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OBJECTIVES: The antiphospholipid syndrome (APS) is an autoimmune disease associated with thrombotic and non-thrombotic neurologic manifestations. APS is classified as primary (PAPS) or secondary (SAPS) when it co-exists with another autoimmune disease. We aim to describe the spectrum of acute cerebrovascular disease among patients with APS, their differences between stroke subtypes, and long-term functional outcomes. METHODS: Retrospective cohort study including adult (≥18 years) patients with APS followed in the stroke clinic of a tertiary-care reference center for autoimmune diseases in Mexico from 2009 to 2019. RESULTS: We studied 120 cases; 99 (82.5%) women; median age 43 years (interquartile range 35-52); 63.3% with SAPS. Demographics, comorbidities, and antiphospholipid antibodies (aPL) positivity were similar between APS type and stroke subtypes. Amongst index events, we observed 84 (70%) acute ischemic strokes (AIS), 19 (15.8%) cerebral venous thromboses (CVT), 11 (9.2%) intracerebral hemorrhages (ICH), and six (5%) subarachnoid hemorrhages (SAH). Sixty-seven (55.8%) were known patients with APS; the median time from APS diagnosis to index stroke was 46 months (interquartile range 12-96); 64.7% of intracranial hemorrhages (ICH or SAH) occurred ≥4 years after APS was diagnosed (23.5% anticoagulation-related); 63.2% of CVT cases developed before APS was diagnosed or simultaneously. Recurrences occurred in 26 (22.8%) patients, AIS, in 18 (69.2%); intracranial hemorrhage, in eight (30.8%). Long-term functional outcomes were good (modified Rankin Scale ≤2) in 63.2% of cases, during follow-up, the all-cause mortality rate was 19.2%. CONCLUSION: We found no differences between stroke subtypes and APS types. aPL profiles were not associated with any of the acute cerebrovascular diseases described in this cohort. CVT may be an initial thrombotic manifestation of APS with low mortality and good long-term functional outcome.

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RESUMEN INTRODUCCIÓN: El manejo endovascular de la estenosis de la arteria vertebral en pacientes con infarto cerebral recurrente continúa siendo un tema con múltiples lagunas de conocimiento debido a la poca evidencia científica con la que se cuenta en la actualidad. CASOS CLÍNICOS: Se informan dos casos típicos de estenosis vertebral y recurrencia de infarto cerebral cerebral manejados con dispositivos endovasculares alternativos a los utilizados en la actualidad (stent balón expandible medicado con zotarolimus), con desenlaces clínicos e imagenológicos satisfactorios. Se describe la técnica usada, la condición clínica y se ilustran los resultados angiográficos. CONCLUSIÓN: A la luz de las nuevas generaciones de dispositivos y técnicas neuroendovasculares, consideramos que debe realizarse una evaluación cuidadosa e individual de los pacientes con recurrencia de enfermedad cerebrovascular y estenosis vertebral, a pesar de un manejo médico optimizado. Aún se requieren estudios conrolados que permitan la uniformidad futura en la selección de pacientes y la toma de decisiones.

SUMMARY INTRODUCTION: Endovascular management of vertebral artery stenosis in patients with recurrent cerebral infarction remains a topic with multiple gaps in knowledge because of poor scientific evidence is available today. REPORT OF CASES: Here are reported two typical cases of cerebral infarction recurrence due to vertebral artery stenosis managed with new endovascular devices (balloon-expandable-stent medicated with zotaroli-mus), with satisfactory clinical and neuroimaging outcomes. Herein it is described the technique used and the angiographic findings are illustrated. CONCLUSION: In light of new devices and neurointerventional techniques, we consider that it should be done a careful and individual evaluation of patients with vertebral stenosis and stroke recurrence despite an optimized medical management. It is still required more studies that allow future consistency in the selection of patients and decision making.

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