Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN

Usefulness of haptoglobin and serum amyloid A proteins as biomarkers for atherothrombotic ischemic stroke diagnosis confirmation.

Atherosclerosis. 2009 Aug;205(2):561-7

Authors: Brea D, Sobrino T, Blanco M, Fraga M, Agulla J, Rodríguez-Yáñez M, Rodríguez-González R, Pérez de la Ossa N, Leira R, Forteza J, Dávalos A, Castillo J

OBJECTIVE: To identify protein biomarkers in order to classify ischemic stroke subtypes using proteomic analysis and immunoenzymatic tools for clinical validation. METHODS AND RESULTS: We performed a proteomic analysis in serum samples of 24 patients with ischemic stroke (12 atherothrombotic patients and 12 cardioembolic patients). In this study, based on two-dimensional electrophoresis and mass spectrometry we found four spots whose expression intensity was at least four times stronger in atherothrombotic patients than in cardioembolic patients. These spots were identified as haptoglobin related protein, serum amyloid A (two spots) and haptoglobin alpha chain. We validated the possible value of haptoglobin and serum amyloid A in a larger series of patients (n=262) with ischemic stroke using ELISA techniques. Haptoglobin levels >1040microg/mL identified atherothrombotic patients with 95% sensitivity and 88% specificity whereas serum amyloid A levels >160microg/mL identified atherothrombotic patients with 91% sensitivity and 83% specificity. CONCLUSIONS: Haptoglobin and serum amyloid A are useful biomarkers for atherothrombotic ischemic stroke diagnosis confirmation.

PMID: 19171342 [PubMed - indexed for MEDLINE]

Whole-body periodic acceleration reduces brain damage in a focal ischemia model.

Neuroscience. 2009 Feb 18;158(4):1390-6

Authors: Martínez-Murillo R, Serrano J, Fernández AP, Martínez A

Stroke is the second most common cause of death and major cause of disability worldwide. Actual treatment involves surgery and/or thrombolytic drugs, but there is an urgent need for new approaches. Periodic acceleration, a rocking headward to footward movement of the whole body, is a non-invasive method to induce pulsatile shear stress on the vascular endothelium eliciting an enhanced production and secretion of endothelium-derived products such as nitric oxide, prostacyclin, prostaglandin E2, tissue plasminogen activator (tPA), and adrenomedullin. All these products have been shown to protect the brain from ischemic injuries. A rat model of focal brain ischemia was treated with application of periodic acceleration for 3 h immediately after the onset of ischemia. Controls remained static for the same period of time. Brain damage was assessed by magnetic resonance imaging (MRI) and biochemical markers. A significant reduction in brain damage was observed, 7 days post-ischemia, in rocked rats when compared with the static controls, through MRI. Furthermore, rocked animals had significantly lower levels of Beclin 1 and fractin than their static counterparts, and some isoforms of nitric oxide synthase were regulated by periodic acceleration. Our results show that periodic acceleration may provide a novel, affordable, non-invasive therapeutic option for the treatment of stroke.

PMID: 19135137 [PubMed - indexed for MEDLINE]

Statins and stroke.

Ther Adv Cardiovasc Dis. 2008 Jun;2(3):157-66

Authors: Rodríguez-Yáñez M, Agulla J, Rodríguez-González R, Sobrino T, Castillo J

Statins play an important role in brain ischemia. These drugs reduce cholesterol levels, which have been related to a reduction in vascular event risk, but they also have other functions besides cholesterol metabolism, called pleiotropic effects. Statins play an important role during the acute phase of ischemia, and might have neuroprotective effects, as they act in several mechanisms during the acute phase of stroke, such as in nitric oxide (NO) and glutamate metabolism, inflammation, platelet aggregation, immune responses and apoptosis. They also have other functions that can be related, with better long-term outcome, to neurorepair mechanisms. Statins promote angiogenesis, endogenous cell proliferation, neurogenesis and new synapse formation.

PMID: 19124419 [PubMed - indexed for MEDLINE]

Imaging changes in lymphoid organs in vivo after brain ischemia with three-dimensional fluorescence molecular tomography in transgenic mice expressing green fluorescent protein in T lymphocytes.

Mol Imaging. 2008 Jul-Aug;7(4):157-67

Authors: Martin A, Aguirre J, Sarasa-Renedo A, Tsoukatou D, Garofalakis A, Meyer H, Mamalaki C, Ripoll J, Planas AM

Stroke induces a strong inflammatory reaction in the brain and depresses the immune system. We sought to assess longitudinal changes in T-cell numbers in the lymphoid organs of living mice after brain ischemia. Middle cerebral artery occlusion was carried out in transgenic mice expressing green fluorescent protein (GFP+) in the T-cell population under the control of the hCD2 locus control region. Imaging was performed by three-dimensional fluorescence molecular tomography (FMT) before and at several time points after ischemia or sham operation and in controls. At day 7, GFP+ cell content in lymphoid organs was measured postmortem by flow cytometry. GFP+ cell numbers and in vivo FMT signal intensity were reduced at day 7 after ischemia and, to a lesser extent, after sham operation. Linear regression analysis demonstrated that postmortem GFP+ cell numbers and corresponding in vivo FMT data were significantly correlated in the thymus (r2 = .65, p < .0001) and lymph nodes (r2 = .67, p < .0001). These relationships allowed inferring the number of GFP+ T cells from in vivo FMT data. The results show the time course reduction of T-cell content in the lymphoid organs of living mice, providing in vivo evidence of lymphoid organ atrophy after stroke and, to a lesser extent, after head surgery with craniectomy and dura mater opening in sham-operated mice.

PMID: 19123986 [PubMed - indexed for MEDLINE]

The metabolic syndrome is associated with a higher resistance to intravenous thrombolysis for acute ischemic stroke in women than in men.

Stroke. 2009 Feb;40(2):344-9

Authors: Arenillas JF, Sandoval P, Pérez de la Ossa N, Millán M, Guerrero C, Escudero D, Dorado L, López-Cancio E, Castillo J, Dávalos A

BACKGROUND AND PURPOSE: The metabolic syndrome (MetS) might confer a higher resistance to intravenous thrombolysis in acute middle cerebral artery (MCA) ischemic stroke. MetS increases the risk of stroke in women to a greater extent than in men. We aimed to investigate whether there might be sex differences in the impact of MetS on the response to intravenous thrombolysis for acute MCA ischemic stroke. METHODS: We prospectively studied consecutive ischemic stroke patients, treated with intravenous tissue-type plasminogen activator according to SITS-MOST criteria, with an MCA occlusion on prebolus transcranial Doppler examination. Resistance to thrombolysis was defined as the absence of complete MCA recanalization 24 hours after tissue-type plasminogen activator infusion by transcranial Doppler criteria. MetS was diagnosed according to the criteria established by the American Heart Association/National Heart, Lung, and Blood Institute 2005 statement. RESULTS: A total of 125 patients (75 men, 50 women; mean age, 67.6+/-11 years) were included. MetS was diagnosed in 76 (61%) patients. Resistance to clot lysis at 24 hours was observed in 53 (42%) patients. Two multivariate-adjusted, logistic-regression models identified that MetS was associated with a higher resistance to tissue-type plasminogen activator, independently of other significant baseline variables (odds ratio=9.8; 95% CI, 3.5 to 27.8; P=0.0001) and of the individual components of the MetS. The MetS was associated with a significantly higher odds of resistance to thrombolysis in women (odds ratio=17.5; 95% CI, 1.9 to 163.1) than in men (odds ratio=5.1; 95% CI, 1.6 to 15.6; P for interaction=0.0004). CONCLUSIONS: The effect of MetS on the resistance to intravenous thrombolysis for acute MCA ischemic stroke appears to be more pronounced in women than in men.

PMID: 19109538 [PubMed - indexed for MEDLINE]

Fixed-dose combination therapy and secondary cardiovascular prevention: rationale, selection of drugs and target population.

Nat Clin Pract Cardiovasc Med. 2009 Feb;6(2):101-10

Authors: Sanz G, Fuster V

Ischemic heart disease and stroke are the leading causes of death worldwide. A large proportion of individuals at high 10-year risk of a cardiovascular event live in low-income and middle-income countries, and the large majority of all cardiovascular events occur in developing countries. A large amount of evidence supports the use of pharmacological treatment for the prevention of cardiovascular death in this population, including antiplatelet drugs, beta blockers, lipid-lowering agents and angiotensin-converting-enzyme inhibitors. However, the efficacy of cardiovascular prevention is hampered by several problems, including inadequate prescription of medication, poor adherence to treatment, limited availability of medications and unaffordable cost of treatment. Here we examine the use of fixed-dose combination therapy (a 'polypill'), and how this therapy could improve adherence to treatment, reduce the cost and improve treatment affordability in low-income countries.

PMID: 19104519 [PubMed - indexed for MEDLINE]

Biological signatures of brain damage associated with high serum ferritin levels in patients with acute ischemic stroke and thrombolytic treatment.

Dis Markers. 2008;25(3):181-8

Authors: Millán M, Sobrino T, Arenillas JF, Rodríguez-Yáñez M, García M, Nombela F, Castellanos M, de la Ossa NP, Cuadras P, Serena J, Castillo J, Dávalos A

BACKGROUND AND PURPOSE: Increased body iron stores have been related to greater oxidative stress and brain injury in clinical and experimental cerebral ischemia and reperfusion. We aimed to investigate the biological signatures of excitotoxicity, inflammation and blood brain barrier disruption potentially associated with high serum ferritin levels-related damage in acute stroke patients treated with i.v. t-PA. METHODS: Serum levels of ferritin (as index of increased cellular iron stores), glutamate, interleukin-6, matrix metalloproteinase-9 and cellular fibronectin were determined in 134 patients treated with i.v. t-PA within 3 hours from stroke onset in blood samples obtained before t-PA treatment, at 24 and 72 hours. RESULTS: Serum ferritin levels before t-PA infusion correlated to glutamate (r = 0.59, p < 0.001) and interleukin-6 (r = 0.55, p < 0.001) levels at baseline, and with glutamate (r = 0.57, p < 0.001), interleukin-6 (r = 0.49, p < 0.001), metalloproteinase-9 (r = 0.23, p = 0.007) and cellular fibronectin (r = 0.27, p = 0.002) levels measured at 24 hours and glutamate (r = 0.415, p < 0.001), interleukin-6 (r = 0.359, p < 0.001) and metalloproteinase-9 (r = 0.261, p = 0.004) at 72 hours. The association between ferritin and glutamate levels remained after adjustment for confounding factors in generalized linear models. CONCLUSIONS: Brain damage associated with increased iron stores in acute ischemic stroke patients treated with iv. tPA may be mediated by mechanisms linked to excitotoxic damage. The role of inflammation, blood brain barrier disruption and oxidative stress in this condition needs further research.

PMID: 19096131 [PubMed - indexed for MEDLINE]

The prognostic value of capillary glucose levels in acute stroke: the GLycemia in Acute Stroke (GLIAS) study.

Stroke. 2009 Feb;40(2):562-8

Authors: Fuentes B, Castillo J, San José B, Leira R, Serena J, Vivancos J, Dávalos A, Nuñez AG, Egido J, Díez-Tejedor E,

BACKGROUND AND PURPOSE: Evidence is accumulating regarding the prognostic influence of hyperglycemia in patients with acute ischemic stroke. However, the level associated with poor outcome is unknown. Our objectives were to establish the capillary glucose threshold with the highest predictive accuracy of poor outcome and to evaluate its hypothetical value in influencing functional outcome by adjusting for other well-known prognostic factors in acute stroke. METHODS: The authors conducted a multicenter, prospective, and observational cohort study of 476 patients with ischemic stroke within less than 24 hours from stroke onset. Capillary finger-prick glucose and stroke severity were determined on admission and 3 times a day during the first 48 hours. Poor outcome (modified Rankin Scale >2) was evaluated at 3 months. RESULTS: The receiver operating characteristic curves showed the predictive value of maximum capillary glucose at any time within the first 48 hours with an area under the curve of 0.656 (95% CI, 0.592 to 0.720; P<0.01) and pointed to 155 mg/dL as the optimal cutoff level for poor outcome at 3 months (53% sensitivity; 73% specificity). This point was associated with a 2.7-fold increase (95% CI, 1.42 to 5.24) in the odds of poor outcome after adjustment for age, diabetes, capillary glucose on admission, infarct volume, and baseline stroke severity and with a 3-fold increase in the risk of death at 3 months (hazard ratio, 3.80; 95% CI, 1.79 to 8.10). CONCLUSIONS: Hyperglycemia >or=155 mg/dL at any time within the first 48 hours from stroke onset, and not only the isolated value of admission glycemia, is associated with poor outcome independently of stroke severity, infarct volume, diabetes, or age.

PMID: 19095970 [PubMed - indexed for MEDLINE]

Elective cross-hand transfer with thumb transposition: case report.

J Hand Surg Am. 2008 Dec;33(10):1813-9

Authors: Cavadas PC, Ibañez J, Landin L

An elective case of cross-transfer of the right hand to the left distal forearm stump is reported in a long-standing left radial-carpal amputee who developed a contralateral cerebrovascular accident with severe right-sided spasticity. The thumb column of the right hand was transposed to the ulnar side of the hand as a free flap to improve the appearance of the transferred hand, the tendons were reciprocally repaired, the nerves were connected to permit correct cortical sensory reorientation, and a modified Sauvé-Kapandji procedure was performed to allow for forearm rotation. The functional and cosmetic result was satisfactory for the patient, allowing him to regain independence in activities of daily living.

PMID: 19084184 [PubMed - indexed for MEDLINE]

Inflammation as therapeutic objective in stroke.

Curr Pharm Des. 2008;14(33):3549-64

Authors: Jordán J, Segura T, Brea D, Galindo MF, Castillo J

Ischemic stroke is the most frequent cause of persistent neurologic disability in modern Western societies. Albeit it is still not clear whether inflammation is merely an epiphenomenon or rather has a disease-promoting function, accumulating evidence implicates inflammation in many forms of acute neurodegenerative disorders including ischemia. The immune cell influx during a neuropathological event is thought to be elicited by glial cells, especially microglia. This article reviews the cellular and molecular pathways involved in stroke-induced inflammatory response in the CNS. We focused on how CNS innate immune cells including microglia and macrophages play integral roles in receiving and propagating inflammatory signals, and how activated microglia secrete a wide range of factors. We present the relevance of the expression of adhesion molecules after ischemia including selectin, immunoglobulin superfamily, integrins, and the role of inflammatory mediators such as cytokines, chemokines and matrix metalloproteinases. Further, we explore the role of transcription factors in inflammation, and the function of immunomodulation and innate and adaptive immunity in brain ischemia, focusing on immunosupression therapies for acute stroke. Although several approaches for anti-inflammatory treatment have proven effective in animal models, clinical trials of immune system modulation therapy after stroke have not yet proved successful. There is still much to be done in order to translate interesting findings into therapies, but undoubtedly studying the cellular and molecular pathways may not only improve our understanding of inflammatory mechanism but also serve as a basis for designing effective therapies.

PMID: 19075732 [PubMed - indexed for MEDLINE]

Cell fusion contributes to pericyte formation after stroke.

J Cereb Blood Flow Metab. 2009 Mar;29(3):480-5

Authors: Piquer-Gil M, García-Verdugo JM, Zipancic I, Sánchez MJ, Alvarez-Dolado M

Recent reports have shown that bone marrow-derived cells (BMDCs) contribute to the formation of vasculature after stroke. However, the mechanism by which mural cells are formed from BMDC remains elusive. Here, we provide direct evidence that the cell fusion process contributes to the formation of pericytes after stroke. We generated mouse bone marrow chimeras using a cre/lox system that allows the detection of fusion events by X-gal staining. In these mice, we detected X-gal-positive cells that expressed vimentin and desmin, specific markers of mature murine pericytes. Electron microscopy confirmed that fused cells possessed basal lamina and characteristics of pericytes. Furthermore, induction of stroke increased significantly the presence of fused cells in the ischemic area. These cells expressed markers of developing pericytes such as NG2. We conclude that cell fusion participates actively in the generation of vascular tissue through pericyte formation under normal as well as pathologic conditions.

PMID: 19066613 [PubMed - indexed for MEDLINE]

Parameters of inflammation in morbid obesity: lack of effect of moderate weight loss.

Obes Surg. 2009 May;19(5):571-6

Authors: Solá E, Jover A, López-Ruiz A, Jarabo M, Vayá A, Morillas C, Gómez-Balaguer M, Hernández-Mijares A

BACKGROUND: Obesity has been associated with a chronic activation of the acute-phase response. The aims of our study were to investigate whether levels of inflammatory cytokines are higher in obese patients, to evaluate their relationship with metabolic syndrome, and to analyze the effect of moderate weight loss upon their levels. METHODS: Sixty-seven severe or morbid obese patients were compared with 67 controls. Patients were submitted to a 4-week very low calorie diet followed by a low calorie diet for 2 months. Exclusion criteria were organic disease, ischemic heart disease or stroke, diabetes mellitus, hyperlipidemia, and hypertension. An evaluation was performed before and after the diet, in which fibrinogen, blood count, high-sensitive C-reactive protein (CRP), interleukin 6 (IL-6), and tumoral necrosis factor alpha (TNF-alpha) were measured. The Student t test was employed to compare differences between the groups and Pearson correlation coefficients were calculated. RESULTS: Obese patients showed higher levels of CRP (P < 0.001), IL-6 (P < 0.001), TNF-alpha (P < 0.001), leukocyte (P = 0.001), and neutrophil count (P < 0.001) than controls. In obese patients, inflammatory parameters were significantly correlated with anthropometric parameters and did not differ between obese subjects with or without metabolic syndrome. Moderate weight loss (excess weight loss 19.6%) was achieved through dieting, but no change was observed in any inflammatory parameter. CONCLUSIONS: Obesity is associated to a chronic inflammatory state that seems to be due to an increased secretion of cytokines, and this state is not related to the presence of metabolic syndrome. Moderate weight loss does not ameliorate this inflammatory state in the short term.

PMID: 19050985 [PubMed - indexed for MEDLINE]

Body temperature and response to thrombolytic therapy in acute ischaemic stroke.

Eur J Neurol. 2008 Dec;15(12):1384-9

Authors: Millán M, Grau L, Castellanos M, Rodríguez-Yáñez M, Arenillas JF, Nombela F, Pérez de la Ossa N, López-Manzanares L, Serena J, Castillo J, Dávalos A

OBJECTIVE: To determine the relationship between body temperature (BT), arterial recanalization, functional outcome, and hemorrhagic transformation (HT) of cerebral infarction in patients treated with i.v. tissue plasminogen activator (tPA). METHODS: We studied 254 patients treated with tPA within 3 h from stroke onset. National Institute of Health Stroke Scale score, BT, and transcranial Doppler ultrasound (n = 99) on admission and at 24 h were recorded. Hypodensity volume and HT were evaluated on CT at 24-36 h. Poor outcome (Rankin Scale > 2) was evaluated at 3 months. RESULTS: Arterial recanalization at 24 h was found in 70.7% of patients, HT in 24.8% (symptomatic in 4.7%) and poor outcome in 44.1%. Baseline BT was not associated with greater stroke severity at admission or at 24 h, HT or poor outcome. However, BT at 24 h correlated to stroke severity (P < 0.001) and hypodensity volume (P < 0.001) at 24 h, and was higher in patients who did not recanalize (P = 0.001), had symptomatic HT (P = 0.063) and poor outcome (P < 0.001). The adjusted odds ratio of poor outcome for patients with BT at 24 h > or = 37 degrees C was 2.56 (1.19-5.50, P = 0.016). CONCLUSION: Body temperature > or =37 degrees C at 24 h, but not at baseline, is associated with a lack of recanalization, greater hypodensity volume and worse outcome in stroke patients treated with tPA.

PMID: 19049558 [PubMed - indexed for MEDLINE]

The beneficial effect of statins treatment by stroke subtype.

Eur J Neurol. 2009 Jan;16(1):127-33

Authors: Martínez-Sánchez P, Rivera-Ordóñez C, Fuentes B, Ortega-Casarrubios MA, Idrovo L, Díez-Tejedor E

BACKGROUND AND PURPOSE: Statins have shown some protective effect after ischaemic stroke in observational studies. However, this effect has never been assessed by etiological subtypes. METHODS: Observational study using data from the Stroke Unit Data Bank from consecutive patients with cerebral infarction. Variables analyzed: demographic data, cardiovascular risk factors, treatment with statins at stroke onset, stroke severity, stroke subtype, in-hospital complications, length of stay, and functional status at discharge (modified Rankin Scale). RESULTS: A total of 2742 patients were included, 1539 were men. Mean age was 69.17 years (SD 12.19). Of these, 281 patients (10.2%) were receiving statins when admitted. The logistic regression analyses showed that previous treatment with statins was an independent predictor for better outcome at discharge among all strokes (OR, 2.08; 95% CI, 1.39 to 3.1) as well as for the atherothrombotic (OR, 2.79; 95% CI, 1.33 to 5.84) and lacunar strokes (OR, 2.28; 95% CI, 1.15 to 4.52) after adjustment for demographic data, risk factors, previous treatments, stroke subtypes, stroke severity, in-hospital complications and length of stay. This benefit was not observed either in cardioembolic or in other etiology strokes. CONCLUSIONS: Previous treatment with statins is an independent factor associated with good outcomes in patients with ischaemic stroke. Atherothrombotic and small vessel strokes show the greatest benefit.

PMID: 19049507 [PubMed - in process]

Muscle strength in the Mataró aging study participants and its relationship to successful aging.

Aging Clin Exp Res. 2008 Oct;20(5):439-46

Authors: Puig-Domingo M, Serra-Prat M, Merino MJ, Pubill M, Burdoy E, Papiol M,

BACKGROUND AND AIMS: Successful aging is a worldwide aim, but its related factors and instruments of measurement are currently hotly debated. To investigate the relationship between muscle strength and functional capacity, and its association with successful aging. METHODS: A population-based cross-sectional study was performed in Mataró (Spain). Included in the study were 313 subjects (153 men, 160 women) aged 70 years and over. Physical and cognitive functions were assessed, as well as muscle strength, nutritional status, lifestyle factors, and associated morbidities. RESULTS: A state of successful aging (SA), defined as optimal functional and cognitive capacities with absence of cancer, stroke, cardiovascular or pulmonary chronic diseases, was found in 20% of women and 32% of men. SA was associated with higher muscle strength in comparison with the non-SA condition. Muscle strength measurements were higher in men, and decreased with age, poor balance, decreased functional capacity, and impaired cognitive status. It was also associated with higher academic level, regular exercise, and nutritional status in both genders. Multivariate analysis showed that independent variables related to SA were: hand grip, arthrosis, deafness and unipodal balance test, but not age or gender. CONCLUSIONS: Muscle strength is positively associated with the successful aging condition, and may be one of its functional links, reflecting the integrated health status of old men and women. The systematic inclusion of the measurement of muscle strength may be helpful in clinical evaluation of the elderly.

PMID: 19039286 [PubMed - indexed for MEDLINE]

Volume and composition of emboli in neuroprotected stenting of the carotid artery.

AJNR Am J Neuroradiol. 2009 Mar;30(3):473-8

Authors: Piñero P, González A, Martínez E, Mayol A, Rafel E, González-Marcos JR, Moniche F, Cayuela A, Gil-Peralta A

BACKGROUND AND PURPOSE: Periprocedural microembolization is a major and permanent risk for patients treated by angioplasty and stent placement of high-grade carotid stenoses. Little is known however about the characteristics and significance of these embolized particles. Our aim was to assess the volume and composition of debris captured by filters during carotid angioplasty and stent placement (CAS) of severe internal carotid artery (ICA) stenoses. MATERIALS AND METHODS: Institutional review board approval and informed consent from all subjects were obtained. Two hundred one patients (mean age, 66.2 years; range, 35-82 years) with > or = 70% stenosis of the ICA underwent filter-protected CAS. Ultrastructural and semiquantitative analysis of the volume of filters was obtained. Multifactorial statistical analysis was performed to determine factors related to debris volume and composition. RESULTS: Transient ischemic attack occurred in 6 patients (3%), and a major stroke, in 1 (0.5%). Debris was found in 117 filters (58.2%), with volume <1 lambda (0.001 mL) in 71%. The number of balloon dilations, age older than 65 years, and calcified plaques in pre-CAS angiography were significantly associated with the presence of particulates inside the filters (P < .03, P < .004, and P < .05, respectively). CONCLUSIONS: Vessel wall and atheromatous plaques are the main source of microemboli during CAS. Embolization is mainly related to the number of balloon dilations during CAS. Planning a proper and individualized strategy for the procedure in each patient is essential to minimize the potential effects of manipulation during CAS.

PMID: 19039048 [PubMed - indexed for MEDLINE]

Blood pressure in the initial phase of acute ischaemic stroke: evolution and its role as an independent prognosis factor at discharge and after 3 months of follow-up.

Blood Press. 2008;17(5-6):284-90

Authors: Armario P, Mártin-Baranera M, Miguel Ceresuela L, Hernández Del Rey R, Iribarnegaray E, Pintado S, Avila A, Bello J, Luis Tovar J, Alvarez-Sabin J

BACKGROUND: A prospective observational study was aimed at assessing the role of blood pressure (BP) during the first 24 h from stroke onset on the outcome of acute ischaemic stroke. METHODS: Subjects admitted within the first 3 h from stroke onset were included. Stroke severity was evaluated with the Canadian Stroke Scale (CSS). Functional recovery was defined as a modified Rankin Scale score < or =2. RESULTS: One hundred subjects were included. In a logistic regression model, the independent predictors of poor functional recovery at discharge were: age (OR = 1.12; 95% CI 1.04-1.21; p = 0.0033), non-lacunar stroke subtype (OR = 4.31; 95% CI 1.07-17.31; p = 0.0395), diabetes mellitus (OR = 8.38; 95% CI 1.67-41.95; p = 0.0097), a CSS score at admission < or =8 (OR = 28.64; 95% CI 5.59-146.68; p<0.0001), an average systolic BP during the first 6 h > or =180 mmHg (OR = 13.34; 95% CI 1.34-133.10; p = 0.0272) and a lower diastolic BP average from 6 to 24 h (OR for 5 mmHg increase: 0.57; CI 95% 0.36-0.88; p = 0.0115). Similar results were observed after 3 months of follow-up. CONCLUSION: In ischaemic stroke patients, systolic BP over 180 mmHg in the first 6 h and a decrease of diastolic BP during the 6-24 h from stroke onset were independent predictors of a poor functional recovery.

PMID: 19023686 [PubMed - indexed for MEDLINE]

Ischemic stroke and epilepsy in a patient with Tourette's syndrome: association with the antiphospholipid syndrome and good response to levetiracetam.

Open Neurol J. 2008;2:32-4

Authors: Seijo-Martínez M, Mosquera-Martínez JA, Romero-Yuste S, Cruz-Martinez J

The role played by different humoral factors, including antiphospholipid antibodies, in the pathogenesis of Tourette syndrome (TS) is still presently unclear. We present a patient with chronic and severe TS who, at the age of 16 years, presented an ischemic stroke in the left posterior cerebral artery and/or postero-inferior temporal branch of the left medial cerebral artery. A complete study was negative with the exception of a positive lupus anticoagulant. The stroke was related with the primary antiphospholipid syndrome (APS). The stroke manifested visual abnormalities and thereafter by secondary generalized complex partial seizures. The epileptic syndrome was initially difficult to control but responded dramatically to levetiracetam. With this therapy, the manifestations of TS, especially the tics, improved. We conclude that some TS cases may present APS. In addition, levetiracetam may be useful in the management of TS. Further investigations should pursue both these facts.

PMID: 19018305 [PubMed]

Patent foramen ovale not so patent.

Echocardiography. 2009 Apr;26(4):465-8

Authors: López-Haldón J, López-Pardo F, Rodríguez-Puras MJ, Martínez-Martínez A

Transesophageal echocardiography (TEE) with agitated saline contrast is the most sensitive tool for diagnosing patent foramen ovale (PFO), but false positives can result. We report a patient who underwent a TEE during the study of a cryptogenic stroke. Contrast appeared in the left atrium with the Valsalva maneuver. However, the contrast exit site was not identified, and contrast continued to appear with Valsalva once the saline microbubbles had disappeared. Combined with the contrast characteristics, this suggested a spontaneous contrast phenomenon rather than a PFO. This phenomenon must be kept in mind to avoid overdiagnosing PFO.

PMID: 19017320 [PubMed - indexed for MEDLINE]

Late complication of classic Fontan operation: giant right atrial thrombus and massive pulmonary thromboembolism.

J Card Surg. 2008 Nov-Dec;23(6):776-8

Authors: Mosquera VX, Marini M, Portela F, Cao I

Thrombus formation can be a significant cause for morbidity and mortality after Fontan operation. Intracardiac thrombus formation can lead to chronic pulmonary embolic disease if formed on the right side, or stroke, if on the left side of the heart. Right-sided embolism may result in ventilation/perfusion mismatch or elevation of pulmonary vascular resistance, both of which may seriously hamper cavopulmonary physiology. We report the case of a 22-year-old patient, with past history of classic Fontan procedure performed at the age of six to palliate a single-ventricle tricuspid atresia, who presented with a massive pulmonary embolism and hemodynamic instability. Due to his critical status, mechanical fragmentation of the clot using the angiography catheter was started, followed by a local catheter-directed infusion of urokinase. This case demonstrated that pharmacomechanical thrombolysis therapy with a standard Pig-tail catheter and thrombolytic therapy with urokinase is secure, effective, and appropriated to manage heart chamber and pulmonary arterial thrombosis in patients with congenital heart disease.

PMID: 19017011 [PubMed - indexed for MEDLINE]