RESUMEN
BACKGROUND: Transcranial Doppler (TCD) is used to select children with sickle cell disease (SCD) for primary stroke prevention using regular blood transfusion. Whether it can also identify high stroke risk in adults with SCD is not known. METHODS: The authors examined 112 adult patients from two convenience population samples with SCD and 53 healthy control subjects to compare velocities in adults to those reported in children with SCD and to evaluate the influence of age and hematocrit on TCD. RESULTS: Adults with SCD had a higher mean time-averaged maximum mean velocity (110.9 +/- 25.7 cm/s) compared with healthy controls (71.1 +/- 12.0 cm/s), and the difference is approximately proportional to their anemia. No cases with velocities >/=200 cm/s (the threshold used in children for prophylactic treatment) were found in this sample. CONCLUSIONS: Transcranial Doppler velocities in adults with sickle cell disease (SCD) are lower than those in children with SCD. Velocity criteria used in children cannot be used to stratify risk of stroke in adults.
Asunto(s)
Anemia de Células Falciformes/diagnóstico por imagen , Anemia de Células Falciformes/epidemiología , Medición de Riesgo/métodos , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/epidemiología , Ultrasonografía Doppler Transcraneal/estadística & datos numéricos , Adulto , Brasil/epidemiología , Comorbilidad , Femenino , Georgia/epidemiología , Humanos , Incidencia , Masculino , Pronóstico , Factores de RiesgoRESUMEN
Headache occurs in sickle cell disease (SCD), but its characteristics and frequency have not previously been studied. Our aim was to study patterns of headache in adults with SCD and to correlate its presence with blood flow velocities measured by transcranial Doppler (TCD) and with brain magnetic resonance imaging (MRI) abnormalities. We studied 56 adults with SCD. Twenty-eight patients (50%) had severe and frequent headaches. In 20 patients (35.7%) the headache met the International Headache Society criteria for migraine without aura. Patients with frequent and severe headache presented TCD velocities significantly higher than those without headache, or with milder headache. No correlation was found between headache and abnormalities in brain MRI. A migraine-mimicking headache occurs in SCD but we should not understand it as a primary headache because the blood flow abnormalities secondary to SCD detected by TCD seem to play an important role in these patients.
Asunto(s)
Anemia de Células Falciformes/complicaciones , Anemia de Células Falciformes/diagnóstico , Cefalea/diagnóstico por imagen , Cefalea/etiología , Trastornos Migrañosos/diagnóstico por imagen , Trastornos Migrañosos/etiología , Ultrasonografía Doppler Transcraneal/métodos , Adolescente , Adulto , Anemia de Células Falciformes/diagnóstico por imagen , Diagnóstico Diferencial , Femenino , Cefalea/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Trastornos Migrañosos/diagnóstico , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
The authors prospectively studied transcranial Doppler changes in patients with refractory congestive heart failure before and after cardiac transplantation. They evaluated 22 patients preoperatively and 14 patients after transplantation. Mean postoperative flow velocity increased by 53.3% (p < 0.0001). Preoperative waveform changes became normal after transplantation.
Asunto(s)
Isquemia Encefálica/diagnóstico por imagen , Trastornos Cerebrovasculares/diagnóstico por imagen , Trastornos del Conocimiento/diagnóstico por imagen , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/cirugía , Trasplante de Corazón/estadística & datos numéricos , Adulto , Atrofia/diagnóstico , Atrofia/etiología , Encéfalo/irrigación sanguínea , Encéfalo/fisiopatología , Isquemia Encefálica/etiología , Isquemia Encefálica/fisiopatología , Gasto Cardíaco , Arterias Cerebrales/diagnóstico por imagen , Arterias Cerebrales/fisiopatología , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/fisiopatología , Trastornos del Conocimiento/etiología , Trastornos del Conocimiento/fisiopatología , Electroencefalografía , Femenino , Insuficiencia Cardíaca/fisiopatología , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recuperación de la Función/fisiología , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Ultrasonografía Doppler TranscranealRESUMEN
Coronary artery bypass surgery (CABG) without cardiopulmonary bypass (CPB) may potentially reduce the number of microembolic signals (MES) associated with aortic manipulation or generated by the pump circuit, resulting in a better neurologic outcome after surgery. Our aim was to compare the frequency of MES and neurologic complications in CABG with and without CPB. Twenty patients eligible to routine CABG without CPB were randomized to surgery with CPB and without CPB and continuously monitored by transcranial Doppler. Neurologic examination was performed in all patients before and after surgery. The two groups were similar with respect to demographics, risk factors, grade of aortic atheromatous disease and number of grafts. The frequency of MES in the nonCPB group was considerably lower than in CPB patients, however, we did not observe any change in the neurologic examination during the early postoperative period. Neurologic complications after CABG may be related to the size and composition of MES rather than to their absolute numbers. A large prospective multicentric randomized trial may help to elucidate this complex issue.
Asunto(s)
Puente Cardiopulmonar/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Embolia Intracraneal/diagnóstico por imagen , Complicaciones Intraoperatorias/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/etiología , Puente Cardiopulmonar/instrumentación , Puente de Arteria Coronaria/instrumentación , Femenino , Humanos , Embolia Intracraneal/etiología , Complicaciones Intraoperatorias/etiología , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Factores de Riesgo , Ultrasonografía Doppler TranscranealRESUMEN
Heart valve calcifications are rarely recognized as a potential source for cerebral embolism. Previous studies have identified mitral, but not aortic, valve calcifications to be risk factors for stroke. Based on these studies, heart surgery is unlikely to be indicated in patients who present with a stroke and an 'incidental' aortic valve calcification. We report a case of a 46-year-old man presenting with acute onset of left-sided weakness and numbness. A previous smoking history was the only cardiovascular risk factor found. Head CT scan revealed a right middle cerebral artery territory infarct and an adjacent high-density lesion. CT angiography demonstrated the presence of calcific embolic material in the middle cerebral artery. A search for embolic sources revealed a calcific aortic stenosis (CAS). Initially placed on coumadin, the patient developed silent myocardial infarction 2 months later, presumed to be also embolic in origin from the CAS. After aortic valve replacement, the patient has been symptom-free during a 2-year follow-up. In conclusion, CT angiography may be the method of choice for detecting calcific cerebral emboli, and demonstration of a causal relationship between CAS and an embolic stroke by CT angiography may be an important adjunct in surgical decision-making.
Asunto(s)
Estenosis de la Válvula Aórtica/diagnóstico , Calcinosis/diagnóstico , Accidente Cerebrovascular/diagnóstico por imagen , Angiografía Cerebral , Diagnóstico Diferencial , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Embolia Intracraneal/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Tomografía Computarizada por Rayos XRESUMEN
INTRODUCTION: Several recent studies have analyzed a possible effect of thrombophilia risk factors such as factor V Leiden, the prothrombin variant (allele 20210 A), and homozygosity for thermolabile methylenetetrahydrofolate reductase (MTHFR-T) on the development of ischemic stroke (IS). In the present study, we determined the role of these prothrombotic polymorphisms in the early onset of arterial IS or cerebral venous thrombosis (CVT) in a group of young Brazilian adults of Caucasian and African descent. MATERIALS AND METHODS: We conducted a cross-sectional study of 167 survivors of IS (153 patients with arterial IS and 14 cases of CVT; 66 men: 101 women; 124 of Caucasian and 43 of African origin; median age: 32.6 years; range: 15 to 45 years) and compared the prevalence of inherited thrombophilia risk factors with a control group of 225 sex and age matched individuals of the same ethnic background. To determine the interaction with atherogenic risk factors, the following diagnoses were considered: hypertension, hyperlipoproteinemia, diabetes mellitus, smoking status and use of oral contraceptives. RESULTS: In the arterial IS group, no significant variation was found between patients and controls of Caucasian origin regarding the prevalence of factor V Leiden (P = 0.92), the prothrombin variant (P = 0.13) or homozygosity for MTHFR-T (P = 0.61). Among Brazilians of African descent, 10.3% were homozygous for MTHFR-T, which was significantly elevated, odds ratio of 5.9 (95% CI: 0.88 to 49.15). In the CVT group, two Caucasian patients (20%) were heterozygous for the prothrombin variant, odds ratio of 9.7 (95% CI: 0.95 to 89.71) and one patient was carrier of factor V Leiden (P = 0.49). No prothrombotic polymorphism was identified in patients with CVT of African descent. All women in the CVT group were in use of oral contraceptives or in the post-partum state. DISCUSSION: Inherited thrombophilia risk factors were not found to increase the risk of arterial IS among young patients of Caucasian descent. However, a potential role of homozygosity for MTHFR-T was observed in a small group of patients of African origin. The analysis of patients with CVT revealed an increased risk due to the prothrombin gene variant or oral contraceptive use. Further studies including all incoming patients with IS are necessary to evaluate the impact of inherited thrombophilia risk factors on early mortality.
Asunto(s)
Isquemia/genética , Accidente Cerebrovascular/genética , Trombofilia/genética , Adolescente , Adulto , África/etnología , Alelos , Arterias/patología , Brasil/epidemiología , Anticonceptivos Orales/efectos adversos , Estudios Transversales , Factor V/genética , Salud de la Familia , Femenino , Frecuencia de los Genes , Variación Genética , Homocigoto , Humanos , Isquemia/epidemiología , Masculino , Metilenotetrahidrofolato Reductasa (NADPH2) , Persona de Mediana Edad , Oxidorreductasas actuantes sobre Donantes de Grupo CH-NH/genética , Mutación Puntual , Periodo Posparto , Embarazo , Prevalencia , Protrombina/genética , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Trombofilia/epidemiología , Enfermedades Vasculares/epidemiología , Enfermedades Vasculares/genética , Población Blanca/genéticaRESUMEN
OBJECTIVE: To evaluate the neurologic morbidity after orthotopic heart transplantation (OHT), we examined consecutive Chagas' (Ch) and non-Chagas' (NCh) patients, before and after surgery. MATERIAL AND METHODS: We undertook neurological and neuropsychological evaluations in Ch and NCh patients with end-stage cardiac failure, from September 1993 to September 1995. RESULTS: Of 10 Ch patients (mean age = 33.6 years; 7 male; mean follow-up = 10.8 months) and 13 NCh patients (mean age = 50.9 years; 12 male; mean follow-up = 15 months) 3 died (rejection and sepsis) without neurologic symptoms. Neurologic complications occurred in 4 Ch and 5 NCh patients. Two Ch patients had skin and myocardial Chagas' reactivation successfully treated, without CNS involvement. NPS performance and return to work rates were similar in both groups. CONCLUSION: Although Ch patients are potentially at a higher risk of Trypanosoma cruzi reactivation, in addition to all known neurologic complications of OHT, early neurologic complications detected in this sample were similar in Ch and NCh patients and could not be specifically related to Chagas' disease.
Asunto(s)
Cardiomiopatía Chagásica/cirugía , Trasplante de Corazón/fisiología , Trastornos Neurocognitivos/fisiopatología , Examen Neurológico , Pruebas Neuropsicológicas , Enfermedades del Sistema Nervioso Periférico/fisiopatología , Complicaciones Posoperatorias/fisiopatología , Adulto , Cardiomiopatía Chagásica/diagnóstico , Cardiomiopatía Chagásica/fisiopatología , Enfermedad de Chagas/diagnóstico , Enfermedad de Chagas/fisiopatología , Femenino , Rechazo de Injerto/diagnóstico , Rechazo de Injerto/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Trastornos Neurocognitivos/diagnóstico , Enfermedades del Sistema Nervioso Periférico/diagnóstico , Complicaciones Posoperatorias/diagnóstico , RecurrenciaRESUMEN
PURPOSE: To evaluate thrombolytic therapy with rt-PA for acute stroke within 6h of symptom onset, and assessment of neurologic outcome. METHODS: We studied 6 patients, four women, mean age 63 +/- 18 years, with severe neurologic deficit within 6h of stroke onset, and with no spontaneous improvement. The stroke was embolic in 3, and thrombotic in the others. All patients were submitted to a head CT scan followed by either a cerebral angiography in 3 patients, or a transcranial Doppler, in the other 3 for assessment of arterial obstruction, and patency after thrombolytic therapy. We used 0.9 mg/kg of rt-PA, IV, over 60 min in 5 patients, and 0.5 mg/kg by intra-arterial infusion, over 60 min, in one. At the beginning a bolus of 10% of the total dose was delivered during 1 to 2 min. Head scan was repeated 24h and 7 days after treatment to detect ischemic areas and hemorrhagic complications. RESULTS: Middle cerebral artery occlusion was observed in 5 patients and posterior cerebral artery occlusion in one. The obstruction was cleared in 4 patients with persistence of the patency after 24h. A complete neurologic recovery was found in one patient, and a partial recovery in three. In two patients there was failure of arterial recanalization with no neurologic recovery. Only one patient had hemorrhagic transformation of ischemic tissue, without neurologic worsening. Death occurred in one patient due to pulmonary infection. CONCLUSION: Arterial patency with thrombolytic therapy was effective in 4 of our 6 patients. All 4 patients also disclosed a certain degree of neurologic improvement, rt-PA can be successfully used in selected patients up to 3h of the event onset, as shown in randomized studies.
Asunto(s)
Isquemia Encefálica/tratamiento farmacológico , Activadores Plasminogénicos/uso terapéutico , Activador de Tejido Plasminógeno/uso terapéutico , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico por imagen , Angiografía Cerebral , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
Tolosa-Hunt syndrome (THS), or painful ophthalmoplegia is associated to a non-specific granulomatosis of unknown etiology, that involves the superior orbital fissure and its nervous and vascular structures. The clinical picture that responds to steroid therapy, is variable and is always associated with pain. Inflammatory conditions, tumors and aneurysms can produce similar symptoms. Computed tomography, cerebral angiography and orbital phlebography are the imaging methods of choice for making the diagnosis. We revised the results of these radiological examinations of eight patients seen at the Hospital São Paulo from 1989 to 1991, with the diagnosis of THS according to Hunt and Hannerz criteria. The analysis of orbital phlebographic changes based upon Hannerz et al. systematization showed non-specific features, but those were able to help the diagnosis.
Asunto(s)
Arteria Oftálmica/diagnóstico por imagen , Oftalmoplejía/diagnóstico por imagen , Flebografía , Adulto , Anciano , Angiografía Cerebral , Femenino , Humanos , Masculino , Persona de Mediana Edad , Síndrome , Tomografía Computarizada por Rayos XRESUMEN
A Síndrome de Tolosa-Hunt (STH) ou oftalmoplegia dolorosa é associada a granulomatose inespecifica de etiologia desconhecida que acomete a fissura orbitária superior. Compromete estruturas nervosas e vasculares causando quadro clínico variável que sempre se associa a dor e apresenta resposta favorável à corticoterapia. Processos inflamatório, tumores e anmeurismas dessa regiäo podem causar sintomas semelhantes. A tomografia computadorizada, a angiografia cerebral e a flebografia orbitária säo métodos de imagem indicados para orientar o diagnóstico. Revisamos os resultados destes exames radiológicos de oito pacientes atendidos no Hospital Säo Paulo no período 1989 a 1991, com diagnóstico de STH segundo os critérios de Hunt e Hannerz. A análise das alteraçöes da flebografia orbitária, de acordo com a sistematizaçäo feita por Hannerz e col. Mostrou ser este exame inespecífico, porém capaz de orientar melhor mo diagnóstico
Asunto(s)
Adulto , Persona de Mediana Edad , Humanos , Masculino , Femenino , Arteria Oftálmica , Oftalmoplejía/diagnóstico , Flebografía , Angiografía Cerebral , Síndrome , Tomografía Computarizada por Rayos XRESUMEN
The encephalopathy is characterized by an important arteriosclerotic involvement of the vessels of the cerebral white matter and a diffuse subcortical demyelination, sparing the cortex. The diagnosis is presently possible, ante mortem, by connecting the clinical picture with the CT scan findings, which are essential. Three cases with Binswanger encephalopathy are reported and the following picture was found: age 50 to 70 years old at the onset; dementia with scanty neurological signs; systemic arterial hypertension; subacute course of the disease; and a CT scan, highly characteristic, that shows bilateral and symmetric subcortical hypodensity. In one of the patients, that eventually died, an angiography disclosed a right internal carotid thrombosis and a diminished flow in the thalamic striate arteries in both sides. The other two patients are apparently stabilized with anti-hypertensive medication. Binswanger encephalopathy is still seldom described in spite of being a very well defined entity. This diagnosis should be considered much more frequently because it is possible to prevent the encephalopathy avoiding systemic hypertension that is probably intimately linked with the genesis of the disease.