RESUMEN
BACKGROUND: Brain edema is the leading cause of death in patients with malignant middle cerebral artery (MCA) infarction. Midline shift (MLS) has been used as a monohemispheric brain edema marker in several studies; however, it does not precisely measure brain edema. It is now possible to directly measure hemisphere brain volume. Knowledge about the time course of brain edema after malignant middle cerebral artery infarction may contribute to the condition's management. OBJECTIVE: Therefore, our goal was to evaluate the course of brain edema in patients with malignant MCA infarction treated with decompressive craniectomy (DC) using hemispheric volumetric measurements. METHODS: Patients were selected consecutively from a single tertiary hospital between 2013 and 2019. All patients were diagnosed with malignant middle cerebral artery infarction and underwent a decompressive craniectomy (DC) to treat the ischemic event. All computed tomography (CT) exams performed during the clinical care of these patients were analyzed, and the whole ischemic hemisphere volume was calculated for each CT scan. RESULTS: We analyzed 43 patients (197 CT exams). Patients' mean age at DC was 51.72 [range: 42-68] years. The mean time between the ischemic ictus and DC was 41.88 (range: 6-77) hours. The mean time between the ischemic event and the peak of hemisphere volume was 168.84 (95% confidence interval [142.08, 195.59]) hours. CONCLUSION: In conclusion, the peak of cerebral edema in malignant MCA infarction after DC occurred on the 7th day (168.84 h) after stroke symptoms onset. Further studies evaluating therapies for brain edema even after DC should be investigated.
ANTECEDENTES: O edema cerebral é a principal causa de morte em pacientes com infarto maligno de artéria cerebral média. O desvio da linha média tem sido utilizado como marcador de edema cerebral mono-hemisférico em alguns estudos; porém, ele não mede de forma precisa o edema cerebral. Atualmente é possível mensurar diretamente o volume do hemisfério cerebral. O conhecimento sobre a evolução temporal do edema cerebral após infartos malignos da artéria cerebral média pode contribuir para o cuidado clínico desta condição. OBJETIVO: Nosso objetivo é avaliar o edema hemisférico ao longo do tempo, em pacientes com infarto maligno da artéria cerebral média, tratados com craniectomia descompressiva. MéTODOS: Os pacientes foram selecionados de forma consecutiva, em um hospital terciário, entre 2013 e 2019. Todos os pacientes apresentavam diagnóstico de infarto maligno de artéria cerebral média e foram submetidos a craniectomia descompressiva. Todas as tomografias computadorizadas de crânio destes pacientes foram analizadas, e o volume do hemisfério cerebral infartado foi mensurado. RESULTADOS: Analisamos 43 pacientes (197 tomografias de crânio). A idade média dos pacientes na craniectomia descompressiva foi 51,72 (4268) anos. O tempo médio entre o ictus e a craniectomia descompressiva foi 41,88 (677) horas. O tempo médio entre o ictus e o pico do volume hemisférico foi 168,84 (142,08195,59) horas. CONCLUSãO: O pico do volume cerebral em pacientes com infarto maligno de artéria cerebral média submetidos a craniectomia descompressiva ocorreu no 7o dia (168,84 horas) após o infarto. Mais estudos avaliando terapêuticas direcionadas ao edema cerebral seriam úteis neste contexto.
Asunto(s)
Edema Encefálico , Craniectomía Descompresiva , Accidente Cerebrovascular Isquémico , Accidente Cerebrovascular , Humanos , Adulto , Persona de Mediana Edad , Anciano , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/cirugía , Edema Encefálico/diagnóstico por imagen , Edema Encefálico/etiología , Edema Encefálico/cirugíaRESUMEN
BACKGROUND: After a case of stroke, intracranial pressure (ICP) must be measured and monitored, and the gold standard method for that is through an invasive technique using an intraventricular or intraparenchymal device. However, The ICP can also be assessed through a non-invasive method, comprised of the measurement of the optic nerve sheath diameter (ONSD) through ultrasound (US). OBJECTIVE: To evaluate the ICP of patients who underwent wide decompressive craniectomy after middle cerebral artery (MCA) infarction via preoperative and postoperative ONSD measurements. METHODS: A total of 17 patients, aged between 34 and 70 years, diagnosed with malignant MCA infarction with radiological edema and mid-line shift, who underwent decompressive surgery, were eligible. From the records, we collected data on age, sex, preoperative and postoperative Glasgow Coma Scale (GCS) scores, National Institutes of Health Stroke Scale (NIHSS) score, the degree of disability in the preoperative period and three months postoperatively through the scores on the Modified Rankin Scale (MRS), and the preoperative and postoperative midline shift measured by computed tomography (CT) scans of the brain. RESULTS: Preoperatively, the mean GCS score was of 8 (range: 7.7-9.2), whereas it was found to be of 12 (range 10-14) on the first postoperative day (p = 0.001). The mean preoperative NIHSS score was of 21.36 ± 2.70 and, on the first postoperative day, it was of 5.30 ± 0.75 (p < 0.001). As for the midline shift, the mean preoperative value was of 1.33 ± 0.75 cm, and, on the first postoperative day, 0.36 ± 0.40 cm (p < 0.001). And, regarding the ONSD, the mean preoperative measurement was of 5.5 ± 0.1 mm, and, on the first postoperative day, it was of 5 ± 0.9 mm (p < 0.001). CONCLUSION: The ocular US measurement of the ONSD for the preoperative and postoperative monitoring of the ICP seems to be a practical and useful method.
ANTECEDENTES: Após um acidente vascular cerebral (AVC), a pressão intracraniana (PIC) deve ser medida e monitorada, e o método padrão-ouro para isso é um procedimento invasivo por meio de um dispositivo intraventricular ou intraparenquimal. No entanto, a PIC também pode ser avaliada por um método não invasivo, composto da medida do diâmetro da bainha do nervo óptico (DBNO) por ultrassom (US). OBJETIVO: Avaliar a PIC de pacientes submetidos a craniectomia descompressiva ampla após infarto da artéria cerebral média (ACM) por meio das medidas do DBNO nos períodos pré e pós-operatório. MéTODOS: Um total de 17 pacientes, com idades entre 34 e 70 anos, diagnosticados com infarto maligno da ACM com edema radiológico e deslocamento da linha média, e que foram submetidos a cirurgia descompressiva, eram elegíveis. A partir dos prontuários, coletamos informações relativas à idade, gênero, pontuações pré e pós-operatória na Escala de Coma de Glasgow (ECG), pontuação na escala de AVC dos National Institutes of Health (NIH), o grau de incapacidade no pré-operatório e após três meses da operação pelas pontuações na Escala de Rankin Modificada (ERM), e o desvio da linha média no pré e pós-operatório medido por tomografia computadorizada (TC) cerebral. RESULTADOS: No pré-operatório, a pontuação média na ECG foi de 8 (variação: 7,79,2), e, no primeiro dia do pós-operatório, 12 variação 1014) (p = 0,001). A pontuação média na escala dos NIH foi de 21,36 ± 2,70 no pré-operatório, e de 5,30 ± 0,75 no primeiro dia de pós-operatório (p < 0,00 1). Quanto ao desvio da linha média, no pré-operatório ele teve uma média de 1,33 ± 0,75 cm, e de 0,36 ± 0,40 cm no primeiro dia de pós-operatório (p < 0,001). E o DBNO apresentou uma média pré-operatória de 5,5 ± 0,1 mm, e de 5 ± 0,9 mm no primeiro dia de pós-operatório (p < 0,001). CONCLUSãO: A mensuração ocular do DBNO por US para o monitoramento da PIC no pré e no pós-operatório parece ser um método prático e útil.
Asunto(s)
Hipertensión Intracraneal , Accidente Cerebrovascular , Adulto , Anciano , Preescolar , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/cirugía , Hipertensión Intracraneal/diagnóstico por imagen , Hipertensión Intracraneal/cirugía , Presión Intracraneal/fisiología , Persona de Mediana Edad , Nervio Óptico/diagnóstico por imagen , Nervio Óptico/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVES: To evaluate optic nerve sheath diameter in the acute phase of patients with malignant ischemic middle cerebral artery stroke submitted or not to decompressive craniectomy surgery. MATERIALS AND METHODS: Forty patients participated in the study and were evaluated bilaterally by ultrasound on admission and at 24h, 48h and 72 h after admission. Optic nerve sheath diameter values were correlated with tomographic and/or clinical criteria compatible with severe intracranial hypertension. RESULTS: A Receiver Operating Characteristic curve was drawn for each eye, determining a cut-off value for severe intracranial hypertension in the right eye of 5.4 mm (sensitivity: 62%; specificity: 100%; AUC: 0.82) and in the left eye 5.4 mm (sensitivity: 76%; specificity: 84%; AUC: 0.77). In patients undergoing craniectomy, there was a decrease in the mean value of 1.04mm in the right eye (pre: 5.84 ± 0.47 mm; post: 4.80 ± 0.84 mm; p = 0.001), while in the left, it decreased around 0.86mm (pre: 5.59 ± 0.69 mm; post: 4.73 ± 0.74 mm; p = 0.003). Patients with fatal outcome showed a persistent high mean ocular nerve sheath diameter. CONCLUSIONS: Monitoring optic nerve sheath by ultrasound can be considered a reliable method for identifying severe intracranial hypertension in patients with large vessel occlusion, as well as for monitoring patients undergoing craniectomy. Additional studies will be necessary to include this parameter in craniectomy indication algorithms in the future.
Asunto(s)
Infarto de la Arteria Cerebral Media , Hipertensión Intracraneal , Nervio Óptico , Ojo/diagnóstico por imagen , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Hipertensión Intracraneal/diagnóstico por imagen , Nervio Óptico/diagnóstico por imagen , UltrasonografíaRESUMEN
BACKGROUND: Malignant infarction of the middle cerebral artery (MCA) occurs in a subgroup of patients with ischemic stroke and early decompressive craniectomy (DC) is one of its treatments. OBJECTIVE: To investigate the functional outcome of patients with malignant ischemic stroke treated with decompressive craniectomy at a neurological emergency center in Northeastern Brazil. METHODS: Prospective cohort study, in which 25 patients were divided into two groups: those undergoing surgical treatment with DC and those who continued to receive standard conservative treatment (CT). Functionality was assessed using the modified Rankin Scale (mRS), at follow-up after six months. RESULTS: A favorable outcome (mRS≤3) was observed in 37.5% of the DC patients and 29.4% of CT patients (p=0.42). Fewer patients who underwent surgical treatment died (25%), compared to those treated conservatively (52.8%); however, with no statistical significance. Nonetheless, the proportion of patients with moderate to severe disability (mRS 4â5) was higher in the surgical group (37.5%) than in the non-surgical group (17.7%). CONCLUSION: In absolute values, superiority in the effectiveness of DC over CT was perceived, showing that the reduction in mortality was at the expense of increased disability.
Asunto(s)
Craniectomía Descompresiva , Accidente Cerebrovascular , Brasil , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/cirugía , Estudios Prospectivos , Accidente Cerebrovascular/cirugía , Resultado del TratamientoRESUMEN
ABSTRACT Background: Malignant infarction of the middle cerebral artery (MCA) occurs in a subgroup of patients with ischemic stroke and early decompressive craniectomy (DC) is one of its treatments. Objective: To investigate the functional outcome of patients with malignant ischemic stroke treated with decompressive craniectomy at a neurological emergency center in Northeastern Brazil. Methods: Prospective cohort study, in which 25 patients were divided into two groups: those undergoing surgical treatment with DC and those who continued to receive standard conservative treatment (CT). Functionality was assessed using the modified Rankin Scale (mRS), at follow-up after six months. Results: A favorable outcome (mRS≤3) was observed in 37.5% of the DC patients and 29.4% of CT patients (p=0.42). Fewer patients who underwent surgical treatment died (25%), compared to those treated conservatively (52.8%); however, with no statistical significance. Nonetheless, the proportion of patients with moderate to severe disability (mRS 4‒5) was higher in the surgical group (37.5%) than in the non-surgical group (17.7%). Conclusion: In absolute values, superiority in the effectiveness of DC over CT was perceived, showing that the reduction in mortality was at the expense of increased disability.
RESUMO Introdução: O infarto maligno da artéria cerebral média (ACM) ocorre em um subgrupo de pacientes com acidente vascular cerebral (AVC) isquêmico e a craniectomia descompressiva (CD) precoce é um de seus tratamentos. Objetivo: Investigar o desfecho funcional de pacientes com acidente vascular cerebral isquêmico maligno submetidos à craniectomia descompressiva em um centro de emergência neurológica do nordeste do Brasil. Métodos: Nesta coorte prospectiva, os pacientes foram divididos em dois grupos: aqueles submetidos a tratamento cirúrgico com craniectomia descompressiva (CD) e aqueles que mantiveram tratamento conservador (TC) padrão. A funcionalidade foi avaliada por meio da Escala de Rankin modificada (ERm) ao final de seis meses de seguimento. Resultados: Evidenciou-se desfecho favorável (ERm≤3) em 37,5% dos pacientes craniectomizados e em 29,4% dos pacientes não craniectomizados (p=0,42). A mortalidade foi menor no grupo de pacientes que se submeteram a tratamento cirúrgico (25%) do que entre aqueles tratados conservadoramente (52,8%), porém sem significância estatística. Por outro lado, a proporção de pacientes com incapacidade moderada a grave (ERm 4‒5) foi maior no grupo cirúrgico (37,5%) do que no grupo não cirúrgico (17,7%). Conclusão: Em valores absolutos, percebeu-se superioridade na eficácia do tratamento cirúrgico sobre o conservador, mostrando que a redução de mortalidade se dá à custa de aumento da incapacidade funcional.
Asunto(s)
Humanos , Accidente Cerebrovascular/cirugía , Craniectomía Descompresiva , Brasil , Estudios Prospectivos , Resultado del Tratamiento , Infarto de la Arteria Cerebral Media/cirugía , Infarto de la Arteria Cerebral Media/diagnóstico por imagenRESUMEN
INTRODUCTION: The benefits of thrombectomy for occlusion of M2 segments remain controversial. The aim of this study is to assess thrombectomy's efficacy and safety in patients with M2 segment occlusion and associations between occlusion sites and anatomic variations of M1 division. MATERIALS AND METHODS: A prospective series of 30 patients with acute ischemic stroke (AIS) resulting from M2 segment occlusion of the middle cerebral artery (MCA) who underwent thrombectomy was analyzed. The primary endpoint was assessed by the Extended Treatment in Cerebral Infarction scale (eTICI). The secondary endpoints were the incidence of symptomatic hemorrhagic transformation (sICH), mortality and good functional outcome at three months. RESULTS: The mean patient age was 69.2 years. The mean National Institutes Health Stroke Scale score (NIHSS) upon hospital admission was 16. The recanalization rates were eTICI 2b/3 in 90% and 2c/3 in 60% of the patients. Total recanalization of the M2 branch was achieved in 53% of patients. sICH incidence was 6.6%, the mortality rate was 30%, and a good functional outcome (mRS ≤2) was observed in 50% of the patients. Twenty-seven patients (90%) had a dominant M2 branch and all were occluded. Regarding the site of M2 occlusions, 74% of patients had proximal M2 occlusions. CONCLUSIONS: Thrombectomy appears to be a safe and effective method for the treatment of acute M2 segment occlusions of the MCA. Most of the cases had a dominant M2 branch, and all of them were occluded. Larger studies are needed to verify the benefits of thrombectomy for different settings of M2 occlusions.
Asunto(s)
Infarto de la Arteria Cerebral Media/cirugía , Accidente Cerebrovascular/cirugía , Trombectomía/métodos , Anciano , Angiografía Cerebral , Femenino , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Masculino , Estudios Prospectivos , Accidente Cerebrovascular/diagnóstico por imagen , Tomografía Computarizada por Rayos XAsunto(s)
Isquemia Encefálica/terapia , Fibrinolíticos/uso terapéutico , Accidente Cerebrovascular/terapia , Trombectomía/métodos , Terapia Trombolítica/métodos , Activador de Tejido Plasminógeno/uso terapéutico , Isquemia Encefálica/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Enfermedades de las Arterias Carótidas/terapia , Angiografía Cerebral , Circulación Cerebrovascular , Circulación Colateral , Progresión de la Enfermedad , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/terapia , Accidente Cerebrovascular/diagnóstico por imagen , Factores de TiempoRESUMEN
We report a case of a bihemispheric paradoxical cerebral embolism in a patient with pulmonary thromboembolism and presumptive pulmonary arteriovenous fistula. The echocardiogram showed no intracardiac shunt, and the transcranial Doppler (TCD) revealed spontaneous microembolic signals in the middle cerebral arteries (MCAs), and late passage of a higher number of microembolic signals in the MCAs, compatible with right-to-left shunt (RLS). The TCD and the echocardiogram were useful for identifying the RLS when rapid neurological deterioration occurred.
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Fístula Arteriovenosa/complicaciones , Embolia Paradójica/etiología , Infarto de la Arteria Cerebral Media/etiología , Embolia Intracraneal/etiología , Arteria Cerebral Media , Arteria Pulmonar/anomalías , Embolia Pulmonar/etiología , Venas Pulmonares/anomalías , Anciano , Fístula Arteriovenosa/diagnóstico por imagen , Angiografía Cerebral/métodos , Angiografía por Tomografía Computarizada , Progresión de la Enfermedad , Ecocardiografía , Embolia Paradójica/diagnóstico por imagen , Resultado Fatal , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Embolia Intracraneal/diagnóstico por imagen , Masculino , Arteria Cerebral Media/diagnóstico por imagen , Arteria Pulmonar/diagnóstico por imagen , Embolia Pulmonar/diagnóstico por imagen , Venas Pulmonares/diagnóstico por imagen , Factores de Tiempo , Ultrasonografía Doppler TranscranealRESUMEN
This study aimed to assess the relationship between the recurrence and prognosis of patients with acute middle cerebral artery infarction, atherosclerotic brain infarction, and the existence of microemboli. We continuously enrolled patients with acute atherosclerotic thrombotic cerebral infarction artery stenosis. We performed transcranial Doppler color ultrasound micro emboli monitoring, color Doppler ultrasound carotid artery tests, intracranial and carotid artery magnetic resonance angiography, impairment evaluation of nerve function, and registration of stroke recurrence and stroke mortality. Of the 49 patients enrolled in the study, 123 main arteries presented atherosclerotic stenosis or formed plaques, and 33 patients had symptomatic stenosis. Patients with symptomatic stenosis have a higher incidence of microemboli than patients with asymptomatic stenosis (P = 0.009). The microembolus-positive rate increased in patients with unstable plaques (P = 0.001). Patients who were microembolus-negative were more likely to show a neural function deficient NIHSS (National Institutes of Stroke Scale) score improvement than patients who were microembolus-positive at one week (P = 0.026). However, we found no significant difference between mRS (modified rankin scale) score (P = 0.319), relapse, and death (P = 0.179). The rate of microembolus-positivity increased in patients with atherosclerotic thrombotic cerebral infarction and unstable plaques. Patients who were microembolus-negative were more likely to show an improvement of neural function deficiency than patients with microembolus-positivity at one week (P = 0.026).
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Enfermedades Arteriales Cerebrales/diagnóstico por imagen , Embolia/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Arteriosclerosis Intracraneal/diagnóstico por imagen , Ultrasonografía Doppler Transcraneal/métodos , Anciano , Análisis de Varianza , Arterias Carótidas/diagnóstico por imagen , Enfermedades Arteriales Cerebrales/diagnóstico , Constricción Patológica/diagnóstico , Constricción Patológica/diagnóstico por imagen , Embolia/diagnóstico , Femenino , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico , Arteriosclerosis Intracraneal/diagnóstico , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Examen Neurológico/métodos , Pronóstico , Recurrencia , Factores de Riesgo , Accidente Cerebrovascular/diagnósticoAsunto(s)
Traumatismos de las Arterias Carótidas/complicaciones , Arteria Carótida Común , Angiografía Cerebral/efectos adversos , Infarto de la Arteria Cerebral Media/cirugía , Embolia Intracraneal/terapia , Trombolisis Mecánica/métodos , Procedimientos Quirúrgicos Ultrasónicos , Disección Aórtica/etiología , Afasia/etiología , Hemorragia Cerebral/etiología , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/etiología , Malformaciones Arteriovenosas Intracraneales/complicaciones , Malformaciones Arteriovenosas Intracraneales/diagnóstico por imagen , Embolia Intracraneal/etiología , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Ultrasónicos/instrumentación , UltrasonografíaRESUMEN
INTRODUCTION: Crossed cerebellar diaschisis is a functional deficit in an area that is remote from that of a supratentorial brain lesion, although the two are anatomically and functionally connected. Deactivation of the contralateral cerebellar hemisphere occurs and is believed to be caused by a transneuronal metabolic depression of the cortico-ponto-cerebellar pathway. A reduction in the blood flow in the brain takes place and this gives rise to a diminished oxygenation of the cerebellar hemisphere. This finding can be evaluated by different functional imaging methods. CASE REPORT: A 32-year-old female, without any relevant events in her personal history, presented an extensive supra-tentorial ischaemic lesion on the right-hand side. An MR angiography scan was performed, in which the homolateral middle cerebral artery and internal carotid artery were not identified. With no specific causation and suspecting a probable case of vasculitis (two days after the first ischaemic episode, the patient suffered another one in the left-hand occipital area, although this time it was smaller and clinically asymptomatic), a positron emission tomography/computerised tomography (PET/CT) scan was performed. The results revealed hypoenhancement of the radiotracer in the contralateral cerebellar hemisphere, which was interpreted as hypometabolism. CONCLUSIONS: Determined by a possible prognostic value in the presence of crossed cerebellar diaschisis in supratentorial vascular episodes, with respect to the final clinical outcome of the patients, it is interesting to take this possibility into account when evaluating patients with an acute cerebrovascular accident, either by means of PET/CT, MR imaging (perfusion) or CT (perfusion).
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Isquemia Encefálica/etiología , Estenosis Carotídea/complicaciones , Cerebelo/fisiopatología , Angiografía por Resonancia Magnética , Imagen Multimodal , Tomografía de Emisión de Positrones , Tomografía Computarizada por Rayos X , Vasculitis del Sistema Nervioso Central/complicaciones , Adulto , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/patología , Isquemia Encefálica/fisiopatología , Arteria Carótida Interna/diagnóstico por imagen , Arteria Carótida Interna/patología , Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/patología , Estenosis Carotídea/fisiopatología , Cerebelo/diagnóstico por imagen , Cerebelo/metabolismo , Cerebelo/patología , Circulación Cerebrovascular , Dominancia Cerebral , Disartria/etiología , Femenino , Radioisótopos de Flúor , Fluorodesoxiglucosa F18 , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/etiología , Infarto de la Arteria Cerebral Media/patología , Infarto de la Arteria Cerebral Media/fisiopatología , Vías Nerviosas/fisiopatología , Paresia/etiología , RadiofármacosRESUMEN
BACKGROUND AND PURPOSE: Agitated saline solution (AS) is the contrast agent (CA) of choice for the diagnosis of right-to-left shunt (RLS). The aim of this study was to compare AS to AS with blood (ASb) in the diagnosis and quantification of RLS by contrast-enhanced transcranial Doppler (cTCD). METHODS: Forty-two patients were evaluated for RLS in both of the middle cerebral arteries (MCA) by cTCD. Both AS and ASb were used as CAs while the patient breathed spontaneously and during two different moments of a Valsalva maneuver. Embolus track (ET) counts were obtained from each MCA (MCA analysis) and from each patient (patient analysis). RESULTS: In the MCA analysis, at least one ET was identified in 109 (43.2%) of the AS tests and 136 (54%) of the ASb tests (P= .016). The ET counts were higher with ASb (78.0 ± 117.6) than with AS alone (46.9 ± 66.7; P= .01). In the patient analysis, at least one ET was identified in 62 (49.2%) of the AS tests and 77 (61.1%) of the ASb tests (P= .057). Similar ET counts were generated with both CA solutions. CONCLUSIONS: These findings support the inclusion of ASb as an option for RLS diagnosis in selected patients.
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Sangre , Ecoencefalografía/métodos , Embolia Paradójica/diagnóstico por imagen , Aumento de la Imagen/métodos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Cloruro de Sodio , Ultrasonografía Doppler Transcraneal/métodos , Adulto , Medios de Contraste , Femenino , Humanos , Masculino , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Traumatic ventricular septal defect (VSD) occurs in approximately 5% of blunt or penetrating cardiac injuries and can result in rare complications. OBJECTIVES: To report the serious complication of stroke after a traumatic VSD. CASE REPORT: A 27-year-old man with no previous medical history presented to the Emergency Department with aphasia and right hemiparesis after a stab wound to the chest. He underwent emergent evacuation of a pericardial effusion and repair of a right ventricular wall perforation. Head computed tomography revealed left middle cerebral artery infarct. Post-operatively, he was noted to have a cardiac murmur, and echocardiogram revealed a VSD. The VSD was surgically repaired without complication. CONCLUSION: Stroke can complicate traumatic VSDs.
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Ventrículos Cardíacos/lesiones , Infarto de la Arteria Cerebral Media/complicaciones , Heridas Punzantes/complicaciones , Adulto , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Masculino , Tomografía Computarizada por Rayos XAsunto(s)
Trasplante de Médula Ósea , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/terapia , Tomografía Computarizada de Emisión de Fotón Único , Movimiento Celular , Enfermedad Crónica , Humanos , Inyecciones Intraarteriales , Masculino , Tecnecio , Tomografía Computarizada por Rayos X , Trasplante Autólogo , Adulto JovenRESUMEN
INTRODUCTION: Malignant MCA infarction results in significant space occupying effect and intracranial pressure (ICP) increment. Due to the high mortality rate in such patients, the term malignant MCA infarction was coined. METHODS: We studied a patient who developed a sudden onset of slurred speech, right hemiplegia, and decreased level of arousal. Two days later CT scan showed a massive cerebral infarct, involving the left MCA territory. RESULTS: A transcranial Doppler exam showed a normal flow pattern in the right hemisphere, but in the left hemisphere systolic spikes without diastolic flow were observed in internal carotid artery, anterior cerebral artery, as well as in the MCA. CONCLUSIONS: The pathophysiologic mechanisms leading to BD might asymmetrically begin in cerebral hemispheres in malignant MCA infarcts.
Asunto(s)
Circulación Cerebrovascular , Infarto de la Arteria Cerebral Media/diagnóstico , Infarto de la Arteria Cerebral Media/fisiopatología , Velocidad del Flujo Sanguíneo , Arterias Carótidas/diagnóstico por imagen , Arterias Carótidas/fisiología , Cuidados Críticos , Resultado Fatal , Femenino , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Presión Intracraneal , Persona de Mediana Edad , Arteria Cerebral Media/diagnóstico por imagen , Arteria Cerebral Media/fisiología , Sístole , Tomografía Computarizada por Rayos X , Ultrasonografía Doppler TranscranealRESUMEN
Cervical carotid artery dissections (CCAD) are common in young adults with a mean age of 44 years and may account for as many as 20% of strokes in patients younger than 30 years. Trauma and primary diseases of the arterial wall such as fibromuscular dysplasia are the main predisposing factors. Some CCAD cases are diagnosed solely on clinical history and physical examination, and even imaging tools such as helical/multi-slice computed tomography (CT) and magnetic resonance imaging (MRI) sometimes are not sufficient to reach a diagnosis. We describe the case of an 18-year-old male who presented to our emergency department due to loss of consciousness 18 hours after a car accident. Previously he had been in no acute distress, with fluent speech, and able to follow 3-step commands. Helical CT showed a hypodense lesion in the left-middle cerebral artery territory, as well as hyperdensity of the M1 segment of the middle cerebral artery. Cerebral angiography depicted the left carotid artery dissection in the C1 segment. Physicians should consider this entity in "asymptomatic" patients during their first hours after head injury, among patients who later develop focal neurological symptoms and clinical deficits. Clinical suspicion followed by radiological findings allows early neurovascular treatment, trying to save viable brain tissue in the first hours post injury.
Asunto(s)
Traumatismos de las Arterias Carótidas/complicaciones , Disección de la Arteria Carótida Interna/etiología , Infarto de la Arteria Cerebral Media/etiología , Adolescente , Angiografía , Traumatismos de las Arterias Carótidas/diagnóstico por imagen , Arteria Carótida Interna/diagnóstico por imagen , Disección de la Arteria Carótida Interna/diagnóstico por imagen , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Masculino , Tomografía Computarizada por Rayos XRESUMEN
The mortality of acute bacterial meningitis (BM) has remained stable in the last decades in spite of the use of new antibiotics, probably due to vascular complications. We report a 68-year-old woman with BM who had a malignant infarction of left middle cerebral artery territory 72 hours after admission to the hospital. The patient experienced a bad evolution and died four days after admission. The arterial involvement in patients with BM is explained by vasospasm of large arteries and vasculitis of small arteries. The medical treatment of a malignant middle cerebral artery infarct has a high mortality.
Asunto(s)
Infarto de la Arteria Cerebral Media/etiología , Meningitis Neumocócica/complicaciones , Anciano , Resultado Fatal , Femenino , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/microbiología , Meningitis Neumocócica/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
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.