Sofia Rocha

Epidemiological Profile of Wild Rabies in Brazil (2002-2012).

Rabies is one of the most important zoonosis in the world with high impact on public health. Studies report the presence of Lyssavirus in reservoirs of the wild cycle, highlighting the role of wild canines, marmosets, and vampire and non-vampire bats as potential vectors of the disease to domestic animals and human beings. Therefore, the reintroduction of rabies in urban environments from reservoirs of the wild cycle is a matter of concern. This study describes the profile of rabies cases documented in Brazil from 2002 to 2012, with emphasis on the wild transmission cycle of the disease. We carried out a descriptive study using records with information on the time of infection, persons with infection and location of confirmed cases of rabies in humans and animals, as well as data on anti-rabies treatments obtained from the Information System of Notifiable Diseases (Sinan) database. Within the study period, 82 cases of rabies transmitted by wild animals to humans were reported, predominantly in rural areas of the northern and north-eastern regions. Of the cases in humans, 72% did not receive post-exposure prophylaxis. Among wild mammals, vampire bats were the most frequent vectors of the disease. In the north-east region, 460 terrestrial wild mammals were reported with confirmed rabies. Over the study period, 1703 bats were reported to carry the rabies virus. In the south-east region, the most frequently reported carriers of the virus were non-vampire bats. The midwest and northern regions presented a lower number of records of rabies cases among terrestrial wild mammals. However, the high number of rabies cases among bovines reflects the role of the vampire bat as a maintainer of the rabies virus in the rural cycle. The present results are key to adjust the planning of rabies control in Brazil to the current epidemiological trends.

Atrial ectopic activity in cryptogenic ischemic stroke and TIA: a risk factor for recurrence.

BACKGROUND To characterize atrial ectopic activity in patients with cryptogenic ischemic stroke (CIS) or transient ischemic attack (TIA) and determine its prognostic significance. METHODS Retrospective cohort study, in which 184 patients with CIS or TIA who had performed 24-hour Holter electrocardiogram were included. The median follow-up was 27.5 months. Baseline clinical and imagiologic characteristics, etiologic investigation results, and ischemic stroke and TIA recurrences information were collected. Number of atrial premature complexes (APCs) per hour was categorized as less than 10 APCs/hour, 10-30 APCs/hour, and more than 30 APCs/hour. RESULTS Most of the patients had less than 10 APCs/hour (82.6%), 8.2% had 10-30 APCs/hour, and 9.2% had more than 30 APCs/hour. Patients with more than 30 APCs/hour had a greater median left atrium diameter than patients with 30 APCs/hour or less (42 mm vs. 38 mm; 95% confidence interval [CI], .50-7.00; P = .003). Annual recurrence rate of CIS or TIA was 2.9% in patients with less than 10 APCs/hour, 11.0% in 10-30 APCs/hour, and 22.6% in more than 30 APCs/hour (P = .001). More than 30 APCs/hour were independently associated with recurrence risk in multivariate survival analysis (hazard ratio, 3.40; 95% CI, 1.12-10.32; P = .030). CONCLUSIONS In patients with CIS or TIA, frequent atrial ectopic activity (>30 APCs/h) was independently associated with increased risk of stroke or TIA recurrence. Further studies need to validate frequent atrial ectopic activity as a risk factor for recurrence in cryptogenic stroke and confirm its role as a predictor of occult atrial fibrillation.

Intravenous thrombolysis is more effective in ischemic cardioembolic strokes than in non-cardioembolic?

UNLABELLED It was suggested that intravenous thrombolysis (IT) leads to larger extent recanalization in cardioembolic stroke. In this work we assess if this has beneficial clinical traduction. METHOD We evaluated 177 patients undergoing IT, which were categorized into cardioembolic (CE) and non-cardioembolic (NCE). National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale were compared. RESULTS The mean age was 67.4 ± 12.01 and 53.8% were male. The mean NIHSS was: 14 (admission), 9 (24 h) and 6 (discharge), similar in subgroups. The difference between NIHSS at admission and 24 hours was 4.17 ± 4.92 (CE: 4.08 ± 4.71; NCE: 4.27 ± 5.17, p=0.900) and at admission and discharge there was an average difference of 6.74 ± 5.58 (CE: 6.97 ± 5.68; NCE: 6.49 ± 5.49, p=0.622). The mRS at discharge and 3 months was not significantly different by subtype, although individuals whose event was NCE are more independent at 3 months. CONCLUSION Ours findings argue against a specific paper of IT in CE. It can result from heterogeneity of NCE group.

Recurrent post-ictal hyperthermia.

An 80-year-old hypertensive man, with epileptic seizures of unknown etiology, since his 70th’s, was observed for 3 times in 4 years with self-limited right focal motor seizures with impairment of consciousness. In all these episodes, he had post-ictal global aphasia, right homonymous hemianopsia, right hemiparesis and hyperthermia (38–39.6°C). Complete clinical workups during these events (including C reactive protein, sedimentation rate, leukocyte count, thorax radiograph, urinalysis, and lumber puncture) ruled out an infection. Brain magnetic resonance imaging and computerized tomography showed old lacunar basal ganglia infarcts and generalized atrophy. Electroencephalogram (EEG) obtained in two of these episodes revealed in one of them slow background activity of 6–7 Hz, with continuous slow theta/ delta activity in left fronto-temporal region, with paroxysmal activity (spikes and sharp waves) in the same localization. The patient was treated with valproate and antipyretics (paracetamol and lysine acetylsalicylate). The hyperthermia did not respond to these drugs, but resolved spontaneously in 12–18 hours and the neurological deficits recovered within 24 hours.

Hypertrophic Olivary Degeneration and Cerebrovascular Disease: Movement in a Triangle

Hypertrophic olivary degeneration is a rare kind of trans-synaptic degeneration that occurs after lesions of the dentatorubro-olivary pathway. The lesions, commonly unilateral, may result from hemorrhage due to vascular malformation, trauma, surgical intervention or hypertension, tumor, or ischemia. Bilateral cases are extremely rare. This condition is classically associated with development of palatal tremor, but clinical manifestations can include other involuntary movements. We describe 2 cases: unilateral hypertrophic olivary degeneration in a 60-year-old man with contralateral athetosis and neurologic worsening developing several years after a pontine hemorrhage and bilateral hypertrophic olivary degeneration in a 77-year-old woman with development of palatal tremor, probably secondary to pontine ischemic lesions (small vessel disease).

Phonagnosia and Inability to Perceive Time Passage in Right Parietal Lobe Epilepsy

A 25-year-old otherwise healthy epileptic woman was admitted to the hospital after four seizures without recovery of consciousness. She had experienced two previous identical seizures at ages 12 and 14 years. They all began with left oculocephalic deviation and slow left arm rising, followed by generalized tonic-clonic movements. Results on brain CT scan and EEG were normal, and she was treated for 2 years with valproate and was seizure free until age 23 years. At that time, similar seizures restarted, and after normal results on MRI scan and EEG, levetiracetam was started (1000 g/day) with seizure remission. When seen at our unit, the patient underwent a second brain MRI scan, which showed a right cortical parietal T2-hyperintense lesion without gadolinium enhancement and with discrete impairment of water molecule diffusion (Figure 1). An EEG disclosed right frontoparietal slow activity. Phenytoin (in the acute management) and carbamazepine were used, and the patient had complete seizure remission. During the following 3weeks, she started complaining that she could not recognize familiar voices, including those from relatives and famous persons, although she could identify the talking subjects if permitted to see them. She also said that she was incapable of fully acknowledging the passage of time. She was sometimes scared by stimuli that seemed to occur instantaneously but were really several seconds apart. A brain MRI scan 2 months later showed marked improvement, but a residual cortical parietal thickening remained. These data supported the clinical impression of a cortical change secondary to abundant epileptic activity.

Cerebral hyperperfusion syndrome: A novel presentation of internal carotid artery dissection

Cervical artery dissection (CeAD) occurs preferentially in the middle-aged, and its annual incidence rate is 2.6 to 3.0 per 100,000.1 Manifestations of internal carotid artery dissection (ICAD) include ischemic stroke and TIA (>70% of patients), headache, neck pain, Horner syndrome, cranial nerve palsy, pulsatile tinnitus, and, rarely, subarachnoid hemorrhage.2 Cerebral hyperperfusion syndrome is known to occur after carotid artery revascularization procedures and it is thought to result from the combination of several factors that impair cerebral vascular autoregulatory mechanisms.3

Association of retrospective time estimation and severity of cognitive impairment

ABSTRACT Introduction. Time perception has an important role in everyday life, but is not commonly measured in clinical routine assessment of suspected cognitive impairment, given the complexity of available assessment methods. Furthermore, evidence on the pattern of retrospective time perception in neurodegenerative diseases is contradictory. Method. We asked 321 patients referred to neuropsychological assessment to retrospectively estimate the duration of the neuropsychological assessment session. We calculated the session actual duration, ratio, and accuracy of response. Patients were grouped into three categories: subjective cognitive impairment, mild cognitive impairment, and mild to moderate dementia. Results. We found an overall tendency for underestimation of time, but no significant differences between groups regarding time estimation. There were significant, but weak, associations between time estimation and severity of cognitive impairment in several domains, with slightly different patterns across groups. Conclusions. Regardless of etiology, the majority of patients underestimated time, which was weakly associated with the severity of cognitive impairment. Global retrospective estimation may be clinically informative, particularly in a minority of extreme cases.

A rare cause of recurrent peripheral facial palsy

Recurrent peripheral facial palsy (PFP) is not uncommon and it is reported in 3 to 15% of idiopathic PFPs. Other etiologies include intracranial compressive tumors, parotid gland tumors or inflammation, recurrent otitis media, head trauma, multiple sclerosis, sarcoidosis, tuberculosis, Lyme disease, HIV, and the rare Melkersson-Rosenthal Syndrome (MRS). The MRS is a non-necrotizing granulomatous disease characterized by PFP, lingua plicata and orofacial edema, even though the classic triad is reported in only from 20 to 30% of the patients1. We describe a patient with recurrent alternating PFP with MRS.

Is There Really An Acute Alcohol-Related Axonal Polyneuropathy?

To the Editor: We have read with interest the report by Sahin 1 focusing on a possible alcohol-related polyneuropathy (ARP) with acute onset. It is well known that ARP usually affects sensory more than motor nerve fibers, has an insidious onset, and a chronic progressive course. Nevertheless, an acute axonal form has been proposed, which can be mistaken for Guil