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).
Ictus isquémico
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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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.
