Matrix metalloproteinase-9 concentration after spontaneous intracerebral hemorrhage

OBJECT

Matrix metalloproteinases (MMPs) are overexpressed in the presence of some neurological diseases in which blood-brain barrier disruption exists. The authors investigated the MMP-9 concentration in patients after acute intracerebral hemorrhage (ICH) and its relation to perihematomal edema (PHE).

METHODS

Concentrations of MMP-9 and related proteins were determined in plasma by performing an enzyme-linked immunosorbent assay of samples drawn after hospital admission (< 24 hours after stroke) from 57 patients with ICH. The diagnosis of ICH was made on the basis of findings on computerized tomography (CT) scans. The volumes of ICH and PHE were measured on baseline and follow-up CT scans at the same time that the patient's neurological status was assessed using the Canadian Stroke Scale and the Glasgow Coma Scale. Increased expression of MMP-9 was found among patients with ICH. In cases of deep ICH, MMP-9 was significantly associated with PHE volume (r = 0.53; p = 0.01) and neurological worsening (237.4 compared with 111.3 ng/ml MMP-9; p = 0.04). A logistic regression model focusing on the study of absolute PHE volume showed ICH volume as an independent predictor (odds ratio [OR] 3.37; 95% confidence interval [CI] 1.1-10.3; p = 0.03). A second analysis of relative PHE volume (absolute PHE volume/ICH volume) in patients with deep ICH demonstrated that the only factor related to it was MMP-9 concentration (OR 11.6; 95% CI 1.5-89.1; p = 0.018).

CONCLUSIONS

Expression of MMP-9 is raised after acute spontaneous ICH. Among patients with deep ICH this increase is associated with PHE and the development of neurological worsening within the acute stage.

[Chronic subdural hematoma simulating a TIA. Implications for the management transient neurological deficit]

Chronic subdural hematoma that generally happens after cranial trauma doesn't have clinical manifestations until days or weeks after the traumatism. Due to the lesions nature, symptoms are almost always progressive and presentation as transient ischemic attacks (TIA) is very uncommon. We describe 2 cases of chronic subdural hematoma that started simulating TIA and we discuss its implications in the management of those patients who had presented transient neurological deficit.

Matrix metalloproteinase expression is related to hemorrhagic transformation after cardioembolic stroke

BACKGROUND AND PURPOSE

In animal models of cerebral ischemia, matrix metalloproteinase (MMP) expression was significantly increased and related to blood-brain barrier disruption, edema formation, and hemorrhagic transformation (HT). MMP inhibitors reduce HT after embolic ischemia in tissue-type plasminogen activator-treated animals. We aimed to determine the relationship between MMPs and HT after human ischemic stroke.

METHODS

Serial MMP-2 and MMP-9 determinations were performed by means of ELISA in 39 cardioembolic strokes in the middle cerebral artery territory. Hemorrhagic events were classified according to clinical and CT criteria (hemorrhagic infarction [HI] and parenchymal hematoma [PH]). HT was evaluated on CT at 48 hours (early HT) and again between day 5 and 7 (late HT).

RESULTS

HT was present in 41% of the patients (43.75% early HI, 25% early PH and 31.25% late HI). MMP-2 values were within normal range and were unrelated to HT. Increased expression of MMP-9 (normal range <97 ng/mL) was found among patients with and without HT (159.3+/-82 versus 143.9+/-112.6 ng/mL; P=0.64). According to HT subtypes, the highest baseline MMP-9 levels corresponded to patients with late HI (240.4+/-111.2 versus 102.5+/-76.7 ng/mL for all other patients, P=0.002). Baseline MMP-9 was the only variable associated with late HI in the multiple logistic regression model (OR 9; CI 1.46, 55.24; P=0.010). Peak of MMP-9 at the 24-hour time point (250.6 ng/mL) was found before appearance of PH.

CONCLUSIONS

MMPs are involved in some subtypes of HT after human cardioembolic stroke. Baseline MMP-9 level predicts late HI and a 24-hour peak precedes early PH.

Time course of tissue plasminogen activator-induced recanalization in acute cardioembolic stroke: a case-control study

BACKGROUND AND PURPOSE

The relationship between arterial recanalization, infarct size, and outcome in patients treated with intravenous thrombolytics remains unclear. Therefore, we aimed to determine the time course of recombinant tissue plasminogen activator (rtPA)-induced recanalization in patients with cardioembolic stroke treated <3 hours from symptom onset and to investigate the relationship between arterial recanalization, infarct volume, and outcome.

METHODS

We prospectively studied 72 patients with an acute cardioembolic stroke in the middle cerebral artery territory: 24 treated with rtPA at <3 hours and 48 matched controls. Serial transcranial Doppler examinations were performed on admission and at 6,12, 24, and 48 hours. Infarct volume was measured by use of CT at day 5 to 7. Modified Rankin Scale score was used to assess outcome at 3 months.

RESULTS

Rate of 6-hour recanalization was higher (P<0.001) in the rtPA group (66%) than in the control group (15%). Five (20.8%) rtPA patients and 15 (31.2%) controls recanalized between 6 and 12 hours, and 2 (8.3%) patients and 12 (25%) controls between 12 and 48 hours, respectively. At 48 hours, 75% of rtPA patients and 27% of controls had improved (P<0.001). Infarct volume was 50.2+/-40.3 cm(3) in rtPA patients and 124.8+/-81.6 cm(3) in controls (P<0.001). Moreover, infarct volume was associated strongly (P<0.001) with duration of middle cerebral artery occlusion. At 3 months, 14 (58%) rtPA patients and 11 (23%) controls (P=0.037) became functionally independent (modified Rankin Scale score </=2). A close relationship (P=0.002) existed between modified Rankin Scale score at 3 months and time to reperfusion. In addition, clinical outcome was associated strongly (P=0.001) with degree of 6-hour recanalization. Logistic regression analysis identified National Institutes of Health Stroke Scale score <17 (odds ratio 12.1, 95% confidence interval 2.8 to 68, P=0.001) and early recanalization (odds ratio 23.4, 95% confidence interval 5.4 to 96, P=0.001) as independent predictors of functional independence at 3 months.

CONCLUSIONS

Intravenous rtPA is associated with early recanalization, which leads to lower infarct size and better clinical outcome. Early recanalization is a powerful independent predictor of functional independence at 3 months.

Progression and clinical recurrence of symptomatic middle cerebral artery stenosis: a long-term follow-up transcranial Doppler ultrasound study

BACKGROUND AND PURPOSE

Patients with symptomatic intracranial atherosclerotic stenosis have a high rate of recurrence. We conducted a prospective study to determine which factors are associated with the progression of symptomatic middle cerebral artery (MCA) stenosis and to evaluate the relationship between progression and clinical recurrence.

METHODS

Between January 1996 and February 2000, of a total of 2564 consecutive first-ever transient ischemic attack (TIA) or stroke patients admitted to our cerebrovascular unit, 145 showed an MCA stenosis signal on transcranial Doppler (TCD) on admission, and 40 fulfilled all criteria to enter this study, including angiographic confirmation. Patients were prescribed antiplatelet or anticoagulant agents following the criteria of the neurologist in charge. TCD recordings and clinical interviews were performed regularly during follow-up. Progression of MCA stenosis was defined as an increase >30 cm/s in TCD-recorded maximum mean flow velocity. Logistic regression analyses were used to identify predictors of progression and clinical recurrence.

RESULTS

With a median follow-up of 26.55 months, 13 (32.5%) MCA stenoses progressed, 3 (7.5%) regressed, and 24 (60%) remained stable. Absence of significant extracranial internal carotid artery (ICA) stenosis (P=0.049) and the use of oral anticoagulants (P=0.045) were significantly associated with a lower progression rate in univariate analysis, and anticoagulation remained an independent predictor when a logistic regression model was applied (OR 7.25, CI 1.1 to 48.1, P=0.019). A new ischemic event during follow-up in the territory supplied by the stenosed MCA occurred in 8 cases (20%), and 13 patients had a major vascular event. Progression of the MCA stenosis detected by TCD was independently associated with a new ipsilateral ischemic event (OR 2.89, CI 1.09 to 7.71, P=0.031) and with the occurrence of any major vascular event (OR 7.03, CI 1.6 to 30.9, P=0.0071).

CONCLUSIONS

Progression of symptomatic MCA stenosis detected by means of TCD predicts clinical recurrence. Anticoagulation is independently associated with a lower progression rate of symptomatic MCA stenosis.

Matrix metalloproteinase expression after human cardioembolic stroke: temporal profile and relation to neurological impairment

BACKGROUND AND PURPOSE

Uncontrolled expression of matrix metalloproteinases (MMPs) can result in tissue injury and inflammation. In animal models of cerebral ischemia, the expression of MMP-2 and MMP-9 was significantly increased. However, their role in human stroke in vivo remains unknown. Therefore, we sought to determine the temporal profile of MMP expression in patients with acute ischemic stroke and to investigate its relationship to stroke severity, location of arterial occlusion, and total infarct volume.

METHODS

Serial MMP-2 and MMP-9 determinations were made in 39 patients with cardioembolic strokes that involved the middle cerebral artery territory by means of enzyme-linked immunosorbent assay. Blood samples, transcranial Doppler recordings, and National Institutes of Health Stroke Scale (NIHSS) scores were obtained at baseline and at 12, 24, and 48 hours after stroke onset. Infarct volume was measured with CT scanning at 48 hours.

RESULTS

No correlation was found between MMP-2 and NIHSS score at any time point, although a close relation appeared between mean MMP-9 and final NIHSS score (r=0.486, P=0.002). MMP-9 value was the only factor associated with the final NIHSS score in the multiple logistic regression model (OR 4.54, 95% CI 1.5 to 13.75). A cut-point of MMP-9 142.18 ng/mL had a positive predictive value of 94.4% to assess a patient's NIHSS (<8 or >/=8) by the end of the study. Final MMP-2 and MMP-9 levels were significantly lower when recanalization occurred (528+/-144.3 versus 681.4+/-239.2 ng/mL, P=0.031 for MMP-2; 110.2+/-100.9 versus 244.8+/-130 ng/mL, P=0.004 for MMP-9). A positive correlation was found between mean MMP-9 and infarct volume (r=0.385, P=0.022).

CONCLUSIONS

MMPs are involved in the acute phase of human ischemic stroke. MMP-9 levels are associated with neurological deficit, middle cerebral artery occlusion, and infarct volume.

[Correlation between the expression of proinflammatory cytokines and matrix metalloproteinases in the acute phase of an ischemic stroke]

INTRODUCTION

Proinflammatory cytokines are the main responsible for the onset of postischemic inflammatory cascade. Recently, the deleterious effect of matrix metalloproteinases (MMPs) in the acute phase of stroke has been described. Animal models suggest a link between both families.

OBJECTIVE

We aimed to investigate possible relations between the MMP overproduction and proinflammatory cytokine expression after human ischemic stroke.

PATIENTS AND METHODS

From all consecutive stroke patients attended during a 10 months period, we selected and prospectively studied those presenting as a cardioembolic stroke involving the MCA territory. MMP 9, MMP 2 and IL 6 were serially measured by means of ELISA at study entry and at 12, 24 and 48 hours after symptoms onset.

RESULTS

A total of 39 patients were studied. A positive correlation was found between mean expression of both MMPs and IL 6 (r= 0.33, p= 0.040 for MMP 2 y r= 0.45, p= 0.004 for MMP 9). From all measured timepoints, the best obtained correlation was that of MMP 9 with IL 6 at 24 hours (r= 0.418, p= 0.010). At 24 h a peak value of IL 6 was observed. Baseline MMP 2 and MMP 9 levels showed a trend to correlate with that peak of IL 6 (r= 0.329, p= 0.061 for MMP 2 y r= 0.325, p= 0.061 for MMP 9).

CONCLUSION

MMP expression correlates with the inflammatory cascade activation after acute cardioembolic stroke.

Transient ischaemic attack: a common initial manifestation of cardiac myxomas

BACKGROUND AND AIMS

Cardiac myxomas may present clinically with many different features. Since highly effective treatments exist, it is important that they are diagnosed quickly in order to avoid further complications. Our aim was to determine the influence of neurological presentation in diagnosis and prognosis of cardiac myxomas.

METHODS

We have reviewed the clinical charts of 28 patients diagnosed with cardiac myxomas seen at our centre in the last 20 years.

RESULTS

Mean age at diagnosis in patients with neurological events was 49.22 years and 60.84 years in those without neurological manifestations (p = 0.0325). Most frequent presentations were: cardiac manifestations (92.8%), general manifestations (71.4%) and embolic events (39.3%). Nine patients (32.1%) presented with cerebral embolism; 7 of whom presented with transient ischaemic attacks (TIA), which was the first manifestation in 6 of them; 3 of them later suffered complete cerebral infarction with sequelae. Echocardiography confirmed diagnosis in 26 out of 27 patients in which it was performed. None of the patients presented neurological symptoms after surgery.

CONCLUSION

The most frequent initial neurological manifestation in our series was TIA. Nevertheless, none of the patients were diagnosed after the first neurological symptom. Although the contribution of cardiac myxomas to the total amount of TIA is low, since surgery is highly effective and of low risk, and patients with neurological manifestations are younger, it is vital to consider the possibility of cardiac myxoma after a TIA of unknown origin.

Timing of spontaneous recanalization and risk of hemorrhagic transformation in acute cardioembolic stroke

BACKGROUND AND PURPOSE

The relationship between reperfusion and hemorrhagic transformation (HT) remains uncertain. Therefore, we aimed to clarify the relationship between the time course of recanalization and the risk of HT in patients with cardioembolic stroke studied within 6 hours of symptom onset.

METHODS

Fifty-three patients with atrial fibrillation and nonlacunar stroke in the middle cerebral artery (MCA) territory admitted within the first 6 hours after symptom onset were prospectively studied. Serial TCD examinations were performed on admission and at 6, 12, 24, and 48 hours. CT was performed within 6 hours after stroke onset and again at 36 to 48 hours.

RESULTS

Proximal and distal MCA occlusions were detected in 32 patients (60.4%) and 18 patients (34%), respectively. Early spontaneous recanalization occurring within 6 hours was identified in 10 patients (18.8%). Delayed recanalization (>6 hours) occurred in 28 patients (52.8%). HT on CT scan was detected in 17 patients (32%) within the first 48 hours. Only large parenchymal hemorrhage (PH2) was significantly associated with an increase (P=0.038, Kruskal-Wallis test) in the National Institutes of Health Stroke Scale (NIHSS) score compared with the other subtypes of HT. Univariate analysis revealed that an NIHSS score of >14 on baseline (P=0.001), proximal MCA occlusion (P=0.004), hypodensity >33% of the MCA territory (P=0.012), and delayed recanalization occurring >6 hours of stroke onset (P=0.003) were significantly associated with HT. With a multiple logistic regression model, delayed recanalization (OR 8.9; 95% CI 2.1 to 33.3) emerged as independent predictor of HT.

CONCLUSIONS

Delayed recanalization occurring >6 hours after acute cardioembolic stroke is an independent predictor of HT.

[Acute phase response after stroke: differences between ischemic stroke and intracerebral hemorrhage]

BACKGROUND

To evaluate differences in the temporal profile of acute phase response (APR) between ischemic stroke (IS) and intracerebral hemorrhage (ICH).

PATIENTS AND METHOD

We studied APR parameters (< 24 h and 3-5 day) in 88 consecutive patients (43 ICH and 45 IS). The increase/decrease of the parameters between both dates was analyzed.

RESULTS

Leukocyte increase (LI) and fibrinogen increase (FI) is significantly higher in ICH than in IS (p = 0.047 and p = 0.035).

CONCLUSIONS

APR temporal profile is different for ICH and IS.

Cerebral microembolism in acute spontaneous internal carotid artery dissection

The rate and risk factors for early ischemic recurrence in patients with internal carotid artery dissection (ICAD) are largely unknown. Serial transcranial Doppler (TCD) monitoring of microembolic signals (MES) was performed in 28 consecutive patients with acute ICAD. MES were identified in 13 patients, and early ischemic recurrence occurred in 7. Six of 13 patients with MES and 1 of 15 without MES experienced early ischemic recurrence (p = 0.029). MES detection on serial TCD monitoring may be associated with an increased risk of early ischemic recurrence in patients with acute ICAD.

[Hypertrophic pachymeningitis. A review of the histories of two cases and pathological relationship with the Tolosa-Hunt syndrome and the orbital pseudotumor]

INTRODUCTION

Hypertrophic pachymeningitis is an infrequent condition which starts with a thickening of the dura mater and whose pathogenesis is unknown. We present two new cases of unknown aetiology.

CLINICAL CASE

Case 1. A 53 year old man complained of occipital headache, tinnitus and deafness since February 1981. In October 1981 he was admitted to hospital with a worse headache, perio-orbital pain, dysgeusia and ipsilateral peripheral facial palsy. In December he had generalized tonic-clonic seizures and paralysis of the VII and XI right cranial nerves and IX, X and XII left cranial nerves. In February 1982 he developed right trigeminal neuralgia. He was readmitted in November 1983 with continuous headache, vomiting and a behavior disorder. On CT there was marked attenuation of the posterior dura mater, which the neurosurgical department considered unsuitable for biopsy. He died in March 1985. On necropsy there was hypertrophic pachymeningitis. Case 2. A 62 year old patient consulted in November 1995 complaining of right hypoacusia for the past six months, progressively accompanied by ipsilateral paralysis of the II, IV, VI, VII and VIII cranial nerves but with no other alterations on physical examination. Analytical and serological investigations were normal. Cranial MR showed an extraparenchymatous infiltrating lesion in the middle cranial fossa. Biopsy was decided on when no clinical improvement was seen with corticosteroid treatment. The pathologist reported hypertrophic pachymeningitis. Treatment was started with cyclophosphamide in monthly doses and the condition has remained stable to date.

CONCLUSION

With these two cases we wish to establish a pathogenic relation between the Tolosa-Hunt syndrome and orbital pseudotumor and show the role played by immunosuppressive treatment in the control of hypertrophic pachymeningitis.

[Lack of correlation between plasma homocysteine levels and cerebral microangiopathy in patients wtih transient ischemic attack]

OBJECTIVE

The aim of this study is to evaluate cerebral MRI findings in patients with atherothrombotic transient ischemic attacks (TIA) and its correlation with plasma homocysteine (Hcy) levels.

PATIENTS AND METHODS

A total of 62 consecutive patients with the diagnosis of TIA of atherothrombotic origin were studied. MRI examinations were performed in all patients for the evaluation of the presence of infarct and/or white matter hyperintensities (WMHI). Plasma Hcy levels were determined according to the method described by Smolin and Schneider modified.

RESULTS

Plasma Hcy levels were significantly (p < 0.036) higher in patients with MRI-detected infarcts (9.69 +/- 2.06 mumol/l) compared with patients without infarcts (8.65 +/- 1.7 mumol/l. There was no correlation (p < 0.33) between plasma Hcy levels and the presence or absence of WMHI seen on MRI.

CONCLUSIONS

In TIA patients, plasma Hcy levels were significantly higher in patients with cerebral infarcts, but did not correlate with the presence of WMHI. Our results suggest that mild hyperhomocysteinemia would be associated with large-medium vessel rather than with small vessel disease.

[Acute pseudobulbar paralysis: the use of diffusion techniques with magnetic resonance]

INTRODUCTION

Acute pseudobulbar palsy produced by bilateral cerebral infarctions is a rare syndrome, which includes among its symptoms mutism, severe dysphagia and diverse sensory-motor signs.

CLINICAL CASES

We report two middle-aged patients who suddenly developed a severe dysarthria and dysphagia, which impeded their ability to speak and to feed themselves, with spasmodic laughing and crying and slight motor deficit ('pure' pseudobulbar palsy). The acute lesions, using conventional and diffusion-weighted magnetic resonance imaging, corresponded partially to the anterior choroidal artery (case 1: acute lesion in the left periventricular white matter and a subacute one in the right semioval centrum; case 2: acute lesions in the right frontal subcortical white matter and in the periventricular white matter adjacent to the left lateral ventricle). The favorable evolution of these patients in contrast to previously described patients with acute pseudobulbar palsy could indicate that the motor deficit is a prognostic factor for this syndrome.

CONCLUSIONS

Diffusion-Weighted magnetic resonance imaging permits differentiation with high precision of the acute lesions in patients who present old ones. Sometimes multiple acute lacunar infarctions (MALI) are found to be responsible of the syndrome. Hypertension and diabetes are the risk factors for the small vessel disease underlying these MALI.

[Determination of Doppler parameters in the study of basal cerebral veins: basal vein of Rosenthal and middle cerebral vein]

INTRODUCTION

To date, little attention has been paid to the study of the venous system by means of transcranial Doppler ultrasound. The objective of our study was to learn how to localize cerebral blood flow and find the normal values of different ultrasonographic parameters.

PATIENTS AND METHODS

We studied 20 healthy persons in whom the arterial system of the circle of Willis had previously been shown to be normal. Transcranial Doppler scan was done with the person lying face upwards, using a transtemporal 2 MHz catheter. In the study we included persons in whom at least one of the two veins could be studied unilaterally.

RESULTS

We studied twelve men and eight women aged between 25 and 78 years. The basal vein of Rosenthal, localized bilaterally in 70% of the cases, was identified as a wave of low pulsation between segments P1 and P2 of the posterior cerebral artery, going away from the catheter at a speed of about 11 cm/second. The middle cerebral vein was found bilaterally in only 35% of the cases as a wave near to the middle cerebral artery but in the opposite direction, at an average velocity of approximately 11.7 cm/second and of low pulsation.

CONCLUSIONS

In spite of the technical problems, which can be solved using contrast agents, it is possible to study the cerebral venous system by means of transcranial Doppler. Our Unit is the first in Spain to show this. We therefore wish to promote the use of transcranial Doppler in cerebral venous disorders.

Impaired cerebrovascular reactivity as a risk marker for first-ever lacunar infarction: A case-control study

BACKGROUND AND PURPOSE

Functional assessment of small arteries and arterioles could provide valuable information regarding the extent of diffuse arteriolosclerosis in patients with small-vessel disease. Therefore we attempted to clarify the role of cerebrovascular reactivity (CVR) as a risk marker for first-ever symptomatic lacunar infarction.

METHODS

Forty-six patients with lacunar infarction and 46 sex- and age-matched control subjects were prospectively evaluated. Cerebral hemodynamics were studied with transcranial Doppler ultrasonography. CVR was examined by calculating the percent increase in mean flow velocity occurring after 15 mg/kg acetazolamide administration (Diamox test).

RESULTS

CVR was significantly (P<0.0001, Student's t test) lower in cases (50.0+/-12. 7%) as compared with control subjects (65.2+/-12.4%). A multiple logistic regression analysis identified male sex (odds ratio [OR] 2. 3, P=0.02), age (OR 3.6, P<0.005), and the presence of lacunar infarction on magnetic resonance imaging (OR 5.3, P<0.001) as significant and independent factors associated with a reduction of CVR. Moreover, a cut-point of 55.6% (sensitivity 67%, specificity 82%) was established as the threshold value for distinguishing between pathological and normal CVR. CVR was significantly (P=0.02) lower in patients with multiple (46.38+/-12.6%) than with single (54. 83+/-11.58%) lacunar infarction. In addition, a trend of negative correlation was found between CVR and the number of lacunar infarctions (r=-0.26, P=0.08). In the multiple logistic model, history of hypertension (OR 7.24; 95% confidence interval 2.95 to 17. 79) and CVR (OR 0.8; 95% confidence interval 0.81 to 0.93) emerge as significant and independent predictors of first-ever lacunar infarction.

CONCLUSIONS

These data suggest that impaired CVR is a risk marker for first-ever lacunar infarction.

["Stroke code". Shortening the delay in reperfusion treatment of acute ischemic stroke]

BACKGROUND

"Stroke Code" is a system for the rapid identification, pre-notification and transport of acute ischemic stroke patients. The objective of this study was to evaluate the impact of delay reduction for thrombolytic therapy in these patients.

SUBJECTS AND METHODS

We evaluated acute ischemic stroke patients admitted in the emergency unit within the first 6 hours after onset of symptoms and included into reperfusion clinical trials. We compared the delay for initiating reperfusion treatment related to the activation or not of the stroke code.

RESULTS

From 454 patients evaluated, 25% were admitted to the hospital in less than 6 hours from stroke onset. 59% of these patients were candidates for reperfusion treatment. "Stroke Code" was activated in 13 (55%). We observed a significant reduction in the delay since the onset of symptoms in relation to "Stroke Code" activation or not (mean X [SD]): emergency room arrival: 49.6 (48) vs 80 (48) min; Stroke Team evaluation: 65.3 (57) vs 133.6 (58) min; CT scan performing: 86.2 (60) vs 171.8 (62) min; Start of treatment; 212.9 (51) vs 287.3 (59) min.

CONCLUSIONS

"Stroke Code" activation reduced in 50% pre- and in-hospital delay to start reperfusion treatment in acute ischemic stroke patients.

[Value of cranial MRI in the follow-up of dural sinus thrombosis]

INTRODUCTION

At the present time it is well established that cranial magnetic resonance (MR) is the imaging technique of choice for diagnosis of thrombosis of the dural sinuses. However, few studies have been done to evaluate its role in follow-up in this cerebrovascular disorder.

OBJECTIVE

To assess the alterations in resonance signal in follow-up of patients with thrombosis of the dural sinuses and the clinical correlation of this.

MATERIAL AND METHODS

We reviewed the clinical histories of 12 patients diagnosed on cranial MR as having thrombosis of the dural sinuses; 8 cases were also seen again six months later. The cranial MR study was done using a 1.5 or 1.0 T superconductive apparatus to do measured spin-echo sequences (SE) in T1 and T2 in sagittal, transverse and coronal planes. The time elapsed between diagnosis on MR and clinical diagnosis was between 24 hours and 6 months.

RESULTS

All patients had stronger resonance signals in T1 and T2 indicating a subacute phase of the thrombosis (oxidative conversion of deoxyhaemoglobin to methoxyhaemoglobin) and complete absence of blood flow in the sinuses. The eight patients seen again after six months were found to be normal on neurological. On cranial MR partial recanalization was seen in 5 of these (62%).

CONCLUSION

Changes in the resonance signal persist for a long time both with and without signs of recanalization. This finding does not affect the medium term clinical course.

[Isolated axial lateral pulse as a sign of latero-bulbar ischemia: clinical topographic correlation]

INTRODUCTION

Isolated body lateropulsion in absence of vertigo, cerebellar syndrome, sensory loss or motor weakness is an extremely rare. This condition has only been reported four times.

CLINICAL CASES AND CONCLUSION

We present four patients in whom isolated body lateropulsion was a single manifestation of lateral medullary ischemia.

[Jugular megabulb as a cause of pulsatile tinnitus]

INTRODUCTION

Pulsatile tinnitus (AP), possibly of vascular origin, may be a sign of various vascular and non-vascular pathological processes. Arteriovenous fistulas and malformations are, perhaps, the commonest cause of AP.

CLINICAL CASE

A 64 year-old woman presented with AP of the right ear for the past 14 years. It was continuous all day and could be observed externally by the examiner. The intensity of the tinnitus diminished on right later-cervical compression and on turning her head to the left. There was bilateral transmission deafness. Neurological examination was normal. Complementary explorations (MR, CT of the base of the skull and cerebral arteriography) showed the presence of a jugular megabulb of the right side.

CONCLUSIONS

The presence of AP may be for many years the only sign of subjacent vascular pathology, such as a megabulb of the jugular vein.