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Background Dyke–Davidoff–Masson syndrome is an uncommon constellation of radiological and clinical findings. Few reports describe co-occurring psychiatric manifestations. Systemic lupus erythematosus is a systemic disease with vascular, neurologic, and psychiatric involvement. To the best of our knowledge, no case reports have been made associating these entities. Case presentation We present the case of a 21-year-old Mexican mestizo woman with a history of systemic lupus erythematosus diagnosed at 4 years of age, who developed focal impaired awareness seizures when she was 8-years old, which became treatment-resistant at age 15. Two years prior to our evaluation, she developed deep vein thrombosis; clinical and laboratory criteria were met to diagnose secondary antiphospholipid syndrome. After being treated with anticonvulsants, glucocorticoids, and immunosuppressants with only a partial response, she developed a severe major depressive episode 1 year prior to our assessment, including two suicide attempts. She was referred to the out-patient clinic of our department for evaluation; intellectual disability, depressive symptoms, and behavioral symptoms were documented. Imaging studies revealed structural abnormalities in the left cerebral hemisphere: cortical atrophy, enlargement of sulci and cisternal spaces, and hyperpneumatization of the frontal sinus. Treatment with an antidepressant was initiated and maintained for 1 year, added to anticonvulsants and immunosuppressants. Depressive and behavioral symptoms diminished and no suicidal ideation has been noted at follow-up. Conclusions Dyke–Davidoff–Masson syndrome was diagnosed, accompanied by clinical symptoms previously reported as epilepsy and intellectual disability. This case report illustrates the complexity of syndrome presentation in an adult female, constituting a diagnostic and therapeutic challenge. This constellation of symptoms and structural brain abnormalities should be kept in mind in patients with neuropsychiatric manifestations and systemic diseases with central nervous system involvement, especially when diagnosed at a young age.

espanolAntecedentes y objetivo: Las unidades de cuidados neurovasculares (UCN) impactan favorablemente en el pronostico funcio- nal del paciente con ictus en comparacion con las salas de internamiento general. La efectividad de las UCN en Mexico no ha sido evaluada. Nuestro objetivo fue determinar el impacto que tiene una UCN en un hospital academico de tercer nivel del no- reste de Mexico. Metodo: Estudio de cohorte prospectivo, observacional y analitico. La poblacion fue dividida en dos periodos: el primero consistio en aquellos pacientes ingresados antes de la implementacion de la UCN (2008-2010), y el segundo consis- tio en pacientes ingresados posterior a la implementacion de la UCN (2010-2014). Se evaluo el estado funcional al egreso y a los 3 meses. Resultados y conclusiones: Se incluyeron 598 pacientes (periodo 1: 246; periodo 2: 352). En el periodo 2 se incremento la profilaxis de trombosis venosa profunda (razon de momios [RM]: 3.235; intervalo de confianza del 95 % [IC 95 %]: 2.18-4.80; p = 0.01) y se redujeron la estancia hospitalaria (RM: 0.42; IC 95 %: 0.29-0.62; p = 0.01) y la discapacidad funcional grave (Rankin ≥ 3) a los 3 meses de seguimiento (RM: 0.42; IC 95 %: 0.29-0.62; p = 0.01). La implementacion de una UCN mejoro el desenlace funcional a 3 meses y disminuyo los dias de estancia intrahospitalaria de pacientes con ictus. EnglishBackground and objective: Neurovascular care units (NCU) have a positive impact on the functional prognosis of stroke patients. The effectiveness of NCUs in Mexico has not been evaluated. Our objective was to determine the impact of an NCU in a third-level academic hospital in northeastern of Mexico. Method: We performed a prospective observational, analytic cohort study. The population was divided into two periods: the first one consisted of those patients admitted before the im- plementation of the NCU (2008-2010), and the second period consisted of patients admitted after the implementation of the UCN (2010-2014). Functional status was assessed with the modified Rankin scale at discharge and 3 months. Results and conclusions: 598 patients were included (period 1: 246; period 2: 352). Patients in period 2 had a higher deep venous thrombosis prophylaxis (odds ratio [OR]: 3.235; 95 % confidence interval [95 % CI]: 2.18-4.80; p = 0.01), a shorter hospital stay (OR: 0.42; 95 % CI: 0.29-0.62; p = 0.01) and less severe disability (Rankin ≥ 3) at 3 months of follow-up (OR: 0.42; 95 % CI: 0.29-0.62; p = 0.01). The implementation of an NCU in a third-level academic hospital improved the functional outcome at 3 months and decreased the days of in-hospital stay of patients with stroke.

Alteplase is the only approved drug for the treatment of acute ischemic stroke, but it is offered to a minority of patients, not only because of the short therapeutic window but also because of the numerous contraindications associated with thrombolysis, such as thrombocytopenia. There is some controversy on the true risk associated with thrombolysis in patients with thrombocytopenia. Here we report the case of a young patient, who developed an in-hospital acute ischemic stroke involving a large territory of the right middle cerebral artery, who was successfully treated with intravenous alteplase, despite having thrombocytopenia and prolonged prothrombin times due to systemic lupus erythematosus and antiphospholipid syndrome. This case exemplifies the need to reassess contraindications for thrombolysis, many based on expert opinion and not clinical evidence, especially in complex clinical situations.

Lupus podocytopathy (LP) is an uncommon proteinuric disorder in the spectrum of lupus nephropathy. Its histological features are similar to those described in minimal change disease (MCD) with or without mesangial immune deposits. Although infrequent, a close relationship between systemic lupus erythematosus (SLE) and thrombotic thrombocytopenic purpura (TTP) is well accepted. Proteinuria in the setting of SLE has previously been associated with the development of TTP-like syndrome. As far as we know, LP first presenting as a TTP-like syndrome has never been reported. Here, we describe the case of a previously healthy 45-year-old woman who developed simultaneously these two conditions and then we briefly review the literature on the topic, emphasizing the previous cases of concurrent initial diagnosis of both SLE and MCD (n = 7) and SLE and TTP (n = 72). In conclusion, renal biopsy is central to the management of SLE patients with nephrotic syndrome. Furthermore, in a SLE patient with anemia and thrombocytopenia, TTP should be part of the differential diagnosis, even when no schistocytes were detected in peripheral blood smear.

Pituitary apoplexy is a life-threatening illness due to acute infarction of the pituitary gland. The most common symptoms associated with pituitary apoplexy are headache, nausea, vomiting, visual impairment, hypopituitarism, and altered mental status. Diabetic ketoacidosis is a common acute complication of diabetes mellitus and is itself associated with similar symptoms. We present the case of a 38 year old woman, who presented with altered mental status and biochemical alterations suggestive of diabetic ketoacidosis who was found to have a pituitary apoplexy. The low frequency of this condition coupled with an acute and usually dramatic presentation that includes non-specific symptoms makes it a diagnostic challenge. Pituitary apoplexy can simulate a wide range of neurological conditions.