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Community psychiatry in Mozambique – a transcultural journey - read full article

By: Ana Guerra and Marta Croca

Introduction: Historically the psychiatric clinical practice in Mozambique evolved from an eminently reclusive care setting, during the colonial period, to a phase where the patients were rapidly deinstitutionalized into their communities, in the post-independence years. In 1990, in order to restructure the mental health care network, the National Mental Health Plan was approved. Its main goal was to promote a semi-open treatment setting, activating the community role in the rehabilitation and social reintegration of the psychiatric patient. Additionally, to cope with the scarcity of human resources, a three-year technical degree was created, training medical technicians in psychiatry. From 1990 to 1996 the network expanded from six sanitary units to twenty-four, covering the country’s eleven provinces, with ambulatory consultations functioning in some of the general hospitals and in all of the provincial hospitals. Presently, there are two specialized psychiatric hospitals, one in Maputo and another in Nampula.

Objectives and Methods: Through the description of our 3-month community psychiatry internship in Mozambique, we intend to depict the country’s mental health care reality.

Results: Our internship took place in São João de Deus Mental Health Centre, the psychiatric hospital located in Nampula, which is responsible for the country’s northern region. Besides offering in-patient and ambulatory treatment, it also aims to intervene at a community level by promoting educational talks, theatrical plays, radio and television discussions and the production of didactic material. The various components of our internship will be addressed, namely: the hospital’s community intervention project, the developed activities, the most commonly observed pathologies, the cross-cultural relevant aspects, as well as the challenges we had to face in an occasionally harsh environment.

Discussion and Conclusions: As one would expect, the social and medical realities we encountered were quite different from the ones we are used to, forcing us to adapt constantly in order to surpass challenges of a multiple nature. Nonetheless, these were also the circumstances that turned this experience into something unique, extremely enriching and certainly unrepeatable.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O1

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Parental unemployment and post-traumatic stress disorder symptoms: a study through the fog of Greek financial crisis - read full article

By: A. Kanellopoulos, I. Beratis, E. Syngelaki, and A. C. Tsiantis

Introduction: The aim of the present study was to explore the impact of parental unemployment on the development in students of post traumatic stress disorder (PTSD) symptoms that are related to exposure to school bullying.

Methods: Participants were 2377 primary school students from Athens. The questionnaires were group-administered in each classroom by trained research staff.

Results: The findings showed that children that reside in families that both parents are unemployed have on average significantly higher PTSD scores related to exposure to school bullying. However, the greater PTSD scores in this group of students cannot be explained by the presence of a greater victimization rate, since the chi-square test for independence did not reveal a significant association between paternal employment status and bullying/victimization engagement. The greater PTSD scores in the group of students that experience paternal unemployment can be an outcome of severe economic stress in family life that influences their psychosocial development and reduces their capacity to overcome successfully adverse events, such as school bullying. The presence of various emotional problems that are more common in this group of students according to previous findings, maybe played a role in reducing the threshold for the development of PTSD symptoms.

Discussion and Conclusions: Properly designed interventions should provide support to students that experience economically stressful conditions, such as paternal unemployment.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O2

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Psychiatric residents’ cultural competence training: could it contribute to commitment against Stigma and Inequality? - read full article

By: H. Esteves, Z. Gameiro, A. F. Freitas, and A. Bento

Introduction: Cultural competence has become an obligation in a society that highlights human rights and equity. Due to its colonial history Portugal has always been a multiracial country. This diversity has been further expanded due to the recent arrival of different migrant populations to Portugal. Psychiatric services reflects this diversity with growing admissions of foreigners with different cultural backgrounds which bring increasing difficulties in the management of this patients.

Objectives: To review the existent European residents’ training programs concerning cultural competence and to compare them with the ones delivered in Portugal.

Methods: EPA guidance on cultural competence training outlines was analysed. A literature review on cultural competence residency training programs was taken. PubMed search was done using with the following terms: psychiatric residency; cultural competence training programs and importance.

Results: Cultural competence is part of good clinical practice and comprises the process of how a clinician regards each patient in the context of the patient’s own culture as well as from the perspective of the clinician’s cultural values and prejudices. The EPA Guidance on cultural competence training outlines some of the key issues related to cultural competence and how to deal with these. Cultural competence represents a comprehensive response to the mental health care needs of immigrant patients and requires knowledge, skills and attitudes which can improve the effectiveness of psychiatric treatment.

Discussion and Conclusions: Cultural competency and training are believed to be a positive value in psychiatric residents’ training. Furthermore, this training and the contact with diverse migrant populations could contribute to build a stronger awareness against stigma and inequality in future professionals.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O3

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Occupational stress and burnout among physicians - read full article

By: Marco M. Oliveira, Ana S. Costa, Maria J. Peixoto, and Cassiano Santos

Introduction: Burnout has been defined as a psychological condition involving a continuous exposure to stressful work events leading to adverse consequences both in physical and mental health of workers. Among physicians, it is extremely hazardous given that it might affect their work and unintentionally harm the patients.

Objectives: The aim of this review was to collect data on the risk factors for burnout among physicians.

Methods: The review was based in articles published on PubMed database, using the following terms: “occupational stress”, “burnout”, “risk factors”, “predictive factors”, “healthcare professionals” and “physicians”.

Results: Studies showed that 25-60% of physicians reported symptoms or complaints related to burnout which also varies at different rates among different areas of specialty. Personal factors and workplace-related factors have been described and associated to burnout. As personal risk factors the studies describe higher levels of burnout in younger ages, unmarried status and, in women, being married with children. As workplace-related factors a positive association with burnout was found in physicians with less work experience, longer working hours, shift duty and working in higher-grade hospitals.

Discussion and Conclusions: Burnout has negative impact on physicians’ quality of life and for those who experience these symptoms there is a potentially increased risk for medical errors. This study highlights the importance of creating evaluation programmes for burnout in healthcare professionals, and the necessity to establish preventive protocols and specialized assistance.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O4

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Human trafficking – are we ignoring modern-day slavery? - read full article

By: Marta Queirós

Objectives: Review available literature regarding Human Trafficking in Europe.

Methods: Non systematic review using PubMed database with the MeSH word "Human Trafficking". Review of the relevant international publications regarding "Human Trafficking".

Results: PubMed database found 46 results from which 10 were found relevant. Four international publications regarding the subject available online were also considered relevant.

Discussion: Although it is estimated that there are at least 2.4 million victims of human trafficking worldwide there is few available literature about this subject. According to the European Commission the number of people trafficked to or within the European Union amounts to several hundred thousands a year. The number of reported cases in 2012 was 10998, most of them are adults and about 80 percent are female. In Europe the most frequent purpose for human trafficking is sexual exploitation (69%) followed by labour exploitation (19%). The majority of them are European citizens. Health care professionals are not aware of this nor have been trained to recognize these victims and as a consequence, opportunities to identify this cases are missed.

Conclusions: Further research is needed to understand the causes, consequences and scope of human trafficking. Health care providers play a major role in identifying these victims. Educational programs concerning this subject should be offered to increase awareness, promote early detection and assure effective management of modern-day slavery

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O5

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Innovative strategies for mental health education in low and middle income countries (LAMICs) - read full article

By: Asanga Fernando, Angharad Piette, Christopher Kowalski, Deborah Sebbane, Ashwini Rajan, Chrishanthi Rajasooriyar, and Walter Mangezi

Introduction: The improvement of mental health education in LAMICs has been highlighted as an imperative. Scarcity of resources necessitates innovative and creative approaches to this, such as human factors workshops and mental health simulation training. These have been little researched to date.

Objectives: To examine the feasibility and transferability of innovative mental health education strategies into low resource settings.

Methods: The authors comprise a collaboration spanning the UK, Zimbabwe, France and Sri Lanka, developing training courses for implementation in LAMICs, in collaboration with local partners. One involved multi-professional human factors workshops for mental health (and other healthcare) workers in Sri Lanka, whilst the other was a simulation-based training on the recognition and management of depression for medical students in Zimbabwe. We examined participants’ experiences, educational impact, feasibility and acceptability of these interventions in LAMICs.

Results: In Zimbabwe (n=27), student confidence scores in assessment and management of depression increased from mean 15.90 to 20.05 (95% CI = 2.58- 5.71) t (20) = 5.52, (p > 0.0001) following the simulation session. Feedback was positive overall with students commenting that it was “helpful”, “enjoyable” and “boosted confidence”. In Sri Lanka (n=196), descriptive data evaluation of ‘pre’ and ‘post’ course questionnaires demonstrated an identification of a knowledge deficit in areas covered by the workshops, and clear subsequent post course improvements in understanding .Furthermore, qualitative feedback demonstrated a high level of learner awareness, relevance, satisfaction and engagement.

Discussion and Conclusions: Work in Zimbabwe has demonstrated that simulation-based teaching is effective in improving student confidence and was enjoyable and acceptable. Local stakeholder input is essential in adapting materials to ensure culturally acceptability of interventions. Lack of funding for actors becomes an issue of sustainability. The workshops in Sri Lanka were, we believe the first multi-professional human factors workshops in the country. Evaluation has demonstrated that learners find this learning modality enjoyable, thought-provoking and relevant to improving patient safety across healthcare institutions in Sri Lanka. Innovative strategies for mental health education in LAMICs can be implemented in a cost-effective and effective manner. This implementation must be carefully considered locally in order to ensure cultural acceptability and sustainability.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O6

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Psychiatry trainees’ experiences of providing training in the WHO’s mhGAP manual in Kashmir, India - read full article

By: H. Ryland, L. Potter, and P. Hughes

Introduction: Global mental health is an increasingly important component of training and is being integrated in to all specialty curricula in the UK.

Objectives: The Royal College of Psychiatrists Volunteer scheme allows psychiatrists, including trainees, to participate in volunteering opportunities abroad. This report outlines the experiences of psychiatry trainees who travelled to Kashmir in India to provide training in the World Health Organisation’s (WHO) mhGAP tool and reflects on volunteering as a mechanism for obtaining global health competencies.

Methods: The Kashmir project has run for two years, with the support of the Royal College of Psychiatrists’ Volunteer Scheme. Psychiatrists from the UK travelled to Kashmir to deliver training in the use of the WHO mhGAP tool, which has been specifically designed to support primary care workers to identify and treat common mental health problems in resource limited settings. Health professionals from across Kashmir and beyond were invited to attend the training, focusing on the pilot region of Gandabal. Trainees attended a two-day ‘train the trainer’ course in the UK to prepare them to use the mhGAP and were supported throughout the volunteering experience by consultant psychiatrists.

Results: Participation in the volunteering project in Kashmir provided trainees with real world experience of many of the key issues in global mental health, such as the influence of cultural factors, stigmatisation of mental illness and the varying resources and structure of health systems to respond to mental health needs. Trainees were also able to develop a number of generic competencies of relevance to their practice back in the UK. This included educational skills and the completion of work place based assessments.

Discussion: Global mental health is increasingly prominent on the training agenda, especially in countries with high numbers and diversity of immigrants, such as the UK. Volunteering schemes offer a mechanism whereby psychiatry trainees can gain hands-on experience of delivering training in Low and Middle Income Countries (LMIC).

Conclusions: As well as the opportunity to use skills to improve mental healthcare in LMIC, volunteering can enable psychiatric trainees to gain specific competencies in global mental health.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O7

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A kangaroo on my couch: the mental health system and psychiatry training in Australia - read full article

By: Prashanth Puspanathan

Introduction: Due to its geographical isolation, cultural history and immigration policies, Australia possesses a population demographic rather unique to its borders. Heavily influenced by these factors is the resultant psychological landscape which presents itself to clinical eyes by the way it colours the spectrum of psychiatric manifestations.

Objective: Understanding the ramifications of national health policy which dictate the parameters by which the mental health system negotiates these hurdles. Exploring distinctly Australian travails: the mental health of the Indigenous Australian population, the Asylum Seeker Syndrome, the current Ice epidemic and the welfare state’s failings in the psychological realm.

Discussion: The impact of identified issues on psychiatric training and the role of trainees in the system.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O8

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Investigating microglial activation in schizophrenia: post-mortem or in vivo? - read full article

By: L. De Picker, M. Morrens, D. Oche, and B. G. C. Sabbe

Background: Ensuing from the psychoneuroimmunology hypothesis, neuroinflammatory activation of microglial cells is explored as a hallmark of neurodegenerative and neurodevelopmental aberrations in schizophrenia. Because extrapolation of preclinical research results to the human brain - particularly in pathological conditions - is limited, investigation of microglial activation in schizophrenia is preferably done using immunohistochemistry on post-mortem brain tissue or with in vivo TSPO PET-CT nuclear imaging.

Objective: To compare immunohistochemistry and nuclear imaging methods for the study of microglial activation in schizophrenia.

Methods: We reviewed existing literature on microglial immunostaining and TSPO nuclear imaging in schizophrenia on PubMed.

Results: The scarcity of post-mortem tissue with sufficient clinical information, required for the careful selection of cases to minimize heterogeneity due to confounding variables such as cause of death, means few studies have examined microglial activation on post-mortem tissue in schizophrenia. In immunohistochemistry, the specificity of different microglial markers represents both a challenge and an asset, but currently only HLA-DP/DQ/DR and CD68 markers have been used in schizophrenia tissue. Also for TSPO nuclear imaging, different markers have been developed. Newer TSPO markers offer higher specificity but require genotyping of subjects for rs6971 polymorphism. Three studies have investigated microglial activation in schizophrenia patients with nuclear imaging.

Conclusion: Both immunohistochemistry with specific microglial phenotypic markers and TSPO PET imaging involve specific advantages and challenges, and the combination of both techniques offers the optimal chance to determine the role of microglial activation in the pathophysiology of schizophrenia.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O9

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Autism parent support group - read full article

By: Beatriz Rosa, M. Pinto da Costa, Joana Jorge, Sara Cunha, Filipa Moreira, Fernando Ochoa, Daniela Rego, Camila Gesta, and Graça Fernandes

Introduction: Receiving a diagnosis of an autism spectrum disorder for one's child can be a painful experience for parents, that may require an adjustment of their beliefs, feelings, and expectations regarding the child so that they continue coping with raising their child. Because of the characteristics of autism spectrum disorders, parents' psychological adjustment can be especially challenging. Literature shows higher stress in parents of children with autism once compared to parents of children with other developmental disabilities. These findings must raise the clinicians awareness to improve methods of supporting families of children with autism.

Objectives: Provide information to parents about the characteristics of this disorder, advising them about the resources and interventions available and at the same time allowing them to share their concerns with other parents facing similar difficulties. These groups enable parents to increase their knowledge, skills and competencies needed to directly deal with their children, sometimes facing stressful events, which shows to increase the parent's self-confidence and self-assurance.

Methods: The authors with this work briefly present a parenting group model applied in the Child and Adolescent Psychiatry Department of Centro Hospitalar do Porto.

Results: Children's family with autism spectrum disorders participate in a group during 6 sessions (twice a month), that covers several topics, such as interventions, medication, social support, family stress, and counts with the contribution from the different elements of the multidisciplinary team involved in this intervention process (child psychiatrist, psychologist, paediatrician, social worker and occupational therapist).

Discussion: In-depth investigation in this area must be done to understand the best approach to the support of these high risk families. Randomized controlled trials of group intervention are required in order to confirm the effectiveness of these interventions.

Conclusions: Groups for parents of children with Autism can be an approach to the high stress levels of these families and therefore professionals should develop efforts to provide them the best support.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O10

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Benzodiazepines in clinical practice: how to avoid and stop them? - read full article

By: Luisa Cabrita, Olivier Andlauer, Ozden Gokdemir, and Cristiano Figueiredo

Introduction: To manage anxiety and insomnia GPs and psychiatrists prescribe benzodiazepines, which have proven to be very helpful in the short term. However, in the longer term, their use can cause many difficulties. Memory problems or falls, especially in older adults, are a concern. In addition, misuse and dependency often appear after a few weeks/months. Clinicians and patients therefore end up with a prescription difficult to stop that doesn’t help any more with the initial complaint. There are other non-pharmacological ways to cope with anxiety and insomnia, and teaching these techniques to clinicians and patients has proven to be efficient.

Objectives: The aim of this workshop is to provide GPs and psychiatrists with skills to avoid prescribing benzodiazepines that can translate into their clinical practice, and to stop them in patients who have developed an addiction.

Methods: Using an interactive approach, presenters will alternate clinical vignettes and theoretical points to keep the workshop as close as possible to clinical practice. In addition, three group sessions using basic CBT (Cognitive and Behavioural Techniques) and motivational interviewing techniques will be held during the workshop to make participants practice with each other the techniques explained during the workshop.

Results: Basic CBT and motivational interviewing techniques will be taught to the participants and they will have the opportunity to practice them during the workshop. More general knowledge of the benefits and risks of benzodiazepines will help clinicians prescribe based on evidence.

Discussion and Conclusions: We believe the workshop was designed to suit early career doctors’ needs and will contribute to decrease unnecessary prescriptions of benzodiazepines both in the community and hospital. A balanced view of risks and benefits and a very practical approach will ensure the knowledge and skills learnt translate into clinical practice.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O11

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On suicide – an integrative model of Stoicism and Scholasticism - read full article

By: Gustavo Santos

Introduction: Traditionally considered under the medical model, in psychiatry, the suicide remains a philosophical problem of laborious and complex approach.

Objectives and Methods: We confronted the philosophic perspective of suicide in two antagonistic times, the Ancient Age and the Middle Ages, analyzing the following works: Phaedo (Plato, 428 BC - 348 BC), Epistulae morales ad Lucilium (Seneca, 4 BC – 65 AD), The City of God (Saint Augustine, 354-430), The Summa Theologiae (Thomas Aquinas, 1225-1274) and Del Homicidio (Francisco de Vitoria, 1492-1546).

Results and Discussion: We argued that the demand of a worthy life with virtue, which for Stoics had the maximum moral value, was progressively replaced, during the Middle Ages, by the acceptance of suffering and misery of everyday life. The authors of the Ancient Age conceded a philosophical suicide, under particular conditions, while the Scholastic authors rejected suicide under any circumstances. The Stoic ethical paradigm “When is possible and desirable for a man to commit suicide?” was overridden by the Scholastic moral prohibition “Why the man should not commit suicide?”. We demonstrated how the theological standard overlapped the man’s ethical disposition, during the Middle Ages.

Conclusions: Finally, we propose an integrative model of these paradigms, which we believe may contribute to highlight the philosophical and medical discussion on suicide.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):O12

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Acute stroke and early carotid endarterectomy: a centre experience - read full article

By: João Rocha Neves, Joel Sousa, Marta Casal-Moura, José Oliveira-Pinto, Bruno Guimarães, João Paulo Castro, André Ferreira, Mário Vieira, Ana Sofia Ferreira, and José Teixeira

Introduction: Data from the literature concerning symptomatic carotid stenosis show that the long term benefits of surgery are greater when it is performed within 2 weeks after the event. The aim of this study is to evaluate our centre’s capacity and outcomes. Methods: Forty-eight consecutive patients submitted to carotid endarterectomy (CEA) due to symptomatic carotid stenosis [3 ocular transient ischaemic attacks (TIA); 15 TIAs; 30 strokes] in a reference Vascular Surgery and Stroke centre were evaluated (July 2014 – June 2015). A prospective registry was made with follow-up from 6 months to a year. All the diagnoses were confirmed by a neurologist and a vascular surgeon. Patients with more than 180 days of waiting time for surgery were excluded (2 patients).
Results: The mean time from event to surgical proposal was 15 days (median 4) and from event to CEA was 28 days (median 10) (20 inpatients, 25 outpatients, 3 other hospitals). The median ABCD2 score after observation was 5. Ninety-two percent of the patients were operated under loco-regional anaesthesia, with 3 conversions to general anaesthesia (2 intra-operatory deficits after clamping with necessity of shunt, 1 intolerance). Most of the patients were submitted to patch closure (88%) and 8% with eversion. Post-operatively 6% of the patients needed reintervention due to neck hematoma, 1 had hyperperfusion syndrome and 1 had hypoperfusion syndrome. Thirty-day death/stroke rates were 0%, and at 1 year, 4 deaths were registered. 
Conclusion: Fast-track protocols are needed for legis artis patient treatment. Primary referentiation also has to be optimized. Indications for surgery are well established and practiced. Surgery outcomes are according to the recommendations.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O1

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Middle cerebral artery thrombectomy plus carotid stenting or postponed carotid endarterectomy: which is the best approach in acute stroke treatment? - read full article

By: Ana Luísa Rocha, Pedro Abreu, Pedro Castro, and Elsa Azevedo

Introduction: While performing endovascular techniques for middle cerebral artery (MCA) recanalization in hyperacute stroke, there is some controversy regarding immediate stenting of a concomitant carotid stenosis, or postponing for endarterectomy in a more stable clinical condition within the first 2 weeks since symptom onset. Aiming to raise discussion around this issue, we present two acute stroke clinical cases where both attitudes could be considered. Case Reports: Case 1: 57-year-old male, previously anticoagulated (rivaroxaban 20mg) for deep venous thrombosis, presented right MCA occlusion symptoms, scoring 15 on NIHSS. Angio-CT scan showed right ICA stenosis, and a thrombus in the right MCA M1 segment. Due to anticoagulation, the patient was immediately selected for thrombectomy (Thrombolysis in Cerebral Infarction (TICI) 2b), with an end-of-procedure NIHSS of 8. Duplex ultrasound confirmed a 75% ICA atherosclerotic stenosis. The patient was discharged to his reference hospital with indication for endarterectomy, scoring 3 on NIHSS. Case 2: 59-year-old female presented with left MCA occlusion symptoms, scoring 12 on NIHSS. Angio-CT showed occlusion of left ICA and MCA (M1 segment). We performed thrombolysis followed by MCA thrombectomy (TICI 3), with an end-of-procedure NIHSS score of 19; angiography showed a sub-obliterative ICA stenosis (>90%) at the end of the procedure (occlusion opened by the thrombectomy catheter passing through?), also observed in a duplex ultrasound exam. NIHSS subsequently improved to 4, and a successful endarterectomy was performed 7 days after admission. 
Conclusion: Although we decided to postpone carotid stenosis treatment, using later endarterectomy instead of immediate endovascular treatment during the thrombectomy procedure, doubts were raised regarding the best approach. We suggest a systematic register of these cases in a multicentre study, to gather more information that might lead to supported decisions, as there are no current specific guidelines addressing this issue.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O2

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Acute treatment of symptomatic intracranial internal carotid stenosis - read full article

By: Sofia Costa Martins, Vanessa Oliveira, Ricardo Martins, and Rui Felgueiras

Introduction: Nowadays, stroke centres use extensive imagological data to support hyperacute treatment of stroke. Although simple CT scan is enough to decide intravenous treatment, endovascular procedures obligate an angio-CT documenting an occlusion and some centres use perfusion CT to show a small core of infarct. Hyperacute treatment of symptomatic carotid stenosis is controversial, even more when referring to intracranial segments. Case Report: A 57-year-old woman, with multiple cardiovascular risk factors, was admitted to our emergency department one day after an elective surgery. She clinically presented a right total anterior circulation infarction with 5 hours and 30 minutes of evolution (anosognosia, right conjugate eye deviation, left homonymous hemianopia, hemiparesis grade 3 and hemisensory loss), scoring 12 on NIHSS. The brain CT scan was normal. The CT angiogram showed a slight reduction in the diameter of the right carotid bulb and apparent severe stenosis of the cavernous segment of the internal carotid artery. CT perfusion revealed an elevated mean transit time with no apparent lesion on cerebral blood volume. First, we tried to improve perfusion with dopamine, but neurological deficits remained stable. After 1 hour and 30 minutes, we performed angioplasty with stenting of the cavernous segment of the internal carotid artery resulting in a frank improvement of symptoms. The final outcome revealed only a left hemiparesis (grade 4) with an NIHSS of 2. 
Conclusion: Although controversial, acute endovascular treatment of intracranial symptomatic stenosis may be an option when best medical treatment is not feasible.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O3

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Sulcal effacement: does it mean irreversible infarction? - read full article

By: Francisca Costa, Ricardo Soares-dos-Reis, and Tiago Parreira

Introduction: Sulcal effacement is widely regarded as an early CT sign of stroke. The authors present a case where the interpretation of this sign was confounded by other factors. 
Clinical Case: A 45-year-old female patient, previously autonomous and without any relevant medical conditions, was admitted to the emergency room due to sudden onset of left hemiparesis, dysarthria and central facial paralysis. The patient was anosognosic and had a left-side sensory neglect (NIHSS 12). Brain CT revealed a right hyperdense middle cerebral artery sign, signs of early ischaemic changes on basal ganglia and fronto-insular cortex and sulcal effacement on the right fronto-parietal convexity, but preserving the cortical-subcortical differentiation. Intravenous thrombolysis was administered two hours after onset, and the patient was immediately transferred to a mechanical thrombectomy centre. On arrival the patient was stable. CT angiography confirmed the right M1 segment occlusion and the perfusion study was not readable due to motion artefacts. Mechanical thrombectomy was performed at four hours and forty-five minutes after onset, with complete recanalization of the affected territory (TICI 3). NIHSS at discharge was 5 (central facial paralysis and left hemiparesis). At one-month follow-up, she scored 2 on the NIHSS (mild left hemiparesis). 
Discussion: This clinical case pretends to allude to the fact that sulcal effacement in an ischaemic onset might be due to cytotoxic oedema, but might also be due cerebral hyperaemia associated with compensatory vasodilation after an ischaemic insult, and thus falsely overestimate the ASPECTS score. Being so, the distinction is not only of major clinical relevance, but also influences the therapeutic approach.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O4

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Anticoagulation choice in patients receiving biologic drug therapy - read full article

By: Mafalda Seabra and Pedro Abreu

Introduction: The management of stroke, particularly haemorrhagic stroke, in patients taking oral anticoagulants still poses some challenges. 
Case Report: A 57-year old woman with multiple vascular risk factors and ulcerative colitis presented to our hospital after noticing speech impairment and headache when she woke up. This patient was taking, among other medications, acenocoumarol, methotrexate, prednisolone and adalimumab. Her initial ECG demonstrated atrial fibrillation and her CT scan showed acute haemorrhage of the right cerebellum. Anticoagulant therapy was stopped. The patient’s clinical status improved steadily during her stay at our centre. On the twenty third day, the haemorrhage had already been reabsorbed, and discussion was raised concerning the patient’s orientation. The haemorrhagic stroke was considered to be due to the patient’s history of hypertension. Despite the spontaneous haemorrhage, given the risk of further cardioembolic stroke episodes due to atrial fibrillation and associated risk factors, reinitiating anticoagulation was deemed necessary. At this stage, introducing a novel oral anticoagulant was considered. Nevertheless, this idea was discarded for the lack of experience regarding these drugs in ulcerative colitis patients on biologic drug therapy. This question was also debated with Cardiology and, to reduce haemorrhagic risk, left atrial appendage closure was considered and scheduled. 
Conclusion: This patient illustrates the difficulties faced when dealing with multiple comorbidities and simultaneous risk of bleeding and ischaemia.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O5

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A subtle stroke - read full article

By: Rafael Nascimento, Sofia Nóbrega, João Miguel Freitas, João Patrício Freitas, and Rafael Freitas

Introduction: The authors present a clinical case of an ischaemic stroke that presented with anomic aphasia. 
Case Report: A 75-year old woman was brought to the emergency department with an anomic aphasia that had started that day. The neurological exam confirmed the anomic aphasia with no other associated findings. The CT-Scan showed focal points of ischaemic gliosis without any other acute changes that could suggest vascular lesions particularly in the middle cerebral artery territory. The patient was hospitalized in the cerebrovascular disease unit with the diagnosis of ischaemic stroke. During her stay at the unit, the patient developed a decreased nasolabial fold prominence on the left side, motor aphasia, dysmetria and a lack of balance while walking. On the fourth day, the patient underwent an MRI that revealed a sub-acute infarction in a partial territory of the left middle cerebral artery with a partially re-canalized thrombus in the inferior M2 branch of this artery. Blood work showed a mixed dyslipidaemia. The echocardiogram detected a type 1 diastolic dysfunction with an ejection fraction of 55%. Patient was discharged after 8 days. Currently, the patient is followed in the cerebrovascular diseases department. The neurological evaluation demonstrates aphasia with some impairment of comprehension and naming. Her speech has fluency loss showing occasional anomic pauses and paraphasia.
Conclusion: The authors alert to the fact that a stroke can present itself in multiple ways, stressing the role of the clinical symptoms in its diagnosis.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O6

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The unexpected should be expected - read full article

By: Rafael Nascimento, João Miguel Freitas, João Patrício Freitas, and Rafael Freitas

Introduction: The authors present a venous sinus thrombosis that started in a woman 10 days after labour. 
Case Report: A 34-year old woman, who had gone into labour 10 days before her admission, presented to the emergency department with paraesthesia on the right side of the body and dysarthria which started that day. The neurological exam showed predominant right brachial paresis associated with a diminished sensitivity in the right arm and leg. The CT-Scan revealed a venous thrombosis that reached the straight, superior sagittal and transverse sinus, with a greater extension on the right side involving multiple tributary veins. The admission in the cerebral vascular diseases unit was followed by heparin perfusion. Ten days after the onset of the episode the patient was submitted to another CT-Scan that showed resolution of the thrombosis. Goldman campimetry was considered normal. The patient was discharged from the unit and started an etiologic search. The echocardiogram and cervical duplex ultrasound were normal. The blood work showed a positive lupus anticoagulant. Currently, the patient does not show any sequels and maintains anticoagulation. 
Conclusion: The authors highlight the role of the internist in the diagnosis of a rare entity in a woman, 10 days after labour, without any relevant past medical history.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O7

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Internuclear ophthalmoplegia: a subtle neurological sign of a stroke - read full article

By: Elsa Meireles, Tiago Fernandes, and Manuela Alves

Introduction: First described by Jean Lhermitte, internuclear ophthalmoplegia is a disorder characterized by the inability of horizontal gaze conjugation with weakness in the adduction of the affected eye and horizontal nystagmus in abduction of the contralateral eye. This entity is commonly associated with a lacunar brainstem stroke, but also with multiple sclerosis, infection, trauma or tumour involving the medial longitudinal fascicles. 
Case Report: A 71-year-old man went to the emergency department with binocular diplopia with 12 hours of evolution. He had personal antecedents of chronic hepatic disease, Child Pugh B, probably with alcoholic etiology. Upon physical examination, he was afebrile, normotensive, with limitation in adduction of the left eye and right eye nystagmus in conjugate gaze to the right, with no other changes. Analytically, he had thrombocytopenia of 57000/µL, the electrocardiogram showed no dysrhythmia and the CT was normal. The diagnosis of an ischaemic stroke of the posterior circulation was assumed, involving the medial longitudinal fasciculus. The patient was admitted for surveillance and stratification of cardiovascular risk. He experienced full recovery in 24 hours. Doppler ultrasound of the cervical and intracranial vessels showed severe focal stenosis of the left posterior cerebral artery and right and left carotid stenosis, estimated at 30 and 50%, respectively. 
Conclusion: Internuclear ophthalmoplegia is a discreet and informative sign whose clinical recognition is essential for an accurate topographical diagnosis.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O8

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A hole in the heart: the link between patent foramen ovale and stroke - read full article

By: Ana Luísa Martins, Ana Pontes, Beatriz Leite da Cunha, Diogo Ramos, and Cristina Nobre

Introduction: In about 40% of younger patients with acute ischaemic stroke, the cause remains undefined despite an extensive diagnostic evaluation. Patent foramen ovale (PFO) is a hemodynamically insignificant interatrial communication present in about 25% of the adult population. Large PFO with a substantial shunt has been identified in many studies as an anatomical comorbidity associated with stroke. 
Case report: We describe a case of a 49-year-old man who presented to the emergency department with left hemiplegia, left-sided neglect, and aphasia. Cranial computed tomography showed an acute left partial anterior circulation ischaemic stroke. Duplex ultrasound of the carotid arteries did not identify atherosclerotic lesions or reduced blood flow velocities. The patient had been healthy until this event, and his only apparent risk factor for vascular disease was smoking of approximately 15 cigarettes/day. Transoesophageal echocardiography was performed a week later and revealed a thromboembolus straddling a PFO. The patient was informed as to the options of treatment, and he decided to use long-term oral anticoagulation. 
Conclusion: This case deals with a stroke cause that can be documented and treated both as primary and secondary prevention. The choices of antiplatelet agents, oral anticoagulants, transcatheter placement of an occlusive device or cardiac surgery present a broad range of options which entail different risks.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O9

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Stroke-like symptoms for 24 hours: transient ischaemic attack or stroke? Aspirin or warfarin? - read full article

By: Ana Lima, Karla Marin, Ana Cunha, and Rita Oliveira

Introduction: Mitral valve prolapse involves a spectrum of structural and functional mitral valve dysfunction, characterized by central weakening of the fibrous core tissue. Such lesions may lead to thrombus formation, vegetation and calcification of the valve that may cause thromboembolism. This condition may be asymptomatic, with stroke or transient ischaemic attack (TIA) being the first sign. Approximately 10-14% of ischaemic strokes occur in young adults. Studies revealed high incidence rates of hypertension, diabetes mellitus, dyslipidaemia and smoking as being the most frequent risks factors for ischaemic strokes. 
Case Report: Male, 33 years, with hypertension and dyslipidaemia, medicated with ACE inhibitor and statin, with poor control. In April 1999, he went to the emergency room (ER) with the following complaints: right facial paraesthesia, dysarthria and headache with 24-hour duration. CT scan showed a small ischaemic lesion located in the left middle cerebral artery territory. Antiplatelet therapy was initiated with a successful and complete recovery. The TIA’s etiology was a mitral valve prolapse. Warfarin was initiated, as well as cardiology follow-up. Five years later, warfarin was discontinued and aspirin was resumed. 
Conclusion: The patient was initially treated with aspirin at the ER but the cardiologist changed it to warfarin, which was discontinued in 2006 and changed back to aspirin. Since the duration of symptoms was 24 hours, the clinical distinction between TIA or stroke is difficult, with the constant revision of definitions contributing to that. This leads to different therapeutic approaches, as the guidelines support aspirin for cerebral transient ischaemic attacks and warfarin for selected post-stroke patients.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O10

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Antiplatelet drugs: no matter when? - read full article

By: Ana Catarina T. Rodrigues

Introduction: Stroke is a leading cause of death in our country. Although, there are better methods of detection and more effective treatments for prevention, their occurrence remains high. Thus, its prevention and proper treatment are crucial. In this sense, antiplatelet therapy (AT) gains an important role in primary and secondary prevention of events. However, the clinician cannot forget the side effects of this drug. 
Case Report: Man, 81 years old. Personal background: breast neoplasm, hypertension, type 2 diabetes, lacunar stroke, anaemia (with constant need for transfusion support) due to intestinal angiodysplasia, aortic stenosis and coronary heart disease. Patient sought medical attention due to gastrointestinal bleeding. After a hospital stay, he returned home medicated with enoxaparin and indication for considering AT suspension. The attending physician opted to suspend clopidogrel and the patient presented an improvement of his haemoglobin. 
Conclusion: This patient carries a high cardiovascular risk. Given the age of the patient and the fact that the risk of events seems to be more dependent on anaemia than the release of atherosclerotic plaques, wouldn’t it be more appropriate to suspend clopidogrel? The fact that the family denied invasive treatments seems to point to a knowledge of the unfavourable clinical situation, so controversial treatments should be avoided. Suspending AT can decrease the risk of bleeding and thus better control of anaemia, which reduces the risk of cardiovascular events. The quaternary prevention starts gaining ground in clinical practice and, in this case, it seems to have been the solution.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O11

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Risk factor management and post-stroke disability: the tertiary prevention - read full article

By: Marta Ferreira and Soraia Dantas

Introduction: Despite the downward trend, stroke is a major cause of mortality and morbidity in Portugal and in the world, accounting for different degrees of disability, and consequently marked decrease in quality of life. Prevention, in its various levels, is the main strategy, stressing the importance of primary health care and family doctor's role. 
Case report: 72-year-old male, widower, with controlled hypertension, type 2 diabetes mellitus, atrial fibrillation, dyslipidaemia and sleep apnoea. The patient had a history of multiple cerebral ischaemic events: acute ischaemic stroke in 2008 (right carotid artery), posterior circulation stroke with right carotid artery restenosis in 2014. In 2016, the patient underwent stenting of the basilar artery after episodes of vertebrobasiIar ischemia, under dual antiplatelet therapy and hypocoagulation. As a complication of enoxaparine use, he had a spontaneous rectus sheath hematoma. At the first consultation in primary care after discharge, the patient was clinically and analytically stable, but with a total loss of interest in all his daily activities. The medical focus was not only the risk factor control but the improvement of psychological and functional status. 
Conclusion: Given the current population ageing, it becomes imperative to adjust the available health resources, in order to reduce the morbidity inherent to stroke. Tertiary prevention allows the patient reintegration, so that an interdisciplinary approach is fundamental. Post-stroke disability, especially the psychological impairment, constitute a major obstacle to the treatment adherence and rehabilitation. The knowledge of the patients' social and familiar context is key to treatment success.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O12

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From dissection to rehabilitation - read full article

By: Nelson Albuquerque, Ana Gomes, Irina Peixoto, Mário Vaz, Pedro Teixeira, Maria Carvalho, Jorge Caldas, and António Monteiro

Introduction: Stroke in young patients has been receiving higher attention recently, mostly because global stroke incidence decreased in the last three decades. Nowadays, almost 10% of ischaemic strokes occur in patients younger than 50 years. The aim of this study is to report a case of stroke with internal carotid artery (ICA) dissection in a young patient and highlight the importance of rehabilitation. 
Case report: A 41-year-old woman, with no relevant medical history, independent in the activities of daily living, was brought to the emergency room after being found lying on the floor unconscious, and having a history of throwing up and sudden headache with aura about 4 hours prior to the event. Physical examination revealed prostration (Glasgow Coma Scale of 13), right oculocephalic deviation, left hemianopsia, left central facial palsy, dysarthria and left hemiparesis. The CT scan showed a hypodensity compatible with acute ischaemic injury in the middle cerebral artery territory, or watershed regions. A CT angiography demonstrated occlusion of the right ICA with potential dissection. After 15 days of in-patient stay in the Stroke Unit, she was transferred to the Rehabilitation department to undergo an intensive rehabilitation program. She was admitted with a Functional Independence Measure (FIM) scale of 66/126, and left with 106/126. 
Conclusion: Pathogenesis of stroke in young patients is challenging. Although rare, ICA dissection remains an important cause. Its diagnosis is usually difficult and so, the incidence may be underestimated. Rehabilitation treatment plays an important role in those patients, promoting patients’ independence, social/vocational reintegration and quality of life.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O13

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Chronic pain after stroke: a systematic review - read full article

By: Cláudia Gemelgo, Ana Teresa Gaspar, and Filipe Antunes

Introduction: Pain after stroke is a very debilitating and underestimated condition, affecting patients’ quality of life. For its complex character, the main challenge is to recognize its prevalence and its developing process so as to enable an early approach and avoid its chronification. 
Methods: A systematic review of the literature was completed using PubMed database, with 59 studies identified regarding the main causes of chronic pain after stroke, diagnostic strategies and therapeutic attitudes. 
Results: A variety of direct and indirect processes can underlie pain after stroke. Previous musculoskeletal pathology that worsens due to neurological deficits, hemiplegic shoulder pain, pain related to spastic limbs and neuropathic pain (such as central pain and type I complex regional pain syndrome) are the main causes of post stroke chronic pain. Hemiplegic shoulder pain is the most common one and accounts for about 70-80% of them. Because of their own clinical and pathophysiological particularities, each is to be individually approached and treated. 
Conclusion: Pain after stroke is not negligible. For its prevalence and impairment both in quality of life and rehabilitation process, it is essential to recognize the main causes as well as the diagnostic strategies and subsequent therapeutic alternatives.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O14

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I had a stroke and I need to renew my medication - read full article

By: Paula Jardino

Introduction: Stroke has a large population impact not only for the high mortality, but also for its potential to generate motor and cognitive disability. Stroke patients have a 15–fold increased risk of a recurrence. 
Case report: Female, 69 years old, went 3 times to the emergency room with dizziness and decreased strength and, on the fourth time, she had dysarthria and paresis of the right lower limb. The CT scan showed a cerebral infarction. She was discharged on the same day and medicated. Fifteen days after the onset of symptoms, she requested a consultation with her family doctor for medication renewal. On this consultation, she maintained dysarthria and paresis of the right leg. No referral for follow-up consultation and monitoring of the clinical status was found. During the consultation, the risk factors were identified and corrective measures were implemented. The investigation of the main causes of stroke showed no alterations on the echocardiogram and Holter monitoring. The carotid ultrasound revealed a 70-80% stenosis of the left internal carotid artery. The medication was reviewed and the patient was referred to a neurologist and to physical rehabilitation. Later on, she had an endarterectomy. 
Conclusion: The follow-up of post-stroke patients should address the quantification of the disabilities and implement treatments. In order to reduce recurrent disabilities and mortality, identification and correction of the main risk factors, and a search for treatable causes of stroke, should be performed. 

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O15

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Paroxysmal atrial fibrillation: the doubt remains - read full article

By: Cristiana Martins and Rita Ferreira

Introduction: There is a causal relationship between atrial fibrillation (AF) and stroke. Cardioembolic stroke accounts for 20-30% of ischaemic strokes and AF is the most common cause of cardioembolic stroke. This arrhythmia is relatively common in the general population and its prevalence increases with age. 
Case Report: A 59-year-old male, with arterial hypertension (8 years of evolution), overweight (BMI = 29 kg/m2), without other cardiovascular risk factors, came for a routine hypertension visit, without any symptoms. Physical exam revealed irregular radial pulse on digital palpation, irregular rhythm on cardiac auscultation and blood pressure of 120/85mmHg. The remaining physical examination was normal. In a previous electrocardiogram (ECG), the rhythm was always sinus. An urgent ECG and thyroid function study were ordered. The patient came back in two days with ECG and levels of thyroid-stimulating hormone (TSH). At this consultation, the radial pulse and cardiac auscultation were regular in rhythm. TSH was 2.19 mU/L and ECG revealed sinus rhythm at a rate of 69 beats per minute and right bundle branch disturbance. An echocardiogram and 24-hour Holter monitoring were requested, whose results are pending. 
Conclusion: The clinical case described aims to highlight the importance of heart rate measurement by pulse palpation and cardiac auscultation on routine consultations. This may identify possible arrhythmias in an opportunistic way. In this patient, further study should be pursued due to the possibility of paroxysmal arrhythmia.

Special Issue on Stroke. From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 7–8 June 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 2):O16

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Vertebral artery occlusion with distal ischemia of posterior inferior cerebellar artery territory: two clinical cases and imaging correlations - read full article

By: Ana André, Ana Félix, Helena Machado, Motasem Shasmana, and Patrícia Guilherme

Introduction: Stroke is the commonest etiology of neurological focal deficits and ischaemic events are the most frequent stroke cause. The vertebrobasilar territory represents approximately 20% of all ischemic strokes. Vertebral artery (VA) occlusion results in ischaemia of the posterior inferior cerebellar artery (PICA) territory, which causes lateral medulla and cerebellum damage. In elderly patients, local atherothrombosis is the most common etiology. 
Case Report: A 71-year-old female patient and a 77-year-old male patient with previous history of hypertension, presented at the emergency department with a history of sudden onset of headache, nausea, vomiting, dizziness and unsteadiness of stance and gait. The neurological examination disclosed the presence of dysmetria, right dysdiadochokinesia and ataxic gait. Cranial Computed Tomography (CT) showed a cortico-subcortical paramedian hypodensity in the posteroinferior region of the right cerebellar hemisphere, in both cases. Cervical and transcranial ultrasonography revealed characteristic spectral waves of right vertebral artery occlusion, with retrograde flow through V4, in both patients. CT angiography confirmed an occlusion of the V2-V4 segment of the right VA. Antiplatelet therapy was started in both patients and vascular risk factors controlled. A rehabilitation program was started during hospitalization and continued after discharge. 
Conclusion: Vertebral artery atherothrombosis usually results in a slow and progressive manifestation of symptoms. In these cases, there was a sudden onset of neurological deficits. However, the symptoms reflected ischaemia of distal PICA territory, instead of a full syndrome after a sudden occlusion. The left VA likely provided sufficient retrograde flow through the V4 segment of the right VA to preserve medullary supply.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O1

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Cryptogenic cerebral microangiopathy and non-aneurysmal subarachnoid haemorrhage – a case report - read full article

By: Rita Rodrigues and José Mário Roriz

Introduction: Cerebral microangiopathy usually manifests as lacunar infarcts, white matter lesions and cerebral microbleeds, resulting in lacunar stroke episodes and/or progressive cognitive impairment. 
Case Report: Fifty-eight-year-old woman, without remarkable past medical history or known vascular risk factors. Admitted to the stroke unit with an isolated mild left hemiparesis beginning three days before. Brain computed tomography (CT) and magnetic resonance imaging revealed abundant scattered microangiopathic lacunar sequelae and leukoaraiosis. Protocol blood panel, cervical and transcranial ultrasonography, 24h-Holter, transthoracic echocardiogram and 24h-ambulatory blood pressure monitoring were unremarkable. Autoimmunity tests were normal (except for borderline cryoglobulins and IgM anticardiolipin). Urinalysis showed mild proteinuria. Genetic testing for CADASIL was negative (results pending for Fabry disease). Neuropsychological assessment showed mild cognitive impairment with a “frontal-subcortical” profile. She was readmitted five months later with a thunderclap headache after sexual activity, without focal neurological deficits. The CT scan revealed a diffuse subarachnoid haemorrhage. Acute-phase CT Angiogram and classical angiography excluded cerebral aneurysms or vascular irregularities. Cerebrospinal fluid analysis after approximately one month was normal. An angiographic control was programmed within 6 months. 
Conclusion: Considering the age and absence of conventional risk factors, the patient underwent an exhaustive etiologic study. Nevertheless, a clear association between these events could not be demonstrated. We present this case to discuss how far we should investigate disproportionate small vessel disease, and whether these two events could be explained by a common cause.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O2

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Not just vertigo – the importance of repeating the head computed tomography - read full article

By: Ana Lima, Ana Cunha, Rita Oliveira, and Karla Marín

Introduction: Sudden onset of focal neurologic deficits is the hallmark of the diagnosis of ischaemic stroke. Symptoms like speech disturbance and weakness on one-half of the body are almost always present. Headache and non-orthostatic dizziness are only estimated to be present in about 13-14% of the cases of ischemic stroke. Dizziness is more common in posterior circulation stroke.
Case Report: Female, 74 years old, dementia, hypothyroidism, diabetes mellitus, dyslipidaemia, medicated with memantine 10mg, levothyroxine 50mcg, sitagliptin 100mg, simvastatin 20mg and acetylsalicylic acid 100mg. She was admitted in the emergency room with the following complaints: dizziness, nausea and vomiting, accompanied by disorientation. Brain computed tomography (CT) showed no acute lesions, and the patient was discharged medicated with beta-histine. She returned the next day with the same complaints and history of a fall with head trauma without loss of consciousness. CT showed doubtful “…sequelae of cerebellar infarcts?”. She repeated the CT 24 hours later and the cerebellar lesion was larger - probable right posterior inferior cerebellar artery /basilar stroke with small regions of haemorrhagic transformation. The patient stayed hospitalized for 15 days and was discharged with the same medication, with a Neurology appointment because she maintained disorientation likely related to her dementia.
Conclusion: Posterior circulation strokes may be difficult to diagnose. Dizziness is a common complaint in the general population, mainly in the elderly, with many possible causes, which could lead to misdiagnosis of some posterior circulation stroke cases, despite this presentation being rare. Even when the first CT is not diagnostic, repeating the CT 24 hours later may help establish or exclude stroke as the cause for dizziness.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O3

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Stroke in a young woman: a case report - read full article

By: Maria Teresa Saavedra, Vera Felisberto, Cristina Saavedra, Tiago Silva, and Amadeu Duarte

Introduction: Carotid artery dissection (CAD), although relatively uncommon in the general population, is the most common single etiology of ischaemic stroke (IS) in young adults. The specific role of vascular risk factor profile in CAD is poorly understood and intriguing. 
Case Report: A 46 year-old woman presented with sudden onset of left hemiparesis. This followed an episode of frontal headache. Her medical history included being overweight, current smoking, combined oral contraceptive use, thyroiditis that lead to hypothyroidism medicated with levothyroxine 100 micrograms, mixed dyslipidaemia under lifestyle intervention and hypertension under study. Obstetric history: 1 pregnancy, 1 childbirth, uneventful. On physical examination, left dysmetria on finger-to-nose-test and pathologically brisk osteotendinous reflexes. Brain computed tomography imaging was normal. Brain magnetic resonance imaging (MRI) and MR angiography revealed IS in the territory of the right middle cerebral artery with ipsilateral carotid dissection. From the etiological study carried out, including an analytical study with immunology, serology and imaging, only the aforementioned conditions were detected. She initiated anti-aggregation and, subsequently, hypocoagulation with warfarin demonstrating good evolution. 
Conclusion: It is crucial to improve the understanding of the mechanisms of CAD, as it is a major cause of IS in young adults, in whom the impact of stroke can be truly dramatic. Although the link between environmental factors and CAD remains speculative, some precipitating events are associated with CAD such as tobacco use, hypertension and the oral contraceptive use. Hypercholesterolemia appears to have an inverse association, which may have implications for follow-up and secondary prevention.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O4

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Stroke in a dizzy patient – Case report - read full article

By: Margarida Vaz Pinto, Paula Ponte, and António Luz Pereira

Introduction: Dizziness is a nonspecific symptom, often disabling, common in primary health care. The terms vertigo and dizziness are often used indistinctly, but it is fundamental to differentiate vertigo, which has a vestibular cause (peripheral or central). Some studies suggest that stroke may account for 25% of acute dizziness without other neurological signs or symptoms. 
Case Report: A 51-year-old male, independent, married, living in Porto with his wife, worked as a general contractor. He had a prior history of hypertension, dyslipidaemia and past smoking. His usual medication was Perindopril/Indapamide 8/2.5 mg id and Simvastatin 20 mg id. He was admitted in the emergency department on 13/01/17 at about 9:20 pm for general malaise, dizziness, nausea and vomiting. He was diagnosed with a peripheral vertigo syndrome. Because of refractoriness to the medication, blood tests were performed and were normal. The next day, around 9:12 am, he had right conjugate eye deviation. His neurological exam revealed eye deviation, minor left facial paralysis, right hypoesthesia and slight dysarthria. No limb paresis or dysmetria was observed. Brain computed tomography (CT) revealed a right cortical-subcortical cerebellar hypodense area, corresponding to an already established ischaemic injury. The cerebral CT angiography revealed right vertebral artery occlusion. Additionally, a likely thrombus was identified at the origin of the basilar artery. 
Conclusion: Vertigo in an emergency department has specific epidemiological characteristics. The family physician must recognize the situations that motivate an immediate referral to an emergency department.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O5

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CADASIL – A case report - read full article

By: Joana Fernandes, Sara Évora, Ana Carina Sá, João Girão, and André Jordão

Introduction: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is the most prevalent monogenic small vessel disease, caused by a mutation in the NOTCH3 gene, situated in chromosome 19. The mutation is probably responsible for a disturbance in vascular mechanotransduction, reducing flow-induced vasodilatation and increasing vascular myogenic tone. In addition, deposition of granular osmiophilic material occurs in smooth muscle cells. With time these alterations will be responsible for several clinical aspects such as migraine with aura, subcortical ischemic events, encephalopathy and psychiatric disturbances, all of which will aggravate with aging. Life expectancy is shortened and only symptomatic treatment is available to these patients. 
Case Report: A 34 year-old female patient with migraine without aura and sensory deficit after transient ischemic attack (TIA) underwent vascular and genetic investigations after her mother was confirmed with CADASIL. The genetic test confirmed a c.752>A (p.Cys251Tyr) mutation of the NOTCH3 gene, confirming the diagnosis of CADASIL.
Conclusion: Diagnosis of CADASIL is confirmed by the finding of mutations in the NOTCH3 gene. Suspicion must be high upon the presence of family history of stroke, clinical manifestations suggestive of vascular disease and/or suggestive imaging. It is important to think about CADASIL as a differential diagnosis since it is a misdiagnosed disease where confirmation may be obtained long after the development of clinical manifestations. In this case report, the patient already had a pure sensory TIA as well as migraine without aura diagnosed years before she was sent to genetic counselling, where CADASIL was confirmed. 

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O6

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When the headache is not the symptom – A clinical case - read full article

By: Ana Cunha, Ana Lima, Rita Oliveira, and Karla Marín

Introduction: Stroke is a common cause of death in Portugal. The most frequent symptoms such as intense headache, hemiparesis, dysarthria and visual disturbances are not always present, depending on the affected cerebral area. 
Case Report: Male, 79 years old, with atrial fibrillation and dyslipidaemia medicated with Pravastatin/Fenofibrate 40 mg/160 mg and Rivaroxaban 15 mg. He was admitted in the Emergency Room (ER) with vertigo and bilious vomiting with one-day duration. Physical examination showed no motor or sensory deficits, no dysarthria and the patient was haemodynamically stable, conscious, oriented and cooperative. Blood tests were all normal and computed tomography (CT) scans revealed absence of acute ischaemic or haemorrhagic lesions. He was examined by an otorhinolaryngologist who ruled out acute peripheral vestibular disorder. The patient remained very symptomatic and without improvement, so he was hospitalized and brain magnetic resonance imaging (MRI) was performed, revealing cerebellar ischemic stroke. He was hospitalized for 9 days with therapeutic optimization and physiotherapy and was discharged with physical therapy and a neurologist’s appointment. 
Conclusion: In cases of acute vertigo, within its numerous peripheral and central causes, we must include cerebellar infarcts as differential diagnosis. The otorhinolaryngologists may not recognize cerebellar infarction as causal agent of acute vertigo. Large infarcts are easily diagnosed, with vertiginous symptoms obscured by obvious neurological signs (cerebellar ataxia, dysarthria). The small cerebellar infarcts may present only as peripheral-pattern vestibular dysfunction, generally without cochlear symptoms, being diagnosed by CT and/or MRI. It is important to raise professional awareness of other forms of presentation for early diagnosis and intervention.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O7

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Basilar artery stenosis stroke treated conventionally: a case report - read full article

By: Marta Valentim, Ana Gameiro, José Ramalho, and Sónia Almeida

Introduction: Atherosclerotic stenosis of the Basilar artery (BAS) is a rare cause of posterior circulation stroke. The treatment described includes: intra-arterial/intravenous thrombolysis, thrombectomy or conservative treatment. 
Clinical Report: A 56-year-old man with history of hypertension and chronic kidney disease had two recent admissions (1 month apart). The first was due to a hypertensive crisis and the second due to a right temporo-parietal stroke without sequelae. He was admitted with blood pressure of 125/72 mmHg, dysarthria, right-beating nystagmus, left-sided hemiparesis (grade 4/5), dysmetria and wide-based gait (NIHSS 8) of unknown onset. Cranial computed tomography at admission and after 24 hours did not show acute alterations. The study revealed: haemoglobin 10.4g/dL, creatinine 3.8 mg/dL, urea 171 mg/dL, cholesterol 242 mg/dL, HDL 26 mg/dL, LDL 157 mg/dL, triglycerides 225 mg/dL, homocysteine 18.5 µmol/L; thrombophilia, coagulation and autoimmunity studies were negative. Echocardiogram showed diastolic dysfunction. Carotid ultrasound revealed extensive bilateral carotid atheromatosis, occlusion of the right internal carotid artery and stenosis (50-69%) of the left one. Brain magnetic resonance with angiography showed acute ischaemic vascular injury of the mesencephalon, pons and right cerebellum, associated with stenosis of the entire basilar artery. The patient received conservative treatment with clopidogrel and enoxaparin, with partial recovery of the deficits (NIHSS 4). 
Conclusion: The follow-up of patients with cardiovascular risk factors and symptomatic basilar stenosis requires an early action in order to avoid a catastrophe derived from ischaemic stroke. Improved therapy for BAS-related stroke is required. Endovascular treatment is probably the best option; however, most hospitals are not equipped and therefore, other treatment protocols should be considered.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O8

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Strange Percheron - read full article

By: Filipa Ribeiro Lucas, Ana Teresa Boquinhas, Liliana Olim, and Fernando Pita

Introduction: Artery of Percheron’s occlusion is unusual and causes bilateral thalamic infarctions. A single branch of the posterior cerebral artery, commonly known as the artery of Percheron, irrigates both paramedian thalamic regions and can be occluded by embolic events. 
Case Report: An 88-year-old hypertensive and dyslipidaemic woman, with sudden loss of consciousness, was admitted to our emergency department 2 hours after symptom onset. Her daughter found her collapsed on a coffee shop. She had no previous history of substance abuse, head injury, trauma or seizure activity.
The physical examination after the admission revealed right-sided weakness, right hemihypostesia and dysarthria. The tendon reflexes were less brisk on her right side. The Glasgow Coma Scale value was 7/15 and the National Institutes of Health Stroke Scale score was 15. The brain computed tomography (CT) scan after the first hour of admission disclosed no ischaemic changes. The routine blood results showed high inflammatory parameters.
However, on the second day after admission, her level of consciousness was fluctuating and the patient displayed left facial droop, left homonymous hemianopsia and left hemihypostesia. Afterwards, a repeated brain CT scan showed a deep bilateral thalamic lesion that suggested ischemic stroke of Percheron artery territory. Deep thalamo-capsular and left-hemispheric ischaemic lesions were also found. The final diagnosis was bilateral ischaemic thalamic stroke with unpaired symptoms, like fluctuating weakness and level of consciousness.
Conclusion: Embolic occlusion of the Artery of Percheron can be the cause of the patient’s loss of consciousness and must be one of the differential diagnosis conducted by an interdisciplinary team. 

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O9

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About a case of stroke in a young patient - read full article

By: Mariana Carvalho, Sara Santos, and Vanda Pereira

Introduction: Stroke is one of the leading causes of death and disability in Portugal. It is more frequent in individuals aged 50 or more, particularly in men. Stroke can be prevented through the control of modifiable risk factors such as diet, alcohol abuse and smoking. 
Case Report: We present a case of a female Caucasian 48- year old married patient. She had Wolff-Parkinson-White syndrome, diagnosed at age 17 (with multiple unsuccessful attempts of treatment through ablation), uterine myoma, urinary incontinence, post-appendectomy status (surgery in 2006) and was a smoker (10 pack-years). Chronic medication: atenolol. She had no family history of cardiovascular disease. The patient was able to perform her activities of daily living independently until October 2016 when she presented with syncope followed by left homonymous hemianopia, dysarthria and left hemiparesis, caused by right middle cerebral artery and internal carotid artery occlusion. After being discharged from the hospital, the patient maintained the neurological deficits requiring a rehabilitation program. At this moment, the patient is following this rehabilitation program, which involves physiotherapy, occupational therapy, speech and language therapy, under the orientation of several medical specialties, namely, physical medicine and rehabilitation, neurology and psychology. 
Conclusion: Stroke has high social and economic costs, with negative effects in the patient and their family. Therefore, its prevention through the control of risk factors is essential.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O10

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Cerebrovascular accident in paediatric patients – Case report - read full article

By: Patrícia Sousa and Diana Pinto

Introduction: Stroke is one of the ten major causes of death among children and adolescents under 18. Several risk factors were established including cardiac disease, metabolic and haematological diseases, and trauma. The diagnosis of stroke poses a challenge in medical practice, not only because of the existence of multiple differential diagnosis, but also because of their prevalence. The prognosis of childhood stroke is better than the one found in adulthood, despite having a huge health and socio-economic impact in the lives of patients and their families.
Case Report: A 17-year-old female, without any relevant medical history or family disease, seeks medical attention because of an intense occipital headache, with a sudden onset and without any other red flags. Physical examination and brain computed tomography (CT) were normal. Before subsequent medical evaluation, the patient was admitted to the emergency room with progressive right hemiparesis and aphasia. New brain CT showed an extensive intraparenchymal haemorrhagic lesion with tetraventricular leakage. The patient later underwent surgical drainage. The clinical investigation revealed an arteriovenous malformation and mitral valve endocarditis. The surgical treatment was done using a biologic valvular prosthesis. Today, the patient has a residual right hemiparesis, stable hydrocephalus and a neuropsychiatric syndrome.
Conclusion: Healthcare providers must be trained in early diagnosis of paediatric cerebrovascular accidents and in identification and prevention of known risk factors. This is an essential first step in minimizing the impact of this disease. 

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O11

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Is acute-onset stuttering a focal neurologic sign? - read full article

By: Jeniffer Jesus, Andreia Carvalho, Manuel Ribeiro, Miguel Veloso, and Pedro Barros

Introduction: Stuttering has been defined as speech dysfluency characterized by involuntary repetitions and prolongations in syllables and words sounds. Acquired stuttering can have a neurogenic etiology, usually following dominant hemisphere stroke. 
Case Report: A 55-year-old right-handed woman, with history of multiple cardiovascular risk factors and target-organ damage – bilateral atherosclerotic carotid disease, symptomatic on the right, for which she was submitted to endarterectomy six years before and three-vessel coronary artery disease treated by percutaneous coronary intervention three years earlier – presented to the emergency department for acute-onset speech disorder at wake-up. On admission she presented stuttering, with preserved naming/repetition/comprehension, and a previously known left claw hand, possibly secondary to post-traumatic ulnar neuropathy (NIHSS 1). Cranial computed tomography (CT) showed non-recent ischaemia in cortico-subcortical right fronto-parietal region, without acute ischaemic signs; angio-CT displayed occlusion of left common carotid artery with patency of ipsilateral internal carotid artery (ICA) and right ICA stenosis >80%. She received an antiplatelet loading dose and was admitted to our stroke unit. Brain magnetic resonance imaging revealed the non-recent infarction in the right anterior/middle cerebral artery watershed area, surrounded by foci of acute ischaemia with restriction to water diffusion. A symptomatic right ICA re-stenosis was assumed; she started double antiplatelet therapy and was submitted to carotid angioplasty with stunting. 
Conclusion: Acquired neurogenic stuttering is more often reported after dominant hemisphere and subcortical lesions, rather than in cortical speech and motor regions. However, this case shows that acquired stuttering may result from non-dominant cortical infarction. Thus, we cannot consider stuttering a focal neurological sign.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O12

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The curious case of a woman with multiple dissecting aneurysms - read full article

By: José Poupino and Catarina Fonseca

Introduction: Arterial dissections result from primary or secondary lacerations of the arterial wall due to a mural hematoma. The CADISP (Cervical Artery Dissections and Ischaemic Stroke Patients) study showed that spontaneous dissections can be frequently multiple. 
Case Report: A 52-year-old woman was admitted to the Emergency Department with sudden onset of headache, nausea and vomiting. There was no history of trauma. Brain computed tomography (CT) showed acute ischaemic stroke in the posterior inferior cerebellar artery (PICA) territory and a subarachnoid haemorrhage in the basal cisterns and inter-hemispheric cleft. Brain Angiography detected signs of chronic dissection of the right internal carotid artery and a small dissecting aneurysm of the proximal right PICA. During a therapeutic angiography, a new dissection of the right vertebral artery (VA) was found. Therapeutic angiography was rescheduled. It revealed almost total resolution of the dissection of the right VA, and right PICA fusiform aneurysm with more regular calibre. It was decided not to perform endovascular treatment and control with brain and cervical CT angiography in 2 months. No evidence of vasculopathy was found. Three weeks later, the patient was discharged without neurological deficits and without event recurrence. 
Conclusions: Spontaneous dissections can sometimes present with multiple dissections in the absence of a vasculopathy. These dissections may occur without an explicit event in the past, indicating vascular fragility, and have a spontaneous recovery.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O13

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Cerebral amyloid angiopathy presenting as recurrent superficial siderosis - read full article

By: Ângela Abreu, Lia Leitão, Daniela Garcez, Elsa Parreira, Amélia Nogueira Pinto, and Sara Machado

Introduction: Cerebral amyloid angiopathy (CAA) is characterized by the deposition of ?-amyloid in cortical and leptomeningeal vessels where intracerebral macro and microhaemorrhages are the most frequent presentations. Recently, superficial siderosis (SS) emerged as a possible manifestation of CAA. The association of CAA with Alzheimer’s disease (AD) has also been increasingly recognised. 
Case Report: We report a case of a 67-year-old woman with a previous hospitalization in 2013 due to cerebral lenticulo-caudate haemorrhage. Both cerebral magnetic resonance imaging (MRI) and MR-angiography were unremarkable. In September 2016, she presented with sensory deficits, diagnosed as subarachnoid haemorrhage (SAH) and later discharged without neurological deficits. In March 2017, she returned to the emergency department with dizziness and persistent vomiting. Once again, the brain computed tomography revealed SAH. Brain and spinal cord MRI revealed deposition of hemosiderin in cerebellar and hemispheric sulci. Conventional cerebral angiography excluded aneurysmal malformation and Pittsburgh compound B positron emission tomography showed a moderate increase of B-amyloid deposition. Cerebrospinal fluid evaluation identified a decrease of B-amyloid and an increase of both Tau and phospho-Tau levels. The neuropsychological assessment emphasized a marked defect of the interfered, immediate, semantic and visual verbal memories with moderate impairment of associative verbal memory and a low verbal initiative. A diagnosis of cerebral amyloid angiopathy was proposed. 
Conclusion: Our patient presented with an lenticulo-caudate haemorrhage and recurrent SS associated with cognitive impairment due to CAA. With this case, we aim to demonstrate that SS can be an important indicator of CAA and subsequent cognitive impairment due to AD.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O14

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The role of vessel wall imaging: a new diagnostic imaging approach? - read full article

By: Carolina Soares, João Pedro Filipe, Daniela Ferro, Adilson Marcolino, and Pedro Abreu

Introduction: Primary angiitis of the central nervous system (PACNS) is an uncommon disorder of unknown cause but, nonetheless, an important diagnosis since immunosuppressive treatment timing sets the prognosis. Despite new advances in magnetic resonance imaging (MRI), brain biopsy remains the only definitive diagnostic procedure. 
Case Report: A 63-year-old man with diabetes, hypertension and obesity presented with sudden onset of speech impairment. Neurological examination revealed a minor right central facial palsy and dysarthria. Computed tomography depicted frontal lobe leukoencephalopathy. Transcranial doppler ultrasound identified increased cerebral blood flow velocity in multiple intracranial artery segments: middle cerebral arteries (MCA) and right anterior (ACA) and posterior cerebral (PCA) arteries. MRI demonstrated multiple small T2-hyperintense foci in the fronto-parietal white-matter, showing restricted diffusion. Additionally, stenoses of both posterior communicant arteries and in segments of the MCA and ACA were found. Finally, intracranial vessel wall MRI (VWMRI) was performed, showing two eccentric stenoses of both A2 segments, suggestive of atheromatosis, and uniform concentric contrast-enhancement in MCA and PCA, whose distribution would favour vasculitis although vessel obliquity affects an accurate evaluation. Other autoimmune diseases were excluded and cerebrospinal fluid examination was unremarkable. Due to these overlapping findings, a thorough vigilance will be done and brain biopsy may be considered. 
Conclusion: VWMRI may help in the diagnosis of PACNS, as shown by this clinical case. Nevertheless, this technique still has equivocal and overlapping findings. We hope that in the future this imaging method may allow a better non-invasive study of intracranial artery disease aetiology.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O15

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Cerebral vasculitis and pulmonary tuberculosis - read full article

By: Joana Ferreira, Tiago Seco, Maria João Tavares, Margarida Rocha, and Jorge Cotter

Introduction: Autoimmune diseases can affect any organ or system in the body. Systemic lupus erythematosus (SLE) is a multisystem autoimmune chronic inflammatory disease. Infectious intercurrences are a challenge in these SLE patients and should be closely monitored. 
Case Report: We present a male patient, 35 years old, with a history of SLE, lupus nephritis and arterial hypertension. He was admitted to the Emergency Department with right hemiparesis with one hour and a half of evolution. He was hospitalized with an ischaemic stroke. He had a carotid ultrasound with a stenosis of approximately 50-60% in the left internal carotid artery and brain magnetic resonance imaging with evidence of acute ischaemic lesions, sequelae of old infarcts and vasculitis phenomena. In view of the existence of cerebral vasculitis, and in order to initiate therapy with cyclophosphamide, the patient performed the screening of infectious complications. Chest computed tomography revealed peribronchovascular infiltrate with areas of necrosis and cavitation with hydroaeric levels, favouring the diagnosis of pulmonary tuberculosis. Collected bacilloscopy showed evidence of multiple alcohol-acid resistant bacilli. Therapy with isoniazid, rifampicin, pyrazinamide and ethambutol was instituted. Mycobacterium tuberculosis was identified in sputum samples. We performed a lumbar puncture to exclude central nervous system infection which was unremarkable. The patient remained asymptomatic, nonfebrile and had a good clinical evolution, with total recovery of motor deficits.
Conclusion: Early diagnosis and appropriate treatment are mandatory in situations in which SLE is associated with pulmonary tuberculosis, especially in areas endemic to this disease.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O16

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Reversible cerebral vasoconstriction syndrome and primary angiitis of the central nervous system – the differential diagnosis challenge - read full article

By: Gisela Henriques Leandro, João Pedro Filipe, Pedro Marques, Daniela Ferro, Carolina Soares, Adilson Marcolino, and Pedro Abreu

Introduction: Primary angiitis of the central nervous system (PACNS) and reversible cerebral vasoconstriction syndrome (RCVS) are two possible etiologies in cases of cerebral arteriopathies. In spite of their contrasting prognosis and treatment, these two entities are not always easy to distinguish. We present a challenging clinical case, which illustrates the difficulty encountered in differentiating them.
Case Report: A 65-year-old woman was admitted with sudden onset of numbness of the left face and upper limb and dysarthria. Cerebral computed tomography-angiography showed discrete subarachnoid haemorrhage in central and postcentral sulcus, no aneurysms or vascular malformations were depicted. A cerebral magnetic resonance-angiography (MRA) (with venogram) performed later showed two small ischemic foci in the right fronto-insular territory, a subtle focal narrowing of the right adjacent M2 branch and hematic deposition in the right perisylvian sulci. Transcranial-doppler ultrasonography displayed increased left middle cerebral artery cerebral blood flow velocity, compatible with minor luminal stenosis (30%). She was discharged without focal neurologic symptoms, with the diagnosis of possible RCVS. Three months later, the patient was readmitted due to aphasia and right central facial palsy. Brain MRA showed new left anterior insular and left frontal subcortical ischemic lesions and rarefaction of the left middle cerebral artery vascular tree, raising the hypothesis of PACNS. Transthoracic echocardiogram, 24h-Holter monitoring and cerebrospinal fluid study were unremarkable. She is still waiting the result of cerebral angiography.
Conclusion: This patient has several features that make the differential diagnosis between PACNS and RCVS difficult. In order to avoid other unnecessary diagnostic tests and to institute a correct therapy, we hope that the result of other ancillary exams, such as cerebral angiography, may help to distinguish them. 

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O17

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The puzzling case of proptosis worsening after a cerebral angiography - read full article

By: Isabel Taveira, Daniela Ferro, João Pedro Filipe, Rita Figueiredo, Maria Luís Silva, João Tavares Ferreira, and Marta Carvalho

Introduction: Although carotid-cavernous fistula (CCF) and cavernous sinus thrombosis may have clinical similarities, their management is totally different. 
Case Report: A 66-year-old male was admitted for a control angiography nine months after embolization of a left post-traumatic direct CCF secondary to gun shot, with consequent moderate left proptosis. The angiography showed partial closure of the CCF and patency of the left cavernous sinus. The patient vomited before and after the procedure, without apparent cause. On the following day, the proptosis was much more conspicuous and was accompanied by hyperaemia and raised intraocular pressure (up to 54 mmHg in the 4th day). There was no bruit over the left orbit. Cerebral angiography was repeated and there was evidence of complete left cavernous sinus thrombosis. The remaining CCF was unchanged. Anticoagulation was started with clinical improvement. The patient was discharged 11 days after starting anticoagulation, with controlled intraocular pressure and only moderate proptosis and chemises. 
Conclusion: This case posed several diagnostic and management challenges. The acute worsening of the proptosis and chemosis after angiography raised the suspicion of re-opening of the direct CCF, although the underlying mechanism would be difficult to explain. The absence of bruit argued against this diagnosis. We hypothesized that the hyperviscosity of blood following contrast administration, as well as some dehydration related to vomiting might have facilitated the left cavernous sinus thrombosis together with the haemodynamic changes related to the CCF. We stress the importance of a multidisciplinary team approach to these rare and not straightforward cases.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O18

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To treat or not to treat? – The aneurysmatic question - read full article

By: Daniela Ferro, João Pedro Filipe, Ana Luísa Rocha, Gisela Leandro, Tiago Parreira, Maria Luís Silva, Maria Goreti Moreira, and Pedro Abreu

Introduction: Basilar artery perforator aneurysms are an extremely rare type of brain aneurysms. Current treatment options are based on a conservative approach and surgical or endovascular treatment, although it is not well defined which option applies best to each patient. Case Report: We present two cases of subarachnoid haemorrhage (SAH) originating from small basilar artery perforator aneurysms. Two male patients, 66 (patient A) and 57 (patient B) years old, were admitted in the emergency room with severe headache after a Valsalva manoeuvre. Computed tomography scans revealed the presence of SAH, mainly in the territory of the posterior circulation. Initial angiography showed no evidence of aneurysms or other vascular malformations. Angiography with posterior circulation 3D acquisition was repeated, 2 to 3 weeks post-SAH, and the presence of a small saccular aneurysm (1mm) was noted in the ventral surface of the basilar artery in both patients. After multidisciplinary decision, an expectant attitude with careful monitoring was adopted in both patients. Patient A was discharged and angiographic control showed spontaneous thrombosis of the aneurysm. Patient B will soon be re-evaluated with a new angiography. Both patients remain stable. Conclusion: Due to the rarity of these types of lesions there is still no consensus regarding the ideal treatment option. As in other cases described in the literature, the aneurysm naturally resolved in one of the patients: should we consider this to be the natural course of the disease or might it be just a joyful coincidence?

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 20–21 June 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):O19

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