Glavobolja i afazija u mlade žene s nedostatkom proteina S i nefrotskim sindromom

We present sequential brain imaging findings in a young woman who while being evaluated for a newly discovered nephrotic syndrome developed headache followed by aphasia. The patient’s symptoms were due to cerebral venous thrombosis in the setting of protein S deficiency and oral contraception.Predstavljamo sekvencijski nalaz slikovnog prikaza mozga mlade žene kod koje je tijekom kliničke evaluacije novootkrivenog nefrotskog sindroma došlo do pojave glavobolje praćene afazijom. Simptomi su bili uzrokovani cerebralnom venskom trombozom koja se razvila uslijed nedostatka proteina S i uporabe oralnih kontraceptiva

Cerebral Hemodynamic and Cognitive Performance in Bilateral Asymptomatic Carotid Stenosis

Background: Preliminary studies have reported cognitive dysfunction in unilateral asymptomatic carotid stenosis (ACS). Impaired cerebral hemodynamic status measured by cerebrovascular reactivity has been associated with cognitive dysfunction in unilateral ACS. Objectives: (1) To evaluate cognitive performance in bilateral ACS compared to unilateral ACS and healthy subjects and (2) to explore the relationship between cognitive performance and cerebral hemodynamic status in bilateral ACS. Method: Asymptomatic patients with ultrasound evidence of bilateral or unilateral ACS (60%-99% diameter reduction) were prospectively collected. Healthy subjects (HS) comparable for demographics and vascular risk profile served as controls. A neuropsychological investigation included phonemic and categorical Verbal Fluency (VF) tests to explore the left hemisphere and Colored Progressive Matrices (CPM), and Complex Figure Test Copy (CFTC) tests to explore the right hemisphere. Cerebrovascular reactivity (CVR) to hypercapnia using the transcranial Doppler (TCD) based breath-holding index (BHI) test was performed in each subject. Impaired CVR was defined as a BHI < 0.69. Generalized linear multivariate and univariate models were employed to evaluate the mean difference on left and right cognitive test abilities in bilateral ACS patients with left and right preserved or impaired CVR. Vascular risk factors, education years, mini-mental status examination (MMSE), and current medications were included as covariates. Results: Three-hundred-thirty-three consecutive subjects were included: 126 bilateral ACS; 73/75 left/ right unilateral ACS; 56 HS; mean age: 70 \ub1 3.78 yrs; males: 65%; education years: 10.3\ub13.7; MMSE score: 26.7\ub11.27. Bilateral and unilateral ACS patients showed significantly lower scores in all cognitive tests compared to HS (p<0.05). In the multivariate analysis, among bilateral ACS an impaired CVR in the right side was associated with a significantly reduced CPM score: from an estimated mean of 32.6 [95% Confidence Interval (CI): 29.8-35.4) to 23.0 (95% CI: 20.2-25.8) and the CFTC score from 34.7 (95% CI: 32.0-37.4) to 26.0 (95% CI: 23.3-28.7). Similarly, an impaired CVR on the left side was associated with a reduced phonemic VF score: 13.5 (95% CI: 11.2-15.8) to 7.5 (95% CI: 5.4-9.7) and categorical VF score from 21.1 (95% CI: 18.1-24.1) to 12.3 (95% CI: 9.5-15.1). All comparisons were p<0.05. Conclusion: Patients with unilateral or bilateral ACS are more likely to suffer cognitive dysfunction compared to healthy controls. Impaired CVR predicts the development of cognitive dysfunction in bilateral ACS. A non-invasive assessment of CVR using the TCD-based BHI test may contribute to a more comprehensive risk stratification in these patients

Cerebral hemodynamics and cognitive performance in bilateral asymptomatic carotid stenosis

Objectives: To evaluate cognitive performance in subjects with bilateral asymptomatic carotid stenosis (B-ACS) compared to subjects with unilateral ACS and to subjects with no carotid stenosis (CS) and to explore the relationship between cognitive performance and cerebral hemodynamics status in B-ACS. Methods: The neuropsychological investigation included phonemic (ph) and categorical (ca) Verbal Fluency (VF) tests for exploring the left brain functions and Colored Progressive Matrices (CPM) and Complex Figure Copy Test (CFCT) for the right brain. Cerebral hemodynamics status was assessed using the transcranial Doppler-based breath-holding index test. Results: A total of 333 subjects were included: 127 B-ACS, 73/77 left/right unilateral ACS, 56 no CS, mean age 70 \uc2\ub1 3.78 years, 65% male. Subjects with B-ACS and subjects with unilateral ACS showed significantly lower scores in all cognitive tests compared to subjects with no CS (p < 0.05). Subjects with B-ACS with left impaired hemodynamics status showed a significantly reduced ph-VF score, from 13.4 (95% confidence interval [CI] 11.2-15.8) to 7.5 (95% CI 5.4-9.7), and a reduced ca-VF score, from 19.7 (95% CI 18.1-24.1) to 10.8 (95% CI 9.5-15.1), compared to subjects with no CS. Similarly, impaired cerebral hemodynamics in the right side was associated with a significantly reduced CPM score, from an estimated mean of 34.2 (95% CI 29.8-35.4) to 24.6 (95% CI 20.2-25.8), and CFCT score from 37.0 (95% CI 32.0-37.4) to 27.1 (95% CI 23.3-28.7). All comparisons were p < 0.05. Conclusion: Subjects with B-ACS and subjects with unilateral ACS are more likely to have cognitive dysfunction compared to subjects with no CS. There appears to be a link between cognitive dysfunction and hemodynamics impairment due to carotid stenosis. Copyright \uc2\ua9 2012 by AAN Enterprises, Inc

Noninvasive Ventilatory Correction as an Adjunct to an Experimental Systemic Reperfusion Therapy in Acute Ischemic Stroke

Background. Obstructive sleep apnea (OSA) is a common condition in patients with acute ischemic stroke and associated with early clinical deterioration and poor functional outcome. However, noninvasive ventilatory correction is hardly considered as a complementary treatment option during the treatment phase of acute ischemic stroke. Summary of Case. A 55-year-old woman with an acute middle cerebral artery (MCA) occlusion received intravenous tissue plasminogen activator (tPA) and enrolled into a thrombolytic research study. During tPA infusion, she became drowsy, developed apnea episodes, desaturated and neurologically deteriorated without recanalization, re-occlusion or intracerebral hemorrhage. Urgent noninvasive ventilatory correction with biphasic positive airway pressure (BiPAP) reversed neurological fluctuation. Her MCA completely recanalized 24 hours later. Conclusions. Noninvasive ventilatory correction should be considered more aggressively as a complementary treatment option in selected acute stroke patients. Early initiation of BiPAP can stabilize cerebral hemodynamics and may unmask the true potential of other therapies

From head to toe: Sex and gender differences in the treatment of ischemic cerebral disease

Stroke is a major cause of mortality and morbidity, particularly in the older ages. Women have a longer life expectancy and are more likely to experience stroke than men. Interestingly, the increased risk of ischemic stroke in women seems to be independent from age or classical cardiovascular risk factors. Notwithstanding the fact that stroke outcomes and survival are usually poorer in women, current evidence suggests that thrombolysis, antiplatelet and anticoagulant therapies are more beneficial in women than in men. A possible explanation of this paradox might be that females are often undertreated and they have fewer chances to be submitted to an effective and timely treatment for stroke than the male counterpart. The first step in the attempt to solve this obvious discrimination is surely to emphasize any reasons for differences in the therapeutic approach in relation to gender and then to denounce the lack of a sustainable motivation for them. In this article, we aimed to review the existing literature about gender-related differences on efficacy, administration and side effects of the most common drugs used for the treatment of ischemic stroke. The most striking result was the evidence that the therapeutic approach for stroke is often different according to patients' gender with a clear detrimental prognostic effect for women. A major effort is necessary to overcome this problem in order to ensure equal right to treatment without any sexual discrimination