Hypertension and Stroke: Update on Treatment

Stroke is the second most common cause of mortality worldwide and the third most common cause of disability. Hypertension is the most prevalent risk factor for stroke. Stroke causes and haemodynamic consequences are heterogeneous which makes the management of blood pressure in stroke patients complex requiring an accurate diagnosis and precise definition of therapeutic goals. In this article, the authors provide an updated review on the management of arterial hypertension to prevent the first episode and the recurrence. They also present a discussion on blood pressure management in hypertensive urgencies and emergencies, especially in the acute phase of hypertensive encephalopathy, ischaemic stroke and haemorrhagic stroke

Traumatic spinal cord injury: current concepts and treatment update

Spinal cord injury (SCI) affects 1.3 million North Americans, with more than half occurring after trauma. In Brazil, few studies have evaluated the epidemiology of SCI with an estimated incidence of 16 to 26 per million per year. The final extent of the spinal cord damage results from primary and secondary mechanisms that start at the moment of the injury and go on for days, and even weeks, after the event. There is convincing evidence that hypotension contributes to secondary injury after acute SCI. Surgical decompression aims at relieving mechanical pressure on the microvascular circulation, therefore reducing hypoxia and ischemia. The role of methylprednisolone as a therapeutic option is still a matter of debate, however most guidelines do not recommend its regular use. Neuroprotective therapies aiming to reduce further injury have been studied and many others are underway. Neuroregenerative therapies are being extensively investigated, with cell based therapy being very promising.Univ Fed Sao Paulo, Dept Neurol & Neurocirurgia, Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Dept Neurol & Neurocirurgia, Sao Paulo, SP, BrazilWeb of Scienc

Uso da craniectomia descompressiva no tratamento do acidente vascular cerebral isquêmico hemisférico

Decompressive craniectomy (DC) has demonstrated efficacy in reducing mortality in hemispheric infarction of the middle cerebral artery. The aim of our study was to compare the outcome of patients submitted to DC to patients treated in a conservative way. Eighteen patients were submitted to DC and 14 received conservative treatment. Neurological status was assessed by the Glasgow Coma Score and National Institutes of Health Stroke Scale score. Mortality, modified Rankin Scale and Barthel Index scores were assessed at 90 days to evaluate outcome. We did not observe reduction in overall mortality and functional outcome in patients submitted to DC. The differences between our group and previously published series are probably related to the neurological status of the patients at the time of therapeutic decision.Craniectomia descompressiva (CD) tem demonstrado eficácia em reduzir a mortalidade em pacientes com infarto hemisférico (IH) da artéria cerebral média. Este estudo avaliou o prognóstico dos pacientes submetidos a CD comparando a pacientes com IH tratados de maneira conservadora. Dezoito pacientes foram submetidos a CD e 14 receberam tratamento conservador. Escala de Coma de Glasgow e Escala de AVC do National Institutes of Health foram utilizadas para graduar o déficit neurológico. A mortalidade, bem como os escores obtidos na escala modificada de Rankin e índice de Barthel foram avaliados em 90 dias. Não foi observada redução de mortalidade nos pacientes submetidos a CD. Essa diferença entre os nossos resultados e os estudos publicados previamente se deve, provavelmente, à decisão cirúrgica tardia em pacientes com sinais clínicos de herniação cerebral.Universidade Federal de São Paulo (UNIFESP) Department of Neurology and NeurosurgeryCentro de Medicina Diagnóstica FleuryUNIFESP, Department of Neurology and NeurosurgerySciEL

Manifestações neurológicas da doença celíaca

Celiac disease (CD/ Nontropicalsprue, gluten-sensitive enteropathy) is a malabsortive condition in which an allergic reaction to the cereal grain-protein gluten (present in wheat, rye and barley) causes small intestine mucosal injury. The onset is in the first four decades of life, with a female to male ratio of 2:1. It may be associated with a wide spectrum of neurological manifestations including cerebellar ataxia, epileptic seizures, dementia, neuropathy, myopathy and multifocal leucoencephalopathy. We report three patients with neurological manifestations related with CD: one with cerebellar ataxia, one with epilepsy and one with cognitive impairment. The diagnosis of CD was confirmed by serologic tests (antiendomysial and antigliadin antibodies) and biopsy of the small intestine. In two patients the neurological symptoms preceded the gastrointestinal abnormalities and in all of them gluten restriction failed to improve the neurological disability. Conclusion: CD should be ruled out in the differential diagnosis of neurological dysfunction of unknown cause, including ataxia, epilepsy and dementia. A gluten free diet, the mainstay of treatment, failed to improve the neurological disability.A doença celíaca (DC, enteropatia sensível ao glúten) é desordem caracterizada por mal absorção causada por reação alérgica ao glúten, proteína presente em diversos cereais. As manifestações iniciais ocorrem nas primeiras quatro décadas de vida, sendo cerca de duas vezes mais freqüente no sexo feminino. DC pode estar associada a largo espectro de manifestações neurológicas incluindo ataxia cerebelar, epilepsia, demência, neuropatia, miopatia e leucoencefalopatia multifocal. Relatamos três casos de pacientes com manifestações neurológicas da DC: um com ataxia cerebelar, outro com epilepsia e o último com déficit cognitivo. O diagnóstico de DC foi estabelecido com base em testes sorológicos (anticorpos antiendomísio e antigliadina) e biópsia intestinal. Em dois pacientes as alterações neurológicas precederam as gastrointestinais. Em todos os casos a dieta livre de glúten não influenciou o quadro neurológico. Concluímos que o diagnóstico de DC deve ser considerado em pacientes com alterações neurológicas de etiologia indeterminada, incluindo ataxia, epilepsia e demência. Uma dieta sem glúten, a base do tratamento das manifestações gastrointestinais, não foi eficiente em melhorar os sintomas neurológicos em nossos pacientes.Federal University of Ceará Department of Internal MedicineFederal University of Ceará Hospital Universitário WalterUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

The Challenge of Managing Fusiform Basilar Artery Aneurysms: From Acute Ischemic Stroke to a Massive Subarachnoid Hemorrhage

We present the case of a patient with acute brain stem ischemic stroke who was found to have a fusiform basilar aneurysm with a thrombus within the dilated vessel. Three days after the ischemic stroke, the patient had a massive subarachnoid hemorrhage and died. This case illustrates the difficulties in the acute management of ischemic events in patients with basilar fusiform aneurysms, because the natural history of this disease encompasses both bleeding and thrombosis

Suscetibilidade da Bacia do Rio Bengalas a deslizamentos de terra

Resumo: Deslizamentos de terra vêm ocorrendo frequentemente nos últimos anos, devido ao crescimento desordenado das cidades e à ocupação de áreas de risco pela população mais carente, causando impactos sociais, ambientais e econômicos. Áreas urbanas em sua expansão avançam para áreas geologicamente instáveis e topograficamente inclinadas, como é o caso da Bacia do Rio Bengalas, localizada no Município de Nova Friburgo, Região Serrana do Estado do Rio de Janeiro, Brasil. Este artigo tem por objetivo apresentar o levantamento realizado para avaliar a suscetibilidade da Bacia do Rio Bengalas a deslizamentos de terra, que em janeiro de 2011, com a ocorrência de fortes chuvas, estes desastres impactaram na morte de 429 pessoas no Município de Nova Friburgo. Para este artigo foram feitas diversas investigações relacionadas às áreas da bacia, como declividade, pedologia, litologia, uso e cobertura do solo, curvatura vertical, curvatura horizontal. Com este estudo foi possível compreender como os elementos naturais e antrópicos do local de estudo estão relacionados com a dinâmica local dos desastres no que diz respeito às suas interferências na indução dos deslizamentos de terra, possibilitando assim a melhoria da gestão pública do Município no tocante ao uso e parcelamento do solo, a partir da identificação de áreas da Bacia do Rio Bengalas suscetíveis a deslizamentos de terra. Abstract: Landslides have frequently occurred in last years, due to the disorderly grownth of the cities and the occupation of risk areas by the poor population, causing social, environmental and economic impacts. Urban areas in expansion move to geologically unstable areas and topographically inclined, such as the Basin of River Bengalas, located in the city of Nova Friburgo, mountainous region of the State of Rio de Janeiro, Brazil. This article aims to present the model survey to assess the susceptibility of the Basin of River Bengalas to landslides, which in January 2011, with the occurrence of heavy rains, caused landslides that impacted in the death of 429 people in city of Nova Friburgo. For the case study, several investigations have been made related to the areas of the basin, such as slope, soil conditions, lithology, land use and cover, vertical curvature and horizontal curvature. With this study it was possible to understand how the natural and anthropics elements of the basin are related to the local dynamics of the disasters regarding to their interferences in the induction of landslides, thus enabling improved public management of the Municipality regarding the use and division of land, from the identification of areas Basin of River Bengalas susceptible to landslides

Score for atrial fibrillation detection in acute stroke and transient ischemic attack patients in a Brazilian population: The acute stroke atrial fibrillation scoring system

OBJECTIVE: Atrial fibrillation is a common arrhythmia that increases the risk of stroke by four- to five-fold. We aimed to establish a profile of patients with atrial fibrillation from a population of patients admitted with acute ischemic stroke or transient ischemic attack using clinical and echocardiographic findings.METHODS: We evaluated patients consecutively admitted to a tertiary hospital with acute ischemic stroke or transient ischemic attack. Subjects were divided into an original set (admissions from May 2009 to October 2010) and a validation set (admissions from November 2010 to April 2013). The study was designed as a cohort, with clinical and echocardiographic findings compared between patients with and without atrial fibrillation. A multivariable model was built, and independent predictive factors were used to produce a predictive grading score for atrial fibrillation (Acute Stroke AF Score-ASAS).RESULTS: A total of 257 patients were evaluated from May 2009 to October 2010 and included in the original set. Atrial fibrillation was diagnosed in 17.5% of these patients. Significant predictors of atrial fibrillation in the multivariate analysis included age, National Institutes of Health Stroke Scores, and the presence of left atrial enlargement. These predictors were used in the final logistic model. For this model, the area under the receiver operating characteristic curve was 0.79. The score derived from the logistic regression analysis waThe model developed from the original data set was then applied to the validation data set, showing the preserved discriminatory ability of the model (c statistic = 0.76).CONCLUSIONS: Our risk score suggests that the individual risk for atrial fibrillation in patients with acute ischemic stroke can be assessed using simple data, including age, National Institutes of Health Stroke Scores at admission, and the presence of left atrial enlargement.Universidade Federal de São Paulo (UNIFESP) Departamento de Neurologia e NeurocirurgiaHospital Israelita Albert Einstein Setor de EcocardiografiaHospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo Instituto de Radiologia Setor de EcocardiografiaHospital Israelita Albert Einstein Programa Integrado de NeurologiaUNIFESP, Depto. de Neurologia e NeurocirurgiaSciEL

Score for atrial fibrillation detection in acute stroke and transient ischemic attack patients in a Brazilian population: The acute stroke atrial fibrillation scoring system

OBJECTIVE: Atrial fibrillation is a common arrhythmia that increases the risk of stroke by four- to five-fold. We aimed to establish a profile of patients with atrial fibrillation from a population of patients admitted with acute ischemic stroke or transient ischemic attack using clinical and echocardiographic findings. METHODS: We evaluated patients consecutively admitted to a tertiary hospital with acute ischemic stroke or transient ischemic attack. Subjects were divided into an original set (admissions from May 2009 to October 2010) and a validation set (admissions from November 2010 to April 2013). The study was designed as a cohort, with clinical and echocardiographic findings compared between patients with and without atrial fibrillation. A multivariable model was built, and independent predictive factors were used to produce a predictive grading score for atrial fibrillation (Acute Stroke AF Score-ASAS). RESULTS: A total of 257 patients were evaluated from May 2009 to October 2010 and included in the original set. Atrial fibrillation was diagnosed in 17.5% of these patients. Significant predictors of atrial fibrillation in the multivariate analysis included age, National Institutes of Health Stroke Scores, and the presence of left atrial enlargement. These predictors were used in the final logistic model. For this model, the area under the receiver operating characteristic curve was 0.79. The score derived from the logistic regression analysis was The model developed from the original data set was then applied to the validation data set, showing the preserved discriminatory ability of the model (c statistic = 0.76). CONCLUSIONS: Our risk score suggests that the individual risk for atrial fibrillation in patients with acute ischemic stroke can be assessed using simple data, including age, National Institutes of Health Stroke Scores at admission, and the presence of left atrial enlargement