AISYF: first national, prospective, multicenter study of young patients with stroke in Argentina

Up to 15% of all strokes affect young patients and the incidence of ischemic stroke in this population is rising. Nevertheless, there is limited information of cerebrovascular events in this population both in our country and in Latin America. The aim of our study was to evaluate the clinical characteristics and risk factors of young adults with stroke in Argentina. This is a prospective, multicenter study of stroke in young adults (18 - 55 years) in Argentina. Patients presenting with a cerebrovascular event within 180 days were included. Stroke subtypes were classified according to TOAST criteria. A total number of 311 patients were enrolled (men 53.9%, mean age: 43.3 years). Ischemic strokes occurred in 91.8% (brain infarcts 82.6%, transient ischemic attack 9.2%) and hemorrhagic strokes in 8.2%. The most frequent vascular risk factors (including ischemic and hemorrhagic strokes) were: hypertension 120 (41%), smoking 92 (31.4%), dyslipidemia 81 (27.6%) and, overweight/obesity: 74 (25.3%). Stroke subtypes were: large artery disease 12.3%, cardioembolism 7.5%, small artery occlusion 11.5%, other defined etiology 27.1%, and undetermined etiology 41.6%. Our study demonstrates that vascular risk factors are very frequent in young adults with stroke. Our findings underline that urgent strategies are required for primary and secondary stroke prevention in this group of patients.

Abstract TP315: Initial Stroke Severity and Reperfusion Treatment in Latin-America. Findings From the Lase Registry

Information about clinical outcome and reperfusion treatment in Latin-America is not widely known. Our aim was to determine this association and other clinical factors according to the initial clinical severity in functional outcome in the population from the Latin-America Stroke Registry (LASE).

Methods: Data were collected prospectively from consecutive patients admitted from January 2012-January 2017 in 20 Latin-American centers. The initial clinical severity was stratified according to the baseline NIHSS; 0-3 minor, 4-7 mild, 8-14 moderate, and ≥15 severe. Clinical outcome was defined by mRS at 3 months, dichotomized in good (0-2) and poor (3-6) groups for univariate and logistic multivariate analysis.

Results: Among 5381 patients, 823(15.3%) patients received any reperfusion treatment. Of these, 84.7% received I.V. fibrinolytic, 13.2% bridging therapy, and 0.9 % primary endovascular treatment. In overall, according to initial clinical deficit by NIHSS, reperfusion treatment was associated with good outcome in mild (82.8% Vs 66.1% p=0.005), moderate (55.9 % vs. 41.6% p=0.002) and severe deficits (29.4 Vs. 18.8% p=0.002). In patients with a baseline NIHSS ≥4, multivariate analysis showed that lower NIHSS (p<0.001 OR: 1,194 CI95%: 1,169-1,219), reperfusion treatment (p<0.001 OR: 2.132 CI95%: 1.625-2.797) and urban setting (p<0.001 OR: 2.310 CI95%: 1,702-3,134) were predictors for good outcome. In reperfusion treatment patients group, multivariate analysis showed that the presence of prior ischemic cardiopathy (p=0.009 RO: 4,304 CI95%: 1,430-12,953) and lower baseline NIHSS (p< 0.001 OR: 1,232 CI95%: 1,173- 1,293) were independent variables associated with a good outcome.

Conclusion: In this study, the rate of reperfusion treatment in 20 stroke Latin-American centers is lower than that reported from other world regions. A significant association between reperfusion treatment and good clinical outcome was observed in mild up to severe baseline deficit in our study. The effect of ischemic cardiopathy in clinical outcome in reperfusion treated patients deserves further studies. Its association with recanalization, remote pre-conditioning ischemia and collateral circulation could be explored in our population.

Mechanical thrombectomy for reperfusion of acute ischemic stroke in a Stroke Unit in Argentina

OBJECTIVE

Stroke is an important cause of morbidity and mortality worldwide. Reperfusion therapy with intravenous tissue plasminogen activator (IV-tPA) was first implemented in 1996. More recently, endovascular reperfusion with mechanical thrombectomy (MT) demonstrated a robust beneficial effect, extending the 4.5 h time window. In our country, there are difficulties to achieve the implementation of both procedures. Our purpose is to report the early experience of a Comprehensive Stroke Center in the use of MT for acute stroke.

METHODS

Analysis of consecutive patients from January 2015 to September 2018, who received reperfusion treatment with MT. Demographic data, treatment times, previous use of IV-tPA, site of obstruction, recanalization, outcomes and disability after stroke were assessed.

RESULTS

We admitted 891 patients with acute ischemic stroke during this period. Ninety-seven received IV-tPA (11%) and 27 were treated with MT (3%). In the MT group, mean age was 66.0±14.5 years. Median NIHSS before MT was 20 (range:14‒24). The most prevalent etiology was cardioembolic stroke (52%). Prior to MT, 16 of 27 patients (59%) received IV-tPA. Previous tPA treatment did not affect onset to recanalization time or door-to-puncture time. For MT, door-to-puncture time was 104±50 minutes and onset to recanalization was 289±153 minutes. Successful recanalization (mTICI grade 2b/3) was achieved in 21 patients (78%). At three-month follow-up, the median NIHSS was 5 (range:4‒15) and mRS was 0‒2 in 37%, and ≥3 in 63%.

CONCLUSIONS

With adequate logistics and strict selection criteria, MT can be implemented in our population with results like those reported in large clinical trials.

[Consensus on acute ischemic stroke]

Stroke is the third cause of death and the first cause of disability in Argentina. Ischemic events constitute 80% of cases. It requires the implementation of systematized protocols that allow reducing the time of care, morbidity and mortality. Specialists from nine medical societies related to the care of patients with cerebrovascular disease participated in the consensus. A separate agenda was agreed upon in chapters and for the writing of them, work groups were formed with members of different medical specialties. The level of recommendation was discussed and agreed upon for each topic based on the best clinical evidence available for each of them. An adaptation to the local scope of the recommendations was made when it was considered necessary.The American Heart Association system was used to draft the recommendations and their level of evidence. The correction and editing were done by five external reviewers, who did not participate in the writing and with extensive experience in vascular pathology. Once the preliminary document was finalized, a general meeting was held with all the members of the working groups and the reviewers to reach final recommendations. The consensus covers the management of ischemic stroke in the pre-hospital phase, initial evaluation in the emergency center, recanalization therapies (thrombolysis and/ or mechanical thrombectomy), decompressive craniectomy, neuroimaging and clinical care in the hospital.

[In-hospital mortality due to stroke]

Overall mortality due to stroke has decreased in the last three decades probable due to a better control of vascular risk factors. In-hospital mortality of stroke patients has been estimated to be between 6 and 14% in most of the series reported. However, data from recent clinical trials suggest that these figures may be substantially lower. Data from FLENI Stroke Data Bank and institutional mortality records between 2000 and 2010 were reviewed. Ischemic stroke subtypes were classified according to TOAST criteria and hemorrhagic stroke subtypes were classified as intraparenchymal hematoma, aneurismatic subarachnoid hemorrhage, arterio-venous malformation, and other intraparenchymal hematomas. A total of 1514 patients were studied. Of these, 1079 (71%) were ischemic strokes,39% large vessels, 27% cardioembolic, 9% lacunar, 14% unknown etiology, and 11% others etiologies. There were 435 (29%) hemorrhagic strokes, 27% intraparenchymal hematomas, 30% aneurismatic subarachnoid hemorrhage, 25% arterio-venous malformation, and 18% other intraparenchymal hematomas. Moreover, 38 in-hospital deaths were recorded (17 ischemic strokes and 21 hemorrhagic strokes), accounting for 2.5% overall mortality (1.7% in ischemic strokes and 4.8% in hemorrhagic strokes). No deaths occurred associated with the use of intravenous fibrinolytics occurred. In our Centre in-hospital mortality in patients with stroke was low. Management of these patients in a Centre dedicated to neurological diseases along with a multidisciplinary approach from medical and non-medical staff trained in the care of cerebrovascular diseases could, at least in part, account for these results.

Tongue necrosis in temporal arteritis

Temporal arteritis is a form of systemic vasculitis that involves branches of the carotid artery. Clinical features are headache, visual loss, ophthalmoplegia, jaw claudication, temporal headache, with tenderness and thickening on the affected temporal artery. We present 3 cases of tongue necrosis due to this granulomatous arteritis. Ischemic necrosis of the tongue is unusual and appears to be an association between its occurrence and high dose steroid tapering.

Stroke precipitated by moderate blood pressure reduction

Rapid lowering of blood pressure can precipitate or worsen ischemic strokes. This usually has been observed in the setting of profoundly lowered pressure and hypotension. We report on six patients in whom ischemic neurologic injury ensued or worsened after moderate reduction of blood pressure by pharmacological treatment. The 6 patients suffered new or worsened ischemic neurologic deficits after receiving oral or intravenous antihypertensive medications, mostly after relatively small doses. Mean arterial blood pressure in these patients was decreased by 25 +/- 7.7%, or 37 +/- 16 mm Hg (mean +/- SD) without resultant hypotension. These cases emphasize the potential hazards of moderate blood pressure reduction by antihypertensive medications in the setting of an acute ischemic stroke or transient ischemic attack (TIA), as well as rapidly treated hypertension even in those who have not yet manifested ischemic symptoms.

Sinusitis and carotid artery stroke

The relationship between sinusitis and ischemic stroke is unexplored. The anatomic proximity between the paranasal sinuses and the internal carotid artery suggests that inflammation of the sinuses could easily extend to the intracranial vasculature. We report 4 patients with acute ischemic stroke and extensive disease of the paranasal sinuses. All patients had large vessel stroke involving the internal carotid artery territory. All patients had extensive disease of the sphenoid and other sinuses. The sinus disease was demonstrated by magnetic resonance imaging. These case report observations suggest a relationship between inflammation of the paranasal sinuses, particularly sphenoid sinusitis, and ischemic stroke.

Transient focal neurologic deficits complicating interleukin-2 therapy

We report 2 patients with transient, focal, repetitive, stereotyped episodes of neurologic deficits during treatment with interleukin-2. One patient had recurrent monocular blindness, while the 2nd had recurrent homonymous quadrantanopia. We suggest that these attacks are provoked by endothelial cell activation induced by interleukin-2.

Chronic pachymeningitis associated to hypereosinophilia: case report

A male 22 years old patient who consulted due to headache and increasing visual loss is being presented. Alterations in the exam were represented by right amaurosis and left temporal hemianopsis. Pathological and tomographical studies revealed chronic pachymeningitis with eosinophilic infiltration. An elevated eosinophilia and an increasing in anti-A and anti-B isoagglutinins were associated to the clinical course. They returned to normal values after treatment with tiabendazol. Even though there is not a certain conclusion as regards the etiology, the probable parasitary nature of the process is outlined.