RESUMEN
INTRODUCTION: Crescendo transient ischemic attacks or "Stroke Warning Syndromes" consist of stereotyped frequent short-lasting episodes of focal neurological deficits. This is explained by intermittent hypoperfusion of the vascular territory of terminal arteries with insufficient collateral flow, presenting a high risk for subsequent infarction. Pontine warning syndrome (PWS) is a subtype of this atypical presentation of stroke/transient ischemic attack and is considered a challenge for diagnosis. CASE REPORT: We describe 2 cases of patients with PWS who were admitted to our institution. They presented acute neurological deficits that fluctuated during the course of their hospitalization; interestingly, this neurological worsening and improvement was associated with blood pressure fluctuations. In both cases, brain magnetic resonance imaging revealed an ischemic lesion in the paramedian pons due to basilar artery branch disease. No outstanding infectious or metabolic factors contributed to neurological worsening/fluctuations. These patients received standard medical care without IV-thrombolysis because of the presence of contraindications for IV tissue plasminogen activator. Permissive hypertension was promoted to achieve adequate perfusion during hospitalization. At discharge and follow-up, the patients showed partial resolution from their stroke symptoms. CONCLUSIONS: PWS is a diagnostic and management challenge for the clinician. Because of its low incidence, this syndrome has been underestimated and understudied. There is, currently, no standard treatment for this condition; however, it is paramount, during treatment, that hypotension/hypoperfusion be avoided, with the goal being asymptomatic normotension to permissive hypertension. The probable mechanism of disease is hypoperfusion due to basilar artery branch disease and perhaps cerebral vascular dysregulation in the affected area.
Asunto(s)
Infartos del Tronco Encefálico/fisiopatología , Ataque Isquémico Transitorio/fisiopatología , Puente/fisiopatología , Insuficiencia Vertebrobasilar/fisiopatología , Anciano , Presión Sanguínea , Infartos del Tronco Encefálico/diagnóstico por imagen , Femenino , Humanos , Ataque Isquémico Transitorio/diagnóstico por imagen , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Puente/irrigación sanguínea , Puente/diagnóstico por imagen , Insuficiencia Vertebrobasilar/diagnóstico por imagenRESUMEN
BACKGROUND: Patients with cerebral infarction often present impaired consciousness and unsatisfactory extubation. We aimed to assess the respiratory mechanics components that might be associated with the success of extubation in stroke patients. METHODS: Twenty consecutive patients with stroke who needed mechanical ventilation support were enrolled. The maximal inspiratory pressure, gastric and the esophageal pressure (Pdi/Pdimax), minute volume, respiratory rate, static compliance, airway resistance, rapid and superficial respiration index (RSRI), inspiratory time/total respiratory cycle (Ti/Ttot), and PaO(2)/FiO(2) were measured. RESULTS: The group who presented success to the extubation process presented 12.5±2.2=days in mechanical ventilation and the group who failed presented 13.1±2=days. The mean Ti/Ttot and Pdi/Pdimax for the failure group was 0.4±0.08 (0.36-0.44) and 0.5±0.7 (0.43-0.56), respectively. The Ti/Ttot ratio was 0.37±0.05 (0.34-0.41; p=0.0008) and the Pdi/Pdimax was 0.25±0.05 for the success group (0.21-0.28; p<0.0001). A correlation was found between Pdi/Pdimax ratio and the RSRI (r=0.55; p=0.009) and PaO(2)/FiO(2) (r=-0.59; p=0.005). Patients who presented a high RSRI (OR, 3.66; p=0.004) and Pdi (OR, 7.3; p=0.002), and low PaO(2)/FIO(2) (OR, 4.09; p=0.007), Pdi/Pdimax (OR, 4.12; p=0.002) and RAW (OR, 3.0; p=0.02) developed mechanical ventilation extubation failure. CONCLUSION: Muscular fatigue index is an important predicting variable to the extubation process in prolonged mechanical ventilation of stroke patients.
Asunto(s)
Extubación Traqueal , Infartos del Tronco Encefálico/fisiopatología , Mecánica Respiratoria , Músculos Respiratorios/fisiopatología , Desconexión del Ventilador , Anciano , Resistencia de las Vías Respiratorias , Índice de Masa Corporal , Infartos del Tronco Encefálico/complicaciones , Infartos del Tronco Encefálico/terapia , Trastornos de la Conciencia/etiología , Femenino , Humanos , Rendimiento Pulmonar , Masculino , Manometría , Persona de Mediana Edad , Fatiga Muscular , Estudios Prospectivos , Respiración Artificial , Pruebas de Función Respiratoria , Volumen de Ventilación PulmonarRESUMEN
Se presenta un caso de síndrome de Weber de naturaleza isquémica. Su expresión clínica como debut de una enfermedad vascular cerebral del sector vertebro-basilar es rara, lo cual motiva la comunicación de este caso (AU)