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Stroke Care 2.0: updating and moving beyond hyperacute stroke care - read full article

By: Ana Aires, Ricardo Soares-dos-Reis, Marta Carvalho, and Elsa Azevedo

In an era of constant significant changes in stroke therapy, where medical treatments continue to be optimized and multiple large randomised controlled clinical trials support mechanical thrombectomy, we also must focus on patients best medical and social care once they are discharged from the stroke unit. We believe continuity of care impacts health outcomes in this patient population. Inpatient and outpatient care should be part of the same integrated stroke care pathway, with contributions from Neurologists, Internists, Primary Care Physicians, Physical Medicine and Rehabilitation, Public Health Physicians, Nurses, Physical and Speech Therapists, Neuropsychologists, Social Service professionals, etc. Our goal is to foster this view of integrated stroke care. Thus, in our annual course, we bring together those healthcare professionals so we can align our views and contribute to a consistently high level of quality in stroke care. In this process, rehabilitation assumes a prominent role. We feel it should begin as soon as possible and that treatment plans should be regularly reviewed, lest we lose the health gains brought by the acute therapies. In this issue, we focus on primary and secondary prevention of stroke, namely new antiplatelet drugs, anticoagulation after stroke and novel data regarding intracranial atherosclerosis. We also highlight the importance of an organized stroke care infrastructure to achieve better results. An update on endovascular treatment will be followed by interesting interventions approaching several themes, such as intracerebral haemorrhage and special populations. The relevance of an early rehabilitation will be put in the spotlight. Its role in spasticity, the importance of music therapy in language disorders and the several tools available during the period of hospitalization, including dysphagia screening and treatment, will deserve special consideration. Last, but certainly not least, we would like to give a warm welcome to the presence, for the first time, of patient associations in this course. It is definitely a further step in the right direction for truly providing a continuum of care.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):S1

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Lecture


The most efficacious strategies for tobacco cessation - read full article

By: Ricardo Moreira

During recent years, there have been many advances in different types of pharmacological and non-pharmacological tobacco cessation treatments. Varenicline, Nicotine Replacement Therapies (NRT) and Bupropion, are the most supported ones, and, in combination with educational strategies, seem to have better results. Although the safety of these pharmacologic treatments for smoking cessation in patients with cardiovascular (CV) disease has yet to be definitively established, until now, studies suggest that there is no significant increase in CV risk.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L1

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What is the current role of the new antiplatelet agents or double antiplatelet therapy in stroke prevention? - read full article

By: Paulo Castro Chaves

Stroke is one of the main causes of death and neurological disability and is also a major cause of dementia and age-related cognitive decline in the adult. Guidelines recommend urgent assessment and treatment of stroke patients, including risk factor control, carotid endarterectomy or stenting, and immediate oral anticoagulation for documented atrial fibrillation or aspirin therapy for most other cases. The International Stroke trial (IST) found that acute ischemic stroke patients who received 300 mg of aspirin within 48 h of experiencing symptoms had significant reductions (3.9% vs 2.8%) in recurrence of ischemic stroke as evaluated over a period of 14 days. Emerging studies suggest that early administration of dual antiplatelet therapy may be better than monotherapy for prevention of early recurrent stroke and cardiovascular outcomes in acute ischemic stroke and transient ischemic attack (TIA). There is also ongoing research on novel antiplatelet agents, with the aim of decreasing recurrent stroke rates as well as bleeding events. In fact, few randomized trials have tested aspirin directly against other antiplatelet agents for the treatment of ischemic stroke or TIA in the acute period. However, in the SOCRATES trial of over 13,000 subjects with acute ischemic stroke or TIA, ticagrelor monotherapy was not significantly better than aspirin monotherapy (both started within 24 hours of symptom onset) for the 90-day composite endpoint of stroke, myocardial infarction, or death. There are new developments expected in the shortcoming that address future possibilities for antiplatelet treatment for ischemic stroke and that may ultimately contribute to risk reduction. All these aspects will be reviewed in the current presentation.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L2

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Intracranial atherosclerosis: what’s new? - read full article

By: Marta Carvalho

Intracranial atherosclerosis is a major cause of stroke worldwide, especially in Black, Asian and Hispanic populations. It affects more often the middle cerebral and basilar arteries and may coexist with cervical atherosclerosis. Modifiable risk factors are common to other locations of atherosclerosis, namely hypertension, diabetes mellitus, hyperlipidaemia, smoking, metabolic syndrome, and physical inactivity. The possible mechanisms for stroke related to intracranial atherosclerosis are artery-artery embolism or in situ occlusion due to thrombosis over a pre-existing atherosclerotic plaque; distal hypoperfusion; and/or occlusion of the origin of small perforating arteries. It is necessary to establish a correlation between clinical syndromes and infarct patterns in neuroimaging in order to understand the underlying mechanism, since they have different recurrence rates and responses to treatment. Although the gold standard for diagnosis is cerebral angiography, non-invasive or minimally invasive methods such as transcranial Doppler, computed tomography angiography or magnetic resonance angiography, are usually enough in clinical practice. High–resolution magnetic resonance imaging may be useful in the identification of high-risk atherosclerotic plaques. The risk of stroke recurrence in patients with intracranial atherosclerosis is very high, especially in the first month and for stenosis between 70-99%. Although endovascular treatment has been widely used, clinical trials have shown that medical treatment alone, consisting of antiplatelet drugs and aggressive modification of vascular risk factors, is more efficient in reducing the risk of stroke recurrence and mortality. Physical exercise should be particularly encouraged. In recently symptomatic stenoses, the combination of aspirin with clopidogrel should be used for 3 months followed by antiplatelet monotherapy. Despite aggressive medical treatment, some patients still have a high risk of stroke recurrence, and, currently, there are still many uncertainties concerning the management of these patients.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L3

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Reversal of anticoagulation of NOACs in patients with acute stroke - read full article

By: Luciana Ricca Gonçalves

Management of patients taking Novel Oral Anticoagulants (NOACs) and acute stroke is challenging. The risk of intracranial haemorrhage (ICH) is reduced in patients treated with NOACs compared with patients treated with vitamin K antagonists (VKAs). However, the prognosis of ICH associated with anticoagulation is always poor, with high mortality rate, especially in patients with haematoma expansion. The occurrence of ICH requires prompt interruption of anticoagulation, regardless of the underlying thromboembolic risk of the patient. The coagulation status of patients receiving NOACs with ICH must be evaluated and corrected as soon as possible. The current treatment of an acute ICH occurring during treatment with factor Xa inhibitors (FXaI) – apixaban, edoxaban, rivaroxaban - is based on experience with ICH associated to VKAs: administration of coagulation factors concentrates, namely as prothrombin complex concentrate (PCC), activated PCC, activated factor VII. However, the efficacy and safety of coagulation factors are not well documented. Andexanet alfa, an FXaI reversal agent, is currently being evaluated in patients with acute major bleeding, including ICH. In patients treated with dabigatran, idarucizumab, a specific reversal agent for dabigatran, is recommended as first line therapy. If not available, coagulation factor concentrates should be administered. Haemodialysis can also be considered in patients with dabigatran-associated ICH and renal insufficiency, as a rescue therapy. If the last intake of NOAC was less than 6 hours ago, oral activated charcoal can be given to reduce absorption. In patients with acute ischemic stroke (AIS), systemic thrombolysis is the most effective medical therapy, though associated to a significant increase in ICH rate. Prior anticoagulation is a contra-indication for thrombolysis. The last recommendation of AHA states that thrombolysis should not be administered to patients who take NOACs, unless sensitive tests are normal and the patient took the last dose >48 hours prior. However, since the approval of idarucizumab, several reports have been published about its use in patients taking dabigatran with AIS before systemic thrombolysis and the results are very promising. Mechanical thrombectomy can be an option for some anticoagulated patients with AIS.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L4

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Lecture


Anticoagulation after stroke: how soon is too late? - read full article

By: Ricardo Soares-dos-Reis and Pedro Castro

Anticoagulation is the mainstay of long term therapy for the primary and secondary prevention of cardio-embolic ischaemic stroke. However, when the patient presents with an ischaemic or haemorrhagic stroke, and is a candidate for long-term anticoagulation, the issue of when to start anticoagulation arises. The delicate balance between the risk of a new embolic event and the risk of haemorrhage of an ischaemic lesion/new haemorrhage shifts as time from the index event passes. Therefore, there should be an optimal cut-off point, where the risk of a new event clearly offsets the risk of bleeding and where introducing anticoagulation would be clearly advantageous. Unfortunately, there is no good-quality evidence regarding the optimal timing of anticoagulation in acute stroke therapy. 
Current atrial fibrillation guidelines favour decision on a case-by-case basis. Regarding ischaemic stroke, factors such as presenting National Institutes of Health Stroke Scale (NIHSS), infarct extension on computed tomography (CT) images, perceived recurrence risk, clinical stability, age, blood pressure control and need for surgery should be taken into account, together with repeat CT before starting anticoagulation, preferably with a novel oral anticoagulant. Anticoagulation can generally be introduced 1 to 12 days from stroke onset [1 day for transient ischaemic attack, and 3, 6 or 12 days for mild (NIHSS<8), moderate (NIHSS 8-15) or severe (NIHSS>15) stroke, respectively]. On the other hand, for haemorrhagic stroke, the factors leading to bleeding, such as blood pressure control, anticoagulant dosing and blood levels, embolic risk, alcohol consumption and prior bleeding history, should be carefully examined to decide whether the patient is a candidate for resuming anticoagulation. If so, anticoagulation can be started 4-8 weeks after stroke onset. 
At the time of writing, there are multiple ongoing clinical trial such as RASS, DATAS II, START, ELAN, RELAXED and APACHE-AF which are trying to compare early versus late initiation of anticoagulation after stroke, and will certainly provide better quality evidence supporting or disproving current guidelines. 

This lecture will cover current guidelines, observational data and ongoing clinical trials in an effort to answer the question of how soon is too late to start anticoagulation after stroke.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L5

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Strategies for a new dynamic in stroke management - read full article

By: Elsa Azevedo

Although a significant improvement has occurred in stroke patient’s approach, it is still a heavy burden in the Portuguese public health. Along with the efforts regarding primary prevention measures, the acute stroke care must be a focus of health care organization. Recent advances in ischaemic stroke treatment, namely using mechanical thrombectomy, have allowed a significant increase in the number of stroke patients who are independent in their daily activities at 3 months after stroke. As the acute management with thrombolytic and thrombectomy treatment is only helpful if undertaken very early after symptom onset, a finely tuned organization is crucial to achieve the best results. All the steps of the chain of acute stroke care are important to its global efficacy, and therefore all of them should be optimized. The population should be better informed about the stroke alarm signals and instructed to dial 112 immediately. Both the pre-hospital and intra-hospital emergent pathways must increase their efficacy to allow stroke patients to be identified and timely treated. With the development of the interventional neuroradiology centres a new challenge emerged with the necessity to easily and rapidly communicate and transfer CT scan images, and to transfer patients from other hospitals to these centres. A better organization of this system is urgent. The inclusion criteria for stroke code activation, for intravenous thrombolysis and for mechanical thrombectomy must be standardized among all the institutions with a role in acute stroke management. Telemedicine has been proven to enhance stroke treatment efficiency, helping the development of stroke teams in smaller hospitals and allowing an increase in the number of patients treated with more effective approaches. It is time to also implement telemedicine in our region. With the multiplicity of professionals and institutions involved in the stroke code chain and given its huge importance for population healthcare, it is indispensable to have a robust database behind a platform with epidemiologic and logistic indicators that allow quality evaluation and monitoring, and to implement measures to optimize the results. The parameters should be automatically collected from the stroke code pathway, and therefore should be systematically registered. A feedback to the main professional agents of this stroke code pathway is essential. They should have access to the whole pathway data, and they should be active in their contribution to organizing these systems.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L6

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Lecture


Criteria for the endovascular treatment of brain vascular malformations - read full article

By: Luís Cardoso

Brain Arteriovenous Malformations (AVMs) are abnormalities of the intracranial vessels regarding a connection between the arterial and venous systems without an intervening normal capillary bed. Patients with AVMs are at a lifelong risk for haemorrhagic strokes (1.4% to 2% of all haemorrhagic strokes), but their natural history, especially for those unruptured, is still poorly understood. When symptomatic, they can present with intracranial haemorrhage, seizures, headaches or other focal neurologic deficits unrelated to haemorrhage that can be due to vascular steal phenomenon and/or venous hypertension. AVMs can be graded according to size, location and pattern of venous drainage. The gold standard for diagnosis of AVM is cerebral angiography; however, the evolution of non-invasive imaging has helped with the detection of AVMs and the proportion of AVMs diagnosed still unruptured has almost doubled over the past decades, which now brings new challenges regarding their management. Prior haemorrhage, deep AVM location, exclusively deep venous drainage and associated aneurysms constitute significant risk factors for AVM haemorrhage. Previous series demonstrated an overall annual haemorrhage rate of 3.0% for AVMs, the annual re-bleeding rate as 4.5% and at least 6% in the first year after haemorrhage. Today, different management options are available for AVMs, such as medical management alone, microsurgical resection, stereotactic radiosurgery and endovascular embolization. Management of these lesions is complicated by the fact that AVMs form a very heterogeneous group of lesions, with variable locations, morphologies and angioarchitecture, imparting different risk of haemorrhage for each patient and, thus, requiring individualized treatment decisions. Also, the risks associated with treating a given AVM patient vary and must be weighted individually against the natural history of haemorrhage anticipated in that particular patient. The appropriate management of patients with AVMs can therefore range from simple observation to aggressive multimodality approach aimed at total AVM obliteration.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L7

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Lecture


Mechanical thrombectomy: technique and results - read full article

By: Luís Augusto

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. The approaches to a mechanical resolution of the occlusion have also evolved. Following the 2013 “unhappy” trials, MR CLEAN has been the first randomized controlled trial to demonstrate the superiority of mechanical thrombectomy plus intravenous thrombolysis over the best medical treatment option. Many other trials have since done the same. Stent-retrievers are considered the preferred option for mechanical thrombectomy, although aspiration techniques are evolving becoming progressively more effective and important in this setting. These trials have also been the basis for the establishment of a consensus for the approach, management and treatment of patients with large vessel occlusions.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L8

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Lecture


“Should we stay or should we go now?” A brief guide to the most common doubts regarding mechanical thrombectomy - read full article

By: Marta Rodrigues and Manuel Ribeiro

Endovascular thrombectomy of large vessel occlusion, combined with best medical treatment, improves the outcome of appropriately selected patients with acute ischemic stroke. The positive results of randomized trials led to guidelines changes. However, despite the strong evidence, there are areas of uncertainty and the need for clinical judgment remains. Which patients should be treated outside the boundaries established by the randomized trials? Which stroke reperfusion technique should be used: aspiration or stent retriever? Do we really need rT-PA immediately before thrombectomy? These questions will be approached in our lecture.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L9

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Lecture


Mutual Help Groups after Stroke - read full article

By: António Conceição

Mutual help groups, social clubs, self-help groups, supporting groups... it might have several denominations, but its name is probably the least important concern! Groups for and with stroke survivors are the simplest form of action to answer, perhaps, the most serious problems for those who have suffered a stroke: isolation and closure in oneself and in their concerns. In fact, if not "fought against", these problems tend to become progressively bigger and are often accompanied by other problems, such as social self-exclusion, depression, among others. The social, architectural, professional and any other context often do not help. People have been fighting for many years for a progressive alteration of this panorama, and, slowly, something is being changed. But this is a fight that can only be won with the presence of the affected ones, the stroke survivors, who, with very rare exceptions, are not united and organized. Here too, groups, no matter how informal, can help! These groups are the cells in the basis of organizations (and of rights recognition!) that we often admire, and are found everywhere: in the United Kingdom (± 500 groups), Germany (± 480), United States, Canada, Australia, and even in other realities with a socioeconomic context similar to ours! The creation, maintenance and consistency of these groups are not easy tasks, but they are also not difficult: all it takes is will and minimal organization! Curiously, this time, the requirements are not the funds; it is rather some volunteer work!

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L10

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Lecture


Paediatric Stroke - read full article

By: Cristina Garrido

Although stroke is often viewed as occurring mainly in adults, it also strikes children, adolescents and can also arise in foetal life. The incidence of paediatric stroke is estimated at 1.6 out of 100,000. The incidence rate increased in the last decades mainly due to more sensitive diagnostic tests such as magnetic resonance imaging and increased survival in previously lethal paediatric diseases that predispose to stroke (congenital heart disease, malignancies and sickle cell disease). Black children and those in the first year of life (particularly in the perinatal period) are at higher risk for stroke. Clinical presentation of childhood acute ischaemic stroke (AIS) differs from adults due to a great frequency of seizures and non-focal neurological signs (irritability, headache and altered mental state). Stroke risk factors for children are also different than those for adults. About half of the children presenting with a stroke had a previously identified risk factor (for example, sickle cell disease or congenital heart disease). Other risk factors for stroke in children include vasculopathy, infection, trauma and prothrombotic conditions. Arteriopathy, including focal or transient cerebral arteriopathy, primary angiitis of the central nervous system, arterial dissection, Moya-Moya syndrome and genetic arteriopathies are present in >50% of children with AIS. Therefore, vascular imaging is essential for accurate identification and classification of arteriopathy in children with stroke. Childhood stroke has a mortality of 5% to 10% and is among the top 10 causes of death in children, but may be declining. More than 50% of childhood stroke survivors have long-term moderate to severe neurological impairment or epilepsy. Stroke symptoms, risk factors, prevention strategies, and treatment differ between children and adults. However, as in adults, there is a need for timely diagnosis and treatment and age appropriate rehabilitation to minimize sequelae. In addition, more research is needed to better understand the unique aspects of diagnosing and treating stroke in children.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L11

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Lecture


Early management of paediatric patients with acute ischemic stroke - read full article

By: Ana Aires

Stroke is an acute neurological disease whose recognition in children is a challenge. When diagnosed, it is crucial to evaluate and treat it efficiently and correctly. Presently, information on urgent management of stroke in children has only been exposed in case reports, case series and hospital database documentation. Therefore, our purpose in this presentation is to propose a protocol for better approaching acute paediatric stroke. Common presenting signs of acute stroke in children include seizures, focal weakness and altered mental status. Considering possible etiologies, cardiac conditions, haematological disorders, trauma, vascular compression, infections, vascular malformations, vasculopathies, metabolic and genetic causes may account for stroke in this population. A differential diagnosis must be made with seizures due to another cause, infectious encephalitis, metabolic disorders and acute disseminated encephalomyelitis. Once a paediatric patient is admitted with a potential ischaemic stroke, the priorities are controlling vital signs and adjusting analytical and hemodynamic parameters. If a possible stroke is confirmed by a neurologist (who performed Paediatric NIHSS - National Institutes of Health Stroke Scale), the preferred imaging modalities to be executed are brain computed tomography (CT)/brain magnetic resonance imaging (MRI), CT/MRI angiography and perfusion weighted imaging. All clinical, laboratory and imaging data will then be taken into account to define the eligibility for treatment with tissue plasminogen activator (tPA), always considering the estimated evolution time, a persistent deficit and no tPA contraindications. The role of mechanical thrombectomy in the paediatric group is not clearly settled. However, it may be safe and effective for large vessel occlusions. During the whole process, neuroprotective measures can be executed and include glycaemia and blood pressure management, seizure control and decompressive hemicraniectomy in selected cases. This presentation proposes a clinical algorithm for assessment and management of paediatric acute stroke in order to encourage discussion about this subject.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L12

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Lecture


Stroke in women - read full article

By: Carla Ferreira

During most of their lifespan, men have a higher incidence of stroke than women. However, over the age of 85 years more women suffer strokes, leading to an excess of disability and mortality in older women. This disproportionate mortality rate in women is mostly because of the older age of women at stroke occurrence and the fact that women live longer than men. However, after controlling for baseline differences between men and women, women continue to have poorer functional outcomes after stroke. Women are more likely to present at hospitals with stroke chameleons (“non-traditional” stroke symptoms) and it has been noted that women suffer more cardioembolic strokes than men. Several studies suggest that women may be treated less aggressively for primary and secondary stroke prevention and acute stroke than men (women have longer waiting times once they arrive at the emergency room and receive less intensive treatment and therapeutic workup once they are admitted). Women also have a higher rate of depression and lower quality of life than men and are more likely to require assistance after a stroke, even when controlling for factors such as age and premorbid function.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L13

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Lecture


Differential diagnosis of Central Nervous System Vasculitides - read full article

By: Andreia Costa

Central nervous system vasculopathy refers to any process that affects central nervous system vessels. It includes either inflammation of the vessel wall (vasculitis) or other non-inflammatory etiologies. In the first group, primary central nervous system vasculitides are an uncommon and laborious diagnosis that must be remembered. Secondary causes of vasculitis include systemic vasculitis with central nervous system impairment, infectious causes and others. Non-inflammatory vasculopathies include a wide range of diseases where the reversible cerebral vasoconstriction syndrome should be emphasized due to its distinct presentation, treatment and clinical course. The challenge remains on precociously differentiating these entities to start the appropriate treatment earlier and thus impact prognosis. Some main differential diagnoses will be discussed in detail. A possible diagnostic algorithm will be presented.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L14

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Guideline update on the management of subarachnoid haemorrhage - read full article

By: Pedro Castro

Subarachnoid haemorrhage (SAH) remains a significant cause of morbidity and mortality throughout the world. This oral presentation aims to provide a comprehensive review of the current guidelines and best practice in acute treatment of SAH. Oral nimodipine remains the only prophylactic drug that should be administered to all patients with SAH. After any aneurysm repair, immediate cerebrovascular imaging is generally recommended to identify remnants or recurrence of the aneurysm that may require treatment. The risk of early aneurysm re-bleeding is high and is associated with very poor outcomes. Acute diagnostic workup should include non-contrast head computed tomography, which, if non-diagnostic, should be followed by lumbar puncture. Digital subtraction angiography with 3-dimensional rotational reconstruction is indicated for detection of aneurysm. Before aneurism obliteration, systolic blood pressure should be kept under control (< 160 mm Hg is a reasonable cut-off). In addition to the size and location of the aneurysm and the patient’s age and health status, it might be reasonable to consider morphological and hemodynamic characteristics of the aneurysm when discussing the risk of aneurysm rupture. Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm. Maintenance of euvolemia and normal circulating blood volume is recommended to prevent delayed cerebral ischemia (DCI). Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it. Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy. Acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion or lumbar drainage. Heparin-induced thrombocytopenia and deep venous thrombosis, although infrequent, are not uncommon occurrences. SAH patients should be managed in a fast-track fashion to achieve better outcomes.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L15

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Lecture


Spontaneous intraventricular haemorrhage - read full article

By: António Vilarinho

Intraventricular haemorrhage (IVH) comprises a very wide range of situations: from a minor deposition of blood in the occipital horns, to the complete filling of the ventricular system with a clot. Intraventricular blood can be caused by the drainage into the ventricular system of spontaneous intracerebral haemorrhage or, in case of subarachnoid haemorrhage, by the circulation of the blood together with the cerebrospinal fluid (CSF). The symptoms are similar to any haemorrhagic stroke: headache, vomiting, stiff neck, with or without altered state of consciousness. The main causes of IVH are arterial hypertension, rupture of arteriovenous malformations (AVMs) or aneurysms (for example, anterior communicant, anterior choroid or posterior inferior cerebellar arteries) and bleeding of sub-ependymal cavernomas or intraventricular tumours. Other causes are related to coagulation disorders such as hypocoagulation and use of toxic substances. There are also some IVHs of unknown cause. For diagnostic investigation, in addition to the evaluation of blood pressure and bloodwork with coagulation study, brain computed tomography and magnetic resonance imaging are performed. Angiography can also be requested when considered relevant in the etiological investigation. This research is essential for diagnosis and therapeutic orientation. As a consequence of IVH, intracranial hypertension or hydrocephalus may occur. This may be due to the disturbance of the CSF circulation or to the toxic effects of blood and its degradation products. Patients with hydrocephalus usually undergo external ventricular drainage (EVD), the main risks being infections (meningitis, ventriculitis, abscess) or iatrogenic lesions due to the introduction of the catheter. Fibrinolysis through EVD is also a possibility of treatment. However, the risk of EVD placement in patients with coagulation disorders or untreated AVMs and aneurysms increase, so the use of fibrinolytics is contraindicated in these cases. It is important to treat intracranial hypertension and/or hydrocephalus and correct etiological factors to prevent further bleeding.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L16

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Lecture


NurAiD-II in stroke recovery: scientific reasoning and real-world evidence - read full article

By: Carlos de la Cruz Cosme

Background: NurAiD-II is an herbal supplement designed to help in ischemic stroke recovery. Lack of products in this field makes it mandatory to review the available evidence to decide about recommending it to patients who have suffered a brain infarction. 
Methods: Review of related Medline literature and a primary stroke center experience were performed. 
Results: Neuroprotection and neuroregeneration are Nur-AiD properties as basic research demonstrates: It increases brain-derived neurotrophic factor expression, inducing neuronal proliferation and synaptogenesis, it enhances vascular endothelial growth factor and angiogenesis, and in this way, enhances brain recovery after ischaemia in different animal models. Recent clinical trials including the multicentric Chinese Medicine NeuroAiD Efficacy on Stroke Recovery (n=1,100) reported a delayed but significant benefit in stroke patients who used it for three months after infarction OR 1.49 (1.11-2.01) and NNT=13 for modified Rankin scale 0-1 at 6 months, adding a significant reduction in fatal stroke recurrences (0% vs 0.7% at 3 months, p=0.045) and demonstrating an excellent safety profile. Poor prognosis factors in the total population as age>60, baseline NIHSS 10-14, stroke onset to initiation of treatment >48 hours and female sex were found to be positive predictive factors to obtain benefit of NurAiD-II. Finally, a primary stroke centre cases series (n=20) confirmed safety profile and suggested a benefit in patients who other way were not expected to improve as much as they did. 
Conclusions: NurAiD-II enhances neurorestorative processes in preclinical models of stroke and clinically improves long-term functional recovery and reduces early vascular events after a stroke. A subgroup of patients with poorer prognosis factors is more likely to achieve a benefit. Although real-word experience seems to support these results, further registries are required to confirm them. Lack of other effective treatments to enhance rehabilitation-induced stroke recovery makes it reasonable to report the availability of NurAiD-II to patients and/or relatives.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L17

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Lecture


Considerations regarding therapeutic interventions in post-stroke spasticity - read full article

By: Fernando Parada

Spasticity is a common complication that occurs in those patients that have suffered a stroke. It Is a functionally limiting disorder that may lead to disability and pain. Botulinum toxin type A is the recommended first line treatment for spasticity. Reducing the severity of spasticity and its long-term complications may be facilitated by early intervention, making identification of stroke patients at high risk for developing spasticity. Several predictors of spasticity post-stroke have been proposed, including development of increased muscle tone, greater severity of paresis, hypoesthesia and low Barthel index score. The definition of early treatment of spasticity is that it begins before the first three months after stroke. The results of all trials support the beneficial effects of botulinum toxin type A treatment on improving hypertonicity within 3 months post-stroke and emphasize the importance of concomitant neurorehabilitation therapy.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L18

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The neuroplasticity of speech and language early after stroke - read full article

By: Maria José Festas

More than ninety-five percent of people depend on the left hemisphere for language processing related to grammar, vocabulary, and phoneme construction. In the early phase of stroke, one third of patients have impairment of speech and language. Global aphasia, which is the complete loss of the ability to understand language, formulate speech, and repeat sentences, or the combination of Broca's, Wernicke's and conduction aphasias, is caused by lesions in the anterior frontal gyrus (Broca’s area), upper temporal gyrus (conduction), and posterior regions of language (Wernicke area). These patients almost do not produce speech and present a serious deficit of auditory comprehension, although they can fulfil properly contextualized commands. It is like "falling asleep" in Portugal and "waking up" in Japan. However, the ability to sing familiar songs is preserved, since musical areas are represented in the non-dominant hemisphere. Music therapy is a method to treat patients with non-fluent aphasia. Singing ability remains unchanged, with several studies showing that the right hemispherical regions are more active during singing. Nevertheless, Hebert in 2003 showed that singing does not facilitate articulation of words in non-fluent aphasia, suggesting there are two systems for vocal production. The main pathways for the recovery from aphasia in the small lesions of the dominant hemisphere of language are the recruitment of the perilesional cortex, but, in major lesions, the recruitment and training of rudimentary structures compatible with language in the non-dominant hemisphere is needed. Music therapy involving melodic elements is considered a potential treatment for non-fluent aphasia, since singing can activate the right hemisphere of patients, compensating the injured left hemisphere. Both music and language use different sound parameters for their hierarchical sound organization. In spite of their differences, singing and language have both syntactic organization and imply semantic understanding. In aphasia, the preserved ability to sing can result from a cerebral circuit reserved for this purpose, which suggests that singing and speaking involve different neural pathways in the human brain. Therefore, right hemisphere partial replacement of the injured left hemisphere is one of the possible mechanisms of music therapy in non-fluent aphasia. Stahl has shown that rhythm, rather than singing, is the key element of music therapy that benefits aphasic patients. Sonic identity is the set of energies, sounds, music and movements that characterize the individual, from his intrauterine life until stroke, providing him with a nonverbal interaction to open channels of communication, stimulating different functions and abilities. This is the basis of the first approach by the speech therapist, in early phase after stroke. Strategy includes melodic intonation therapy (MIT), brief sentences spoken in melodic sequences, or in recitative, with increasing levels of difficulty, in time and in rhythm, using only two musical tones, where the most acute syllable represents the naturally marked syllable in speech. Each chanted syllable is accompanied by a beat of the left hand to stimulate the right hemisphere. In chronic non-fluent aphasia, left hand movement is used to benefit the verbal articulation in aphasic patients, involving the neurological network that coordinates the movement of the hand and the articulatory movement of the speech in the patients' right hemisphere.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L19

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Lecture


The acute inpatient rehabilitation process after stroke - read full article

By: Hugo Amorim, Maria-José Festas, and Fernando Parada

Introduction: Nowadays, the burden of stroke is still notoriously high. Stroke also has a significant impact in the quality of life of the patients. The rehabilitation process is usually long, and its acute phase is frequently paramount in its success. 
Purpose: The aim of this lecture is to provide an outline of the clinical practice in the acute inpatient rehabilitative care of adults recovering from stroke. 
Results: The best rehabilitation setting for stroke patients is often a difficult decision that takes multiple factors into account. Patients that have higher functional impairments after stroke and that, at the same time, are able to cooperate in an intense impatient rehabilitation program benefit the most from admission to an acute inpatient rehabilitation unit. In this setting, stroke rehabilitation requires a sustained and coordinated effort from a diverse team that includes the patient, family and caregivers, physicians, nurses, physical and occupational therapists, speech-language therapists, psychologists, and social workers. The coordination of these team members is vital in maximizing the effectiveness of the rehabilitation process. The main areas of intervention include gait training, upper limb rehabilitation, speech therapy, dysphagia rehabilitation, cognitive assessment, pain management and spasticity prevention. Medical complications also arise more commonly in the acute rehabilitation phase rather than later, and the rehabilitation team is responsible for identifying and treating them accordingly. The concept of function is omnipresent throughout the various interventions and the rehabilitation specialist should establish a functional prognosis according to all the variables involved. The social integration of the stroke survivor in society is usually a measure of the success of the rehabilitation process and the secondary prevention measures are also reinforced during this period of time. 
Conclusion: The acute phase rehabilitation of stroke survivors is a complex process that strives to maximize their vital and functional prognosis.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L20

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Lecture


Workshop: neurological emergencies - read full article

By: Cláudia Marques-Matos, Carolina Lopes, and Marta Carvalho

Neurologists are probably the most required non-surgical specialists in the Portuguese adult Emergency Departments. Whenever neurologists are not available, the internal medicine specialists or the general practitioners face the challenge of correctly evaluating neurological patients, struggling to go through confusing, yet invaluable, clinical history taking, neurological examination and clinical reasoning. This workshop will address the most common neurological complaints in the Emergency Department. Acute stroke will be extensively reviewed, focusing on practical issues of management and on the updates of the stroke “fast track” in the era of thrombectomy. Acute vestibular syndromes and the not always straightforward differentiation between central and peripheral etiologies will also be addressed. The span of pathologies that may present as headache in the Emergency Department is vast and the emergency physician must soon learn to identify those patients that need a thorough investigation, without neglecting symptomatic relief. We will address the particularities of clinical history taking and red flags in the history and neurological examination, pointing towards the most worrisome not-to-miss diagnoses. We will then review the clinical approach to the patient with seizures, both new-onset and as a part of previously diagnosed epilepsies, and the management of convulsive and non-convulsive status epilepticus. Other causes of altered mental status and delirium will also be presented. To conclude, the topic of the patient presenting with acute neurological deficit not caused by stroke, with a focus on spinal cord lesions and Guillain-Barré syndrome, will be briefly discussed.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L21

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Lecture


Mechanical thrombectomy – practical workshop - read full article

By: Luís Albuquerque, João Pedro Filipe, Tiago Parreira, and Ângelo Carneiro

Mechanical thrombectomy (with or without intravenous thrombolysis) has improved the outcome of patients with acute large vessel occlusion of the anterior circulation, with impressive results: successful recanalization (mTICI 2b or 3) – 59 to 88%; number needed to treat – 3 to 7. As recent trials have demonstrated the benefit of mechanical thrombectomy, there is a demand for an increased number of well-trained practitioners who are able to perform these procedures. Stent retriever (SR) technique is still the standard of care; however, aspiration techniques have emerged and they have been demonstrated to be as effective as SR. A thorough knowledge of the different arterial approaches, materials and techniques is mandatory in order to improve recanalization rates, decrease procedure times and avoid complications. Apart from the procedural skills required to manipulate multiple catheters and other devices, mechanical thrombectomy might offer other specific challenges, such as difficult vascular access, patient movement and partial visualization of the intracranial circulation. Thrombectomy scenario practice using simulators (with specific models and dedicated software) is a useful educational resource for trainees. These might contribute towards an easier, safer and faster training.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L22

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Lecture


Workshop: Dysphagia management in stroke patients - read full article

By: Bárbara M. Cruz

Stroke is the major cause of neurogenic dysphagia. Incidence of dysphagia in stroke patients ranges from 20% to 70%, in the literature. Nevertheless, the majority of the authors state that the incidence of swallowing disorders in stroke patients is around 50%. Dysphagia is a major issue in the acute phase of stroke, but it tends to resolve in two weeks in 80% of the cases. About 15% of stroke patients will maintain swallowing problems after three months since stroke onset. Dysphagia is associated with poorer stroke outcome, less participation in rehabilitation and higher mortality. Complications described as associated with dysphagia are: death, pneumonia, malnourishment, dehydration, institutionalization, increased length of stay, depression and higher healthcare costs. Stroke patients with dysphagia have a 3-fold higher risk of having pneumonia when compared with stroke patients without dysphagia. If dysphagia is severe enough to result in aspiration, the risk of pneumonia is eleven-fold higher when compared to stroke patients without dysphagia. In order to prevent the complications and the bad outcomes associated with swallowing disorders, it is extremely important to screen for dysphagia, with formal evaluation, and to treat it properly.

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

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 2):L23

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Oral Presentation


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

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

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

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

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

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Oral Presentation


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

By: Rita Rodrigues and José Mário Roriz

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

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

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

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Oral Presentation


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

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

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

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

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

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Oral Presentation


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

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

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

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

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

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Oral Presentation


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

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

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

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

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

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Oral Presentation


CADASIL – A case report - read full article

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

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

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

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

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Oral Presentation


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

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

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

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

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

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Oral Presentation


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

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

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

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

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

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Oral Presentation


Strange Percheron - read full article

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

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

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

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

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Oral Presentation


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

By: Mariana Carvalho, Sara Santos, and Vanda Pereira

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

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

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

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

By: Patrícia Sousa and Diana Pinto

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

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

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

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

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

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

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

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

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

By: José Poupino and Catarina Fonseca

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

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

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

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Oral Presentation


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

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

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

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

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

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Oral Presentation


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

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

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

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

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

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Oral Presentation


Cerebral vasculitis and pulmonary tuberculosis - read full article

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

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

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

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

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Oral Presentation


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

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

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

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

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

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

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

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

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

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

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Oral Presentation


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

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

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

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

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

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Issue: 4 | 2017-04-22

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