A 35-year-old man presented to the emergency department with altered mental status and bilateral tonicclonic seizures. Due to a progressive decrease in consciousness, he was intubated for airway protection. The patient’s relatives reported that he had used cocaine, leading to an initial suspicion of acute cocaine intoxication. However, a head CT scan without contrast revealed a hyperdense basilar artery sign without other signs of infarction (figure 1).
ischemic stroke
Trombectomía mecánica eficaz en paciente con ictus e infección por SARS-Cov-2 con desenlace fatal. Effective mechanical thrombectomy in a patient with stroke and SARS-Cov-2 infection with fatal outcome
Ischemic stroke has been reported in patients with SARS-CoV-2 infection. It is not clear if COVID-19 is causal or simply coexists or triggers the onset of stroke. Stroke is relatively rare in the context of COVID-19 and mostly occurs in the elderly with vascular risk factors. The underlying mechanism of stroke is multiple. We present an 84-year-old male with a stroke due to large vessel occlusion coincident with severe COVID-19 infection, that despite an initial successful mechanical thrombectomy, had a fatal outcome due to respiratory complications and contralateral massive cerebral infarction due to early recurrence. Consequently, vigilance in this type of patients should be extreme since ischemic stroke with active SARS-CoV-2 infection may have a poor prognosis.
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Drip and ship: Una práctica usual en el tratamiento de ictus isquémico por oclusión de arterias proximales en países de altos ingresos pero anecdótica en Colombia. Drip and ship: a prevalent practice in acute stroke with large vessel occlusion in high-income countries but anecdotal in Colombia
The Drip and Ship consists of giving intravenous thrombolysis in the primary center and referral for mechanical thrombectomy.
Objective: To describe the experience of Drip and Ship in acute ischemic stroke in two regions of Colombia.
Methods: We conducted a retrospective case series study of patients undergoing Drip and Ship from 2019 to first quartile of 2021. We compared times: door-to-image, door-to-needle, door-to-groin and clinical outcomes. Measures of central tendency and descriptive statistics were calculated.
Results: Six patients with ischemic stroke and large vessel occlusion were registered. Median of 60 minutes of the onset of symptoms, 75 minutes for door-to-needle, 167.5 minutes for door-in door-out time, and 91.5 minutes for travel time referred from another city. Five patients received mechanical thrombectomy with TICI 2c-3. 50% of patients with favorable modified Rankin scale at discharge and 84% at three months.
Conclusions: According to the RES-Q registry, between 2019 and the first quartile of 2021, there were 5954 cases of ischemic stroke cases in Colombia, and 20 patients received Drip and Ship strategy (0.33%). In agreement to international guidelines, door-to-needle and remission times were longer than recommended, especially in patients from other cities. It is necessary to structure care networks to improve treatment times and the number of patients treated.
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Aterosclerosis Carotidea: Una Causa Frecuente Pero Prevenible de Ictus Isquémico. Carotid Atherosclerosis: A Common But Preventable Cause Of Ischemic Stroke
Carotid atherosclerosis is responsible for 10-20% of all ischemic strokes and is characterized by a high risk of stroke recurrence, as well as by its preventable nature through the control of vascular risk factors, intensive medical management, and surgical revascularization in cases of severe stenosis. Pivotal studies in the 90’s showed significant benefit of carotid endarterectomy in patients with severe symptomatic carotid stenosis (>70%), whereas the benefit in patients with moderate stenosis (50-69%) and those with asymptomatic disease was modest. Active areas of research in the field include the identification of novel non-traditional risk factors directed to the early diagnosis and primary prevention of carotid atherosclerosis, the efficacy of intensive medical management to decrease to the risk of stroke among patients with asymptomatic disease, and the development of new surgical revascularization techniques with lower complication rates. Through this revision manuscript we aim to summarize the current knowledge on carotid atherosclerosis and expose a practical approach for its diagnosis and treatment.
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Conocimiento Acerca Del Ictus Isquémico En Ecuatorianos. Knowledge About Ischemic Stroke In Ecuadorian People.
Introduction. The arrival of patients with ischemic stroke to the hospital in the period of the therapeutic window, depends to a great extent on the identification of their clinical signs and the recognition that it is a medical emergency. Methods. A prospective, longitudinal, cross-sectional study was carried out, based on a structured interview with closed questions. The aim was to assess the degree of the population’s knowledge about the ischemic stroke. Results. A total of 135 subjects without a diagnosis of stroke were interviewed, randomly selected from the relatives of patients. The average age was 42.6 years, women predominated (92 / 68.1%), with an average level of education. 95.5% (129 subjects) admitted having little knowledge about stroke. Only 11.1% correctly indicated the clinical manifestations; The most recognized symptom was damping (59.3%) followed by speech disorders. 80.9% (109 respondents) identify stroke as a preventable condition. Less than half of the participants adequately named the risk factors (66 / 48.9%). 88.2% take a correct attitude to the symptoms. Conclusions. In the group of people interviewed there is a perception of risk regarding stroke, but knowledge about the manifestations and vascular risk factors is poor. It is necessary to carry out information campaigns aimed to improve knowledge of t he disease.
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Retardo en la Llegada de Pacientes con Ictus Isquémico a un Hospital Terciario de Ecuador. Delay In The Arrival Of Ischemic Stroke Patients At A Tertiary Hospital In Ecuador.
Introduction. In an Stroke unit, the ischemic stroke treatment with a pharmacological thrombolysis is associated with a better recovery. The aim of this study is to identify the variables having a significant impact in the delay of the arrival of patients at a tertiary hospital. Methods. A prospective and longitudinal study was undertaken in patients with an ischemic stroke diagnosis, who were admitted to the Stroke Unit of Eugenio Espejo Hospital of Quito city in Ecuador in the time period from November 2016 to July 2017. Patients treated with r-Tpa were compared to those who arrived 4,5 hours later. Results. A total of 61 patients were analyzed: of those, 51 arrived 4,5 hours after first symptoms at the hospital, and 10 (16,4%) were thrombolysed in the period of therapeutic window. None of the social, demographic and clinical variables were related to the early arrival, except the history of an atrial fibrillation. In the group of patients who received r-Tpa, a significantly higher percent sought for medical care as a first option compared with those arriving after the 4,5 hours (90 vs 49%, p 0,0170). The greatest impact of the early referral and the thrombolysis concerned the difference of score between the initial medical evaluation and the hospital discharge in the NIHSS scale. Conclusions. The results of this study point out to the unawareness of the stroke and the behavior to follow. The r-Tpa treatment shows clear benefits to the patients in our environment.
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Accidente Cerebrovascular en poblaciones situadas a grandes alturas: Revisión y análisis de los factores de riesgo.
Despite our understanding about cerebrovascular accident, also known as stroke, its risk factors, treatment and prevention, it remains the leading cause of death of both men and women worldwide. Several risk factors have been associated with higher incidence of stroke such as systolic or diastolic hypertension, diabetes, hypercholesterolemia, cigarette smoking or obesity. Other such as cocaine abuse, heavy alcohol consumption, AIDS, Vitamin D and protein C deficiency are also important non traditional risk factors, associated with increased prevalence of stroke. Nevertheless, high altitude exposure and potential impact of hypoxia as a stroke risk factor –in people living or visiting high altitude environments– has not been clearly established yet. This review will analyze the available evidence concerning about the association of risk factors with higher prevalence of stroke during acute or chronic high altitude exposure, either in high altitude dwellers or new sojourners. The author will examine the available evidence behind the possible physiopathology of ischemic and hemorrhagic stroke in those living at high altitudes. We conclude that living or visiting high altitude locations is a potential non traditional risk factor associated with higher incidence of ischemic stroke, especially in young otherwise healthy men. The hypobaric hypoxia level or the altitude in which stroke commonly starts is very difficult to establish. However, it is well known that as soon as hypoxia causes acclimatization, risk becomes higher. The evidence suggests that high altitude exposure and consequent hypobaric hypoxia are important environmental factors to be considered. The time length of exposure, high levels of hematocrit and polycythemia are the most prevalent risk factors associated with higher incidence of stroke in subjects exposed to chronic or acute hypoxia.
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Infarto cerebral y síndrome antifosfolípido primario.
Antiphospholipid syndrome (AFS) is one of the most frequent acquired thrombophilias, is characterized by venous thromboembolism, and/or arterial thromboembolism, and/or pregnancy morbidity, together with the presence of antiphospholipid antibodies. Thrombosis can be at both venous and arterial level, are usually recurrent and frequently affect cerebral circulation. Cerebral ischemia associated with antiphospholipid antibodies is the most common arterial manifestation and the only neurological manifestation accepted for diagnosis. Although it is difficult to predict which patients with antiphospholipid antibodies will develop thrombosis, once a thrombotic event has taken place, secondary prevention with anticoagulation is mandatory. We review the main epidemiological and diagnostic aspects and secondary prevention treatment in patients with ischemic stroke secondary to AFS.
