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The use of extracts from the hawthorn plant as cardiovascular agents dates back to the 1st century; recently, they have also been made available online as weight loss aids. Herein, we present a case of intentional intoxication with hawthorn root extract (HRE) in an adult patient that resulted in death. A 20-year-old female patient, who was clinically diagnosed with depression, developed hypotension, bradycardia, and depressed consciousness after ingestion of this extract. An electrocardiogram recorded a sinus arrest with a slow nodal rhythm, which rapidly deteriorated, leading to cardiac arrest. This case report illustrates the potentially fatal consequences of HRE for which the constituents have not yet been characterized. All physicians, especially those in the emergency department, should be aware of the dangerous, even potentially fatal interactions of HRE with prescription medications.

Resumen Introduccion El objetivo de este estudio es establecer la correlacion entre los tiempos de circulacion extracorporea (CEC) y pinzamiento aortico y el diametro de la vaina del nervio optico (DVNO). Pacientes y metodos Se estudio una cohorte de pacientes con edad de 0 a 15 anos, sometidos a cirugia cardiaca con CEC. Se calculo un tamano muestral de 23 participantes. Primero se obtuvo el promedio de tres mediciones verticales y tres horizontales del DVNO. Despues, se utilizo para los analisis la media de los valores de ambos ojos. Las mediciones ocurrieron al ingreso y a las 6 y 24 horas poscirugia. Los tiempos de CEC y pinzamiento aortico se obtuvieron del informe quirurgico. Resultados Se analizaron datos de 23 participantes, el 52,2% mujeres, con edad mediana de 14 meses. La mediana del tiempo de CEC fue 60 minutos; la mediana de tiempo de pinzamiento aortico fue 32 minutos. La mediana del DVNO basal fue 3,1 mm. Los valores de DVNO aumentaron por una mediana de 0,015 mm a las 6 horas poscirugia (p = 0,03). Encontramos una correlacion positiva entre el tiempo de CEC y los valores de DVNO (r = 0,476; p Conclusion El estudio encontro una correlacion entre el tiempo de CEC y el DVNO medido 24 horas poscirugia. Hubo variaciones del DVNO incluso en pacientes sin signos o sintomas de incremento de la presion intracraneal. Se requiere mas investigacion para identificar los factores relacionados con estas variaciones.

Objectives In patients with neurocysticercosis (NCC), an accurate risk prediction would allow a better therapeutic approach; however, there are currently no tools that can enhance the accuracy of risk prediction. We designed a prognostic scoring system to be used by neurologists and other physicians managing patients with NCC. Materials and Methods Using data from clinical records of patients from a third-level national reference center for neurological diseases, we assessed demographic, clinical, and tomographic variables among 293 patients diagnosed with NCC. Multivariable logistic regression analyses were used to develop a clinical prognostic scoring instrument. Patients with NCC were assessed for neurological impairment at 3 months after diagnosis. Statistical Analysis Score accuracy was assessed by receiver operating characteristic (ROC) curve analysis. The primary outcome was the presence of neurological impairment, resulting in disability according to self-report or caregiver reports; this outcome was assessed during follow-up visits at 3 ± 1 months after discharge. Results The most common symptoms at presentation were headache (67%) and seizure (63%). A six-item (total score from –4 to + 2) prognostic instrument was constructed on the basis of the presence of seizures/headache at presentation, a leukocyte count above 12x 109/dL, the presence of six to ten parasites, subarachnoid localization, and the use of anthelmintic drugs. Among 113 patients with negative scores, 79.6% developed neurological deficits. Among patients with scores of 1 to 2, 64.6% recovered completely, with an overall accuracy of prediction of 74.7% and area under the ROC curve = 0.722 (95% CI, 0.664–0.780, p < 0.0001). Conclusions The clinical prognostic scoring system for NCC described in this study is a new instrument for use in daily clinical practice. It is simple to administer, and it has a prognostic accuracy of 75%. Its use has the potential to improve the quality of care by guiding appropriate decision-making and early management of patients with NCC.

Background: COVID-19 pandemic has forced important changes in health care worldwide. Stroke care networks have been affected, especially acute admissions and ancillary tests availability. We assessed the impact of the pandemic and the lockdowns imposed in stroke admissions in Latin America. Methods: A multinational study (7 countries, 18 centers) of patients admitted since the pandemic outbreak (January - June 2020). These cases were compared with the same period in 2019. We also assessed patterns during the strictest lockdown period (March-June 2020). Number of cases, stroke etiology and severity, acute care and functional outcomes were compared per periods, months, centers and countries. Results: There were 1863 stroke cases in 2019 and 1781 cases in 2020 (p=0.02). We found a significant increase in strokes of undetermined etiology due to incomplete studies in 2020 [16.8% vs 27.6%, p Conclusions: All-type stroke admissions diminished only slightly during the first months of the COVID-19 pandemic. However, in this region, we found substantial deficiencies in stroke work-up, poor short-term outcome and increased mortality.

Background: Ischemic stroke has been reported to occur in approximately 5% of COVID-19 patients, although some reports are contradictory. Proposed mechanisms of this association are hypercoagulable state, vasculitis and cardiomyopathy, together with traditional vascular risk factors. We analyzed the frequency and clinical characteristics of COVID-19 positive stroke cases during the first months of the pandemic in Latin America. Methods: A multinational study (7 countries, 18 centers) of patients admitted during the pandemic outbreak (March - June 2020). We assessed acute stroke cases associated to COVID-19 infection. Clinical characteristics, stroke etiology and severity, acute care and functional outcomes, were compared between non-COVID-19 and COVID-19 cases. Results: There were a total of 1037 stroke cases; sixty-two of them (6.0%) were diagnosed with COVID-19 infection. This group consisted of 38 men [61.3%], with a median age of 68 years [IQR 59-79 years]. From these cases, 80.6% were ischemic stroke, 16.1% hemorrhagic stroke, and 1.6% transient ischemic attack and cerebral venous thrombosis respectively. The most common etiology reported for ischemic cases was atherosclerotic large vessel occlusion (30.6% vs. 12.7% in non-COVID cases, p Conclusions: COVID-19 infection frequency in stroke patients in Latin America is similar to that reported in several series worldwide, with a higher frequency of atherosclerotic ischemic strokes and mortality compared to non COVID-19 strokes

The objective of the study was to analyse the correlation between extracorporeal life support (ECLS) and aortic cross-clamp times and optic nerve sheath diameter (ONSD).Study in a cohort of patients aged 0 to 15 years that underwent ECLS for cardiac surgery after obtention of signed informed consent. We calculated a sample size of 23 participants. First, we obtained 3 vertical and 3 horizontal measurements of the ONSD for each eye and calculated the mean of both eyes for each measurement to be used in the analysis. The measurements were made at admission and at 6 and 24hours post surgery. We retrieved the ECLS time and the aortic cross-clamp time were from the operative report.We analysed data for 23 participants, 52.2% female, with a median age of 14 months. The median ECLS time was 60minutes; the median aortic cross-clamp time was 32minutes. The median baseline ONSD was 3.1mm. ONSD values had increased a median of 0.015mm at 6hours post surgery (P=.03). We found a positive correlation between ECLS time and ONSD values (r=0.476, p,05). The ONSD values returned to baseline by 24hours post surgery. None of the patients developed signs or symptoms of increased intracranial pressure.Our study found a correlation between ECLS time and ONSD at 24hours post surgery. We found variations in the ONSD even in patients without signs or symptoms of increased increased intracranial pressure. Further research is required to identify the factors related to these variations.

The actual investigation of the body of a patient by the clinician in search for the signs of the disease beginning with the primary vital signs and continues with the careful and attentive observation of the patient. This article reviews the key findings in the physical examination of patients with ischemic stroke that have the potential to indicate the etiology of the infarct and to help to choose the use of ancillary tests. Through a systematic search of articles published in English related to the physical examination of patients with stroke, we identified key findings in the vital signs and classic components of the physical exam (appearance of the patient, auscultation, and eye examination) that have shown clinical significance when determining ischemic stroke etiology. We further suggest that the prompt identification of such findings can translate into better use of diagnostic tools and selection of ancillary confirmatory tests, thus, reducing the time to etiology based treatment and secondary prevention of ischemic stroke. in this manuscript, we aim to show that even though nowadays the clinical skills tend to be overlooked due to the overreliance on technology, the physical exam continues to be a valuable tool in the clinician armamentarium when facing the challenge of a patient with ischemic stroke.

COVID-19 pandemic has forced important changes in health care worldwide. Stroke care networks have been affected, especially during peak periods. We assessed the impact of the pandemic and lockdowns in stroke admissions and care in Latin America.A multinational study (7 countries, 18 centers) of patients admitted during the pandemic outbreak (March-June 2020). Comparisons were made with the same period in 2019. Numbers of cases, stroke etiology and severity, acute care and hospitalization outcomes were assessed.Most countries reported mild decreases in stroke admissions compared to the same period of 2019 (1187 vs. 1166, p = 0.03). Among stroke subtypes, there was a reduction in ischemic strokes (IS) admissions (78.3% vs. 73.9%, p = 0.01) compared with 2019, especially in IS with NIHSS 0-5 (50.1% vs. 44.9%, p = 0.03). A substantial increase in the proportion of stroke admissions beyond 48 h from symptoms onset was observed (13.8% vs. 20.5%, p 0.001). Nevertheless, no differences in total reperfusion treatment rates were observed, with similar door-to-needle, door-to-CT, and door-to-groin times in both periods. Other stroke outcomes, as all-type mortality during hospitalization (4.9% vs. 9.7%, p 0.001), length of stay (IQR 1-5 days vs. 0-9 days, p 0.001), and likelihood to be discharged home (91.6% vs. 83.0%, p 0.001), were compromised during COVID-19 lockdown period.In this Latin America survey, there was a mild decrease in admissions of IS during the COVID-19 lockdown period, with a significant delay in time to consultations and worse hospitalization outcomes.

Background and purpose Stroke has been scarcely studied in Latin America (LA). The Mexican Institute of Neurology Stroke Registry was established in 1990 as a prospective computer-based database to register data obtained from patients admitted with stroke. Using this data, we attempted to define the profile of risk factors and outcomes. Methods The demographic data, stroke description, ancillary tests, vascular risk factors, and modified Rankin scale (mRs) were registered. Ischemic stroke subtyping was based on the Trial of Org 10,172 of the Acute Stroke Treatment classification. We followed-up patients using multiple overlapping methods. Primary outcomes included mRs, recurrence, and death at 30 days and at the end of follow-up. Results We included 4,481 patients with a median follow-up of 27 months, (17,281 person-years follow-up). The mean age was 52.8 ± 18 years. There were 2,229 males (50%) included in the study. CI was present in 64.9%, intracerebral hemorrhage (ICH) in 25.6%, and cerebral venous thrombosis (CVT) in 6.3%. Hypertension was the major risk factor (46.5%). The most common cause of CI was atherosclerosis (27%). ICH was mainly hypertensive (58%), and 60% of CVT were puerperal. Overall, the mortality rate was 24.5%. The recurrence rate was 16.9%. Poor outcome (mRs ≥ 3) was found in 56.2% of patients. The best outcomes were observed in CVT patients (74.5% mRs ≤ 2), whereas 72.1% ICH patients had mRs ≥3. Conclusion This is one of the largest hospital-based registries in LA and shows significant differences with other previously published registries, including a younger age, relatively less hypertension, and larger proportion of CVT. Poor functional outcome was common. This study adds to the understanding of geographic differences in stroke characteristics and outcomes.

The socioeconomic and health effect of stroke and other noncommunicable disorders (NCDs) that share many of the same risk factors with stroke, such as heart attack, dementia, and diabetes mellitus, is huge and increasing.1–4 Collectively, NCDs account for 34.5 million deaths (66% of deaths from all causes)3 and 1344 million disability-adjusted life years lost worldwide in 2010.2 The burden of NCDs is likely to burgeon given the aging of the world’s population and the epidemiological transition currently observed in many low- to middle-income countries (LMICs).5,6 In addition, there is low awareness in the population about these NCDs and their risk factors,7–10 particularly in LMICs.11 These factors, coupled with underuse of strategies for primary prevention of stroke/NCDs on an individual level and the lack of accurate data on the prevalence and effect of risk factors in different countries and populations have been implicated in the ever-increasing worldwide burden of the NCDs.12–15 Of particular concern is a significant increase in the number of young adults (aged

Introduction: It has been shown that sleep-related breathing disorders, especially sleep apnoea, are very common in patients who have had a stroke, and that they also reduce the potential for neurological recovery. Nevertheless, other sleep disorders caused by stroke (excessive daytime sleepiness, insomnia, sleep-related movement disorders) can also cause or increase stroke-related disability, and this fact is less commonly known. Development: Studies with polysomnography have shown many abnormalities in sleep architecture during the acute phase of stroke; these abnormalities have a negative impact on the patient's quality of life although they tend to improve with time. This also happens with other sleep disorders occurring as the result of a stroke (insomnia, narcolepsy, restless legs syndrome, periodic limb movement disorder and REM sleep behaviour disorder), which are nevertheless potentially treatable. In this article, we briefly review the physiopathology and epidemiology of the disorders listed above in order to raise awareness about the importance of these disorders and the effects they elicit in stroke patients. Conclusions: Sleep disorders that are not breathing-related have scarcely been studied in stroke patients despite the fact that almost all such disorders may present as a result of a cerebrovascular event. Resumen: Introducción: Actualmente se reconoce que los trastornos respiratorios, en especial la apnea del sueño, son frecuentes en pacientes con accidente vascular cerebral y que su presencia reduce el potencial de recuperación neurológica de estos pacientes. Sin embargo, es poco conocido el hecho de que otros trastornos del sueño que también se producen a consecuencia de un ictus como la somnolencia diurna, el insomnio y los trastornos del movimiento también son capaces de producir o incrementar la discapacidad asociada al ictus. Desarrollo: Estudios polisomnográficos han evidenciado múltiples alteraciones en la arquitectura del sueño de los pacientes en la fase aguda del ictus, las cuales tienden a mejorar con el transcurso del tiempo pero manteniendo un efecto deletéreo sobre la calidad de vida. Lo mismo ocurre con trastornos del sueño que se producen como consecuencia de un ictus (el insomnio, la narcolepsia, el síndrome de piernas inquietas, los movimientos periódicos de las piernas y el trastorno de conducta del sueño MOR) todos los cuales son potencialmente tratables. Con el objetivo de incrementar la conciencia acerca de estas condiciones y sus efectos sobre los pacientes con ictus, se revisa brevemente la epidemiología y fisiopatología en la subpoblación de pacientes neurológicos con ictus. Conclusiones: A diferencia de los trastornos respiratorios, otros trastornos del sueño han sido escasamente estudiados en pacientes con ictus, a pesar de que prácticamente todos los trastornos del sueño pueden presentarse a consecuencia de esta enfermedad. Keywords: Cerebrovascular disease, Stroke, Sleep, Sleep disorders, Parasomnias, Insomnia, Palabras clave: Enfermedad cerebrovascular, Ictus, Sueño, Trastornos del Sueño, Parasomnias, Insomnio

Resumen: Introducción: Actualmente se reconoce que los trastornos respiratorios, en especial la apnea del sueño, son frecuentes en pacientes con accidente vascular cerebral y que su presencia reduce el potencial de recuperación neurológica de estos pacientes. Sin embargo, es poco conocido el hecho de que otros trastornos del sueño que también se producen a consecuencia de un ictus como la somnolencia diurna, el insomnio y los trastornos del movimiento también son capaces de producir o incrementar la discapacidad asociada al ictus. Desarrollo: Estudios polisomnográficos han evidenciado múltiples alteraciones en la arquitectura del sueño de los pacientes en la fase aguda del ictus, las cuales tienden a mejorar con el transcurso del tiempo pero manteniendo un efecto deletéreo sobre la calidad de vida. Lo mismo ocurre con trastornos del sueño que se producen como consecuencia de un ictus (el insomnio, la narcolepsia, el síndrome de piernas inquietas, los movimientos periódicos de las piernas y el trastorno de conducta del sueño MOR) todos los cuales son potencialmente tratables. Con el objetivo de incrementar la conciencia acerca de estas condiciones y sus efectos sobre los pacientes con ictus, se revisa brevemente la epidemiología y fisiopatología en la subpoblación de pacientes neurológicos con ictus. Conclusiones: A diferencia de los trastornos respiratorios, otros trastornos del sueño han sido escasamente estudiados en pacientes con ictus, a pesar de que prácticamente todos los trastornos del sueño pueden presentarse a consecuencia de esta enfermedad. Abstract: Introduction: It has been shown that sleep-related breathing disorders, especially sleep apnea, are very common in patients who have had a stroke, and that they also reduce the potential for neurological recovery. Nevertheless, other sleep disorders caused by stroke (excessive daytime sleepiness, insomnia, sleep related movement disorders) can also cause or increase stroke-related disability, and this fact is less commonly known. Development: Studies with polysomnography have shown many abnormalities in sleep architecture during the acute phase of stroke; these abnormalities have a negative impact on the patient's quality of life although they tend to improve with time. This also happens with other sleep disorders occurring as the result of a stroke (insomnia, narcolepsy, restless legs syndrome, periodic limb movement disorder and REM sleep behavior disorder), which are nevertheless potentially treatable. In this article, we briefly review the physiopathology and epidemiology of the disorders listed above in order to raise awareness about the importance of these disorders and the effects they elicit in stroke patients. Conclusions: Sleep disorders that are not breathing-related have scarcely been studied in stroke patients despite the fact that almost all such disorders may present as a result of a cerebrovascular event. Palabras clave: Enfermedad cerebrovascular, Ictus, Sueño, Trastornos del Sueño, Parasomnias, Insomnio, Keywords: Cerebrovascular disease, Stroke, Sleep, Sleep disorders, Parasomnias, Insomnia

Background Spontaneous, nontraumatic intracerebral hemorrhage (ICH) is a subtype of stroke that causes a great amount of disability and economic and social burden. This is particularly true in developing countries where it accounts for between 20% and 50% of all strokes. Pharmacological and surgical interventions have been attempted to reduce the mortality and disability caused by ICH, with unsuccessful results. Recently, the use of fluoxetine in addition to physical rehabilitation has been proven useful to improve motor recovery following cerebral infarct. The purpose of this study is to test whether a 3-month treatment with fluoxetine enhances motor recovery in nondepressed patients with acute intracerebral hemorrhage. Methods/design Our study is a randomized, double-blind, placebo-controlled, multicenter clinical trial. We will recruit 86 patients with intracerebral hemorrhage of both sexes, aged >18 years, from four Mexican hospitals. The patients will receive either 20 mg of fluoxetine or a placebo once daily for 90 days. The primary outcome is the mean change in the Fugl-Meyer Motor Scale score between inclusion (day 0) and day 90. The secondary outcomes will be changes in the Barthel Index, the Modified Rankin scale and the National Institutes of Health stroke scale. The outcomes will be measured at day 42 ± 7days and at day 90, for a total of four visits with each subject (at screening and at 0, 42 and 90 days). Discussion Current guidelines recommend early supported hospital discharge and home-based rehabilitation programs as the only cost-effective intervention to aid the recovery of patients with intracerebral hemorrhage. Nevertheless, such interventions are dependent on available resources and funding, which make them very difficult to implement in developing countries. We believe that the identification of a helpful pharmacological intervention to aid the motor recovery of these patients will constitute a breakthrough that will have a major impact in reducing the burden of disease caused by this subtype of stroke worldwide, especially in the developing world. Trial registration Current Controlled Trials NCT01737541