IJCNMH ARCpublishing
ADVANCED SEARCH


Thumb_issue_cover._2018.5.sp2

Issue 5 (2018) – Supplement 2


Special Issue on Stroke 

This supplemental issue comprises the abstracts and proceedings from the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018. 

Guest editors: 
Luís Braz
Ricardo Soares-dos-Reis
Marta Carvalho
Elsa Azevedo

Issue Nr:

5

|    Issue date: 2018-06-25

Lecture


Arterial hypertension control - read full article

By: Jorge Polónia

his talk will be based on a summary of the recently 2018 ESC-ESH Guidelines for the Management of Arterial Hypertension (Williams B & Mancia G, J Hypertension & Eur Heart Journal, 2018 in press) presented in Barcelona in June 2018. The main new concepts / recommendations can be summarized as: It is recommended to stimulate blood pressure (BP) measurement outside the Office (with Home BP and /or ambulatory BP monitoring) to confirm the diagnosis of hypertension, detect white coat and masked hypertension and monitor BP control. It is recommended to have a more aggressive approach regarding BP therapeutic targets even in the elderly and in patients with normal-high BP and very high risk. For most patients, the target will be 120-130/70-80 mmHg providing good tolerance. It is recommended to stimulate strategies to improve adherence to treatment. In the majority of the patients, treatment should start with combination of 2 drugs in a single pill to improve adherence. Start with simplified algorithms based on single pill combinations of Angiotensin Converting Enzyme Inhibitors or Angiotensin Receptor Blockers plus calcium antagonists or diuretics with beta-blockers used for specific indications. An increased importance is given to the role of nurses and pharmacists in the education, support, and follow-up of treated hypertensive patients. A strong emphasis is presented on the importance of evaluating treatment adherence as a major cause of poor BP control.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L1

Icon_pdf Download PDF

Lecture


Dyslipidaemia and stroke: how low should we go? - read full article

By: Guilherme Gama

My aim is to review the latest evidence on dyslipidaemia and stroke. Stroke is a heterogeneous disorder and so should be our prescription of antilipidaemic medication. In recent years, new pharmacological therapeutics were developed, making the statins paradigm look “old”. We think both worlds need not collide, albeit working together for a more adequate treatment of our “pathies”. It is, however, important to remember that we need new drugs for achieving cholesterol goals but we do not need new goals just because there are new drugs.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L2

Icon_pdf Download PDF

Lecture


Anterior Circulation Stroke Syndromes - read full article

By: Daniela Ferro

Acute cerebral ischaemic disease is one of the most frequently observed neurological conditions that physicians must face and is associated with high rates of mortality and morbidity. A stroke may occur whenever there is a lack of oxygen delivery to the neurons of a certain brain region, namely due to a stenotic atherosclerotic plaque or a migrating thrombus originated in the heart or in a proximal vessel, which travels to occlude a smaller artery. Strokes are typically classified based on their topography as affecting the anterior circulation (ACS), the vascular territory supplied by the carotid arteries, or the posterior circulation, the basilar artery territory. The internal carotid arteries supply the majority of both cerebral hemispheres even though the anterior and posterior circulations largely communicate at a vessel structure named circle of Willis. Ischaemic strokes occurring in the anterior circulation account for approximately 70% of the cases. ACS may be caused by occlusion of carotid, middle cerebral arteries, anterior cerebral arteries or one of their branches. The initial clues for revealing the affected vascular territory are given by the detailed clinical history and neurological examination. Patients typically present with sudden onset of focal neurological symptoms, including one or a combination of the following: contralateral hemiparesis and/or sensory loss, a visual field defect (hemianopia/quadrantanopia), forced gaze deviation towards the lesion site, aphasia (dominant hemisphere) and neglect syndrome (non-dominant hemisphere), depending on the stroke size and location. A transitory monocular loss of vision (amaurosis fugax) and a limb-shaking syndrome are usually an indicator of carotid disease. More extensive or bilateral strokes can result in a comatose state. In this session, the main signs and symptoms of strokes affecting the anterior/carotid circulation will be presented since the prompt recognition of these symptoms, both by the patients and physicians, allows the earlier institution of therapeutic strategies leading to better outcomes.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L3

Icon_pdf Download PDF

Lecture


Vertebrobasilar stroke - read full article

By: Vanessa Carvalho

The Vertebrobasilar (VB) vascular system comprises the vertebral, basilar and posterior cerebral arteries and their branches. It feeds the posterior region of the brain, including the brainstem, the thalamus, the cerebellum and areas of the occipital and temporal lobes, representing about 20% of the cerebral blood flow. It is estimated that 20 to 25% of all transient ischaemic attacks (TIA) and strokes occur in the VB vascular territory and the annual adjusted incidence of posterior circulation stroke was estimated as 18 per 100 000 person-years in an Australian study. VB stroke remains more difficult to recognize when compared to other stroke types. Due to the vast cerebral territory it supplies, VB ischaemia can present with a wide range of symptoms and signs, sometimes overlapping with carotid circulation stroke. Most common symptoms include dizziness, vertigo, double vision, ataxia, numbness and weakness. As for signs, the most commonly observed are limb weakness, oculomotor palsies, ataxia and oropharyngeal impairment. However, rather than an isolated symptom, VB stroke classically presents as a cluster of signs and symptoms, reflecting the ischaemic area. Brain computed tomography (CT), usually performed as an initial imaging modality, has a suboptimal visualization of the posterior fossa, making VB stroke an even more challenging diagnosis to the attending physician. Hence, awareness of the posterior fossa anatomy and of the classical VB ischaemia presentations might facilitate early recognition of this disorder, preventing death and disability in these patients. Our aim is to make a comprehensive review of the anatomy, clinical presentation and aetiology of VB stroke.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L4

Icon_pdf Download PDF

Lecture


Clinical stroke syndromes: how to recognize and classify lacunar syndromes - read full article

By: Eduardo Freitas

Lacunar syndromes are usually caused by small, noncortical ischaemic strokes resulting from the occlusion of a single penetrating branch of a large cerebral artery (circle of Willis, middle cerebral artery or the basilar artery) and mostly are localized in the basal ganglia, subcortical white matter and pons. It is estimated that lacunar strokes are responsible for 15-26% of first-ever strokes. There are several proposed aetiological mechanisms, but the two major causes are lipohyalinosis of the penetrating arteries and microatheroma of the origin of the penetrating arteries. They are associated with hypertension, diabetes mellitus and cigarette smoking, among others. Lacunar syndromes usually present with symptoms developing over a short period of time but can also fluctuate for several hours with posterior clinical worsening. There are six validated clinical lacunar syndromes: pure motor hemiparesis, pure sensory stroke, ataxic hemiparesis, sensorimotor stroke, dysarthria-clumsy hand syndrome and hemiballismus/hemichorea, with lesions in different brain regions. These syndromes are characterized by the absence of “cortical” stroke signs. Brain imaging has several limitations in the acute phase and early clinical recognition of this syndrome is essential for a proper approach.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L5

Icon_pdf Download PDF

Lecture


Oxfordshire Community Stroke Project Classification - read full article

By: Denis Gabriel

Aiming to group ischaemic stroke patients into practical subgroups, Bamford et al described, in 1991, four clinically identifiable subgroups of ischaemic stroke in a community-based study of 675 patients with first-ever stroke (Oxfordshire Community Stroke Project Classification of Stroke, OCSP): total anterior circulation infarcts (TACI), partial anterior circulation infarcts (PACI), posterior circulation infarcts (POCI) and lacunar infarcts (LACI). While relying exclusively on neurological exam findings, using OCSP classification accurately predicted the CT or MRI infarct appearance in relation to the clinical syndrome in about three-quarters of patients and showed good interobserver agreement. The frequency of deterioration also differed significantly among the OCSP subgroups, adding useful information about individual patient prognosis and hints on the aetiology of the cerebral infarct. These practical advantages enabled clinicians (especially those working in resource-constrained hospitals) not only to accurately estimate location and volume of ischaemia but also to guide treatment decisions and to assist in aetiology investigation and assessment of recurrence risk helping, in this way, to establish prognosis in a timely manner. With almost 30 years of existence, OCSP classification remains solid. It is suitable for use by all clinicians in the emergency room setting and a useful tool to stratify patients in the hyperacute phase, when CT will almost always be normal.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L6

Icon_pdf Download PDF

Lecture


Neuroimaging in acute ischaemic stroke - read full article

By: Marta Gomes Rodrigues

Imaging studies are essential in the setting of an acute stroke. They need to be targeted towards the assessment of the four Ps described by Rowley – Parenchyma, Pipes, Perfusion and Penumbra. This systematic approach enables the detection of intracranial haemorrhage, differentiation of infarcted tissue from salvageable tissue, identification of an intravascular thrombus and accurate selection of patients for the appropriate treatment. Selection for treatment, be it mechanical thrombectomy and/or intravenous thrombolysis, should be done based on three different factors taken together, i.e. neurological evaluation (NIHSS), the local of vessel occlusion and the infarct core (Fig. 1). Both Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) can be used to distinguish between brain tissue that is irreversibly infarcted and that which is potentially salvageable. In current practice, MRI is not always available, ergo CT (with CT Angiography) is the most effective, widespread available technique in the emergency context. According to the latest American Guidelines (2018), CT provides the necessary information to make decisions about acute management of patients with acute strokes. Imaging of the extracranial carotid and vertebral arteries, in addition to the intracranial circulation, is also recommended to provide information on patient eligibility for treatment and for endovascular procedural planning. Additional imaging beyond CT and CT Angiography, such as perfusion studies, for selecting patients for mechanical thrombectomy in the 6-hour window from symptom onset is not recommended. With the publication of the randomized trials DAWN and DEFUSE 3, the extension of the treatment window beyond 6 hours has been widely accepted. Based on these trials, current guidelines for imaging in patients presenting after the 6-hour window from symptom onset or with wake-up stokes are more restrictive, with recommendations for the use of perfusion studies to help in the decision-making process. In general, imaging techniques have advanced rapidly in the past decade and currently they must be used to identify and select patients that benefit from reperfusion therapies in the acute phase. Fast and effective imaging techniques are needed for a quicker diagnosis and early treatment planning.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L7

Icon_pdf Download PDF

Lecture


Neuroprotection in acute ischaemic stroke: beyond revascularization - read full article

By: Pedro Barros

The past few years have seen radical changes in stroke treatment, particularly, and above all, the development of mechanical thrombectomy as standard of care in selected patients. However, in addition to patients with contraindications to acute reperfusion therapies in acute ischaemic stroke, an important percentage of patients undergoing this type of treatment (including some patients in whom effective recanalization is achieved) do not regain functional independence; hence there is a clear need for the development of new therapies that can respond to these subgroups of patients. By definition, neuroprotection is any action that result in salvage, recovery or regeneration of the nervous system, its cells, structure and/or function. In acute ischaemic stroke, a complex, coordinated, and interrelated cascade of molecular events follows brain ischaemia and infarction. The concept of neuroprotective agents in acute ischaemic stroke has been a focus of attention over past decades, with many experimental neuroprotective compounds being tested both preclinically and in humans. Over 1000 neuroprotective agents have been studied in preclinical stroke research, many with promising results. However, translation of these neuroprotective drugs has failed in the clinical setting. Can neuroprotection be the next revolutionary step in stroke therapy? It is possible and even likely but at present, no pharmacological or non-pharmacological treatment with putative neuroprotective actions have demonstrated efficacy in improving outcomes after ischaemic stroke, and therefore, no neuroprotective agent can be recommended at this point. Thus, this presentation will focus on a set of "simple" and easy to apply measures (in any stroke unit), and whose implementation is clearly associated with an improved prognosis of patients with acute stroke, namely: blood pressure control, correction of hyperglycaemia, optimal oxygen pressure, correction of hyperthermia and patient positioning.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L8

Icon_pdf Download PDF

Lecture


Controversial indications for mechanical thrombectomy - read full article

By: Ângelo Carneiro

After several positive randomized clinical trials (RCT), mechanical thrombectomy (MT) has become the standard of care for patients with acute (up to 24h) ischaemic stroke caused by large vessel occlusion of the anterior circulation, with a tremendous impact on clinical outcome and an impressively low number needed to treat. However, guidelines emanating from the clinical trials advocate MT just for adult patients with important clinical deficits (NIHSS ?6), small ischaemic core (ASPECTS ?6) and either internal carotid artery or middle cerebral artery (M1 segment) occlusions. As such, for the time being, there are still many patients who do not fit these criteria but who could potentially benefit from MT. These include cases of minor symptoms (but with large vessel occlusion), large ischaemic core or distal occlusions (M2, A1). Moreover, the role of MT in posterior circulation strokes or in paediatric patients remains unproven. Some of these uncertainties will presumably be solved by ongoing RCTs. While strong evidence (pro or con) is lacking, individual treatment decisions for each case should be taken by a multidisciplinary team, taking into account the presumed natural history of the disease and the presumed impact (risks and benefits) of the treatment.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L9

Icon_pdf Download PDF

Lecture


Workshop 1: Neurological Emergencies - read full article

By: Daniela Ferro, Ana Aires, Carolina Soares, and Marta Carvalho

In the last years, the role of the Neurologist in the Emergency Department (ED) has been increasingly important. With the development of new diagnostic and therapeutic tools, neurological intervention is essential to define and implement patient management, improving the quality of medical care and reducing futile costs. This workshop will address the most common neurological complaints in the ED. Acute stroke will be addressed in detail, focusing on practical issues of management and most recent advances in reperfusion therapies and stroke care pathway. Likewise, we will discuss headaches, one of the most common symptoms for which patients seek medical attention. We will review the main aetiologies, diagnostic evaluation as well as the management of pain in this setting. Special focus will be made in the differentiation of primary and secondary headaches, highlighting the signs that should alert physicians to proceed investigation. We will address the emergent management of a patient with an epileptic seizure, as well as the basic study that should be performed in the ED. The differential diagnosis will be discussed, as well as the different aetiologies and therapeutic decisions, paying particular attention to the differences between acute symptomatic seizures and recurrent seizures in patients with previously diagnosed epilepsy. Status epilepticus’ protocol will be presented. We will then review delirium, a frequent presentation of elderly patients in ED, exploring its main aetiologies which may be uncovered by a guided history, physical and neurological examination. Recognition of precipitating factors and the management of these patients, as well as of comatose patients in the ED will be discussed. We will then address the approach to patients with acute vestibular syndromes, based on detailed history-taking and HINTS - a combination of manoeuvres that help to differentiate peripheral and central causes of vertigo. Acute neurological deficits of other causes such as those caused by acute neuropathies, neuromuscular junction dysfunction, spinal cord lesions or toxic-metabolic insults will be discussed at the end of the workshop.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L10

Icon_pdf Download PDF

Lecture


Patent foramen ovale closure after cryptogenic stroke: proposal for a new protocol - read full article

By: Carolina Lourenço Soares

Almost one-third of ischaemic strokes has an unknown aetiology and are classified as cryptogenic. Paradoxical embolism due to a patent foramen ovale (PFO) is detected in 40%–50% of these patients and PFO has been reported as a risk factor for patients of all age groups. A common challenge in clinical practice is to distinguish between incidental and pathogenic PFO. The best therapeutic option to reduce stroke recurrence after a cryptogenic stroke with PFO has been a matter of debate for a long time. In contrast to previous randomized trials of transcatheter PFO closure, three recent randomized open-label trials — Gore REDUCE (Gore HELEX Septal Occluder and Antiplatelet Medical Management for Reduction of Recurrent Stroke or Imaging Confirmed TIA in Patients with PFO), CLOSE (PFO Closure or Anticoagulants versus Antiplatelet Therapy to Prevent Stroke Recurrence) and RESPECT (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment) – showed that the risk of stroke was lower with PFO closure compared to medical therapy alone and an updated meta-analysis favours PFO closure over medical treatment after cryptogenic stroke/TIA for the prevention of stroke recurrence. In this session, we will discuss which patient subgroups should be considered for PFO device closure based on results from new studies, creating the basis for a new protocol on how to approach patients with cryptogenic stroke and PFO.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L11

Icon_pdf Download PDF

Lecture


Long-term electrocardiographic monitoring in embolic stroke of undetermined source - read full article

By: Paulo Chaves

Between 15-40% of all ischaemic strokes are of undetermined etiology. The term “cryptogenic stroke” has been extensively used in the literature to describe this subtype of stroke. However, this does not take into account the extent and quality of the investigation performed or the classification system used. In 2014, the term embolic stroke of undetermined source (ESUS) was coined by the CS/ESUS international working group [1]. This allows a more comprehensive investigation and exclusion of presumed non-embolic stroke mechanisms during evaluation. In a systematic literature review to assess the frequency of ESUS, patient features, and prognosis using PubMed from 2014 to present, on the basis of 9 studies, the reported frequency of ESUS ranged from 9% to 25% of ischaemic strokes, averaging 17% [2]. From 8 studies involving 2045 ESUS patients, the mean age was 65 years and 42% were women; the mean NIH stroke scale score was 5 at stroke onset (4 studies, 1772 ESUS patients). Most (86%) ESUS patients were treated with antiplatelet therapy during follow-up, with the annualized recurrent stroke rate averaging 4.5% per year during a mean follow-up of 2.7 years (5 studies, 1605 ESUS patients). There is an important need to better define antithrombotic prophylaxis for this frequently occurring subtype of ischaemic stroke, especially since the recent publication of the NAVIGATE-ESUS trial. In this study, rivaroxaban was not superior to aspirin with regard to the prevention of recurrent stroke after an initial embolic stroke of undetermined source and was associated with a higher risk of bleeding [3]. Frequently patients with ischaemic stroke do not undergo cardiac rhythm monitoring required for the diagnosis of ESUS. Additionally, the CRYSTAL-AF and the EMBRACE trials published in 2014 reported that episodes of previously unrecognized atrial fibrillation (AF) could be detected in 9% to 16% of patients with cryptogenic ischaemic stroke if the duration of cardiac monitoring was prolonged beyond 24 hours of Holter ECG monitoring [4, 5]. Atrial fibrillation after cryptogenic stroke was most often asymptomatic and paroxysmal and thus unlikely to be detected by strategies based on symptom-driven monitoring or intermittent short-term recordings. In these trials, prolonged ECG monitoring offered greater opportunities for the detection and treatment of one of the most common and important modifiable risk factors for recurrent stroke. The detection of AF after ischaemic stroke is relevant since stroke patients with undetected AF have a comparatively high risk of recurrence of ischaemic stroke if they remain untreated. Thus, the diagnosis of AF is important for secondary prevention of ischaemic stroke, even if the documentation of AF does not automatically imply a cardio-embolic cause of stroke. The detection of previously undiagnosed atrial fibrillation can be improved in patients with ischaemic stroke to optimize stroke prevention. Since the optimal duration and mode of ECG monitoring has not yet been finally established, there is an actual need to better identify patients that can, in a cost-effective strategy, be submitted to long term monitoring for AF detection in the ESUS population. Recently, the “Heart and Brain” consortium of the German Cardiac Society and the German Stroke Society emitted an expert opinion based recommendation regarding this subject [6]. In this statement, they propose a strategy combining an extended and high-quality ECG monitoring with patient selection based on clinical, laboratory, echocardiographic and electrographic parameters so that the likelihood of non-permanent AF detection, and thus the efficiency of ECG monitoring, can be improved.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L12

Icon_pdf Download PDF

Lecture


Syncope of unknown cause: when to think of stroke? - read full article

By: Carlos Andrade

Syncope is defined as transient loss of consciousness (TLOC) due to cerebral hypoperfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery. (1) The main pathophysiologic mechanisms are a low peripheral resistance or a low cardiac output [1]. They are not mutually exclusive. As a sudden event, other diagnosis of TLOC are important to consider namely epileptic seizures. Also, there are other events where patients appear to be unconscious, but they are not (such as in cataplexy or in a psychogenic seizure/syncope). Furthermore, the loss of consciousness may have a longer duration (metabolic disorders or intoxication) [2]. Syncope is also considered a stroke mimic (up to 15% of stroke mimic cases) [3]. Quite frequently, patients with syncope underwent a CT-Scan as their initial approach in emergency room. However, this is seldom abnormal (about 5%), except in presence of trauma, neurological deficits or complaints (mainly headache), or age greater than 60 years [4, 5]. This raises a question: how often is syncope caused by central phenomena, in particular, stroke? In the latter, loss of consciousness can only occur in vertebrobasilar events (involving thalami or brainstem) [6], is usually not transient, and is almost always accompanied by focal neurological deficits [1]. Syncope may not be “benign”. Orthostatic hypotension has been considered a risk factor for stroke, even after controlling for risk factors [7]. Focal deficits were observed in 5.7% of patients with syncope [8], and borderline infarctions where more prevalent in subjects reporting hypotensive symptoms at stroke onset [9]. It is particularly important to consider a significant arterial stenosis when neurological focal deficits develop [10]. However, even in these cases, syncope is usually considered the cause of (but is not caused by) cerebral hypoperfusion. In conclusion, syncope is very seldom caused by a stroke, and other etiologies should be pursued, even in the presence of focal deficits. Head imaging should be reserved for trauma patients or if focal neurological deficits are a concern.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L13

Icon_pdf Download PDF

Lecture


Lacunar stroke: what management particularities? - read full article

By: Ana Monteiro

Cerebral small vessel disease (CSVD) is the result of cumulative damage to the cerebral microcirculation, increased blood brain barrier permeability and chronic oligaemia. Lacunar stroke (LS), a type of CSVD, is responsible for about 25% of ischaemic strokes, but it is largely understudied. Far from a benign clinical entity, its consequences are numerous, including increased morbimortality and stroke recurrence, mild cognitive impairment and dementia, gait disturbances and mood disorders. It has several aetiologies, and hypertension is the most frequent culprit. Management includes many of the procedures used in other stroke subtypes, but specific treatment and monitoring strategies are urgently needed for patients with CSVD and LS. Current recommendations and future directions are discussed.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L14

Icon_pdf Download PDF

Lecture


Genetic causes of cerebral small vessel disease - read full article

By: Pedro Castro

Hereditary causes of cerebral small vessel disease (SVD) are rare but important to recognize in patients suffering from stroke or vascular dementia. These include various diseases with particular clinical and imaging features which are helpful in driving the clinician to a proper molecular diagnosis. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is characterized by migraine with aura, ischaemic cerebrovascular events, dementia and a conspicuous pattern of white matter changes. A second type has been described by a mutation in the gene HTRA1. The same gene is responsible for Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy (CARASIL), which presents concomitantly with lumbago and alopecia. More recently, Cathepsin-A-related arteriopathy with strokes and leukoencephalopathy (CARASAL) has been described. COL4A1/A2-related cerebral SVD causes cerebral lacunar infarcts as well as intracerebral haemorrhage. Autosomal dominant retinal vasculopathy with cerebral leukodystrophy is caused by a mutation in TREX1 and shows a more systemic involvement of kidney and retina. Familial forms of cerebral amyloid angiopathy present more frequently with lobar haemorrhage. Lastly, Fabry Disease is caused by mutation of the gene encoding alfa-galactosidase A and distinguishes itself from the other genetic SVD by the fact that it is X-linked. Common characteristics are painful acroparaesthesia, angiokeratomas, kidney failure and suggestive ophthalmological findings.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L15

Icon_pdf Download PDF

Lecture


Management of symptomatic and incidental brain aneurysms - read full article

By: Gonçalo Alves

Brain aneurysms represent a focal pathologic dilatation on the arterial wall of the cerebral vessels and affect 3 to 4% of the population worldwide. About 20 to 30% of those patients have multiple intracranial aneurysms. Saccular type accounts for 90% of them, with the most common locations being the anterior and posterior communicating arteries, internal carotid artery, the middle cerebral artery, and the basilar artery bifurcation. Some medical conditions like the autosomal dominant polycystic kidney disease, Ehlers-Danlos syndrome type IV, coarctation of the aorta and microcephalic osteodysplastic primordial dwarfism are associated with aneurysms and can demand diagnostic screening. Although most of them are incidentally discovered during workup, clinical findings such as headache, seizures and focal neurologic deficits can be present. It is of extreme importance to understand their natural history and the factors that can influence the rupture rates. Smoking and hypertension are modifiable risk factors associated with aneurysm rupture. Nevertheless, the good news is that the overall annual rate of aneurysm rupture is considered to be low. When dealing with a ruptured aneurysm, there is a well-defined approach, as the dreaded re-rupture demands a treatment intervention. The choice between endovascular or surgical treatment depends on several factors. Among the available literature, endovascular rescue seems to carry lower rates of morbidity and mortality in the follow up period and it is the treatment of choice for posterior circulation aneurysms. Aneurysm clipping is still the treatment of choice for MCA aneurysms. On the other hand, saccular unruptured brain aneurysms are increasingly detected but the best management strategy is still under debate. The PHASES score and UIATS scale represent two important tools for the decision. Finding the best available plan for each patient should consider his life expectancy, risk factors for rupture, and expertise of the endovascular/surgical teams. Previous subarachnoid haemorrhage, symptomatic aneurysms and aneurysm growth are listed as strong factors to support a preventive endovascular or surgical treatment. On the other hand, we should predict worse outcomes for older patients, posterior circulation location and large aneurysm size.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L16

Icon_pdf Download PDF

Lecture


Decision of neurosurgical intervention in intracerebral haemorrhage - read full article

By: António Vilarinho

Spontaneous intracerebral haemorrhage (ICH) is an important cause of morbidity and mortality. It has an early fatality rate, poor functional outcome and the role of surgery remains controversial. In the recent guidelines, there are few strong recommendations and most of decisions are based on observational studies and authors' experience. For that reason, there is great variability between neurosurgeons, departments and countries. It is agreed that the best treatment for these patients involves a multidisciplinary work with the coordination of stroke or intensive care units, with collaboration of neurosurgery departments in some patients. For most patients with supratentorial ICH, the usefulness of surgery is not well established, and most do not benefit from it. In which situations neurosurgery can and should act? We can subdivide ICH into several types of haemorrhage (supratentorial; infratentorial or intraventricular) that will be indicated for different neurosurgical treatments. Monitoring of intracranial pressure and cerebral perfusion pressure may be necessary, usually in patients with GCS score of ?8 that is presumed to be related to hematoma mass effect, with clinical evidence of transtentorial herniation, or with significant intraventricular haemorrhage (IVH) or hydrocephalus. CSF drainage may also be considered, in patients with CSF outflow obstruction caused by hydrocephalus or a trapped ventricle, and with decreased level of consciousness. Decompressive craniectomy, with or without drainage of haemorrhage is a possibility, in cases of deep haemorrhage with medically uncontrolled intracranial hypertension. It is agreed that cases of neurological deterioration with lobar haemorrhages less than 1 cm deep from the cortical surface, might benefit from craniotomy with haemorrhage drainage. Supratentorial haematoma evacuation in deteriorating patients might be considered as a life-saving measure. Although controversial, it is generally accepted that the surgery should be performed early when patients have a GCS between 9 and 12. Cerebellar haemorrhages who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the haemorrhage as soon as possible. Initial treatment of these patients with ventricular drainage rather than surgical evacuation is not recommended. GCS score less than 14, haemorrhage size greater than 30-40 mm, and haematoma volume not less than 7 cm3 are usually indications for surgery. Less invasive treatments, namely stereotactic or endoscopic, with or without fibrinolytics, are mostly indicated in deeper or intraventricular haemorrhages. The effectiveness of minimally invasive clot evacuation with stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain. The Minimally Invasive Surgery plus Recombinant Tissue Plasminogen Activator (MISTIE) II RCT, found reductions in haematoma and oedema volume in the intervention group, but no overall difference in clinical outcomes. The Neurosurgical treatment also implies risks with the possibility of deficits induced by the neurosurgical intervention. It is always important to assess individual risk for each patient. Despite factors in favour or against neurosurgical treatment, the final decision of a surgical intervention is based in a multidisciplinary evaluation that takes into account all those factors.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L17

Icon_pdf Download PDF

Lecture


Reversal of anticoagulation in intracranial haemorrhage - read full article

By: Luciana Ricca Gonçalves

Oral anticoagulants are increasingly used for long-term primary and secondary prevention of stroke, systemic embolism and venous thromboembolism. Intracranial haemorrhage (ICH) is the most severe complication of anticoagulation, with high mortality rates (>30%). Oral anticoagulants are associated with 10% to 15% of all ICH. Vitamin K antagonists (VKAs) present the higher rates of ICH (12 to 20%); non-vitamin K oral anticoagulants (NOACs) present a reduction of 50% in ICH rates, when compared with VKAs. The approved NOACs are dabigatran, a direct reversible thrombin inhibitor, and apixaban, edoxaban and rivaroxaban, direct reversible factor Xa inhibitors. In most cases, haematoma expansion is responsible for the high mortality rates associated with ICH, which normally occurs within the first hours after symptoms onset, regardless of whether the patient is under VKA or NOAC. Therefore, reversal of anticoagulation must be performed as soon as possible, as it may limit haematoma expansion and improve outcomes. Anticoagulation activity must be assessed before reversal, but different tests are used according to the anticoagulant agent the patient is taking. VKAs are monitored by international normalized ratio (INR), a widely available test. Routine coagulation tests are less useful for measuring anticoagulation activity of NOACs. However, activated partial thromboplastin time (aPTT) is more sensitive to dabigatran and prothrombin time is more sensitive to rivaroxaban and edoxaban. If available, quantitative tests can be performed to determine NOACs concentration: reversal is required if concentrations are >30ng/ml. It is important to emphasize that reversal should not be delayed due to the lack of these tests. There are two main treatments that must be given to a patient with VKA-associated ICH. Vitamin K, which normalizes INR by providing substrate necessary to the synthesis of clotting factors, must be given intravenously in high doses (5-10mg); however, it takes at least 12 hours to be effective. Prothrombin complex concentrates (PCC) contain the clotting factors II, VII, IX and X, as well as proteins C and S, and correct INR within minutes. They are rapidly administered in small volumes and do not need crossmatching. Several specific reversal agents have been developed. Idarucizumab is the specific reversal agent for dabigatran. It is a Fab fragment of a humanized monoclonal antibody. In REVERSE-AD trial, a dose of 5 g of idarucizumab was given intravenously (5-10 min) to patients with severe bleeding or needing emergent invasive procedures. Idarucizumab reversed dabigatran anticoagulant activity in 88-98% of patients, with an immediate, sustained and complete effect. The mortality rate was 13.6% in the bleeding group, including 98 patients with ICH. In this subgroup, mortality rate was 16.4%. By comparison, mortality rates in patients with ICH included in RE-LY study (a trial to evaluate the efficacy and safety of dabigatran compared with warfarin among patients with atrial fibrillation) were ?35%. Idarucizumab is approved and available worldwide since November 2015. Andexanet alfa is a recombinant human factor Xa that binds and inhibits FXa inhibitors, reversing their anticoagulant activity. It has been evaluated in patients with severe bleeding. Patients receive an intravenous bolus followed by a 2 h infusion. Anticoagulant activity was reduced in >89% patients, but there is a rebound increase after the infusion is stopped. Andexanet alfa has been approved in the USA in May 2018, but it is still waiting approval in Europe. Meanwhile, PCC has been the reversal agent used for FXa inhibitors. Activated PCC (aPCC) has also been used for this purpose if PCC fails to reverse anticoagulation; however, it is more expensive than PCC and the risk of thrombotic complications is higher. PCC and aPCC can also be used to reverse dabigatran anticoagulation activity whenever idarucizumab is not available. Ciraparantag is a synthetic small molecule that binds to heparin, low-molecular-weight-heparin and DOACs, but phase III studies are still lacking. The efficacy of tranexamic acid (TXA) in ICH is also being assessed in TICH-2 trial (Tranexamic acid for hyperacute primary intracerebral haemorrhage: an international randomised placebo-controlled, phase 3 superiority trial). However, patients under anticoagulation were excluded from this trial. Nevertheless, the results of this trial can help to determine if TXA will be an adjuvant therapy in anticoagulation-associated ICH.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L18

Icon_pdf Download PDF

Lecture


Post-discharge care preparation begins in day one of admission - read full article

By: Patrícia Araújo

Cerebrovascular disorders are the main cause of functional disability in people, and an exponential increase of people with disability in the next few years is foreseeable. The Portuguese General Directorate of Health recommends that in an intervention in a patient with stroke there are four preponderant factors: the severity of the stroke, early and intensive rehabilitation, the expectations of rehabilitation on the part of the patient/family and the family support. It is regarding three of these factors that the Neurology nursing team advocates an efficient and effective intervention where family involvement is indispensable to achieve care objectives. This involvement can have several moments: initial evaluation, complementary evaluation, intervention and resolution. In the initial evaluation, the following is carried out: collection of general information about the patient and the family, presentation of the service and a direct telephone contact is provided aiming to create confidence and show availability. In the complementary evaluation, we intend to understand the perception the family has about the clinical state, the future family changes related to the disease process, the features of the family core and identification of strengths and weaknesses. At this stage, we also explain what the patient and the family can expect from nurses and nursing care. We propose that the family accompanies the patient in an extended period of visit with the objective of minimizing the impact of the disease and allowing a partnership of care. In the following phase, we discuss the intervention plan during and after the hospitalization, planning a house visit and aid in the request of support products with the objective of promoting greater autonomy of the patient and reducing the burden of the caregiver. The possibilities for continuity of care are also discussed. We prefer that the final destination is the patient’s home, who can, however, first be discharged to another service/institution or integrated into the National Integrated Care Network. The resolution phase arises as an evaluation of the structured education that was given to the patient and or/caregivers throughout the process (life activities, anticoagulation, modifiable risk factors, among others), trying to understand the indicators of mastery. After hospital discharge, the patient/family stays in contact with us whenever doubts or anxiety arise. When there is worsening of the clinical state or the need for further diagnostic investigation, the patient may have direct admission in the service. We think it is an effective and rewarding intervention for everyone involved in the process by increasing professional satisfaction and decreasing the impact of the disease by transmitting security and trust in care and contributing to a safe continuity of care.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L19

Icon_pdf Download PDF

Lecture


Challenges of a stroke survivor (in the chronic phase) - read full article

By: António Conceição

If we were to synthesize in one word the challenges facing a chronic stroke survivor, it would be integration! (Re) integration that begins on a personal level: it is much easier to achieve satisfactory integration at family, social and even professional level, when one begins by accepting a life plan that may have to be different. Little or nothing has to do with the severity of any sequelae, even less with the type of limitations. In fact, there is a tendency to value what is visible - the physical part – in detriment of what may also be relevant limiting causes for this (re) integration, be it communicative, cognitive, permanent fatigue, and others. And that, easily and in a spiral, slips into a self (which is joined to a hetero) social exclusion. The Cerebrovascular Accident, because it happens in the most complex and differentiating organ of the human being - the brain, tends to be unique in each concrete case, particularly in its sequelae and in the process of recovery and rehabilitation, and its "velocity". For this reason, and not only, it is not understandable that rehabilitation is frequently not delivered as a personalized process, covering different therapeutic areas, in a word, being truly multidisciplinary. And, especially for the citizens with less resources or less information and sensitivity, it is a process that is too much standardized and limited in time. There are a lot of purely administrative and / or political decisions that seem to go exactly in the opposite direction of not only what is expressed here, but also opposite to the recent advances and scientific discoveries. Also for this reason, chronic stroke survivors who achieve good rehabilitation (not to be confused with recovery) are often admired for their psychological strength. Because this is another big challenge!

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L20

Icon_pdf Download PDF

Lecture


ESOC 2018 Highlights - read full article

By: Ana Aires

As in previous conferences, ESOC 2018 was full of interesting lectures on topics covering the whole spectrum of stroke care. This presentation will address the most common important highlights from this amazing scientific meeting. One of the most relevant novelties was the “Stroke Action Plan for Europe” (2018-2030) which consists of a collaborative initiative between the principal professional and patient organisations in order to establish goals for stroke care over the next decade. For three days, the front line results of major clinical trials were presented. The POINT trial showed that clopidogrel-aspirin combination (90 days) soon after minor stroke or TIA reduced the risk of ischaemic stroke (IS) at the cost of a smaller increase in the risk of major haemorrhage, compared to aspirin. The Wake Up study concluded that in patients with stroke of unknown symptom onset and an MRI scan showing limited established infarct, intravenous thrombolysis resulted in a similar functional outcome to patients treated within the 4.5 hour treatment window. On the other hand, CROMIS-2 showed that the identification of cerebral microbleeds on an MRI predicts an increased risk of symptomatic intracranial haemorrhage in patients on oral anticoagulation for atrial fibrillation after recent IS or TIA, but the absolute risk of haemorrhage was still inferior to the risk of recurrent IS. Considering rehabilitation after stroke, the results were controversial: Stroke 123 found that targeted interventions resulted in a significant improvement in delivery of stroke care in Australia but the EXTRAS trial showed no functional benefit from an extended rehabilitation service in the UK. Lastly, we will also focus on the ESO guidelines session that brought together experts who reinforced the recommendation of offering mechanical thrombectomy and best medical therapy in acute IS patients with large artery occlusion presenting within 6 hours, including those over age 80.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L21

Icon_pdf Download PDF

Lecture


Workshop 3, part 1: Functional Independence Measure (FIM) and Functional Ambulation Categories (nFAC) - read full article

By: Tiago Pimenta, André Duarte, Fernando Parada, and Maria José Festas

The Functional Independence Measure (FIM) is an assessment tool that aims to evaluate the functional status of patients throughout the rehabilitation process following a stroke or any motor impairment associated with any condition. Its area of use can include skilled nursing facilities and hospitals aimed at acute, sub-acute and rehabilitation care. It is an 18-item scale of physical, psychological and social function, including bowel and bladder control, transfers, locomotion, communication, social cognition and self-care activities, used to assess a patient's level of disability as well as change in patient status in response to rehabilitation or medical intervention. Each item is rated on a 7-point scale on the basis of how much assistance is required for the individual to carry out activities of daily living (1 = <25% independence; total assistance required, 7 = 100% independence); the level of a patient’s disability indicates the amount of support needed to care for them and thus how dependent he or she will be on help from others. The new Functional Ambulation Classification (nFAC) is a functional walking test that evaluates functional ambulation ability and categorizes patients according to basic motor skills necessary to do so. It does not assess endurance. This 9-category scale assesses how much human support the patient requires when walking, regardless of whether they use a personal assistive device or not (0 - cannot ambulate or requires assistance from more than one person; 8 - can ambulate independently on level surfaces and can negotiate stairs normally, without use of the handrail or a walking stick). It can be used with patients with stroke but is not limited to those. Performed on admission to and departure from a rehabilitation centre, these two measurements function as a consistent data collection tool for the comparison of rehabilitation outcomes across the health care continuum.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L22

Icon_pdf Download PDF

Lecture


Workshop 3, part 2: Assessment and treatment of poststroke spasticity applying the GAS method - read full article

By: Rui Prado Costa

Poststroke spasticity is a neurological condition characterized by a velocity-dependent increase in muscle tone, loss of joint range, pain and loss of function [1, 2]. Spasticity management requires an interprofessional and multidimensional approach to restore the functionality which includes physical therapy, occupational therapy and medical care interventions [3-6]. Standardized measures before and after treatment and interventions must be used for assessment purposes and may include measures of impairment, activity limitation and participation as well as achievement of the patient’s own goals. Treatment goals oriented to each patient deficit or impairment, in an individual and specific way, is an important feature of neurological rehabilitation [7].This goal-oriented approach can be assessed using a goal setting tool such as the goal attainment scaling (GAS). The GAS is a tool that provides an individualized criterion referenced measure of a patient’s goal achievement. It involves the patient in setting their own goals in multiple domains and assists the team with organizing, targeting and defining the rehabilitation process [8-10].The GAS is being increasingly being used in the context of spasticity management [5, 6, 11-21] and has been shown to be sensitive to changes following focal intervention, such as Botulinum toxin, that are not detected by more global measures [11, 12, 19, 22]. When spasticity is present in multiple muscles, the GAS can be an assistive tool to guide clinicians in determining which muscles are a priority for injection to serve a specific goal [17, 21]. GAS is supporting the evidence of Botulinum toxin in improvement on functional level, activity limitations and quality of life in addition to the control of muscle tone and spasticity [12-14, 21, 22].

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L23

Icon_pdf Download PDF

Lecture


Neuroimaging in acute haemorrhagic stroke - read full article

By: Francisca Costa

There are two types of stroke, haemorrhagic and ischaemic. Haemorrhagic events are far less common; in fact studies indicate that only 8-18% of strokes are haemorrhagic [1-2]. However, haemorrhagic stroke is associated with higher mortality rates [3], being responsible for about 40 percent of all stroke deaths. Haemorrhagic stroke is an acute event that follows a haemorrhage in the intra-axial space. Its neurologic effects may be associated with mass effect per se (creating swelling and pressure), but additionally the resulting haematoma triggers a series of adverse events causing secondary inflammatory insults [4]. The haemorrhage might be intracerebral (ICH) or in the subarachnoid space. Subdural and epidural hematomas are commonly associated with trauma and with a different clinical spectrum, and, therefore, are not included in this discussion. ICH is subdivided according to its primary (80% to 85%) or secondary (15% to 20%) causes. Primary causes may be hypertension or cerebral amyloid angiopathy. The causes of secondary ICH include vascular malformations (aneurysms, arteriovenous malformations, cavernoma, dural arteriovenous fistula), tumours, venous thrombosis, haemorrhagic transformation of ischaemic strokes, vasculitis, coagulopathies, and trauma [1]. Patients with haemorrhagic stroke may present with acute focal neurologic deficits like those of ischaemic stroke. Therefore, brain imaging is a crucial step in the evaluation of suspected haemorrhagic stroke and these patients should be quickly and accurately identified. Due to its wide availability and acquisition speed, CT scan is the imaging modality of choice to assess patients with suspected intracranial haemorrhage. Acute extravasated blood, in a patient with a normal haematocrit, will be visible as increased density (hyperdensity, hyperattenuation) on non-enhanced CT scans of the brain. We aim to review imaging patterns and provide some tips to help the clinician recognize intracerebral haemorrhage, and other further underlying aspects that may be helpful in the diagnostic workup of the patient.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L24

Icon_pdf Download PDF

Lecture


Cervical and transcranial vascular ultrasound in the acute stroke patient - read full article

By: Elsa Azevedo

Neurovascular ultrasound can help in several steps during the acute phase of the stroke patient, either for revascularization decisions or for other clinical management decisions. Neurovascular ultrasound can be our brain stethoscope, important for the cerebral haemodynamics, but it also currently provides an accurate evaluation of structural arterial changes. Although the good practice guidelines indicate that an acute stroke patient with a clinical syndrome suggesting a large artery occlusion should rapidly perform a CT scan and CT-angiography for selecting for potential endovascular revascularization, those radiologic exams cannot be repeated whenever the clinician wants to know how cerebral haemodynamics are performing, to make clinical decisions. In the acute stroke unit patients, we want to check the morphologic and haemodynamic condition of the cervical and cerebral arteries, to evaluate stroke aetiology, where Neurosonology is definitely a crucial player. Then we must decide what to do for the secondary prevention, and again Neurosonology can give very specific clues to help in some decisions. Some of the questions where Neurosonology can help in the acute stroke settings are: Is there a large artery occlusion, even with a low NIHSS? Is the artery opening with thrombolysis? Was the revascularization haemodynamically satisfactory? How is the perfusion of the affected tissue? Should we lift the patient from bed early or more progressively? Is there an increase in intracranial pressure? How should we manage blood pressure? What was the stroke aetiology? Does the patient have an atherosclerotic stenosis criterion for revascularization, which stenosis/haemodynamics/imaging/patient parameters are worth to consider? Is a dissection haemodynamically unstable and candidate for revascularization? Are there some clues for a cardioembolic aetiology? Is a PFO closure warranted? Is there a cerebral vasoconstriction syndrome, or clues for vasculitis, or more rare syndromes such as the moyamoya syndrome? Any arteriovenous malformation clues in an intracranial haemorrhage patient? Are the vasospasm criteria for endovascular treatment in a subarachnoid haemorrhage patient? In conclusion, Neurosonology provides an invaluable tool to assist the stroke physician in many of the big decisions in the acute stroke setting.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L25

Icon_pdf Download PDF

Lecture


Action Plan for Stroke in Europe 2018-2030 - read full article

By: Elsa Azevedo

After the Helsingborg Declarations on Stroke Management in Europe of 1995 and the Helsingborg Declaration on European Stroke Strategies in 2006, it was now time for a new set of objectives and plans to face the burden of stroke in Europe. Indeed, implementation of adequate stroke services in Europe in 2018 is unequal and incomplete. Resources for stroke do not match the societal impact and burden of the disease. It is important to say that investing in stroke is a good investment for society, as the return of investment for stroke is excellent. The Action Plan is a collaborative initiative to define the priorities for stroke care and research across Europe over the next decade and provide guidance for European and national plans encompassing the chain of care from primary prevention to rehabilitation and life after stroke. It has been written by the European Stroke Organization in association with the stroke survivor support organization Stroke Alliance For Europe, with input from the World Health Organization's Regional Office for Europe. It is planned to be phased and monitored throughout the timeline 2018-2030, to allow a review of the targets and of the research that might indicate the necessity of some adjustments. The overarching targets for 2030 are the following: to reduce the absolute number of strokes in Europe by 10% to treat 90 % or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care to have national plans for stroke encompassing the entire chain of care from primary prevention to life after stroke to fully implement national strategies for multisector public health interventions to promote and facilitate a healthy lifestyle, and reduce environmental (including air pollution), socioeconomic and educational factors that increase the risk of stroke.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L26

Icon_pdf Download PDF

Lecture


Treatment of acute ischaemic stroke: an updated protocol for patient selection - read full article

By: João Pedro Filipe

Stroke is one of the leading causes of death and morbidity in industrialized countries. Diagnosis and treatment options have largely evolved in the last decades with the aim of rapidly restoring flow in the occluded vessels. Evidence to support mechanical thrombectomy for stroke has previously been poor because randomised trials have used low e?cacy thrombectomy devices, insu?cient selection criteria, and had long delays from symptom onset to reperfusion. In early 2015, five individual trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME and REVASCAT) established that thrombectomy with newer generation devices signi?cantly reduces disability rates after acute ischaemic stroke due to large vessel occlusion, rendering the high-level recommendation for mechanical thrombectomy treatment in patients presenting within 6 hours after symptom onset. By pooling patient-level data from the five trials, the HERMES collaboration further concluded that the consistent results across different patient populations suggested that benefit from thrombectomy could be generalizable to a broad range of patients with large-vessel occlusion regardless of age, initial stroke severity and patient non-eligibility for intravenous rtPA. More recently, the DAWN and DEFUSE-3 trials also proved the benefit of mechanical thrombectomy in a subgroup of patients presenting from 6 to 24 hours after symptom onset and meeting specific advanced imaging criteria. In the past 3 years, many other trials, reviews, guidelines and meta-analyses have been published, leading the American Hearth and the American Stroke Association to release new guidelines in February 2018. All these trials and guidelines have been the basis for the establishment of local and regional consensus for the approach, management and treatment of patients with acute ischaemic stroke and large vessel occlusion.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L27

Icon_pdf Download PDF

Lecture


Emergent procedures in intraparenchymal haemorrhage - read full article

By: Luís Braz

Spontaneous intracerebral haemorrhage (ICH) accounts for greater morbidity and mortality than ischaemic stroke. Despite several clinical trials and contrary to its ischaemic counterpart, ICH emergent medical management has not seen such a huge revolution in last years. However, it is important to bear in mind all the medical management measures with proven benefit. The bigger change in recent years has been brought by the INTERACT2 trial, which proved the safety and better functional recovery of ICH patients in which systolic blood pressure was reduced to <140mmHg in the first few hours. Other trials investigated the use of haemostatic therapy rFVIIa and platelet transfusion to halt haematoma growth, but with negative results. Nevertheless, in the subgroup of ICH patients with platelet or coagulation factors abnormalities, emergent platelet transfusion and prothrombin complex concentrate (PCC) administration is indicated; similarly, reversal of anticoagulation with vitamin K or idarucizumab is recommended for patients under vitamin K antagonists or dabigatran, respectively. Due to its higher incidence in ICH patients, seizures (either clinical or electrographic) should be sought and treated. Finally some simple general measures should be kept in mind when dealing with this patients in an emergent context, such as prevention of aspiration pneumonia and correction of glycaemic extremes.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L28

Icon_pdf Download PDF

Lecture


The role of palliative care - read full article

By: José Eduardo Oliveira

Introduction: Stroke patients and families go through significant distress in their illness trajectory related with symptoms, function loss and psychosocial factors. Often there is a significant uncertainty of prognosis and recovery potential. According to WHO, Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness. 
Case description: We present a clinical case of a 27-year old male with catastrophic stroke after replacement of aortic valve due to endocarditis/aortic stenosis, the challenges in his care and reflect about the role of the different teams involved in his care. After the surgery he did not recover consciousness and needed ventilator support with tracheostomy. The magnetic resonance showed diffuse ischaemia of cerebral hemispheres with generalized cerebral atrophy and microhaemorrhages of the basal ganglia and thalamus. The electroencephalogram reported global dysfunction without epilepsy. The patient was reported as a being at a minimally conscious state at the time of the first evaluation by the palliative care consulting team (PCT). The PCT was requested because of restlessness, perception of discomfort and family suffering. At our first evaluation, the patient scored 8 on the Glasgow coma scale, was breathing with BPAP by tracheostomy, fed by gastrostomy, with dyskinesia of upper limbs and paraplegia and generalized spasticity. Most of the time, there were several non-verbal pain signs such as flexion withdrawal, grimacing and crying facial expression that prompted opioid analgesics administration without relief. His parents were very anxious and in conflict with the surgical team. In the following months, before discharge to a long-term care facility, the PCT worked together with cardiac surgery, neurology and rehabilitation specialists to relief patient suffering by means of identification and treatment of pain and other problems. The opioids were mostly discontinued except for incidental pain and antidepressants were successful at pathological crying/pseudo bulbar affect. He responded to muscle anti-spasticity drugs. There were several challenges at the level of family relation with the clinical team with disagreement of medical limitation of the intervention level that posed ethical dilemmas, in addiction to blaming the team for the late recognition of endocarditis. In the following 2 years after hospital discharge, the patient was submitted to rehabilitation at the long-term care facility and recovered from the minimally conscious state, was successfully decannulated, recovered upper limb motor function and verbal response. He was discharged home with the support of both rehabilitation home team and palliative care team with successful family adaptation. Currently, he he has been discharged from palliative care team and is being followed at a local rehabilitation clinic. 
Discussion: Patients with catastrophic stroke pose several challenges at the level of prognosis, rehabilitation capacity, and definition of levels/limitations of intervention. The palliative care team work was an added layer of support to the patient, family and clinical specialities involved with care. Sometimes patients recover significantly; others do not, but both patients and families need support to adjust to the new realities and that imposes that all the teams involved in care have training in communication, symptom management, ethics and psychosocial intervention that constitute the basic of palliative care intervention.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):L29

Icon_pdf Download PDF

Oral Presentation


Post-exercise intracerebral haemorrhage: a case report - read full article

By: César Magro, Eva Alves, Ricardo Henriques, Teresa Mirco, and Francisco Sampaio

Introduction: Intracerebral haemorrhage (ICH) is the result of bleeding from an arterial source directly into the brain parenchyma. Despite ICH constituting 10-15% of all strokes, its incidence in people under the age of 35 is extremely low (0.3/100 000). Occurrence of ICH without demonstrated tissue pathology is labelled as “primary ICH” with an overall mortality rate estimated to be between 30-50%. Evidence that regular exercise decreases the likelihood of all types of stroke, including ICH has been demonstrated consistently. However, little is known about primary ICH in young adults. 
Case Report: A 19-year-old Caucasian man was admitted for a spontaneous ICH after exercise practice without associated trauma, presenting a left hemiparesis, depression of consciousness and global aphasia. CT performed upon arrival demonstrated a midbrain tegmental hematoma with intraventricular extension. He had an interatrial communication without any other previous issues and was submitted to emergent surgical intervention. Despite a cavernous malformation hypothesis, brain CT and MRI angiography did not show any vascular abnormalities. An early rehabilitation program was started, and a percutaneous endoscopic gastrostomy was placed for severe dysphagia management. He was transferred to a national reference rehabilitation centre with partial recovery of previous functional and neuromotor deficits. 
Conclusion: The reported case highlights the importance of understanding possible etiological factors in spontaneous ICH, knowing that the primary event can obliterate the evidence of the main cause. Early rehabilitation protocols might be beneficial, and the understanding of the possible mechanisms is needed in order to minimize the risk, given the severity of the illness.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O1

Icon_pdf Download PDF

Oral Presentation


Proatlantal artery type I: a case report of a persistent carotid-vertebrobasilar anastomosis - read full article

By: J.B. Madureira, P. Teotónio, F. Proença, P. Sequeira, L. Neto, and L. Biscoito

Background: The proatlantal artery is the most proximal of four intersegmental carotid-vertebrobasilar anastomoses, which are present for a few days in the embryonic period. In the adult, it persists as the horizontal segment of the vertebral arteries (VA). In some cases, it might persist as a primitive carotid-vertebrobasilar anastomosis between the lower segment of the internal carotid artery (ICA) - type I; or less commonly, from the external carotid artery (ECA) - type II. Rarely, it originates from the common carotid artery. This artery reaches the basilar artery by crossing the occipito-atlantal space and foramen magnum and is often associated with hypoplasia or agenesis of the VA. 
Case Description: An 84-year-old male, with history of hypertension, dyslipidaemia and atrial fibrillation, was submitted to a diagnostic angiography for further characterisation of a complete occlusion of the right ICA and lack of flow on both VA, documented on carotid ultrasound imaging. There was no past history of cerebrovascular events. The angiogram confirmed total occlusion of the right ICA bulb segment, and crossflow to the right anterior and middle cerebral arteries through the anterior communicating artery. The origin of both VA was not visualised. The basilar artery and posterior cerebral arteries were supplied by an anastomosis between the left internal carotid artery and the basilar artery - the proatlantal artery (type I). 
Conclusion: Knowledge of the vascular morphogenesis enables the neuroradiologist to distinguish between a pathologic or variant vessel and to understand its importance for the maintenance of the hemodynamic balance of the encephalic circulation.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O2

Icon_pdf Download PDF

Oral Presentation


Endovascular treatment of a ruptured posterior cerebral artery aneurysm in an infant: a case report - read full article

By: João Brandão Madureira, Filipa Proença, Pedro Teotónio, Gonçalo Basílio, Luísa Biscoito, Paulo Sequeira, and Lia Neto

Introduction: Intracranial arterial aneurysms in the paediatric population are rare and may be asymptomatic until rupture. Posterior circulation aneurysms are uncommon (10%) but have higher rupture risk. Endovascular treatment of these aneurysms is challenging not only due to the small size of child vessels, but also due to the risk of life threatening complications in the posterior circulation territories. 
Case Report: An eleven-month old infant presented with hyporeactivity, vomiting, seizures, convergent strabismus, arterial hypertension and a bulging anterior fontanelle. No gestational or postnatal complications were reported until then. On admission, head CT scan and MRI were performed, showing signs of acute right temporo-parieto-occipital ischemic stroke, and subdural and subarachnoid haemorrhage. MRI revealed a partially thrombosed small saccular aneurysm (berry aneurysm) of the ipsilateral distal posterior cerebral artery (P3/P4 segments). The patient was submitted to therapeutic angiography on the following day. The aneurysm was approached by the ipsilateral posterior communicating artery (embryonic origin of the posterior cerebral artery) and embolized with coils. Complete exclusion was obtained without complications. The patient was discharged after 10 days with no sequelae, apart from mild ophthalmologic defects. Conclusion: Posterior cerebral artery aneurysms are rare, representing 1% of intracranial aneurysms. Saccular forms are more common in children; and are also associated with a higher risk of rupture, frequently presenting as subarachnoid haemorrhage. Angiography remains the gold standard, in addition to enabling endovascular treatment. Ruptured brain aneurysms can be life threatening and immediate action is crucial to minimize brain damage.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O3

Icon_pdf Download PDF

Oral Presentation


Iatrogenic internal carotid artery perforation during a thrombectomy attempt - read full article

By: Hugo Dória, Luís Albuquerque, Catarina Pinto, and Ângelo Carneiro

Introduction: Despite rare, complications are an inevitable offset to the benefits thrombectomy brings about. Arterial perforation is among the most feared, as it may be associated with poor functional outcome and higher mortality rates. 
Case Report: A 66-year old male with laryngeal carcinoma was submitted to total laryngectomy, complete cervical lymphadenectomy and phonatory prosthesis insertion with curative intent. During immediate postoperative care, he developed right hemiparesis, left gaze preference and right hemianopia (NIHSS=20). CT scan showed early signs of infarction in the insular and frontal cortices and there was increased mean transit time in most of the area supplied by the left middle cerebral artery (MCA) on CT perfusion. CT angiography revealed a left-sided tandem occlusion of the proximal internal carotid artery (ICA) and distal M1 segment of the MCA. The patient was taken for thrombectomy and while trying to navigate past the proximal occlusion with a hydrophilic guidewire, ICA perforation was made evident through contrast extravasation. The artery was temporarily occluded with a balloon catheter but extravasation persisted. Six detachable coils were then inserted to occlude the ICA, successfully stopping the bleeding. CT scans on the following days showed a complete superficial MCA territory infarct, having spared the greater part of the basal ganglia.
Conclusion: We present the case of an ICA perforation during a thrombectomy procedure. Cases like these remind us that risks are inherent to this type of treatment and even if they are vastly outweighed by the potential benefits, cases should always be assessed individually.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O4

Icon_pdf Download PDF

Oral Presentation


Stroke mimics: a reality in stroke units - read full article

By: Joana Cordeiro e Cunha, Diana Fernandes, Tatiana Salazar, Ana Luísa Cruz, and Augusto Duarte

Introduction: A broad spectrum of diseases may present acutely like strokes – stroke mimics, which can represent up to 30% of the patients admitted to stroke units. The aim of this study was to describe the stroke mimic patient group, and to perform a comparative analysis between this group and the stroke patients group. 
Methods: A cross-sectional, retrospective study was performed, based on clinical data analysis of 211 patients admitted to our stroke unit, during the year of 2017.
Results: From the 211 admissions, 11.3% were classified as stroke mimics. Their mean age was 65 years old and were mainly female patients (75%). The most often described symptoms at admission were headache, sensory changes like dysesthesias or paraesthesia, and decreased muscle strength. The most frequent cause of stroke mimic was conversion disorder, followed by neurological diseases, such as seizures or headache. Thirty-three percent had prior psychiatric history. Median length of stay was 7.16 days. One of the stroke mimics cases deteriorated to a fatal outcome. The authors found a statistically significant difference between both groups in what concerns: median length of stay, prior psychiatric history, gender, decreased muscle strength, imbalance, headache, involuntary movements and non-specific symptoms (such as lethargy) on admission. 
Conclusion: This study may contribute to physician awareness regarding the impact of a stroke mimic diagnosis in the evaluation and guidance of stroke unit patients. These results may act as an alarm, emphasizing the relevance of proper admission anamnesis in a patient with acute neurological deficits.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O5

Icon_pdf Download PDF

Oral Presentation


Cryptogenic stroke in patients with an extracardiac shunt - read full article

By: Teresa Barata Silvério, Liliana Pereira, Ana Ribeiro, and Joana Morgado

Introduction: About one third of ischaemic strokes remain without identified aetiology despite extensive investigation. Possible aetiologies are paroxysmal atrial fibrillation, cancer associated or paradoxical embolism.
Case Reports: We report three patients, aged between 60 and 64 years old, admitted with an acute ischaemic stroke demonstrated by MRI. Only one had common vascular risk factors. Aetiologic investigation was performed: duplex-ultrasound (DUS) revealed slight carotid atheromatosis and, in one patient, symptomatic distal vertebral occlusion; extensive laboratory study (including assessment of autoimmunity and thrombophilia), holter monitoring, and transthoracic echocardiogram were unremarkable; detection of right-to-left shunt (RLS) by transcranial DUS was positive; transoesophageal echocardiogram excluded patent foramen ovale, congenital cardiac defects and potential cardioembolic sources; pulmonary CT angiography excluded pulmonary arteriovenous fistulas or shunts and only one patient demonstrated pulmonary embolism; venous leg DUS were normal. The diagnosis of cryptogenic stroke was established. On follow-up, one patient suffered recurrent stroke. Second transoesophageal echocardiogram remained normal; transcranial DSU with shunt detection were repeated (only in two patients yet), maintaining RLS. 
Discussion: We present three patients with an embolic pattern of cerebral infarction and RLS of unknown localization. Unproven paradoxical stroke is one of the possible aetiologies, given the presence of RLS, however evidence of a venous source of embolism is lacking in two patients. Although the majority of RLS have cardiac origin, our cases are extracardiac, with the localization remaining a diagnostic challenge. Prompt and timely diagnostic workout is fundamental to choose the best therapy and to reduce the stroke recurrence risk.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O6

Icon_pdf Download PDF

Oral Presentation


Cerebral amyloid angiopathy: an important differential diagnosis in case of haemorrhagic stroke - read full article

By: Ana Catarina Chaves, Pedro Carlos, Ana Catarina Dionísio, Carla Gonçalves, Artur Gama, and Leopoldina Vicente

Introduction: Cerebral amyloid angiopathy (CAA) is a progressive disease characterized by B-amyloid deposition in the walls of small and medium-sized arteries in the cerebral cortex and leptomeninges, which can lead to recurrent intracerebral haemorrhage and, in some cases, death. Diagnosis can be a challenge, and the modified Boston Criteria define several levels of confidence. 
Case Report: An 85-year-old woman, independent for activities of daily living, had a past medical history significant for hypertension, controlled with medication, dementia and two haemorrhagic strokes, in 2015 and 2017. In January of 2018, she was brought to the emergency department because she was less responsive, disoriented and presented new-onset right hemiparesis, in the absence of trauma. The head computed tomography showed an acute left frontal cortico-subcortical haemorrhage, with 46x34 millimetres. The application of the modified Boston Criteria revealed probable CAA. Since there were no concerns requiring neurosurgical admission, she was admitted under Internal Medicine care. The patient was initially treated with mannitol for 48 hours, progressing to furosemide and dexamethasone the following week. She presented a favourable clinical recovery, with increased awareness and total recovery of motor deficits, maintaining only dysarthria at discharge. 
Conclusion: CAA has a wide spectrum of clinical manifestations. This diagnosis should be suspected, and excluded, in patients with non-traumatic haemorrhagic stroke, especially when over the age of 60. Although there is no specific treatment, a prior haemorrhagic event increases the risk of recurrence, and thus prevention through modifiable risk factor reduction should be the focus in these patients.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O7

Icon_pdf Download PDF

Oral Presentation


Infectious endocarditis: a diagnostic challenge - read full article

By: Luís Marques Loureiro, Márcia Souto, Ana Alves, Cristiana Sousa, Fernanda Linhares, and Paula Vaz

Introduction: Endocarditis is a disease whose presentation is not uniform, depending on the existence of underlying cardiac pathology, the microorganism involved and the presence or absence of complications. The treatment of this disease involves eradication of the bacterium of avascular vegetation, and an early therapeutic approach is imperative. 
Case Report: A 75-year-old woman with a history of type 2 diabetes, dyslipidaemia, and moderate aortic stenosis, was admitted with sudden dizziness, headache and ataxia. Neurologic examination revealed mild ataxia of her left inferior limb. Blood tests were normal, and admission brain CT showed cortical atrophy and no recent vascular lesions. Patient was hospitalized with a diagnostis of acute stroke or transient ischaemic attack (TIA). Transthoracic cardiac echocardiography revealed severe aortic stenosis and a moderately dilated left atrium. Duplex ultrasonography revealed only minor carotid atheromatosis. At the 6th day of hospitalization, fever and neurological aggravation arose with disorientation and moderate left hemiparesis that persisted during five hours. Blood cultures were positive, with growth of Streptococcus anginosus. Multiple recent punctiform lesions in the pons, and in the cerebellar and cerebral hemispheres suggestive of embolic aetiology were noted in the brain MRI. Although transoesophageal echocardiography did not reveal vegetations, she started treatment for bacterial endocarditis with meropenem and linezolid for 6 weeks. She was referred for cardiothoracic surgery. However, the patient suddenly died before surgery. 
Conclusion: Endocarditis is an important source of cardiac embolism, and the brain is one of the most frequent sites of embolization. In this case, we aim to emphasize endocarditis as a possible cause of stroke and TIA.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O8

Icon_pdf Download PDF

Oral Presentation


Anticoagulation in atrial fibrillation patients: what is the best option? - read full article

By: Júlio Santos, Helena Santos, and Andreia Correia

Introduction: Anticoagulant agents are recommended for preventing stroke in people with atrial fibrillation (AF). Vitamin K antagonists (VKAs) exhibit considerable variability in dose response among patients, are subject to multiple food and drug interactions and have a narrow therapeutic window. Because factor Xa inhibitors appear to offer practical advantages over VKAs, with fewer food and drug interactions, a fixed daily dose, and no need for monitoring of the anticoagulant effect, recent guidelines now also recommend such agents as treatment options for preventing stroke and other thromboembolic events in people with AF. 
Case Report: 74-years-old male, independent in the activities of daily living, with controlled hypertension, smoker, chronic alcohol abuse, transient ischaemic attack in 2010 and atrial fibrillation anticoagulated with warfarin. The patient had labile values of International Normalized Ratio (INR) but was reluctant to change to a factor Xa inhibitor due to skepticism regarding the importance of his problem. In 2017, the patient was admitted to the emergency room because of right hemiparesis and slurred speech. The CT scan showed an acute cerebral infarction and multiple sequelae of ischaemic injuries. The carotid ultrasound revealed 80% stenosis of the right internal carotid artery. After 10 days in the stroke unit, the patient started a rehabilitation program. The medication was reviewed and the patient started apixaban to prevent new strokes.
Conclusion: There is still no consensus regarding the ideal anticoagulant agent in the prevention of stroke. However, in low quality VKA treatment patients, factor Xa inhibitors should be preferred.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O9

Icon_pdf Download PDF

Oral Presentation


Monitoring of anticoagulation in a Family Health Unit: time in therapeutic target in atrial fibrillation - read full article

By: Júlio Santos, Andreia Correia, Beatriz Soares, Carlos Gomes, Ana Luís Pereira, and Ana Torres

Introduction: Atrial fibrillation (AF) increases the relative risk of stroke five times. It is estimated that in the Portuguese population above the age of 40, the prevalence of AF is 2.5%, reaching values of 10% from 80 years and older. This study aims to characterize anticoagulated patients due to AF and their time in therapeutic range in Salvador Machado Family Health Unit. 
Methods: A survey requesting sociodemographic information and INR values was applied to all participants. Time in therapeutic range was calculated by the Rosendaal method. Time in therapeutic range was compared to values reported in previous studies. Statistical tests were used to test the relation between time in therapeutic range and sociodemographic and clinical variables. 
Results: 72 patients were included in the analysis, with median age of 78 years; 68.1% were male. Average time in therapeutic range was 58%. It was even lower in the group with less than one year of treatment (although the difference did not meet statistical significance). We found no significant statistical association between time in therapeutic range and studied variables (AF duration, anticoagulation length, age, gender, level of education, existence of caregiver support). Time in therapeutic range in this study is inferior to the one found in study APOLO I (65.3%), but not different from the 55.2% reported in ROCKET-AF study (p=0.014 and p=0.332, respectively). 
Conclusion: These results reflect the need to focus on improving the monitoring of patients anticoagulated with vitamin K antagonists, both at the patient and at the health care service level.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O10

Icon_pdf Download PDF

Oral Presentation


Cerebral venous thrombosis and its clinical diversity - read full article

By: Giovana Ennis, Nélson Domingues, Joana Marques, Pedro Ribeiro, Cristina Andrade, Luís Isidoro, José Borges Martins, and António Correia

Introduction: Cerebral venous thrombosis (CVT) is a serious medical condition, difficult to diagnose because of its wide range of clinical presentations. The symptoms can vary from isolated headache to coma, or even mimic a stroke. 
Case Report: The authors present a case report of a 76-year-old female patient, with a personal history of immune thrombocytopenic purpura, arterial hypertension, and pulmonary embolism. The diagnosis of CVT was challenging because the initial form of presentation of the disease mimicked a transient ischaemic attack (transient aphasia and right hemiparesis). Therapeutic decisions were also a challenge because, at the time of the diagnosis, the patient was suffering from severe thrombocytopenia (29x109 platelets/L), which had to be considered. After multidisciplinary discussion, it was decided to administer full-dose enoxaparin, resulting in a progressive and significant neurological recovery.
Conclusion: In presenting this case, the authors’ primary goal is to point out that CVT can be difficult to diagnose because of its wide range of clinical presentations. Headache (a symptom that was never present in this case) is the most frequent complaint, occurring in 90% of cases. Following diagnosis, an aetiological study is required.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O11

Icon_pdf Download PDF

Oral Presentation


The strange case of Mr. Weber - read full article

By: Giovana Ennis, Joana Marques, Cristina Andrade, João Pedro Tavares, Ana Gouveia, José Borges Martins, and António Correia

Introduction: Nearly 25% of ischaemic strokes affect posterior circulation brain structures, which are supplied by the vertebrobasilar arterial system. Vascular events in this territory continue to be more difficult to recognise and treat effectively. 
Case Report: A sixty-six-year-old, caucasian, male patient, with a personal history of excess weight, hypertension, dyslipidaemia and a moderate consumer of alcoholic beverages, was admitted to the Emergency Department complaining of sudden onset weakness on the left side. Initial assessment was positive for a mild 4/5 left-sided hemiparesis, with an NIHSS of 2. Initial workup, which included a brain CT scan, was unremarkable. The symptoms slowly subsided. ABCD2 score of 6 classified the patient as having a high risk and therefore the patient was hospitalized. The following morning, unilateral drooping of the right upper eyelid was noted, accompanied by opthlmoparesis and recurrence of left-sided hemiparesis. These findings were consistent with a right midbrain lesion (Weber Syndrome). Brain MRI revealed a recent right thalamic/subthalamic ischaemic lesion, an area supplied by perforating branches of the right posterior cerebral artery. Further investigation of cardiovascular risk factors showed that the patient was also pre-diabetic and had significant carotid and vertebral atherosclerosis. 
Conclusion: Medial midbrain syndromes are characterized by an ipsilateral third cranial nerve palsy and contralateral hemiparesis. Recognition of acute posterior circulation clinical syndromes remains a challenge but is essential for deciding the most appropriate treatment and prevention strategies.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O12

Icon_pdf Download PDF

Oral Presentation


Post stroke movement disorders: a case report - read full article

By: Joana Serôdio, Helena Vilaça, Marta Pereira, Joana Carneiro, and Lurdes Vilarinho

Introduction: Movement disorders can rarely occur in association with stroke, especially if hemorrhagic. They include hyperkinetic and hypokinetic disorders that usually reflect basal ganglia and thalamus damage. Most are self-limiting but symptomatic treatment may be sometimes required.
Case Report: We report the case of a 74-year-old male, mRankin of 0 with obesity, arterial hypertension and diabetes. He woke up with dysarthria and right hemiparesis. His systolic blood pressure at the immediate care admission was 174mmHg and the head CT scan showed a left thalamic intracerebral hemorrhage measuring 10mm. During the stay in the Stroke Unit, he improved his deficits: he had residual dysarthria and was able to walk with a cane at discharge. One week later, he presented involuntary, incapacitating, high-amplitude and irregular movements of the right limbs compatible with hemiballismus. He did not have family history of chorea, his glucose levels, thyroid levels and electrolytes were normal. It was then interpreted as a vascular movement disorder associated with stroke. He was started on haloperidol with a need to uptitrate the dose to 6mg/day. He had a gradual good outcome with an improvement of his choreic movements, which became less intense, despite not having total resolution after 8 months of follow-up. 
Conclusion: This case aims to report the uncommon association of movement disorders and stroke and the importance of an early follow-up. Also, movement disorders can be incapacitating especially when they are an additional deficit after stroke, challenging a proper rehabilitation. Thus, an early identification and prompt start of treatment is crucial.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O13

Icon_pdf Download PDF

Oral Presentation


The ethical challenge of a stroke patient in primary care - read full article

By: Adelino Costa, Tânia Costa, Raquel Patrício, and Sofia Fraga

Introduction: Impaired stroke patients present significant challenges, often with ethical repercussions to the family physician and their relationship with the patient. 
Case Report: A 70-year-old man, with history of hypertension, type 2 diabetes, dyslipidaemia, atherosclerotic disease and poor treatment adherence, suffered a left thalamocapsular ischaemic stroke 8 years ago, initially resulting in right hemiplegia and homonymous hemianopia. He received intensive inpatient rehabilitation, followed by outpatient physical medicine management to present, retaining functional independence, while forced to early retirement and several daily life adaptations. Comorbidities and risk factors have been successfully managed by his family physician since. Recently, he requested clinical information for the renewal of his driving licence. He maintains right hemiplegia (strength grade 3 in forearm and hand), spasticity requiring frequent botulinic toxin treatments and hemiplegic gait, and bilateral corrected 9/10 visual acuity without visual field impairment. Previously attested capable to drive with restrictions, doubts about his ability to drive safely, particularly in stressful events, arose due to lingering motor deficits, ageing and disregard for driving restrictions. The patient reacted anxiously and worried with prospect of driving licence loss. The clinical information requested from physical medicine and rehabilitation was inconclusive. Further evaluation by the disability specialist team eventually reported 66% disability, while advising the maintenance of driving licence with restrictions, which was allowed. 
Conclusion: This case demonstrates the complexity of meeting patient expectations while respecting clinical and ethical responsibilities to him and society. Importance of thorough multidisciplinary evaluation is paramount and family physicians are central to the management of these patients.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O14

Icon_pdf Download PDF

Oral Presentation


When the words don’t come easily: a case of a-a-anomia - read full article

By: Luciana Almeida, Raquel Bastos, Raquel Freitas, and Manuel Sousa

Introduction: About one third of ischaemic strokes in young and middle-aged patients are considered cryptogenic. A patent foramen ovale (PFO) is found in about 50-60% of these and may be the underlying cause in about three quarters, mostly due to paradoxical embolism. 
Case Report: The wife of a 38-year-old man, with no known cardiovascular risk factors, suddenly noticed her husband using a confusing and repetitive speech, with minor memory flaws. Unaware of these symptoms, two days later, he goes to work where his co-workers also notice speech impairments, frequently confusing people’s names. This led her to schedule a medical appointment. After complete examination, anomia was evidenced by semantic paraphasias prompting the diagnosis of motor aphasia and the brain MRI revealed a cortical ischaemic infarct in the territory of the left middle cerebral artery, initiating anticoagulation treatment. A through imaging and analytical study was negative for atherosclerotic lesions, major cardioembolic sources or pro-thrombotic factors but the transoesophageal echocardiogram revealed the presence of a small left-right shunt through the interatrial septum, an atrial septum aneurism and a positive “bubble test” confirming the PFO diagnosis. The PFO was closed percutaneously 8 months later and the patient was discharged with double antiplatelet therapy for secondary prevention. 
Conclusion: Any physician needs to rule out objective deficits since subtle language disturbances may be devalued. It is not easy to prove causality between PFO and cryptogenic stroke, and, therefore, decide the most suitable treatment. In selected patients, especially those with high Risk of Paradoxical Embolism (RoPE) score, PFO closure may be the most beneficial one.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O15

Icon_pdf Download PDF

Oral Presentation


Carotid web, an underdiagnosed cause of young adult ischaemic stroke? - read full article

By: Sofia Tavares, Luisa Fonseca, Goreti Moreira, Carmen Ferreira, Rosa Santos, and Elsa Azevedo

Introduction: A carotid web is a shelf-like linear filling defect in the posterior aspect of the internal carotid artery bulb and thought to represent an intimal variant of fibromuscular dysplasia. It is a rare and frequently misdiagnosed cause of recurrent ischaemic strokes, especially in young adults. 
Case Report: A 38-year-old woman, previously healthy, woke up with dysarthria and left hemiparesis. She arrived at the emergency room two hours later, scoring 5 in NIHSS. Head CT revealed an ischaemic lesion (ASPECTS 5-6) in the right middle cerebral artery territory. Angio-CT showed a thrombus in right M1 segment. She had neurological deterioration with anosognosia and hypoesthesia (NIHSS 9). Mechanical thrombectomy was performed (TICI2B). The catheterization of the right carotid artery revealed a double lumen in the posterior aspect of the carotid bulb, at the moment interpreted as a possible dissection. Carotid ultrasonography revealed hypoechoic stenosis of the right carotid bulb, at the posterior wall, after a shelf-like more echogenic structure, suggesting a thrombus associated with a carotid web membrane. MR-Angiography revealed a thin septum projecting into the carotid bulb lumen. The additional investigation revealed an iron-deficiency anaemia, while the prothrombotic study, EKG and echocardiogram were normal. The patient was anticoagulated and progressively recovered. She was discharged with a minor motor deficit in the left hand and agraphesthesia. After one month on anticoagulation, ultrasound was repeated and the right carotid bulb lesion persisted.
Conclusion: Although there is no pathological confirmation of the diagnosis in this case, the morphological features and the absence of other lesions raise the hypothesis of a carotid web in our patient. The epidemiology, pathophysiology, treatment, and prognosis of carotid web is understudied and thus poorly understood. This case raises awareness of carotid web in young patients who have ischaemic stroke in this territory without any other identifiable causes.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O16

Icon_pdf Download PDF

Oral Presentation


Carotid web: an underrecognized cause of ischaemic stroke - read full article

By: Sofia Xavier, Miguel Quintas Neves, José Manuel Amorim, Margarida Rodrigues, João Soares-Fernandes, Jaime Rocha, João Pinho, and Carla Ferreira

Introduction: Carotid web has been recognized as a possible cause of embolic ischemic stroke, and several studies suggested that the risk of recurrent ipsilateral ischemic stroke during long term follow-up may reach 30%. 
Case Report: A 54-year-old patient with medical history of hypertension and dyslipidaemia presented with speech difficulty with 48 hours of evolution. The only neurological examination finding was motor dysphasia, with non-fluent spontaneous speech and naming difficulty. Non-contrast brain computed tomography (CT) showed hypodensities in the left posterior periventricular white matter, which extended to the cortex in the posterior insular region. Brain magnetic resonance (MR) confirmed a subacute infarction in territory of the left middle cerebral artery and revealed signs of vascular kinking in the distal cervical portion of the left internal carotid artery (ICA) suggesting a vascular dilation. A CT-angiography (CTA) was done to characterize this vascular dilation, and it additionally showed a carotid web on the proximal left ICA. The patient was treated with double antiplatelet therapy. Additional aetiological investigation was negative. We decided to perform carotid artery stenting. 
Conclusion: The prevalence of carotid web is low, but in young patients with cryptogenic ischaemic stroke, this aetiology should be considered, and CTA should be carefully reviewed. The optimal management of patients with carotid web is not established, and some authors suggest that carotid artery stenting may be effective in preventing recurrent strokes. Future studies could help to better understand the factors associated with the thrombogenicity of these lesions and to establish an optimal treatment strategy for each individual patient.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O17

Icon_pdf Download PDF

Oral Presentation


Acute stroke due to bilateral spontaneous carotid artery dissection - read full article

By: Filipa Vilabril, Jorge Rocha Melo, Elza Pires, Lúcia Dias, and Andreia Matas

Introduction: Internal carotid artery dissection (ICAD) accounts for only 1-2% of all ischaemic strokes. It may be traumatic or spontaneous, with multi-factorial aetiology. Most patients with ICAD present with cerebral or retinal ischemic symptoms. Local symptoms such as headache, neck pain and cranial nerve signs (including hypoglossal nerve lesions or Horner’s syndrome) arouse the suspicion of ICAD. Bilateral ICAD at presentation is a rarer event, accounting for approximately 2-10% of all ICADs. 
Case Report: The authors describe the case of a 63-year-old man who was admitted to the emergency department due to abrupt onset of motor aphasia and right-sided hemiparesis (NIHSS 21). He had no significant history of disease or trauma. There were no acute ischaemic lesions on the brain computed tomography (CT). CT-angiography revealed a bilateral ICAD. This diagnosis was later confirmed by magnetic resonance angiography, which also disclosed signs of acute ischaemic lesions in the territory of the left middle cerebral artery. During hospitalization, the patient integrated a rehabilitation program consisting of physical therapy, occupational therapy and speech therapy, with full recovery of the motor deficits. 
Conclusion: ICADs are a noteworthy cause of ischaemic stroke. This case is a reminder that, although bilateral ICAD is a rare event, a high index of suspicion is crucial in order to make the correct diagnosis, especially in the absence of a traumatic event, and even with atypical clinical presentation. The authors highlight the excellent neurological recovery of this patient, who currently has no functional impairment.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O18

Icon_pdf Download PDF

Oral Presentation


Driving ability post-stroke - read full article

By: Ismael Carneiro and Maria João Silva

Introduction: Stroke can lead to a variety of deficits that limit driving activity. However, driving is a frequent goal of patients after stroke. The evaluation of this capacity should be based on clinical evaluation and be complemented with instrument, a driving simulator and psychology evaluation. The authors present a retrospective study, aiming to evaluate a sample of patients with a history of stroke referenced to a specialized outpatient setting with driving ability evaluation. 
Methods: We included all patients diagnosed with stroke between October 2016 and October 2017. Patients were evaluated by a specialist in Physical Medicine and Rehabilitation, by a driving simulator and by Psychology. 
Results: Sample of 50 patients, 70% male, with a mean age of 54 years. The most frequent stroke pathology was ischaemic (78%), followed by haemorrhagic (22%). All patients performed a driving simulator and neuropsychological evaluation. Thirteen patients were not approved for driving. Three of these were approved by psychology but failed the driving simulator. The remaining failed both. Of the approved patients, almost 70% required adaptations (average 4 adaptations). More adaptations were observed in patients with more neuromotor deficits. Adaptations for safety were related with the deficits and the laterality. 
Conclusion: The results of this sample indicate that a considerable percentage of patients after stroke can initiate or resume car driving. However, a large proportion of these patients requires multiple adaptations to ensure safety. For this reason, the authors underline the need of a specialized assessment of driving capacity.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O19

Icon_pdf Download PDF

Oral Presentation


All roads lead to brain: mechanical thrombectomy via the transbrachial approach in a patient with type A aortic dissection - read full article

By: Filipa Proença, Francisco Raposo, João Brandão Madureira, Catarina Campos, Pedro Teotónio, and Lia Neto

Introduction: Endovascular thrombectomy (EVT) has proven to be an effective treatment for proximal occlusions of the major intracranial arteries in stroke patients, improving outcomes. Several risk factors can preclude a traditional transfemoral approach such as vascular anatomy, peripheral vascular disease or aortic dissection. In these situations, alternatives to gain vascular and thrombus access are crucial. We report a case of acute basilar occlusion where a transbrachial approach to revascularization was used due to an aortic dissection. 
Case presentation: A 47-year-old Caucasian male patient, with a previous history of a type A aortic dissection and aortic aneurysm, presented to the emergency department with a basilar occlusion syndrome, with National Institutes of Health Stroke Scale (NIHSS) of 24. In the admission CT scan, the posterior circulation Alberta Stroke Program Early CT Score (PC-ASPECTS) was 10 and CT-angiography revealed a mid-basilar thrombus. There was also a dissection extending between the aortic arch and the left common carotid artery and a right vertebral artery ending in the ipsilateral posterior inferior cerebellar artery. Emergent EVT was performed with stent retriever, using a brachial approach, achieving a thrombolysis in cerebral infarction (TICI) 3 score and an NIHSS of 0. 
Conclusion: Although transfemoral access remains the most frequent approach to acute stroke EVT, if contraindicated, alternative routes should be used to gain vascular access and optimize delivery of thrombectomy devices. Future studies should focus on early and effective triage of patients most likely to require alternative approaches to reduce their morbidity and mortality rates.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O20

Icon_pdf Download PDF

Oral Presentation


MTHFR C677T mutation: a controversial aetiology of cerebral venous thrombosis - read full article

By: Ana Sofia Alves, Marta Lisboa, Luís Marques Loureiro, Andreia Matas, Cristiana Sousa, and Paula Vaz Marques

Introduction: Cerebral venous thrombosis (CVT) is a rare neurological illness that represents 0.5-1% of all strokes and is more common in young women. The major risk factors are prothrombotic conditions, oral contraceptives, pregnancy, malignancy and infections. Headache is the most frequent symptom but seizures, nausea, vomiting and focal deficits can also be present. Imaging is fundamental for its diagnosis. 
Case Report: A 57-year-old man with hypertension presented at the emergency room, for the second time, with headache initiated 4 days before with increasing intensity. Initially, headache was frontal with orbital irradiation and then occipital to cervical accompanied by nausea and vomiting. There was no history of trauma or infection. Vital signs, physical and neurological examination were normal. The investigation revealed: blood count, electrolytes, kidney and hepatic function with no abnormalities; D-dimers 0.74 ug/ml and brain computed tomography and magnetic resonance showed CVT of the superior sagittal sinus, straight sinus and right sigmoid sinus and anticoagulation was started. An extensive diagnostic workup was made during hospitalization with no underlying aetiology or risk factor identified. Prothrombotic study was performed 6 months after treatment and showed normal levels of homocysteine, antithrombin III, protein C and S, factor V Leiden, fibrinogen, D-dimers, anti-cardiolipin antibodies and lupus anticoagulant. Genetic testing for mutations in the prothrombin gene (G20210A) and methylenetetrahydrofolate reductase (MTHFR) gene (C677T) revealed homozygous mutation in the last one. 
Conclusion: The diagnosis of CVT is still a challenge to physicians due to the great variety and lack of specificity on clinical presentation. Based on the aetiological study, it was assumed that the CVT was due to homozygous mutation of the MTHFR gene although there were normal levels of homocysteine, folate and cobalamin. The authors highlight the diagnostic challenge and emphasize the importance of the workup in a disorder with myriad causes. Although some controversy on literature exists, there are reports where the MTHFR C677T polymorphism was associated with CVT.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O21

Icon_pdf Download PDF

Oral Presentation


Stroke as presenting symptom of neurosyphilis: a case report - read full article

By: Margarida Matias and José Lopes

Introduction: Syphilis is an infectious disease caused by Treponema pallidum and it is transmitted sexually. It affects various organs and its clinical manifestations can be intriguing. The central nervous system is affected in less than 10% of patients with syphilis.
Case Report: A 43-year-old Caucasian woman presented in the emergency room with right hemiparesis. Apart from smoking, she had no relevant history. There was no family history of stroke. MRI showed an ischaemic lesion on the left side of the brainstem. Because there was no clear cause for stroke, we performed additional tests, including a lumbar puncture. It showed a positive VDRL and the diagnosis of neurosyphilis was made. 
Conclusion: The patient was treated with benzylpenicillin and made a good recovery.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O22

Icon_pdf Download PDF

Oral Presentation


Malignant cerebellar stroke: two cases with a good outcome - read full article

By: Catarina Faria, Sérgio Brito, Nuno Ferreira, Ana Loureço, and Luís Campos

Introduction: The vertebrobasilar arterial system supplies blood to the posterior part of the cerebral hemispheres, including the occipital lobes and the posterior portions of the temporal lobes, the cerebellum, and the brainstem. Occlusion of large vessels in this system frequently leads to malignant strokes with major disability or death. 
Case Reports: Case 1: a 71-year-old woman with known cardiovascular risk factors presented to the emergency room with disorientation and hallucinatory speech. CT showed recent ischaemic lesion of the right cerebellar cortex. Under surveillance there was neurological deterioration with Glasgow Coma Scale (GCS) of 13 and the CT at 24 hours showed a greater ischaemic area with mass effect and herniation. She was submitted to suboccipital decompressive craniectomy (SDC) achieving a very good outcome with a National Institutes of Health Stroke Scale (NIHSS) score of 1 at discharge. Case 2: a 39-year-old man experienced an acute onset of visual disturbance and subsequently altered mental status with a GCS of 12 and anisocoria. The CT showed an acute ischaemic left cerebellar lesion with mass effect and compression of the IV ventricle. SDC was performed with a good outcome and the patient presented an NIHSS of 1 at discharge. 
Conclusion: Malignant cerebellar strokes are associated with poor outcomes and high mortality, due to infarct swelling with subsequent brainstem compression and herniation. Early detection of rapid neurological deterioration and prompt SDC is crucial for better outcomes.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O23

Icon_pdf Download PDF

Oral Presentation


Haemorrhagic stroke as a first presentation of primary aldosteronism - read full article

By: Rui Osorio, Ramiro Sá Lopes, Teresa Salero, Catarina Frias, Catarina Mendonça, and António Moura

Introduction: Intracerebral haemorrhage (ICH) is the most devastating and disabling type of stroke. It is known that hypertension is the primary risk factor for ICH and its treatment is highly effective in the prevention of stroke. Secondary hypertension represents a small proportion of hypertension aetiology in adults. However due to its appropriate specific treatment, attention should be paid. Primary aldosteronism (PA) may occur in 3-10% of hypertensive patients and it is known that PA has an increased risk of cardiovascular and cerebrovascular complications and an increased rate of metabolic syndrome when compared with patients with primary hypertension. 
Case Report: A 54-year-old male, with previous history of hypertension, presented at the emergency department with history of frontoparietal headache, periods of mutism alternating with speech impairment and right-side muscle weakness. Brain computed tomography (CT) scan showed an intracerebral haemorrhage in the left temporal lobe. From the aetiological study, hypokalemia and hyperglycemia were found, together difficult-to-control hypertension and an elevated aldosterone/renin ratio. Due to a suspicion of hyperaldosteronism, an abdominal CT scan was performed, and a nodular formation was detected in the left adrenal gland. Hypertension was controlled with high doses of anti-hypertensive medication including mineralocorticoid antagonists. The patient was discharged with no symptoms and referred to endocrinology consultation. 
Conclusion: Prevalence of PA is not low among acute stroke patients and due to its increased risk of cardiovascular, cerebrovascular and metabolic syndrome complications, its early diagnosis and treatment are important particularly in ICH patients.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O24

Icon_pdf Download PDF

Oral Presentation


Sudden-onset hemichorea: the importance of differential diagnosis - read full article

By: Ana Rita Silva, Inês Carvalho, Miguel Neves, José Manuel Amorim, Filipa Sousa, João Pinho, and Carla Ferreira

Case Report: A 73-year-old woman with prior history of systemic lupus erythematous (SLE), hypertension, dyslipidaemia, smoking and renal cysts was admitted to the emergency department with a two week history of sudden-onset right-sided involuntary movements. Previous medication included hydroxychloroquine, losartan, hydrochlorothiazide, amlodipine and atorvastatin. Neurological examination revealed right-sided choreiform movements involving the tongue, face and right upper and lower extremities. Extensive laboratory tests revealed positive VDRL and TPHA blood tests, and CSF was normal (namely negative VDRL and TPHA). Brain magnetic resonance (MR) found no recent ischaemic or inflammatory lesions, however MR-angiography showed reduced flow on the left intracranial internal carotid artery (ICA). Computed tomography angiography and Doppler ultrasound confirmed a >70% atherosclerotic left ICA stenosis. Right-sided hemichorea gradually improved after initiation of haloperidol. The patient underwent ICA stenting with angioplasty. At one-month follow-up, slight right-sided choreiform movements of the right upper extremity persisted, with low-dose haloperidol. 
Discussion: Sudden-onset hemichorea may have several causes, of which the most frequent are stroke and nonketotic hyperglycaemia, which were excluded in our patient. Likewise, neurosyphilis was excluded in this patient. ICA stenosis has been suggested as a cause of acute contralateral hemichorea, and some authors have reported patients in whom the involuntary movements completely resolved after carotid revascularization. The hemichorea improvement in our patient was probably related to haloperidol, as there was no significant improvement after carotid revascularization. We suggest that the cause of hemichorea in this patient was SLE and discuss the complexity of the differential diagnosis of hemichorea.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O25

Icon_pdf Download PDF

Oral Presentation


The penumbra of fleeting neurological symptoms: a case of thrombectomy over 6 hours after symptom onset - read full article

By: Margarida Bela, Ana Sardoeira, Carlos Andrade, and José Pedro Rocha Pereira

Introduction: Short-term episodes of neurological dysfunction resulting from focal cerebral ischemia are classically defined as transient ischemic attacks (TIA), while a new infarct on imaging defines stroke. Plain head CT is still the modality of choice in the hyper-acute phase, while advanced imaging - CT-angiography and CT-perfusion - are performed in select centres. We report a case of stroke which highlights the usefulness of advanced imaging. 
Case Report: A 69-year-old woman with hypertension, dyslipidaemia and colic adenocarcinoma in remission presented at another institution complaining of dysarthria and left hemiparesis, which had lasted for 2 hours. Upon evaluation, her neurological exam was reportedly normal, and the brain CT was unremarkable. She was discharged after 12 hours of surveillance without symptom recurrence. Eight hours later, symptoms recurred; she scored 5 on the NIHSS due to dysarthria, hemihypesthesia and left hemiparesis (G4/5). CT-angiography showed a right M2 occlusion and she was transferred for mechanical thrombectomy. Repeat CT ASPECTS was 10. CT-perfusion showed no ischaemic core and a hypoperfused area, centred in the Rolandic region, corresponding to an area of ischaemic penumbra. Mechanical thrombectomy was performed 9 hours after symptom onset. She scored 0 on the NIHSS 24h after the procedure, and the inpatient follow-up was uneventful. No definite stroke aetiology was found, despite comprehensive investigation. 
Conclusion: This case illustrates the TIA-stroke continuum and the importance of early advanced imaging in the setting of the recently published stroke guidelines.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O26

Icon_pdf Download PDF

Oral Presentation


Recurrent stroke in a young adult: a difficult case - read full article

By: Cristina Ionel, Joana Morgado, Ana Ribeiro, and Liliana Pereira

Introduction: Stroke aetiology more often remains undetermined in younger than in older adults. Incomplete investigation and a wider variety of aetiologies could be contributors. 
Case Report: A 26-year-old female, with history of Raynaud phenomenon, chronic anaemia, hormonal contraceptive use and vegetarian diet, presented with sudden onset of visual difficulties and transitory right upper arm paraesthesia. On examination, there was evidence of right superior homonymous quadrantanopia. Brain MRI showed acute ischaemic lesion of the left posterior cerebral artery territory with occlusion of the P2 segment on MR angiography. Further investigation revealed: severe iron deficiency, protein S deficiency, positive anti-nuclear and anti-ribonucleoprotein antibodies, bilateral pulmonary thromboembolism and alpha-galactosidase A low activity. Exams were negative for right-to-left shunt, cardiac disorder, vasculopathy, neoplastic or infectious aetiology. A diagnosis of undifferentiated connective tissue disease was established. On the 8th day of hospitalization, there was sudden clinical deterioration with slight aphasia, right-sided mild paresis and hypoesthesia. Brain MRI revealed another acute cortical ischaemic lesion of the left medial cerebral artery territory. The patient was discharged under anticoagulation treatment with pending genetic results (protein S deficiency and Fabry disease). 
Conclusion: We present a challenging case of recurrent stroke in a young adult female with concomitant pulmonary thromboembolism without right-to-left shunt. Several factors could be contributing to the aetiology (hormonal contraceptive use, protein S and iron deficiencies, connective tissue disease). This case illustrates the complexity of determining the cause of stroke in young adults and the need of extensive diagnostic workup to best direct the treatment.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O27

Icon_pdf Download PDF

Oral Presentation


From cardioembolic to atheroembolic stroke: challenges of triple antithrombotic therapy - read full article

By: Manuel Barbosa, Helena Vilaça, Vítor Costa, Manuel Ribeiro, Sérgio Castro, and Amélia Mendes

Introduction: The introduction of triple antithrombotic therapy on an elderly patient is always an arduous decision to make, particularly if the patient is a Jehovah’s witness. In the event of a much needed carotid revascularization, it might be the only choice. 
Case Report: An 88-year-old male was admitted to our stroke unit. During the previous year he had multiple cerebrovascular events—the first was a cardioembolic stroke (right anterior circulation) due to atrial fibrillation (AF), from which he fully recovered. Rivaroxaban was introduced. Two right carotid artery territory transient ischemic attacks (TIAs) followed, and acetylsalicylic acid was added, as the patient had mild bilateral internal carotid artery (ICA) stenosis. On the event of a third TIA of indeterminate aetiology, anticoagulation was switched to apixaban and a new carotid study was obtained. It showed moderate right ICA stenosis and severe left ICA stenosis (>90%). Shortly after, he was admitted with new onset motor aphasia. During hospitalization, episodes of haemodynamic cerebral hypoperfusion were observed. After multidisciplinary discussion, triple antithrombotic therapy was started and left ICA stenting was scheduled. In the first month post-stenting, apixaban dose was reduced. After a month, clopidogrel was stopped and apixaban returned to full dose. 
Discussion: This case presents the great variability and complexity of cerebrovascular disease and its aetiologies —cardioembolic, atheroembolic and haemodynamic hypoperfusion syndrome. There are no guidelines on how to manage these cases, and so the team decided on a strategy similar to the one used in coronary stenting in the presence of AF.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O28

Icon_pdf Download PDF

Oral Presentation


A prothrombin mutation and hormone replacement therapy: a dangerous combination - read full article

By: André Silva Costa, Andreia Ramalho, Andreia Castro, Catarina Avillez, and Anabela Bitoque

Introduction: The prothrombin G20210A mutation is the second most common inherited thrombophilia after the factor V Leiden mutation. Transmission is considered to be autosomal dominant. The combination of the mutation and other acquired risk factors such as hormonal contraceptive use increases the risk of cerebral vein thrombosis (CVT). 
Case Report: A 41-year-old woman, with a personal history of obesity, hormone replacement therapy for early menopause and depressive syndrome, presented to the emergency department with a new onset of right unilateral headache, intensity of 10/10, associated with prostration, vomiting and increased blood pressure (175/115 mmHg). Brain computed tomography showed "...right temporal-parietal heterogeneous lobar haemorrhagic lesion with surrounding vasogenic oedema...". She also performed an angio-CT and angio-MR which confirmed a diagnostic hypothesis of haemorrhagic vascular lesion secondary to venous sinus thrombosis. She was admitted with diagnosis of haemorrhagic stroke secondary to thrombosis of sigmoid and transverse right sinus. The aetiological investigation identified the existence of heterozygosity for prothrombin mutation (G20210A variant) and hyperfibrinogenaemia (545 mg/dL). The patient was informed about the treatment options and decided to use long-term oral anticoagulation with rivaroxaban. 
Conclusion: This case deals with an intracerebral haemorrhage in a young woman. The aetiology of the event was multifactorial, related with the use of hormone therapy, hyperfibrinogenaemia, heterozygosity for prothrombin mutation (G20210A variant) and obesity. The clinical presentation of venous sinus thrombosis is highly variable. Headache is the most frequent symptom, occurring in almost 90% of patients, with or without vomiting, papilledema, and visual complaints.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O29

Icon_pdf Download PDF

Oral Presentation


Lateral medullary syndrome: a case report - read full article

By: Raquel Costa, Mariana Agre, and Sara França

Introduction: Twenty percent of ischaemic events in the brain involve posterior circulation structures. Of those, the lateral medullary syndrome, also known as Wallenberg Syndrome, is the most common syndrome related to intracranial vertebral artery occlusion. Symptoms include ipsilateral facial sensory loss, impairment of pain and temperature sensation of the contralateral side of the body, ipsilateral Horner syndrome, ataxia, nystagmus, dysphonia and dysphagia. However, variability in the presentation of this syndrome is the rule. 
Case Report: We describe a case of a 44-year-old male who was diagnosed with gastroenteritis in the emergency department after having experienced nausea, vomiting and non-specific difficulty of swallowing, with acute onset. Two days after being discharged, the patient returned to the emergency department due to progressive worsening of the complaints. He presented complete inability to swallow and lack of balance. Magnetic resonance imaging and cranial computed tomography confirmed the diagnosis of lateral medullary syndrome. 
Conclusion: Lateral medullary syndrome is often missed by non-neurologists, leading to a delay or even loss of clinical window for treatment. It is important to be able to recognize the clinical features and raise awareness for this less common form of stroke.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O30

Icon_pdf Download PDF

Oral Presentation


When a stroke diagnosis becomes a headache - read full article

By: Maria João Pinto, Paulo Chaves, and Marta Carvalho

Introduction: The aetiology of acute neurological deficits that present in the emergency department is not always straightforward. Ischemic aetiology implies specific management strategies that may carry risks in case of misdiagnosis. 
Case Report: A 90-year-old female patient with frequent migraine with prolonged aura, paroxysmal atrial fibrillation (under dabigatran 110mg bid) and hypertension, was brought to the emergency department in the evening with behavioural changes, headache and vomiting with five hours of evolution. On neurological exam, she was agitated, behaving as if she had a global aphasia; a minor right central facial paralysis and right visual field defect were suspected (NIHSS 11). Brain CT scan showed no evidence of acute ischaemic or haemorrhagic lesions; CT-angiography showed no vessel occlusion. Blood analysis was unremarkable apart from a raised aPTT (71s). The ECG showed sinus rhythm. Thrombolysis was contraindicated due to time window and anticoagulation, and thrombectomy was not performed since there was no evidence of thrombus. On the following morning, she had fully recovered and insisted that the symptoms were similar to previous migraine attacks. Brain MRI showed chronic lacunar ischaemic lesions and mild leukoencephalopathy. Electroencephalogram showed no epileptiform activity. Considering the absence of acute ischaemic lesions and major vessel occlusion in an adequately anticoagulated patient, the normal EEG and the fact that the complaints resembled her previous migraine episodes, migraine with aura was considered the most likely diagnosis. Prophylactic therapy was started.
Conclusion: This case highlights the complex decision-making process when dealing with older patients with multiple comorbidities and possible differential diagnosis.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O31

Icon_pdf Download PDF

Oral Presentation


Multiple looks of cerebral vasculopathy after brain tumour irradiation: two case reports - read full article

By: Verónica Cabreira, João Pedro Filipe, Ana Monteiro, Luísa Fonseca, António Vilarinho, and Pedro Abreu

Introduction: Radiation-induced vasculopathy is a potential long-term complication after brain irradiation. The association between radiotherapy and stroke has been well documented, although it is a challenging diagnosis. We report two patients with different vascular events 20 years after radiotherapy. 
Case Reports: A 43-year-old woman was admitted, in February 2016, due to a cortical infarction in the right middle cerebral artery territory. In November 2017, she seeks medical attention once more for new-onset of left-sided hemiparesis along with tonic-clonic seizures. A new MRI disclosed previous ischaemic lacunar lesions in the right thalamus and corona radiata. The patient had undergone surgery and radiotherapy (46Gy) for an astrocytoma 20 years earlier, raising the hypothesis of radiation-induced vasculopathy. A 36-year-old woman, with moyamoya syndrome secondary to radiotherapy for a craniopharyngioma more than 20 years ago, presented with wake-up confusion after being seeing well the night before. A left “carotid T” occlusion and an area of penumbra in the left middle cerebral artery territory were observed. The patient had an NIHSS of 6 due to dysarthria and right hemiparesis when upright, and mechanical thrombectomy was attempted. On discharge, she was referred to neurosurgery for consideration of surgical revascularization. 
Conclusion: Head and neck radiotherapy is an underrecognized risk factor for cerebrovascular disease and careful follow up is necessary. Our second case highlights the broad controversy concerning endovascular reperfusion therapy in patients with moyamoya syndrome, since it is typically associated with increased haemorrhagic risk.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O32

Icon_pdf Download PDF

Oral Presentation


Infectious stroke - read full article

By: Laura Bonito Moreira, Carla Maravilha, Tiago Pacheco, Maria do Carmo Fevereiro, Ana Paiva Nunes

Introduction: Infective endocarditis (IE) is an entity with high morbidity and mortality. The occurrence of acute neurological events is not negligible and can lead to serious complications. 
Case Report: We present a 77-year-old man, with history of heart failure due to hypertensive, ischaemic and valvular heart diseases, submitted to coronary artery bypass graft and implantation of a biological aortic valve six months earlier. He was hospitalized due to acute pyelonephritis. On the first day of hospitalization, he presented with syncope and left hemiparesis. The in-hospital stroke response team was activated, and acute occlusion was documented in the territory of the right middle cerebral artery. The patient underwent thrombectomy and thrombolysis with almost total recanalization, maintaining, however, left hemiparesis and ipsilateral hemineglect. From the complementary study, we highlight Enterococcus faecalis bacteraemia; carotid ultrasonography with diffuse atheromatous infiltration and transcranial doppler with a lesion distal to the right middle cerebral artery; Holter and serial electrocardiography in sinus rhythm, transthoracic echocardiography suggesting presence of a vegetation in the biological aortic valve prosthesis, which was confirmed by transoesophageal echocardiography. IE of a complicated biological prosthesis with no surgical indication was assumed. There was good clinical and echocardiographic response to antibiotics.
Conclusion: This clinical case aims to highlight the importance of the aetiological study of stroke and of early detection of potentially treatable causes. The medical treatment of IE must always be performed, and surgery is reserved for cases with haemodynamic instability, acute valve failure and occurrence of embolic phenomena under antibiotic therapy.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):O33

Icon_pdf Download PDF

Guest Editorial


Comprehensive stroke management: a new window of opportunity - read full article

By: Luís Braz, Ricardo Soares-dos-Reis, Marta Carvalho, and Elsa Azevedo

Cerebrovascular disease is one of the major contributors for global mortality and morbidity and the leading cause of mortality in Portugal. Education for patients and healthcare professionals in this area cannot be overemphasized and it is the key to reduce disease burden in future years. This is the moto of this course: from ischaemic to haemorrhagic stroke, from hyperacute to chronic management, from physician to patient, our aim is to provide an overview of comprehensive stroke management. Recent breakthroughs in selection of patients for hyperacute therapy of ischaemic stroke have shifted the concept of a time-based window to an individualized one, while keeping the general “time is brain” concept. Furthermore, primary and secondary prevention approaches for ischaemic cerebrovascular disease have witnessed advances towards a more tailored approach (e.g. dual antiplatelet therapy, prolonged cardiac monitoring, and diversified anticoagulation regimens). Since cerebrovascular disease care is considerably more than its acute management, we also focus on the continuum of care that goes beyond the stroke unit, with perspectives from acute to chronic rehabilitation, nursing and palliative care specialists. Multidisciplinary care impacts health outcomes in stroke patients. Therefore, we bring together diverse healthcare professionals from different institutions so we can align our views, with expert contributions from Neurology, Family, Internal, Intensive Care and Rehabilitation Medicine, Neurointervention, Neurosurgery, Cardiology and Imunohemotherapy. Furthermore, in this years’ course we continue to welcome the Portuguese stroke support association as part of the integrated stroke care management. In keeping with the moto of education, we provide four different workshops touching different facets of stroke patient’s management, from critical patient monitoring to endovascular stroke treatment. Highlights from the “Action Plan for Stroke in Europe 2018-2030” will be presented to include and motivate all participants in a common goal for the forthcoming years. In this year’s course, we have also expanded the time available for oral presentations and case discussion. We feel honoured by the quality, quantity and diversity of submitted presentations, a sign that stroke healthcare professionals share our enthusiasm in this era of great changes but also great opportunities to improve stroke care.

From the Porto University Center of Medicine Stroke Update Course, Porto, Portugal. 26–27 June 2018.

International Journal of Clinical Neurosciences and Mental Health 2018; 5(Suppl. 2):S1

Icon_pdf Download PDF