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Background We aimed to assess baseline inter-hemispheric perfusion differences, before carotid artery stenting (CAS), of severe internal carotid artery (ICA) stenosis, and to evaluate perfusion changes over time after CAS by means of perfusion weighted imaging (PWI). Methods Dynamic susceptibility contrast PWI was performed in 33 patients with severe ICA stenosis 1 day before and 1 day after CAS, and repeated in 23 patients 30 days after CAS. Cerebral blood volume, cerebral blood flow, arrival time (T0), mean transit time, and time to peak (TTP) relative values comparing symptomatic and asymptomatic hemispheres before CAS were obtained. Pre- and post-CAS values were also compared in the treated hemisphere and middle cerebral artery (MCA) territories. The influence of collateral circulation and contralateral ICA stenosis were evaluated. Results Before CAS, TTP was significantly increased in the affected hemisphere and MCA territory in all patients (p=0.007 and p=0.021, respectively). After treatment, normalization was observed for TTP and T0 30 days after CAS in all patients, mainly in patients with any grade of contralateral stenosis and with one or both functioning communicating arteries (42.4% of patients had both, and 42.4% showed only one—anterior communicating artery=11 patients (78.6%) and posterior communicating artery=3 patients (21.4%)). Conclusions Inter-hemispheric perfusion differences in patients with severe ICA stenosis normalize after CAS in the long term, up to 30 days after the procedure.

Resumen: Introducción: El ictus constituye un importante problema sociosanitario. Por ese motivo, el Ministerio de Sanidad aprobó en 2008 la Estrategia Nacional en Ictus (ENI) con el objetivo de mejorar la prevención, tratamiento y rehabilitación del paciente con ictus. Se pretende garantizar una atención neurológica en todo el país y a cualquier hora del día para final del 2010. Nuestro objetivo fue analizar la situación de la atención al ictus en España en el año 2009. Material y métodos: Se constituyó un comité de neurólogos de las diferentes CC. AA. que no hubieran participado en la ENI. Se elaboró una encuesta nacional que recogió el número de unidades de ictus (UI) y la dotación (monitorización, guardia de neurología 24 h/7 días, ratio de enfermería y existencia de protocolos), ratio cama UI/100.000 habitantes, presencia de trombólisis iv, intervencionismo neurovascular (INV) y telemedicina. Resultados: Se incluyeron datos de 145 hospitales. Existen 39 UI distribuidas de un modo desigual. La relación cama de UI/número de habitantes/comunidad autónoma osciló entre 1/75.000 a 1/1.037.000 habitantes, cumpliendo el objetivo Navarra y Cantabria. Se realiza trombólisis iv en 80 hospitales, el número osciló entre 7-536 tratamientos/CC. AA. durante el año 2008. Se realiza INV en el 63% de las CC. AA., teniendo 28 centros capacitados, aunque sólo 1 la realizaba en 2009 las 24 h/7 día. Existen 3 centros con telemedicina. Conclusiones: La asistencia al ictus ha mejorado en España respecto a unos años atrás, pero todavía existen importantes desigualdades por CC. AA. que deberían superarse si se quiere cumplir el objetivo de la ENI. Abstract: Introduction: Stroke is currently a major social health problem. For this reason, the Spanish Ministry of Health approved the Stroke National Strategy (SNS) in 2008 to improve the prevention, treatment and rehabilitation of stroke patients. This plan intends to guarantee 24-hour, 365-days neurological assistance in the whole country by the end of 2010. Our aim was to analyse the situation of stroke assistance in Spain in 2009. Material and methods: A committee of neurologists practicing in the different autonomous communities (AC), and who had not participated in the preparation of the SNS, was created. A national survey was performed including the number of stroke units (SU) and their characteristics (monitoring, 24-h/7-day on-call neurology service, nursing staff ratio and the use of protocols), bed ratio of SU/100,000 people, availability of intravenous thrombolysis therapy, neurovascular intervention (NI) and telemedicine. Results: We included data from 145 hospitals. There are 39 SU in Spain, unevenly distributed. The ratio between SU bed/number of people/AC varied from 1/75,000 to 1/1,037,000 inhabitants; Navarra and Cantabria met the goal. Intravenous thrombolysis therapy is used in 80 hospitals; the number of treatments per AC was between 7 and 536 in 2008. NI was performed in the 63% of the AC, with a total of 28 qualified hospitals (although only 1 hospital performed it 24 h, 7 days a week in 2009). There were 3 hospitals offering clinical telemedicine services. Conclusions: Assistance for stroke patients has improved in Spain compared to previous years, but there are still some important differences between the AC that must be eliminated to achieve the objectives of the SNS. Palabras clave: Ictus, Unidades de ictus, Trombólisis, Encuesta recursos, Keywords: Stroke, Stroke thrombolysis, Stroke unit, Facilities survey

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 ≥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

Background and Purpose— Syncope and carotid sinus reactions (CSR) occur frequently in patients undergoing carotid angioplasty (CA). We investigated risk factors and the neurological consequences of carotid sinus syncope induced by CA. Methods— We examined 359 consecutive patients. Patients underwent assessment of cerebrovascular reserve before CA and continuous electroencephalographical monitoring during the procedure. We examined the impact of vascular risk factors, cerebral hemodynamics, characteristics of plaque, and procedural modality on the incidence of CSR and syncope. The effect of syncopes on periprocedural complication rates was also investigated. Results— CSR and syncope occurred in 62.7% and 18.0% of the procedures, respectively. The occurrence of CSR during angioplasty was significantly associated with the appearance of syncope. The incidence of syncope was significantly higher in longer plaques located in the carotid bifurcation, in the presence of contralateral carotid stenosis, or when protection devices were used. Although TIA during CA was more common in syncopal patients, stroke or death rates were similar in the 2 groups. Conclusions— Syncope occurs more frequently in patients with long plaques proximal to the carotid bifurcation, but it does not increase the periprocedural complications rate.

We evaluated the efficacy and safety of thrombus extraction using a microsnare in patients with acute ischemic stroke (AIS).This was a prospective, observational, cohort study in which consecutive patients with AIS (6 hours of ischemia for anterior circulation and24 hours for posterior circulation) who had been previously excluded from intravenous tissue plasminogen activator (tPA) thrombolysis were included and followed-up for 3 months. Mechanical embolectomy with a microsnare of 2-4 mm was undertaken as the first treatment. Low-dose intraarterial thrombolysis or angioplasty was used if needed. TIMI grade and modified Rankin stroke scale (mRSS) score were used to evaluate vessel recanalization and clinical efficacy, respectively.Nine patients (mean age 55 years, range 17-69 years) were included. Their basal mean NIHSS score was 16 (range 12-24). In seven out of the nine patients (77.8%) the clot was removed, giving a TIMI grade of 3 in four patients and TIMI grade 2 in three patients. Occlusion sites were: middle cerebral artery (four), basilar artery (two) and anterior cerebral artery plus middle cerebral artery (one). The mean time for recanalization from the start of the procedure was 50 min (range 50-75 min). At 3 months, the mRSS score was 0 in two patients and 3-4 in three patients (two patients died).According to our results, the microsnare is a safe procedure for mechanical thrombectomy with a good recanalization rate. Further studies are required to determine the role of the microsnare in the treatment of AIS.

Item does not contain fulltext BACKGROUND: The presence of prodromal transient ischemic attacks (TIAs) has been associated with a favorable outcome in anterior circulation stroke. We aimed to determine the association between prodromal TIAs or minor stroke and outcomes at 1 month, in the Basilar Artery International Cooperation Study, a registry of patients presenting with an acute symptomatic and radiologically confirmed basilar artery occlusion. METHODS: A total of 619 patients were enrolled in the registry. Information on prodromal TIAs was available for 517 patients and on prodromal stroke for 487 patients. We calculated risk ratios and corresponding 95% confidence intervals (CIs) for poor clinical outcome (modified Rankin Scale score >/=4) according to the variables of interest. RESULTS: Prodromal minor stroke was associated with poor outcome (crude risk ratio [cRR], 1.26; 95% CI, 1.12-1.42), but TIAs were not (cRR, .93; 95% CI, .79-1.09). These associations remained essentially the same after adjustment for confounding variables. CONCLUSIONS: Prodromal minor stroke was associated with an unfavorable outcome in patients with basilar artery occlusion, whereas prodromal TIA was not.

To evaluate by MR diffusion weighted image (DWI-MR) the presence of new ischemic cerebral lesions after carotid artery stenting (CAS) and distal cerebral protection, in patients with internal carotid artery (ICA) stenosis70.Sixty-seven CAS were performed under cerebral protection with a distal filter. Mean age of the patients was 68.3 years (range 37-86) and 42 patients (62.7%) were symptomatic. An EZ filter device was used in all cases. The mean length of the procedure was 22.2 minutes (range 8-110). All patients had a cerebral MRI done in the 3 days before CAS and a DW-MR (eco planar single shot, b=1000 mm2/seconds) was done the day after.As a consequence of the CAS, three transient ischemic attacks were observed. There was one minor stroke (1.5%) on day 21, but no major stroke, death or myocardial infarction in a 30-day period. DW-MRI after CAS showed 26 new silent ischemic lesions in 11 asymptomatic patients (16.4%). In six, they were multiple (range 2-5). Lesions were mainly seen in the ipsilateral medial cerebral artery (21); four in the posterior fossa, and one in the contralateral medial cerebral artery.Although the use of distal cerebral protection was safe, new cerebral ischemic lesions, supposedly embolic, were observed in 16.4% of the patients. Although without clinical consequences in our series, their moderate high incidence should promote the investigation of safer techniques and devices.

To determine potential predictors of good outcome in primary medium to large intracerebral haemorrhages (ICH) which could be useful for selecting patients for surgical procedures.Subjects were 138 patients with spontaneous hemispheric ICH20 ml. They were non-surgically treated and were admitted consecutively to 15 hospitals within the first 12 hours of symptom onset (mean (SD), 5.8 (3.1) hours). Haematoma volume was measured on computed tomography (CT) at admission. Stroke severity was assessed by the Canadian stroke scale (CSS). Good outcome was defined as modified Rankin scoreor =2 at three months.At the end of the follow up period, 45 patients (32.6%) had good outcome. Baseline stroke severity, systolic and diastolic blood pressure, body temperature, and acute phase reaction biochemical markers (ESR, C-reactive protein, fibrinogen, neutrophil count) were significantly associated with good outcome in bivariate analyses. Of the initial CT scan variables, intraventricular contamination, deep location, mass effect, and greater ICH volume were related to poor outcome. On multiple logistic regression analysis, cortical location of bleeding (odds ratio 3.79 (95% confidence interval 1.2 to 12.01); p = 0.023), high CSS score (OR 2.3 (1.6 to 3.1); p0.0001), and low fibrinogen concentrations (OR 0.92 (0.87 to 0.97); p = 0.001) were independent predictors of good outcome. These three factors correctly classified 85% of patients.Good outcome in medium to large ICH can be predicted on admission by three readily assessable factors (CSS score, ICH location, and fibrinogen levels). These predictors may be helpful in selecting patients for surgical treatment.

Objective: To identify potential predictors of and factors associated with early neurologic deterioration (END) in primary intracerebral hemorrhage (ICH). Methods: Two hundred sixty-six patients with spontaneous supratentorial ICH admitted within 12 hours of stroke onset were investigated in a multicenter, prospective study. Sixty-one clinical, biochemical, and neuroimaging variables were registered on admission, and 37 clinical and neuroimaging variables were registered at 48 hours. The volumes of the ICH and peripheral edema on admission and at 48 hours were measured on CT scan. Stroke severity and functional outcome were evaluated with the Canadian Stroke Scale (CSS) and modified Rankin Scale. END was diagnosed when the CSS score decreased ≥1 points between admission and 48 hours. With use of logistic regression analyses, baseline variables that predicted END and factors measured after the early acute phase and associated with END were investigated. Results: END occurred in 61 (22.9%) patients. Body temperature of >37.5 °C (odds ratio [OR] 24.5; 95% CI 4.8 to 125), neutrophil count (by 1,000-unit increase; OR 2.1; 95% CI 1.6 to 2.6), and serum fibrinogen levels of >523 mg/dL (OR 5.6; 95% CI 1.9 to 16.2) on admission were independent predictors of END. Among the factors recorded at 48 hours, early ICH growth (OR 4.3; 95% CI 1.3 to 14.5), intraventricular bleeding (OR 2.6; 95% CI 1.4 to 5.0), and highest systolic blood pressure (by 10-unit increase; OR 1.17; 95% CI 1.02 to 1.32) were associated with END in multivariate analyses. Conclusions: Clinical and biologic markers of the inflammatory reaction on admission are predictors of subsequent END, whereas early ICH growth, intraventricular bleeding, and high systolic blood pressure within 48 hours are factors associated with END in patients with spontaneous ICH.

Angioplasty and stenting of the atheromatous internal carotid artery (ICA), besides in patients with a high surgical risk, may be indicated in specific cases such as contralateral occlusion, acute stroke clinical signs, or atherosclerotic pseudo-occlusion (APO). APO of the ICA is an underrecognized condition due to diagnostic difficulties both with noninvasive methods and even with angiography. Once recognized, there is usually the opportunity for successful revascularization with carotid endarterectomy. However, as the natural history of the APO is poorly characterized, the management of patients remains controversial. While some authors advocate a surgical approach, others consider that APO patients are not at high risk of stroke, making any interventional approach unnecessary. The perioperative risk of stroke in patients with APO is not appreciably greater than in patients with lesser degrees of stenosis and clear recommendation of surgery, although at 2 years that risk seems to be considerably much higher than in the latter patients. Looking for safer interventional procedures is worthwhile. Results of angioplasty and stenting in patients with ICA-APO have not been published yet. We report the results and complications associated with this procedure to address the issue of appropriate management of patients with ICA-APO.

Background and Purpose— Bone marrow mononuclear cell (BM-MNC) intra-arterial transplantation improves recovery in experimental models of ischemic stroke. We aimed to assess the safety, feasibility, and biological effects of autologous BM-MNC transplantation in patients with stroke. Methods— A single-blind (outcomes assessor) controlled Phase I/II trial was conducted in patients with middle cerebral artery stroke. Autologous BM-MNCs were injected intra-arterially between 5 and 9 days after stroke. Follow-up was done for up to 6 months and blood samples were collected for biological markers. The primary outcome was safety and feasibility of the procedure. The secondary outcome was improvement in neurological function. Results— Ten cases (BM-MNC-treated) and 10 control subjects (BM-MNC-nontreated) were consecutively included. Mean National Institutes of Health Stroke Scale before the procedure was 15.6. Mean BM-MNCs injected were 1.59×10 8 . There was no death, stroke recurrence, or tumor formation during follow-up, although 2 cases had an isolate partial seizure at 3 months. After transplantation, higher plasma levels of beta nerve growth factor (β-nerve growth factor) were found compared with control subjects ( P =0.02). There were no significant differences in neurological function at 180 days. A trend to positive correlation between number of CD34+ cells injected and Barthel Index was found ( r =0.56, P =0.09). Conclusions— Intra-arterial BM-MNC transplantation in subacute ischemic stroke is feasible and seems to be safe. Larger randomized trials are needed to confirm the safety and elucidate the efficacy of BM-MNC transplantation. Clinical Trial Registration-URL— www.clinicaltrials.gov . Unique identifier: NCT00761982.

Bypass grafting is considered the treatment of choice for occlusions of supraaortic vessels. Percutaneous transluminal angioplasty (PTA) is a well-established treatment for patients with subclavian stenosis, but its efficacy in total subclavian or innominate occlusions is so far not well established. Since 1995, we have carried out 9 PTA revascularizations in 9 patients with total symptomatic atherosclerotic occlusion of supraaortic vessels. The technical success rate was 100%, without any major (death or stroke) or minor complications. In the follow-up period (mean 37.4 months), 1 patient had a symptomatic left internal carotid artery occlusion and an asymptomatic occlusion of the treated subclavian artery. In expert hands, stenting-PTA should be considered as the primary therapeutic option.

Background and Purpose — It is well known that some mitochondrial disorders are responsible for ischemic cerebral infarction in young patients. Our purpose was to determine, in this prospective ongoing study, whether ischemic stroke is the only manifestation of a mitochondrial disorder in young patients. Methods — Patients aged ≤50 years, admitted to the Stroke Unit from January 1999 to May 2000 with a diagnosis of ischemic stroke of unknown origin, were included in the study. All of them had full biochemical and hematologic tests, neuroimaging studies, transesophageal echocardiography, and extracranial and transcranial Doppler sonography. Patent foramen ovale was ruled out. Lactic acid concentrations were measured after anaerobic exercise of the forearm, and a morphological, biochemical, and molecular study after biceps muscle biopsy was performed. Results — Of the 18 patients so far included, 3 (17%) presented lactic acid hyperproduction after physical exercise, and 6 (33%) showed deficit of the mitochondrial respiratory chain complexes. The molecular analyses have confirmed mitochondrial mutations at base pairs 3243 (characteristic of mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes [MELAS]), 4216, and 15 928. Conclusions — These results suggest that ischemic stroke may be the only manifestation or the initial manifestation of a mitochondrial disorder.

We evaluated the effects of plasmapheresis in two patients with Morvan's fibrillary chorea, one of whom had sigmoid carcinoma, with oligoclonal bands in the cerebrospinal fluid, and modifications of the lipid-oxidative muscle pattern. The use of plasmapheresis in the treatment of Morvan's fibrillary chorea has not been reported previously and in our patients improved the symptoms markedly.

BACKGROUND AND PURPOSE: The natural history of the carotid NO is poorly characterized, and the management of patients remains controversial. We report the results and complications associated with CAS and follow-up. MATERIALS AND METHODS: Between March 2000 and March 2009, 116 of 836 CAS procedures were performed in patients with carotid NO (13.9%). A total of 99 men (85.3%) and 17 women (14.7%) with a mean age of 65.8 years were included. Presenting symptoms were TIA in 44 patients (37.9%) and minor stroke or noninvalidating stroke in 61 (52.6%). One hundred five patients (90.5%) were symptomatic. RESULTS: A distal filter was used for cerebral protection in 92 patients (79.3%). Transient hemodynamic alterations were frequent during balloon inflation: hypotension (37.1%), bradycardia (48.3%), and asystole in 24.1%. Four patients (3.4%) developed a TIA after CAS. Stroke in progression was arrested in the 1 patient (0.9%). The median follow-up period for patients was 36 months. Asymptomatic restenosis >70% occurred in 5 patients (4.3%); asymptomatic occlusion occurred in 3 patients (2.6%). During follow-up, 3 patients (2.6%) experienced a stroke, 1 ipsilateral (at 19 months) and 2 contralateral (at 6 and 30 months, respectively). Thirteen patients (11.2%) died, 7 from vascular causes. CONCLUSIONS: Our study showed that carotid NO is an under-recognized condition, and CAS would seem to be beneficial when performed by an experienced neurointerventional team.

We present a high-flow vertebral arteriovenous fistula caused by percutaneous catheterisation of the internal jugular vein. Endovascular transarterial treatment with a self-expanding covered stent was used to close the fistula successfully with preservation of the parent artery.

Knowing why patients fail to complete a clinical trial should help in planning such trials and in estimating their costs. We analyzed reasons why subjects failed to complete two similar acute stroke trials of calcium-channel antagonists. The trials were double-blind, placebo-controlled, and lasted 2 and 3 weeks, respectively. We enrolled 43 patients in the first trial and 37% were withdrawn; 30 patients were enrolled in the second trial and 47% were withdrawn. Reasons for withdrawal were similar in the two trials. When data from the two trials were combined, reasons for withdrawal were errors in administering medication (11%), use of a proscribed drug (7%), early death (7%), a disqualifying illness discovered after enrollment (8%), withdrawal of consent (4%), and enrollment beyond the time limit (

BACKGROUND AND PURPOSE:Carotid sinus syncope may occur acutely during internal carotid artery angioplasty (CA). We performed this study to investigate the clinical, electroencephalographic (EEG), and hemodynamic features of carotid sinus syncope induced by CA. MATERIALS AND METHODS:Between 1992 and 2003, clinical, EEG, and cardiovascular monitoring was performed in 359 consecutive patients undergoing CA. RESULTS:Carotid sinus reaction (CSR) and syncope occurred in 62.7% and 18.6% of the procedures, respectively. CSR and syncopal spells were classified into cardioinhibitory, vasodepressor, and mixed type. Syncope occurred more frequently in patients with cardioinhibitory CSR (P < .001). The odds ratios for the risk of syncope in patients with cardioinhibitory CSR and vasodepressor/mixed CSR were 6.9 and 1.4, respectively. Sixty-one patients had cardioinhibitory syncope; 7 had the vasodepressor/mixed type. Thirteen spells were not related to cardiovascular disturbances. This last syncope subtype was significantly associated with brain hemodynamic disturbances, including a decrease in cerebral vasoreactivity (P = .04) and the absence of function of both communicating arteries (P = .03). Convulsive movements resembling supplementary sensorimotor seizures occurred in 79% of patients who experienced syncopal spells. EEG changes were more prominent in patients with cardioinhibitory syncope. CONCLUSIONS:Syncope occurs frequently in patients undergoing CA and can be misdiagnosed as seizures. The most frequent mechanism was a cardioinhibitory response. Cerebral hemodynamic disturbances may play a crucial role in the pathophysiology of syncope with normal sinus rhythm and normotension. Moreover, direct depression of the CNS following carotid sinus distension is likely to be involved.

We compared carotid artery disease in 99 black and 106 white patients using duplex ultrasonography (B-mode imaging and Doppler spectral analysis). Blacks had significantly less stenosis of the extracranial internal carotid artery than whites. Among the risk factors investigated, hypertension alone, ischemic heart disease, diabetes mellitus, and smoking failed to explain the racial difference. Although carotid stenosis of greater than or equal to 40% correlated significantly with age in both races (p = 0.001 in whites and p = 0.005 in blacks), blacks had significantly less carotid stenosis of any degree even when age was taken into account. Multivariate analysis showed that race is a significant and independent risk factor for carotid stenosis (p less than 0.0001). Hypertension interacting with race was also significant. Our results require verification in population-based studies. Carotid duplex ultrasonography offers a noninvasive method for carrying out such studies.

The incidence of transient ischemic attacks (TIAs) in the Lehigh Valley was analyzed using the Lehigh Valley Stroke Register based on data collected between July 1, 1982, and June 30, 1986. The overall average annual incidence rate was 22.9 per 100,000 population, and 23.2 and 22.5 per 100,000 population in men and women, respectively. Men had a statistically significant higher age-specific rate of TIAs than women. Our incidence appears to be lower than that reported in earlier studies but, because of methodologic differences, only continued observations in our population and in similar populations using a standardized methodology will resolve the question of whether TIA frequency is, in fact, declining.

To the Editor: Once the benefits of intravenous tissue plasminogen activator (tPA) in the treatment of acute ischemic stroke have been proved, it should be interesting to widen its use. We discuss the fact that intravenous thrombolysis with tPA may not be a contraindication to treat an acute ischemic stroke occurring soon after surgical repair of retinal detachment (RD) by means of vitrectomy. A 65-year-old woman with a history of atrial fibrillation underwent vitrectomy for surgical repair of RD in her right eye. Vitrectomy required 3 incisions into the posterior chamber of the eye using a vitreous cutter of 25 G, an infuser of 20 G, and a light source of 20 G. Thirty-two hours later, and …

Background: Despite advances in the surgical treatment of patients with severe internal carotid stenosis (ICA), there are selective groups of patients who, due to several reasons, are not good candidates for surgery. Patients with contralateral occlusion are one of these subgroups. Thereby, other therapeutic alternatives, such as angioplasty may be of value. So far, there has been little published data about carotid angioplasty (CA) or stenting (CAS) in those patients. The objective of this study was to evaluate the efficacy and safety of angioplasty and stenting in patients with severe internal carotid stenosis and contralateral occlusion. Methods: Between 1991 and June 2004, 519 consecutive patients who underwent CA or CAS for severe stenosis of the ICA were registered in our prospective CA Data Bank. Of them, we identified 96 with contralateral occlusion (18.5%), who formed the basis of the present analysis. Results: Mean age was 64 ± 9 (range 40–80), 85 (88.5%) were men, and 61 (63.5%) were symptomatic. Thirty-two patients (33.3%) did not meet the criteria to be included in the NASCET. CA was done in 25 patients (26%) and CAS in 71 (74%). Distal protection was used in 38 patients (39.6%). Asymptomatic stenosis was treated in cases of progression (>85%), exhausted vasoreactivity, positive microemboli detection in transcranial Doppler, and/or asymptomatic lesions in CT/MRI. Transient hemodynamic effects were frequent: hypotension (54.5%), bradycardia (61.5%), asystole (33.3%), and syncope (33.3%). TIA occurred in 1 patient (1%), minor stroke in 1 (1%), and disabling stroke in 2 patients (2.1%). Mortality was 0%. Morbidity was 0% in cases done with distal protection. Conclusion: In our experience, CA/CAS performed in patients with severe carotid stenosis and contralateral occlusion compared favorably with the results obtained with carotid endarterectomy (CEA), to the extent that if randomized series comparing CEA and CA/CAS are done, CA/CAS might be considered as the treatment of choice in this subgroup of patients.

Background and Purpose Carotid endarterectomy reduces stroke risk in patients with >70% symptomatic stenosis. We present our results of percutaneous transluminal angioplasty (PTA) as an alternative treatment. Methods Ninety-eight patients with symptomatic >70% stenosis of the internal carotid artery were considered for PTA. Details of the procedure, complications, and 4-year follow-up were registered. Results Eighty-five PTAs were performed in a 4-year period. Transient cardiovascular effects were frequent: hypotension (54.1%), bradycardia (67.1%), asystole (25.9%), and syncope (16.5%). Transient ischemic attack occurred in 3 of 82 patients (3.7%), and disabling stroke occurred in 4 (4.9%); mortality was 0%. After a mean follow-up period of 18.7 months, 4 patients died, 1 due to fatal stroke. The overall probability of surviving any stroke or death was 86.7%. Restenosis (>70%) was seen in 6 cases (7.4%). Conclusions PTA may be a reasonable treatment for symptomatic atherosclerotic stenosis, at least in patients at high risk for carotid endarterectomy.

Intraluminal thrombus in the internal carotid artery (ICA) is usually found in patients with severe atheromatous stenosis. Having reviewed 300 carotid angioplasties for symptomatic >70% ICA stenosis, we found three patients (1%) with intraluminal thrombus. Conservative treatment with anticoagulants and double antiplatelet coverage can result in lysis of the thrombus without severe risks. Percutaneous transluminal angioplasty and stenting, preferably with distal protection, can be an excellent alternative to carotid endarterectomy.

The aim of this study was to analyze stroke mortality rates in Andalusia during the period from 1975 to 1999 by studying age, cohort and period effects. Deaths due to stroke along with the corresponding population figures were divided into 11 age groups and five 5-year periods. From this, age-specific mortality rates for 15 birth cohorts were then computed. These were plotted and fitted to Poisson regression models to assess age, period and cohort effects. An exponential age effect was present for both sexes regardless of cohort or period. The rates of stroke mortality decreased significantly among both sexes in Andalusia during the study period, although in recent years, this declining trend has started to slow down, primarily in males. Age- and period-adjusted stroke mortality was greater for earlier cohorts and lower for generations born at the beginning of the 20th century.

Background: Epidemiological studies suggest that raised plasma concentrations of total homocysteine (tHcy) may be a common, causal and treatable risk factor for atherothromboembolic ischaemic stroke. Although tHcy can be lowered effectively with small doses of folic acid, vitamin B12 and vitamin B6, it is not known whether lowering tHcy, by means of multivitamin therapy, can prevent stroke and other major atherothromboembolic vascular events. Purpose: To determine whether vitamin supplements (folic acid 2 mg, B6 25 mg, B12 500 µg) reduce the risk of stroke, and other serious vascular events, in patients with recent stroke or transient ischaemic attacks of the brain or eye (TIA). Methods: An international, multi-centre, randomised, double-blind, placebo-controlled clinical trial. Results: As of November 2001, more than 1,400 patients have been randomised from 10 countries in four continents. Conclusion: VITATOPS aims to recruit and follow up 8,000 patients between 2000 and 2004, and provide a reliable estimate of the safety and effectiveness of dietary supplementation with folic acid, vitamin B12, and vitamin B6 in reducing recurrent serious vascular events among a wide range of patients with TIA and stroke.

The aim of this study was to explore temporal changes in stroke mortality in Andalusia over the period 1975–1992. Mortality rates were standardized directly using those of the European population as the standard, and regression analysis was undertaken. Age standardized overall mortality rates for stroke decreased considerably among men, from 199.42 to 103.74 (–3.5% per year). A similar pattern was also observed among women as mortality rates diminished from 160.48 in 1975 to 92.43 in 1992 (–3.3% per year). Despite the remarkable decline in the death rate, this disease still accounted for 1 in 35 deaths in women and for 1 in 23 deaths in men in 1992. This study confirms that time trends in stroke mortality are similar to those of most industrial countries.

A 57-year-old woman without a known neoplasia developed opsoclonus, myoclonus, and ataxia. Positive anti-Ri antibodies were present in both serum and CSF. The patient also had progressive encephalomyelitis with rigidity, an association not previously described.

Although ganglioside administration has been suspected as being responsible for Guillain-Barré syndrome (GBS) and peripheral neuropathies in some patients, current epidemiological, experimental, and clinical data do not support such an association. In Spain, a total of 17 cases of suspected GBS and neuropathy had been reported to the National Drug Surveillance System as of April 15, 1992. No definite relationship between ganglioside administration and the illness in these cases could be established after careful review of available data.

Introduccion. La apofisis estiloides alargada se ha incluido como causa de dolor en la cabeza y cuello. Sin embargo, nunca se ha publicado en la literatura la presentacion de un ataque isquemico transitorio (AIT) debido a una compresion mecanica de la arteria carotida interna (ACI) por la apofisis estiloides alargada. Caso clinico. Varon de 36 anos, con antecedentes desde hacia 10 anos de dolor sordo intermitente en el lado izquierdo del cuello, que empeoraba al rotar la cabeza, sufrio un AIT silviano izquierdo 10 dias despues de un traumatismo leve cervical. La exploracion con eco-Doppler demostro la compresion de la ACI al flexionar la cabeza. La arteriografia revelo una estenosis de la ACI cervical por una compresion externa. La longitud de la apofisis estiloides en la ortopantomografia y en la tomografia era de 35 mm. La angiotomografia mostro una relacion intima entre el extremo de la estiloides izquierda y la estenosis de la ACI. Se realizo una estiloidectomia mediante un abordaje extraoral bajo anestesia general. La pieza quirurgica extirpada midio 30 mm. Tras 3 anos de seguimiento, la sintomatologia del paciente ha desaparecido, sin signos de recurrencia. Conclusion. La aparicion de un AIT deberia tenerse en cuenta en el cuadro clinico asociado a una apofisis estiloides elongada. La angiotomografia es muy sensible para definir la relacion anatomica entre la apofisis estiloides y la ACI. El tratamiento de eleccion es la exeresis quirurgica a traves de un abordaje externo que permita el control adecuado de la arteria carotida.

Introduccion. Los cambios que fisiologicamente tienen lugar en la circulacion cerebral durante la gestacion y el puerperio se conocen todavia poco. El Doppler transcraneal (DTC), por su inocuidad, es un metodo de estudio adecuado. Objetivo. Conocer la velocimetria DTC al final de la gestacion y en el puerperio precoz de gestantes sanas. Sujetos y metodos. Mediante DTC se estudiaron bilateralmente las arterias cerebrales anterior (ACA), media (ACM) y posterior (ACP). Ademas, se midieron la presion arterial y el hematocrito. En el analisis estadistico se utilizaron las variables velocidad media (VM), indice de pulsatilidad (IP), presion arterial media y hematocrito. Se compararon los resultados de 44 gestantes normotensas al final de la gestacion (semana 33 a termino) con los de un grupo control de 58 mujeres de similar edad, no gestantes y normotensas. A las gestantes se les repitio el estudio en el puerperio precoz (cinco primeros dias posparto), y se compararon los resultados en ambos tiempos. Resultados. La edad y la PAM fueron similares en los grupos gestante y no gestante. El hematocrito fue significativamente mas bajo en las primeras (p < 0,001). Las VM fueron significativamente mas bajas en las gestantes en todas las arterias (p < 0,001), mientras que los IP tambien fueron significativamente mas bajos en cuatro de los seis territorios estudiados (p < 0,005). En el puerperio se observo un aumento significativo de las VM en todas las arterias (p < 0,001) y de los IP en tres de ellas (p < 0,05). En esta fase aumento la presion arterial media (p < 0,05), mientras disminuyo el hematocrito (p < 0,001). Conclusiones. Las VM e IP bajos que se observan al final de la gestacion son compatibles con una vasodilatacion cerebral. En el puerperio precoz se incrementan las VM, probablemente en relacion con una relativa hiperperfusion.

Introduccion. La ecografia Doppler transcraneal (EDTC) tiene un uso creciente en el estudio de la hemodinamica cerebral en la preeclampsia/eclampsia. Al puerperio de estas pacientes se le ha prestado menos atencion. Objetivos. Mediante velocimetria por EDTC, por una parte comparar al final de la gestacion a pacientes preeclampticas (PE) con normotensas (NT), y, por otro lado, comparar los resultados de las PE en dos tiempos consecutivos: al final de la gestacion y en el puerperio precoz (PP). Pacientes y metodos. Realizamos EDTC con valoracion, bilateralmente, de las arterias cerebrales anterior (ACA), media (ACM) y posterior (ACP). Como parametros Doppler utilizamos la velocidad media (VM) y el indice de pulsatilidad (IP). Medimos la presion arterial (PA) y el hematocrito. En el analisis estadistico utilizamos como variables la VM, el IP, la PA media (PAM) y el hematocrito. Al final de la gestacion (33 semanas a termino) comparamos los valores medios de estas variables en las PE (n = 38) frente a las NT (n = 44). Por otra parte, comparamos los resultados obtenidos por las PE (n = 30) en dos tiempos consecutivos: al final de la gestacion y en el PP (primeros cinco dias posparto). Resultados. Al final de la gestacion, las VM fueron significativamente mas altas en las PE que en las NT en todas las arterias estudiadas. La PAM fue mas alta en el primer grupo, pero no hubo una correlacion significativa entre la PAM y la VM. Los IP fueron mas bajos en el primer grupo, con significacion estadistica en cuatro de las seis arterias. Las VM subieron significativamente en el PP en las PE, a pesar de existir un descenso de la PAM. Por el contrario, los IP no se modificaron. Conclusiones. Se hallo un patron de VM altas e IP bajos en las PE al final de la gestacion, lo que puede corresponder a un fracaso primario de la autorregulacion cerebral. En el PP se incrementaron las anomalias en la EDTC, a pesar del descenso de la PAM, hecho que podria justificar el predominio de los sintomas neurologicos que se describen en las formas tardias del sindrome

Objetivos. Conocer los valores normales de Doppler transcraneal (DTC) en puerperas normotensas (PNT) en nuestro medio. Evaluar la influencia de diferentes variables sobre el flujo sanguineo cerebral. Pacientes y metodos. Se realizaron 100 estudios DTC en PNT, y se sonorizaron seis arterias intracraneales. Se recogieron diversas variables como presion arterial, hematocrito y datos clinicos referidos al embarazo y parto. Se realizo un analisis descriptivo en el caso de las variables cualitativas, y las variables cuantitativas se expresaron como media mas desviacion estandar (DE). Se compararon las velocidades medias (VM) de cada arteria segun la lateralidad hemisferica, y su relacion con las cifras tensionales, el hematocrito y el resto de las variables. Resultados. Las VM expresadas como media y DE fueron: ACM derecha 73,10±14,33; ACM izquierda 75,68±15,84; ACA derecha 57,61±12,92; ACA izquierda 60,14±14,35; ACP derecha 42,77± 9,28; ACP izquierda 45,54±9,58. Se comprobo un aumento de VM en las arterias de lateralidad izquierda con respecto a las de lateralidad derecha, estadisticamente significativo. Ninguna de las variables del estudio influyo en los valores de flujo sanguineo cerebral. Conclusion. Los valores de VM fueron mas altos en el hemisferio izquierdo. Resulta util conocer valores de referencia puerperales en mujeres asintomaticas para poder identificar alteraciones hemodinamicas cerebrales propias de estados patologicos, como eclampsia tardia y angiopatia cerebral posparto

Introduction Calcium embolism is an uncommon cause of stroke which may not be diagnosed in cases which do not involve cardiac surgery or catheterization. The emboli may come from cardiac valves or calcified atheroma of the aortic or carotid arteries. Case reports Two patients with cerebral infarcts secondary to spontaneous calcium embolism confirmed by neuro imaging. In both cases on CT scans there were dense points corresponding to calcified material within the middle cerebral artery or one of its branches. In the first case migration of the calcified point following the course of the artery was observed. Conclusions Cranial CAT scans are essential for diagnosis of calcium embolism. Migration of the calcified point confirms the diagnosis. It is still not clear whether valve replacement is necessary in these patients and treatment with antiaggregants and/or anticoagulants is controversial.

INTRODUCTION The estimated prevalence of basilar dolichoectasia in the healthy general population is 50 per 100,000 inhabitants. The treatment of symptomatic cases is controversial. Strokes caused by it may be due to thrombosis of the perforating arteries, arterio-arterial emboli or a compressive mechanism. CLINICAL CASE We present the case of a 68 year old woman with repeated stokes in which the vertebrobasilar territory was involved. On neuroimaging there was basilar dolichoectasia associated with aneurismal dilatation of both internal carotid arteries. The patient died of massive subarachnoid hemorrhage after starting heparin treatment. At necropsy the aneurysmic dilatation was confirmed together with signs of arteriosclerosis of the arteries of the circle of Willis. CONCLUSIONS Since subarachnoid hemorrhage secondary to rupture of a dolichoectasia is exceptional, some authors support the use of permanent anticoagulation rather than platelet antiaggregation in patients with conditions due to ischemia, in which dilatation is limited to the basilar artery. However, this is not suitable for cases with associated fusiform aneuryms, or cases such as ours in which the dolichoectasia extends beyond the basilar artery, to become generalized throughout all the arteries of the circle of Willis.

INTRODUCTION Arterial dissection is the cause of 20% of the stroke occurring in adults under the age of 45. The existence of recurrence has been discussed in recent studies, and the overall frequency estimated as 4% to 8%, with a risk of 1% per year. The course of the condition is usually oligosymptomatic, so that a high index of suspicion is necessary for diagnosis to be made. We consider that different connective tissue disorders and anomalies of the vascular wall predispose to dissection. It would seen reasonable to think that these same anomalies may lead to recurrence. However, this cannot always be demonstrated. A family history of dissection is also an important factor in recurrence. CLINICAL CASES We present two cases of recurrent spontaneous dissection of the carotid artery from a series of 22 patients with dissection, during the period 1990-1997. In the first case, the second dissection occurred 15 days after the first and in the second case, seven months later. In both cases the recurrence was in the contra-lateral carotid artery. In the second case the vascular tree was noted to have been formed of ecstatic, tortuous vessels. CONCLUSIONS Our series shows results similar to others published. In one of these, an underlying arteriopathy which predisposed to the condition was shown. Both followed satisfactory courses. In case 2 a high index of clinical suspicion was necessary, since the recurrence presented as headache alone.

Introduction The hyperperfusion syndrome (HS) is described as an infrequent complication of carotid endarterectomy. It may also occur in percutaneous transluminal carotid angioplasty with a similar causal mechanism and clinical features to those seen in HS related to carotid endarterectomy. Clinical case We describe the case of a 69 year old man who developed HS at the time of transluminal carotid angioplasty and 'stenting' of symptomatic, pre-occlusive stenosis of the left internal carotid artery. This complication was not detected on the postoperative arteriography. On CT the presence of a hemispheric hematoma was confirmed. It is thought that HS is caused by a fault in autoregulation of the cerebral blood flow following correction of vascular stenosis in previously ischemic territory. Conclusions Most of the early complications of transluminal carotid angioplasty are ischemic. HS is rare but is a possible complication of transluminal carotid angioplasty and therefore meticulous control of the blood pressure is necessary. A CT scan after any atypical complication of angioplasty may be considered to be essential.

INTRODUCTION Ultrasound is regularly used for the detection of carotid stenosis which can be treated surgically. This technique includes continuous Doppler, which together with study of blood flow in the orbit is very useful and should be used systematically, not only in certain cases. We present a study of the usefulness of this technique in our Cerebral Vascular Pathology Laboratory. PATIENTS AND METHODS We selected 708 patients studied sequentially over 10 years with continuous Doppler and conventional angiography (gold standard). The data obtained independently with each technique were compared in order to establish the degree of concordance between them and the corresponding indicators of validity. Contingency tables were drawn up for different cut-off points corresponding to the different degrees of stenosis (50, 70 and 100%). The parameters for validity (sensitivity, specificity, predictive value and precision) were calculated in each case. RESULTS The percentage coincidence of the two techniques was 91.95%. At the cut-off points there was a high degree of precision (> 94.35%). The specificity and negative predictive value of Doppler compared with angiography was over 95% and 96% respectively. CONCLUSIONS The validity markers obtained in our laboratory support the technique using continuous Doppler as the ideal non-invasive diagnostic method for carotid stenosis and this means that its systematic use is to be recommended in patients with suspected extracranial carotid disease. Moreover, the low cost of the equipment used as compared with other more sophisticated techniques should lead to its more widespread use as a first-line diagnostic method in all Neurology departments.

INTRODUCTION AND CLINICAL CASE: A 38 year old woman, with no previous history of trauma, presented complaining of interscapular pain followed by pulsating headache clearly related to posture, alleviated on lying down and worse on standing up. Subsequently, she also complained of diplopia. On examination there was paresia of the left sixth cranial nerve. Low opening pressure on lumbar puncture confirmed the presence of intracranial hypotension. The protein level of the cerebrospinal fluid was slightly raised. On CT the cortical sulci and small ventricles had disappeared. Cerebral MR (without gadolinium) showed marked diffuse meningeal hyper-intensity and apparent absence of the basal cisterni. Isotopic cisternography showed a pattern compatible with hypotension, without signs of fistulas. On spinal MR no spinal meningeal defects were seen. With conservative treatment the patient improved in a few days and the headache and diplopia disappeared. The absence of traumatism or spinal operations mean that the hypotension may be considered to be spontaneous. We discuss the CSF, neuroimaging and cisternography findings characteristic of the spontaneous intracranial hypotension syndrome. CONCLUSION: Unawareness of this syndrome, the particular neuroimaging changes and the usual CSF anomalies may lead to confusion over diagnosis, leading to the use of invasive techniques unsuitable for a condition which often has a good prognosis and in which the symptoms resolve in a few days or weeks with conservative treatment.

INTRODUCTION The relationship between Chlamydia pneumoniae and atherosclerosis has been assessed in several studies. Development and conclusions. Their results suggest a possible role of Chlamydia pneumoniae in the origin and development of the disease, while the actual link between them are still unknown. However, the presence of Chlamydia pneumoniae in patients with atherosclerosis could be just a coincidence.

Introduction and objective The Central Nervous System (CNS) plays an essential role in the regulation of the cardiac function. There is strong evidence that many CNS lesions, mainly those of hemorrhagic origin, may induce repolarization abnormalities and enlargement of the QT interval (ECG changes) and several types of arrhythmias. In some cases these changes have been related to sudden death. The imbalance between the sympathetic and parasympathetic systems, favoring the former, seems to be the etiopathogenic factor. Material and methods We have carried out a study on thirty-two in-patients suffering from non-severe intracerebral hemorrhage, by means of a Holter ECG examination within the first 72 hours and a second record after two months. We have assessed any significative differences on the ECG findings in relation to the location of the hematoma (left or right hemispheres) and the presence of a personal history of arterial hypertension and/or heart disease. Results One or more ECG changes were present in 69.2% of the patients and 73% showed one or more rhythm abnormalities. There was a higher incidence of supraventricular arrhythmias associated with the right hemisphere hematomas, with an statistical significance for the atrial extrasystolia. No differences were found between the group with a previous history of hypertension and/or heart disease and the one without these conditions. There were two cases of sudden death, both with left hemisphere hematomas, and in one of them the previous rhythm abnormalities were recorded. Conclusions This study corroborates the hypothesis that right hemispheric hematomas induce supraventricular arrhythmias more frequently. The possible association between severe ventricular arrhythmias and sudden death with left-hemisferic hematomas should be studied in a higher number of patients. We recommend monitoring every acute case of intracerebral hematoma when possible.

INTRODUCTION Arteriosclerosis is the commonest aetiology of vertebro-basilar ischemia (VBI). In the literature few studies mention the risk profile of cerebrovascular accidents at this site. MATERIAL AND METHODS In order to establish whether this profile has specific characteristics, we carried out a transversal study of 70 patients with VBI of artherothrombotic origin situated in the brain stem or cerebellum, determining the prevalence of the main risk factors (RF). The results were compared with a control group of individuals who had no cerebral vascular pathology and also with another group who had arteriosclerotic obstructive lesions of the carotid artery as an example of involvement of another vascular territory. RESULTS In the the group of patients with VBI we found greater prevalence of hypertension, smoking, ischaemic cardiopathy, peripheral vascular disease and excessive alcohol consumption together with raised levels of arterial hypertension, haematocrit, haemoglobin and total cholesterol as compared with the control group and within a similar range to the group of patients with ischemia of the carotid territory. We underline the high prevalence of diabetes in patients with VBI (45.7%), considerably greater than that of the control group (12.5%), than those with carotid pathology (20.4%) and that described in the literature (17-25%). CONCLUSIONS According to our results, the prevalence of RF in VBI and in carotid pathology is similar, except in the case of diabetes. This may play a more decisive role in territory such as the vertebro-basilar, where vascularization is basically by small calibre vessels.

Introduction The characteristics of restenosis and remodeling after carotid percutaneous transluminal angioplasty (PTA) were badly known. Objective To describe these characteristics in our series of carotid PTA. Patients and methods A total of 78 cases of PTA for symptomatic > 70% atherosclerotic stenosis of the extracranial internal carotid artery, were selected from our series of PTA if follow-up was > 12 months. All of them were followed with extracranial continuous-wave Doppler. Results Restenosis of any degree was found in 17 cases (21.79%) and always asymptomatic. A restenosis > or = 70% was found in 5 cases (6.4%). Restenosis was mainly found in cases without residual stenosis nor dissection after PTA (p = 0.002). Restenosis was found in 16 cases (94.11%) in the first 6-months, with no progression thereafter. Remodeling of residual stenosis was frequent (17 cases; 53.11%) and found mainly during the first month after PTA. Its incidence was highest in patients with dissection treated with heparin. In cases with restenosis, remodeling was infrequent, incomplete and occurred after 18-24 months. Conclusions 1. Significant restenosis after PTA due to myointimal proliferation, was infrequent. All cases were asymptomatic, under antiplatelet treatment. A new interventional procedure might not be necessary. 2. Complete remodeling was frequently found after 1-month control, mainly in arteries with some residual stenosis and dissection after PTA.