND Historically, tertiary syphilis infection has been the most common cause of thoracic aortic aneurysm, resulting in 5% to 10% of cardiovascular deaths until the era of antibiotics. METHODS A 49-year-old Caucasian man presented to our institution with progressive dysphagia, weight loss, incomplete bladder emptying, alcohol and tobacco consumption, systemic arterial hypertension, Argyll Robertson pupil, leg paresthesias, and mediastinal widening. He was admitted to investigate clinical alterations. Thoracic computed tomography revealed an aortic aneurysm complicated with chronic aortic dissection from the ascending aorta to the iliac vessels with 2 communicating lumens. Cerebrospinal fluid examination tested positive for neurosyphilis in a venereal disease research laboratory test (titre 1/32). RESULTS Chronic syphilitic aortic aneurysm complicated with chronic aortic dissection was diagnosed. CONCLUSIONS This is a unique presentation of a syphilitic infection. Syphilitic aortitis, the hallmark of cardiovascular syphilis, has become rare and is hardly considered by todays clinicians in their differential diagnosis.

Posterior Reversible Encephalopathy Syndrome: Clinical Differences in Patients with Exclusive Involvement of Posterior Circulation Compared to Anterior or Global Involvement

INTRODUCTION Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiologic syndrome not yet fully understood and characterized by transient neurologic symptoms in addition to typical radiological findings. There are only a few articles that describe the clinical differences between patients with PRES that involve carotid and vertebrobasilar circulations. Our study aims to further evaluate the differences between predominantly anterior and posterior circulation PRES. METHODS We review 54 patients who had received the diagnosis of PRES from 2009 to 2015. The patients were divided into 2 groups: (1) exclusively in posterior zones; and (2) anterior plus posterior zones or exclusively anterior zones. Several clinical characteristics were evaluated, including the following: age, sex, previous diseases, the neurologic manifestations, the highest blood pressure in the first 48 hours of presentation, highest creatinine level during symptoms, and the neuroimaging alterations in brain magnetic resonance imaging. RESULTS Mean age at diagnosis was 28.5 years old (9 men and 45 women) and mean systolic blood pressure among patients with lesions only in posterior zones was 162.1 mmHg compared to 179.2 mmHg in the anterior circulation. The most common symptoms in the 2 groups were headache and visual disturbances. DISCUSSION PRES may have several radiological features. A higher blood pressure seems to be 1 of the factors responsible for developing widespread PRES, with involvement of carotid vascular territory. This clinical-radiological difference probably occurs because of the larger number of autonomic receptors in the carotid artery in comparison to the vertebral-basilar system.

PRES with asymptomatic spinal cord involvement. Is this scenario more common than we know

Introduction:Posterior reversible encephalopathy syndrome (PRES) is an entity characterized by neurologic symptoms such as headaches, altered mental status, seizures and visual changes, and it is associated with white matter vasogenic edema predominantly affecting the posterior occipital and parietal lobes of the brain.Case report:A 19-year-old patient developed PRES after the use of chemotherapy for a testicular teratocarcinoma and after the development of a blood pressure elevation.Discussion:Few cases described the involvement of the spinal cord in this syndrome. In the majority of these cases, the spinal cord involvement was asymptomatic or with few symptoms of spinal cord disease.

Malignant Posterior Reversible Encephalopathy Syndrome: A Case of Posterior Irreversible Encephalopathy Syndrome

Dear Editor, Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic syndrome characterized by predominant parietal and occipital lobe edema that is mainly reversible within a few days.1,2 However, many atypical patterns have been identified.3 Reversibility is not always achieved,3 which exposes a contradiction in this supposedly benign entity. We report the case of a 14-year-old patient who presented with classical signs of PRES, but whose condition evolved into a malignant phenotype. A 14-year-old patient received a renal transplant from a cadaveric donor and took tacrolimus, corticosteroids, and antithymocyte immunoglobulin. On the third day, his renal function had not improved and hemodialysis was started. He then immediately developed headache, vomiting, and experienced a tonic-clonic seizure. His blood pressure (BP) peaked at 240/150 mm Hg. Brain CT revealed bilateral edema in the parieto-occipital regions associated with a small hemorrhagic transformation, representing PRES (Fig. 1A, B, and C). Laboratory tests revealed thrombocytopenia (66,000/µL) and elevated serum creatinine (2.52 mg/dL). Tacrolimus was suspended and sodium nitroprusside was administered, which fully controlled his hypertension. Fig. 1 Brain CT in the first presentation. A: Subcortical edema extends to the parietal and frontal region. B and C: Bilateral occipital edema is demonstrated, with minor hemorrhagic transformation, suggesting posterior reversible encephalopathy syndrome. D, ... On the following day his BP was 147/90 mm Hg but his neurological function had deteriorated. Follow-up brain CT revealed extensive cortical and white-matter edema associated with parenchymatous, subarachnoid, and intraventricular hemorrhage (Fig. 1D, E, and F). Brain death was later confirmed, leading to the suspension of life support. PRES pathophysiology remains a mystery even after almost 20 years since its initial description.1 There are two prevailing hypotheses: cytotoxic and vasogenic.4,5 Eclampsia, renal failure, autoimmune diseases, and chemotherapy treatment and other factors may trigger PRES.1,5 Despite its classically favorable outcome, PRES is associated with direct mortality in 5-15% of cases.6,7 Important prognostic factors within PRES have been suggested, such as the anatomical distribution of edema, hemorrhage, and cytotoxic edema in diffusion-weighted imaging sequences, but they have yet to be proven.7,8 Alhilali et al.7 further analyzed the prognostic factors in PRES and found that hemorrhage, even if minor, is the most relevant factor associated with a poor outcome, which may indicate more extensive endothelial dysfunction. Hefzy et al.6 found that hemorrhagic transformation occurred in 17% of PRES cases, mainly small or petechial hemorrhages (<5 mm) and hematomas, but also subarachnoid and intraventricular bleeding. The rates found in other studies have varied from 6.4% to 19.4%, with mortality reaching 26-29% in this group.6,7 The precipitating illness is usually severe, and PRES may be only a marker of such severity, but novel reports unveil the malignant evolution of this condition.7,8 Although many terms have been used to describe this event,7 malignant PRES seems to best encompass the permanent neurological damage or even death that sometimes accompanies this endothelial breakdown in the brain. The optimal management of PRES has yet to be elucidated.8 Better outcomes in malignant PRES have been attributed to aggressive neurointensive care, decompressive craniectomy, and intracranial pressure management.8 These results are promising, but larger studies are needed to confirm the efficacy of this approach. PRES is usually a benign entity; however, it represents a small outlier in the clinical spectrum of this syndrome. A wider range of neurological disabilities encompasses this syndrome and leads to a malignant evolution, suggesting that a good prognosis cannot be assumed with PRES, but rather its occurrence should prompt immediate action to avoid disability.