Streptococcus Constellatus ssp pharingi belongs to the group of Streptococcus Anginosus, it constitutes normal flora of th respiratory, gastrointestinal and genitourinary tracts, it infrequently produces localized or disseminated infections in patients with risk factors. The case of a 41-year-old male patient is reported, with a history of pituitary macroadenoma resection in 2003, undergoing treatment, who consulted the emergency department for 4 days with intense holocranial headache, fever, emesis, associated with temporospatial disorientation and weakness in lower limbs in the last 24 hours. He required management in the intensive care unit, mechanical ventilation, vasopressor support, and tracheostomy, due to respiratory and hemodynamic deterioration. In extension studies, meningitis due to Streptococcus Constellatus ssp pharingi was documented in the presence of sinusitis, cerebrospinal fluid fistula and multi-infarct cerebral vascular compromise, product of vasculitis of infectious origin, a severe manifestation of
bacterial meningitis, not previously reported by this microorganism.
stroke
Accidente cerebrovascular en un paciente con meningitis por Streptococcus Constellatus. Stroke in a patient with Streptococcus Constellatus meningitis.
Evaluación de la calidad de las guías de práctica clínica sobre enfermedad vascular cerebral aguda mediante la herramienta AGREE II. Quality assessment of clinical practice guidelines on stroke using the AGREE II tool
Objetive: Evaluate the quality assessment of the treatment guidelines for stroke between 2010 and 2021.
Methods: Evaluation by AGREE II instrument. Intraclass correlation was performed for two observers, and it was analyzed the consensus on blood pressure goals and the use of prehospital scales.
Results: 21 clinical practice guidelines were included. The consensus between observers was 0.88 (95% CI: 0.69-0.95). The highest score was for clarity of presentation, while the lowest was for applicability. Nine guidelines (42.9%) were “recommended,” seven were “not recommended” (33.3%) and five were “recommended, but with modifications.” There is consensus on the blood pressure goals in the initial phase. The Fast scale was the most recommended.
Conclusions: Less than half of the guidelines analyzed were recommended for clinical use. Since 2016, the guidelines have shown substantial improvements in their quality. Implementing and actively utilizing the guidelines demands strengthening the applicability and editorial independence.
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From hypokinesia to hyperkinesia: An 86-year-old-woman with abnormal movements. De hipocinesia a hipercinesia: Mujer de 86 años con movimientos anormales
An 86-year-old woman presented with an acute onset of confusion, garbled speech, and decreased left arm movement. On exam, she had a forced right gaze, left homonymous hemianopsia, left hemiparesis, and left face and arm hypoesthesia. Forty-eight hours after successful revascularization therapies, the patient started complaining of abnormal involuntary movements. This manuscript discusses the phenomenology of these involuntary movements, their neuroanatomical correlates, management, and evolution. Neurologists should be mindful of post-stroke movement disorders, their latency period after stroke, and the functional-anatomic networks involved.
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Embolismo gaseoso cerebral: a propósito de un caso de ictus masivo. Cerebral air embolism: about a case of massive stroke
Introduction: Cerebral air embolism is a rare but potentially fatal entity, that occurs due to the entry of air into the cerebral blood circulation and is caused by multiple causes, including t hose associated with medical procedures.
Clinical case: We present the case of an 81-year-old male patient who, after removal of the high-flow hemodialysis catheter, begins with a deterioration of the level of consciousness, which worsens progressively. Multiple hypodense lesions, compatible with gas embolism, are evidenced in the cerebral tomography. Due to his slow evolution, he was transferred to the intensive care unit and died a few hours later.
Conclusion: It is essential to know the preventive measures to avoid this complication and the general and specific measures to adopt when it occurs.
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Actualización y aproximación clínica a los modelos teóricos de la apraxia de extremidades. Approaching theorical models of limb apraxia: a clinical update
Apraxia is a common disorder in people who have suffered a left hemispheric stroke, with significant impact on their quality of life. Although several models have been proposed for its interpretation and approach, some aspects are still under study. The objective of this study is to review the current models of limb apraxia, to analyze the available evaluation tools and to make recommendations for clinical practice. The review shows that in the literature there is a greater interest in the conceptual system within the lexical-semantic route, without developing in detail the conceptual system within the visuomotor route. This article proposes a model of apraxia that overcomes these limitations and describes an assessment method focused on body knowledge within the visuomotor route. Finally, it is concluded that more studies are necessary to experimentally validate the proposed model and the associated evaluation methods.
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Asterixis and dysarthria-clumsy hand originated of lacunar infarction: A series of six cases. Asterixis y disartria-mano torpe originado a partir de los infartos lacunares: Una serie de seis casos
La asterixis y la disartria-mano torpe son signos neurológicos poco frecuentes que pertenecen a los trastornos del movimiento después de un accidente cerebrovascular. Clínicamente ellos son clasificados como parte del infarto lacunar y la mayoría de los casos se resuelven espontáneamente en un periodo entre 10 semanas y un mes. El objetivo de este estudio fue reportar seis casos de pacientes masculinos con infarto lacunar y describir los síntomas, localización y tamaño de las lesiones. Se describen casos de infarto lacunar y síntomas motores leves (disartria y asterixis) sin ningún indicio de demencia. En conclusión, nuestros casos presentan movimientos neurológicos anormales como asterixis y disartria-mano torpe en pacientes con hipertensión y / o diabetes mellitus tipo 2. Debido a la transitoriedad de esos movimientos, el diagnóstico en el tiempo adecuado es importante, a partir de eso los médicos pueden solicitar los exámenes de imagen, tratar al paciente y luego acompañarlo previniendo futuros ictus con consecuencias aún más graves. Así, estudios como el nuestro pueden contribuir al correcto diagnóstico de los infartos lacunares.
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Relación Entre Uricemia y El Estado Funcional Neurológico En El Ictus Isquémico Agudo – Estudio Multicéntrico. Relationship Between Uricemia And The Neurological Functional State In Acute Ischemic Stroke – Multicenter Study
INTRODUCTION: Various biomarkers are studied as a prognostic factor in ischemic stroke, the results obtained about uric acid are controversial.
OBJETIVE: To determine if there is a relationship between uricemia and the neurological functional state in acute ischemic stroke.
MATERIAL AND METHODS: A study was carried out that included 151 patients diagnosed with acute isquemic stroke from the neurology department of the Victor Lazarte Echegaray Hospital and Alta Complejidad Virgen de la Puerta Hospital that met the selection criteria, the relationship between uricemia and neurological functional prognosis using the modified Rankin Scale (mRS), using the Eta statics.
RESULTS: 55.6% of the patients had a poor neurological functional prognosis (mRS>2) reporting acid uric levels with a mean of 4.13 mg/dl. An Eta coefficient of 0.940 was obtained.
CONCLUSION: There is a direct relationship between uricemia and neurological functional state in patients with acute ischemic stroke, associating more extreme values with the worst functional prognosis at hospital discharge.
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Principios del aprendizaje motor: Una revisión sobre sus aplicaciones en la rehabilitación del accidente cerebrovascular. Motor learning principles: A review of their applications in stroke rehabilitation
Stroke is one of the leading causes of disability worldwide. Despite the functional consequences, a recovery process can occur in these patients thanks to the neuroplasticity mechanisms preserved after brain damage. Recovery of movement patterns after stroke has been suggested to be based on a learning process. Motor learning is an approach that has recently generated a great deal of attention in the field of neurorehabilitation. Thanks to its association with neuroplastic mechanisms, the implementation of motor learning principles has shown positive results during motor skills learning in stroke patients. The present study offers a review of the fundamentals of motor learning and its various strategies to promote the learning of a motor skill. This article provides a concise overview of the implications of motor learning in stroke rehabilitation, describing the strategies, therapeutic approaches, and assessment parameters used respectively to promote and evaluate motor learning in stroke patients.
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Aplicación de Realidad Virtual Para Tratamiento de la Mano Espástica en la Hemiplejía. Revisión Sistemática. Virtual Reality For Spastic Hand In Stroke Patient. Systematic Review.
Introduction: The virtual reality is as a real-time computer technology system whose use in neurological patients is an innovative process at the service of motor function recovery.
Aim: To determine the effect of virtual reality on the motor function of the spastic hand of the adult with hemiparesis.
Materials and methods: A systematic review of the literature was performed in PubMeD, Science direct, EMBASSE, PeDro, OT Seeker, Cochrane databases; they were selected results and controlled clinical analyzes from an analytical perspective according to the quality standards established to report experimental studies using the CONSORT 2010 strategy, for the inclusion criteria and the methodological quality studies was analyzed using the PEDro scale.
Results: The virtual reality therapy showed effectiveness in the function of the spastic hand of the adult with hemiparesis in selective activities that involve dexterity and execution of daily life skills, as well as favors the recovery of spasticity
Conclusions: Virtual reality therapy is effective in the spastic hand function of the adult with hemiplegia as a cerebrovascular consequence disease in selective activities that involve the dexterity and activities living of daily execution, as well as the recovery of the spasticity.
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Funcionalidad de la Marcha en la Calidad de Vida Relacionada con la Salud en Adultos con Enfermedad Cerebro Vascular: Revisión Sistemática – Metaanálisis. Functionality Of The Gait In The Quality Of Life Related To Health In Adults With Stroke: Systematic Review – Metaanalysis.
Introduction: Stroke causes deficiencies that affect movement; these include deficit in motor function, reflex integrity, sensory integrity, and gait.
Objective: determine the effect of gait functionality on health-related quality of life in adults with Stroke.
Method: databases PUBMED / MEDLINE, EMBASE, LILACS, SCIELO, Central Cochrane Registry of Controlled Trials (CENTRAL) were consulted between November 2016 and February 2017. Randomized clinical trials were selected. For the analysis, the methodological quality was evaluated using the Physiotherapy Evidence Database, PEDro score and the Risk of bias with the Review Manger 5.3 (RevMan) criterias, also RevMan was being used for analysis and data extraction according to the eligibility criteria.
Results: Lokomat as a rehabilitation strategy for gait functionality has a positive effect on improving the quality of life in people with stroke. The analysis of the included studies demonstrated a low level of statistical heterogeneity based on I2 and Chi2, for the global scale of quality of life. The results obtained for quality of life related to health, when the proposed intervention is carried out with the use of Lokomat and measured with the SF-36 scale, an increase of 1.83 points.
Conclusions: The rehabilitation of gait functionality through different protocols and intervention strategies does not present differences, due to its variability in terms of technique, application method, clinical involvement of stroke and the duration of its application. However, clinical changes that favor quality of life related to health are observed.
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Fibrinólisis Farmacológica en el Ictus Isquémico Agudo. Experiencia en un Hospital Terciario del Ecuador. Pharmacological Thrombolysis In Ischemic Stroke. Experience In A Tertiary Hospital From Ecuador.
Introduction. Pharmacological thrombolysis in ischemic stroke is associated with a better recovery.
Objective. Describe the thrombolysis results after using r-Tpa applying an intrahospital stroke code, during one year.
Methods. A prospective, longitudinal study was performed in patients with cerebral infarction admitted to the stroke unit, with clinical follow-up up to 3 months after hospital discharge. The variables evaluated were compared in two groups of patients (only one group received the treatment).
Results. 107 patients were studied: 16 (14.9%) were thrombolyzed, 29 (27.1%) arrived in the therapeutic window period and 76 (71%) arrived after 4.5 hours. The average age was 68, 8 years and women predominated. The greatest impact of thrombolysis was on the difference in score between the initial assessment and the discharge on the NIHSS scale. At three months of evolution, the percentage of patients with mild disability (Rankin 0-2) was almost equal in the two groups. Mortality increased in patients with more severe disability (Rankin 3-5).
Conclusions. Treatment with r-Tpa shows benefits at hospital discharge. Further analysis is required with a greater number of cases.
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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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Riesgo Cardiovascular Entre Hispanos Residiendo en los Estados Unidos: El Sistema Conductual de Vigilancia de Factores de Riesgo 2013. Hispanic Ethnicity and the Risk of Cardiovascular Disease in the United States: The Behavioral Risk Factor Surveillance System 2013.
Background: Although the leading cause of death among Hispanics living in the United States (US) is cardiovascular disease (CVD), the association between Hispanic ethnicity and CVD has been scarcely explored. Objective: To examine whether being Hispanic is associated with an increased risk of CVD compared with the non-Hispanic US adult population in 2013. Methods: Secondary data analysis of a cross-sectional 2013 Behavioral Risk Factor Surveillance System survey in 2013 (n=486,905). The main exposure variable was Hispanic ethnicity (Mexican, Puerto Rican, Cuban or Spanish origin) and the main outcome variable was self-reported CVD (myocardial infarction/coronary artery disease/angina). The main covariates were sex, age, education, income, healthcare access, exercise, body mass index, current smoking, heavy drinking, diabetes, hypertension and hyperlipidemia. Unadjusted and adjusted logistic regressions were used to assess the effect between ethnicity and self-reported CVD. Odds ratios (OR) and 99% confidence intervals (CI) were calculated. Results: In total, 12% of the study participants were Hispanic (n=57,257). Approximately 24% of Hispanics were 25-34 y/o while (21%) of non-Hispanic were >65 y/o. After adjustment, Hispanics were 30% less likely to report CVD compared with non-Hispanics (OR=0.7; 99%; CI=0.6-0.8). Compared with men, women had a 40% decreased risk of having CVD (OR=0.60; 99% CI=0.5-0.6). Advanced age, lower educational attainment, income <$15,000/year, lack of exercise, smoking, non-heavy drinking, diabetes, hypertension and hyperlipidemia increased statistically significantly the likelihood of reporting CVD. Conclusion: The findings suggest that, in general, Hispanics residing in the US are significantly less likely to self-declare if they had a CVD compared with non-Hispanic Americans. These data suggest that although Hispanics are generally poorer and have less access to education and health services, their self-perceived health is better than in non-Hispanic residents of the US.
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Tabaquismo y su Asociación con Mortalidad Intrahospitalaria en Pacientes con Ictus Hemorrágico. Cigarette Smoking And Its Association With In-Hospital Mortality In Hemorrhagic Stroke Patients.
Background: Smoking is a well-known reversible risk factor associated with acute ischemic stroke (AIS), however, some data showed that in-hospital mortality rates among smoker’s patients with hemorrhagic stroke is lower when compared with non-smokers patients. The objective of this analysis was to assess in-hospital patient mortality rate between smokers and non-smokers patients with confirmed diagnosis of hemorrhagic stroke. Methods and Results: We analyzed all the data from patients diagnosed with hemorrhagic stroke that were registered in the Florida Stroke database from 2008-2012. Among the 21,013 patients diagnosed with hemorrhagic stroke, 10.9% of patients were smokers. A Multivariable model was used to estimate the adjusted odds ratio of in-hospital mortality rate in smokers versus non-smokers. Smoking was associated with lower in-hospital mortality in hemorrhagic patients. (UOR= 0.71 vs. AOR= 0.75). Other risk factors like hypertension, BMI>40 and hyperlipidemia, remained significantly associated after modeling, and some others like gender, race, health insurance coverage, and diabetes became insignificant. The difference between unadjusted and adjusted odds ratios for smoking (0.71 versus 0.75) indicates no presence of substantial confounding by age and other control variables. Conclusions: Among patients hospitalized for hemorrhagic stroke, smoking is a risk factor for early age of onset, even among those with few vascular risk factors. The persistent association with lower in-hospital mortality after adjusted analyses probably represents other unmeasured confounding, although a biological effect of smoking cannot be excluded. Further clinical and prospective population-based studies are needed to explore variables that contribute to outcomes in these patients.
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Enfermedad Cerebrovascular en el Ecuador: Análisis de los Últimos 25 Años de Mortalidad, Realidad Actual y Recomendaciones
Background. Cerebrovascular disease is the second cause of death and occupies the third place as a factor causing disability worldwide. At present, despite the recognition of its importance, the available data about Ecuador is scarce and there are not published analysis of its behavior. Methods. Retrospective longitudinal analysis of available public data on cerebrovascular disease in Ecuador, from 1991 to 2015. Results Cerebrovascular disease was the leading cause of mortality by 77 897 (6.70%) deaths and it is the only one with a constant trend pattern in the last 25 years. Conclusions. Cerebrovascular disease is the number one cause of death in Ecuador and its mortality is steadily increasing. Government policies must be implemented to reduce their mortality.
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Post-stroke hemiballismus and Contralateral tremor: Report of two cases.
Involuntary abnormal movements may occur as part of the symptomatology of acute stroke or may be delayed or progressive. We report two cases of post-stroke hemiballismus and contralateral tremor. Both patients presented acute hemiballismus. In one of the patients, the tremor started with acute symptomatology and the other was delayed. We discuss the possible pathogenic mechanisms for their movement disorders. To our knowledge, this is the first report of two cases with the unusual presentation of post-stroke hemiballismus and contralateral tremor.
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Subtipos de Enfermedad Cerebrovascular: Análisis del registro de la Unidad de Ictus del Hospital Clínica Kennedy.
The main goal of this study was to determine the relative incidence of the different subtypes of stroke in a group of people from Guayaquil, considered of a relatively high socioeconomic stratus, to establish a relationship that was previously proposed as a probable cause of the etiologic stroke subtype variation found in our city. We conducted a retrospective study, in which were identified 100 consecutive patients with acute first-ever stroke admitted to the stroke unit of Hospital-Clínica Kennedy. The results were: male prevalence (57% vs 43%), mean age of onset 70 years for infarcts and 54 years for hemorrhages. Sixtythree patients had a cerebral infarction and 37 had an intracranial hemorrhage. As conclusion, we found that this relatively high prevalence of hemorrhages were related to rupture of intracranial aneurysms, and that most infarcts were related to hypertensive vasculopathy. We also found that the main risk factors were arterial hypertension and cardiopathies (p<0.05). Is important to resolve the controversies that were provoke in the last years about onset variability in types and subtypes of stroke, for which more studies and further are required.
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Cadena de supervivencia del Ictus: Un desafío de la medicina actual.
A quasi experimental study was carried out in patients with cerebrovascular disease, through the stroke survival chain at the Municipality Holguín, in order to characterize the access getting of these patients to the secondary care unit at the Hospital Provincial Docente V. I. Lenin, from May to October 2006. Neurological evaluation and cerebrovascular risk scales were applied, obtaining the following results: ages from 60 to 74 years were the more affected, predominantly in male. Atherotrombotic cerebral infarcts were the more frequent. Only 8 patients (23,5%) arrived to the hospital during the first three hours of the event. High blood pressure, history of cerebrovascular disease and cardiopathies were the more frequent risk factors. Glasgow coma scale above 11 points was observed in all the cases. We conclude that, in order to reestablish cerebral blood flow after stroke, it is necessary to participate in a whole performance survival chain.
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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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Epidemiología del Ictus entre los años 2007-2009 en el Hospital Regional Dr. Teodoro Maldonado Carbo.
Objective: Determine the prevalence of the different epidemiological features and risk factors of stroke patients of the Regional Hospital Dr. Teodoro Maldonado Carbo.
Methods:Cross-sectional study of 521 patients with diagnosis of stroke, admitted to the Neurology Service of the Social Security Hospital between the years 2007-2009. Data was recollected from the discharge notes and medical records. The measured variables were duration of hospital stay, diagnosis, mortality, non-modifiable risk factors, and modifiable risk factors. In case of hemorrhagic stroke variables that could represent its cause were also recollected.
Results: Most patients were males (70.5%), the most prevalent risk factors were hypertension (81.1%), diabetes mellitus (27%) and dyslipidemia (16.88%). The mean age was 67±13 years. There was an increased tendency of hypertension in males and of diabetes mellitus in females (p=0.45, p=0.17 respectively). There was a significant difference in the presence of coagulopathy (p=0.01), valvulopathy (p=0.04) and anticoagulant use (p=0.004) in females. Ischemic stroke represented the 80.9% and hemorrhagic stroke the 19.1% of cases.
Conclusions: These results are similar to those found in Latin American and North American publications. The correction of the most prevalent risk factors in our population would markedly decrease the incidence of this disabling disease.
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Activador del Plasminógeno tisular, realidad actual. Estudio transversal retrospectivo entre los años 2007-2009 en el Hospital Regional Dr. Teodoro Maldonado Carbo.
Objective: To determine the proportion in which the variables for the administration of tissue plasminogen inhibitor (tPA) are present in the population admitted to a hospital in Guayaquil-Ecuador.
Methods: Cross-sectional study with patients admitted to the Neurology service at the Regional Hospital Dr. Teodoro Maldonado Carbo between January 1, 2007 and December 31, 2009 with diagnosis of acute stroke. The inclusion and exclusion criteria were the same ones used on the guidelines for the use of tPA in patients with stroke during the first 3 hours and between the first 3-4.5 hours of onset.
Results: 550 patients were included in the analysis. 434 patients had ischemic stroke and 116 hemorrhagic stroke. 6 patients arrived to the hospital in the first 3 hours from onset and 13 patients arrived between the 3-4.5 hours from onset. In the first 3 hours, 4 out of 6 patients (66%) were candidates for the administration of tPA and between the first 3-4.5 hours, 6 out of 13 patients (59%) were candidates for tPA.
Conclusions: The majority of the patients that arrived to this hospital; did so after 4.5 hours from the onset of symptoms. If these patients would have arrived earlier, a great proportion could have received a treatment potentially beneficial that would produce a clinical improvement and a better prognosis if the treatment was available in the hospital.
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Síndrome de Moyamoya en un niño con Drepanocitosis.
Sickle cell disease is one of the main causes of ischemic stroke in the childhood, generally related with stenosis of the arteries of the anterior carotid circulation. We present the results of the studies carried out in a patient with sickle cell with no history of stroke, in treatment with hidroxyurea. Transcraneal Doppler and Magnetic Resonance Imaging demonstrated the existence of stenosis in medial cerebral arteries and a Moyamoya pattern in the cerebral circulation with hemodynamic ischemic lesions.
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Disfagia en el Paciente con Enfermedad Cerebrovascular.
Dysphagia in patients with cerebrovascular disease is a common problem that is associated with increased rates of pneumonia, malnutrition, hospital stay and mortality. A literature search was conducted in MEDLINE and Cochrane Library for recommendations for assessment and management of dysphagia in patients with stroke. Because the evidence is poor in quality, hence doubtful, there are no clear guidelines. Emerging data suggest that the implementation of a protocol for early screening and management of dysphagia improves the prognosis of these patients. Further studies are needed to provide reliable evidence to make valid recommendations.
