Pablo Bonardo

Immune reconstitution inflammatory syndrome associated with PML in AIDS: A treatable disorder

An HIV-1-infected patient with progressive multifocal leukoencephalopathy presented clinical deterioration and contrast-enhancing lesions on brain nuclear MR after the initiation of highly active antiretroviral therapy (HAART). Brain biopsy identified an inflammatory reaction compatible with immune reconstitution inflammatory syndrome. Treatment with corticosteroids and transient suppression of HAART led to marked neurologic improvement.

Central retinal artery occlusion and ophthalmoplegia following spinal surgery

Visual loss and ophthalmoplegia are very infrequent complications after spinal surgery.1,2 Visual loss may be caused by ischaemic optic neuropathy, central retinal artery or vein occlusion, or occipital stroke.2,3 Previous reports have attributed this complication to patient positioning, intraoperative blood loss, and controlled hypotension or shock.2–5 Associated risk factors include anaemia, prolonged surgical time, bradyarrhythmia, hypertension, diabetes, smoking, vascular disease, and increased blood viscosity.2,6 Ophthalmoplegia after spinal surgery is even more unusual than visual loss, and only few reports exist in the literature.6–8 Moreover, magnetic resonance image (MRI) studies to differentiate between cavernous sinus thrombosis and direct compression of orbital contents have not been previously described. We therefore report two patients who developed this unusual combination of ophthalmoplegia and central retinal artery occlusion (CRAO) after spinal surgery. A 62 year old male ex-smoker underwent a L2–L3 posterior spinal decompression and segmental instrumentation for lumbar stenosis and scoliosis, in prone position with ocular protection (gauze swab and tape). The surgery lasted 2 hours and 45 minutes. Before the procedure blood pressure was 140/60 mm Hg and during operation it was maintained at 90/60 mm Hg. Just after surgery he complained of visual loss and left ocular and nasal pain. Examination revealed left palpebral oedema, local erythema, blindness, and total ophthalmoplegia of the left eye. Left pupil was dilated and …

Different pain patterns in patients with vertebral artery dissections

Spontaneous or traumatic cervical artery dissections are an increasingly recognized cause of stroke in young adults.1 The internal carotid artery (ICA) is more frequently involved than the vertebral artery (VA).1 Headache and neck pain are common and suggestive symptoms of VA dissection (VAD).2 However, their clinical characteristics and their relationship with focal neurologic symptoms have not been extensively analyzed. We prospectively analyzed 10 consecutive patients admitted to our hospital with diagnosis of VAD from 1995 to 2003. In all cases, the dissection was confirmed by magnetic resonance angiography (MRA), conventional angiography, or both. The presence of headache, neck pain, or both at the time of the dissection, their characteristics, and their association with neurologic signs and symptoms were registered by direct interview. The history of headache was classified according to the International Headache Society criteria.3 Headache at the time of arterial dissection was classified into that occurring before, during …

BLOOD PRESSURE EVOLUTION IN YOUNG PATIENTS WITH ACUTE ISCHEMIC STROKE: A new model for understanding the natural course of spontaneous hypertension?

ABSTRACT Background: Approximately 80% of patients suffering an acute ischemic stroke develop transient hypertension. The physiopathological mechanism remains unclear. Due to the lack of vascular risk factors, young adults could be a useful model for understanding blood pressure (BP) evolution in this setting. Methods: Patients between 18 and 55 years old admitted with an acute ischemic stroke were included. BP was evaluated during the following 48 h. Hypertension was defined as: systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. Patients were divided into two groups: RF group included those who had a previous vascular risk factor and/or other medical condition known to affect the autonomic function; noRF group included patients without any of the previously stated conditions. Results: Thirty-nine patients were included: mean age: 44.26 years old, 21 were males (53.8%). Mean SBP and DBP at admission were 139.77 ± 5.35 mmHg (range: 90–243) and 84.44 ± 3.02 mmHg (range: 60–128), respectively; 43.58% patients were hypertensive at admission. SBP decreased significantly during the first 48 h (p = 0.044) for the entire population. RF group has higher SBP (p = 0.009) and DBP (p = 0.011) at admission than the noRF group. Conclusion: Most patients were normotensive at admission and BP fell spontaneously despite BP at admission. Young patients without medical conditions that could alter the autonomic system function could be a useful model for understanding acute hypertension in ischemic stroke.

Capsular warning syndrome as a manifestation of isolated middle cerebral artery dissection in a Latin American patient

Dear editor, Isolated middle cerebral artery dissection (MCAD) is a rare cause of stroke usually reported in Asian populations. Capsular warning syndrome (CWS) as a manifestation of MCAD is exceptional. We report on a Latin American patient who presented several episodes of transient motor symptoms secondary to MCAD. A 39-year-old right-handed male patient suffered several episodes of transient right hemiparesis and dysatrhria with mild headache during 72 h. After hospital admission, he suffered more than 10 episodes. Each time they started with mild right-perioral dysesthesia that progressed to severe dysarthria (the patient said: ‘‘I can feel the symptoms coming on’’) with spontaneous resolution in less than 10min. There was no loss of consciousness, or cortical signs or symptoms. The laboratory and the EEG were normal. Brain MRI and magnetic resonance angiography revealed a subcortical brain infarct and a string sign at the M2 segment of the left middle cerebral artery (Figure 1(a) and (b)). Digital subtraction angiography confirmed MCAD (Figure 1(c)). He was treated with aspirin and clopidogrel. He did not repeat any new episodes. MCAD is more likely to be idiopathic, and it is more often in Asian patients than in other regions (Europe and North America). It has been postulated that the higher prevalence found in Asian populations may be due to hemodynamic or genetic differences between ethnicities. A recent literature review of the disease, described a series of 61 cases with a male frecuency of 62.3%, most of the reported cases were from Asian countries (78.7%) and the M2 portion of the MCAD was rarely affected (21.7%). CWS is a distinct form of transient ischemic atack, clinically located at the internal capsule that usually leads to early infarction. It tended to occur over seconds with some patients describing a feeling as ‘‘coming on’’; most patients experience a pure motor hemiparesis often accompanied by sensory symptoms. There were only two reports that described the CWS in patients with MCAD. Our patient presented several brief transient deficits without cortical involment compatible with the syndrome. The CSW in MCAD might be a consecuence of the occlusion of the ostia of the lenticulostriate by the intimal end of the dissected artery or as of an embolic phenomenon. MCAD diagnosis requires a high degree of suspicion due to the low prevalence of the disease in our region; physicians should be awared of the CWS as a form of presentation of MCAD especially in young patients.

RAPIDLY PROGRESSIVE DEMENTIA SECONDARY TO AUTOIMMUNE ENCEPHALITIS: NEUROPSYCHOLOGICAL PROFILES AND RESPONSE TO IMMUNOTHERAPY

P2-313 IS CUED RECALL OF SHARED AUTOBIOGRAPHICAL KNOWLEDGE USEFUL IN CLINICAL DEMENTIA ASSESSMENT? Claudia Frankenberg, Maren Knebel, Christina Degen, Nadeshda Andrejeva, Petra Wetzel, Lina Sidonija Gorenc-Mahmutaj, Sabrina Dominique Navratil, Inga Meyer-K€uhling, Britta Wendelstein, Johannes Schr€oder, Section of Geriatric Psychiatry, University Hospital Heidelberg, Heidelberg, Germany; Interdisciplinary Ageing Research, Faculty of Educational Sciences, Goethe University, Frankfurt am Main, Germany; Institute of Gerontology, University of Heidelberg, Heidelberg, Germany. Contact e-mail: Claudia.Frankenberg@med.uni-heidelberg.de