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- Multiple inherited thrombophilias in a young patient with striatocapsular strokePublication . Taveira, Isabel; Vicente, Claudia; Sobrall, Sofia; Nzwalo, Hipolito; Sousa E Costa, Jose
- Isolated vocal cord paresis as a presentation of acute ischemic strokePublication . Valente, Diana; Gil, InĆŖs; Jacinto, Filipe; Freitas, LuĆs; Nzwalo, HipĆ³lito; Felix, CatarinaStroke presenting with predominant laryngeal dysfunction manifestations is often part of a clinical constellation of neurological signs associated with acute medullar lesion [1]. Isolated laryngeal symptoms as a stroke presentation are extremely rare due to the intimal anatomical relation of swallowing-related structures with the ascending/descending tracts in the lateral medulla [2]. Herein we present a case with isolated vocal cord paresis as the sole manifestation of acute ischemic stroke.
- Late hospital arrival for thrombolysis after stroke in Southern Portugal: Who is at risk?Publication . Sobral, Sofia; Taveira, Isabel; Seixas, Rui; Vicente, Ana Claudia; Duarte, Josiana; Goes, Ana Teresa; Duran, David; Lopes, Joao; Rita, Henrique; Nzwalo, HipĆ³litoBackground: Delayed hospital arrival remains the main reason for the low rates of thrombolysis in eligible acute ischemic stroke (AIS) patients. The role of socioeconomic and clinical factors for the prehospital delay of AIS remains poor and has never been studied in Portugal. Objectives: Describe the socioeconomic and clinical factors leading to delayed hospital admission of AIS patients eligible to thrombolysis. Methods: A case-control study with a consecutive thrombolyzed AIS patients from 2010 to 2015. Controls were patients who did not receive thrombolysis because of late hospital arrival. Logistic regression with stepwise forward regression analysis was used to identify independent predictors of delayed admission to receive thrombolysis with intravenous tissue-type plasminogen activator (rtPA). Results: Of the 1247 patients admitted with AIS, 76 (6%) arrived on-time and received intravenous rtPA. Controls were 65.8% (146/222) of the total number of patients included in the study. Overall, the mean age was 73 years (+/- 11, 61), a minority were below 60 years, and 43.7% were women. Being beneficiary of social insertion income (odds ratio [OR]: .286; .124-.662, P = .003), not having any telephone contact (OR: .145; .039-.536, .004) or having exclusive landline (.055; .014-.210, < .001) and posterior circulation stroke (OR: .266; .087-.811, P = .020) decreased the likelihood of hospital arrive on-time rtPA. The use of prehospital ambulance services increased (OR: 6.478; 2.751-15.254, P < .001) the odds of ER on-time arrival for thrombolysis. Conclusions: Poverty, lack of stroke awareness, or difficulties in requesting immediate medical help are the main factors implicated in late-hospital admission for thrombolysis in AIS. Stroke awareness campaigns, promotion of activation of national emergency number and stroke code can increase the rate of thrombolysis.
- Ischemic stroke and subarachnoid hemorrhage following Epstein-Barr virus infectionPublication . Rios, Jonathan; FĆ©lix, Catarina; ProenƧa, Paula; Malaia, LuĆs; Nzwalo, HipĆ³litoThe epidemiological link between inflammation, infection, and acute ischemic stroke (AIS) is well known.1 Transient prothrombotic status and vasculitis are possible explanatory factors.1 Aneurysm formation in association with central nervous system infections is occasionally reported.2 Ischemic or hemorrhagic complication in relation to neurotropic virus infections, including Epstein-Barr Virus (EBV) are rarely reported in adults. Thus, we report here an extremely rare case of ischemic and hemorrhagic cerebrovascular complications in the context of EBV neuroinfection.
- Non-ketotic hyperglycaemia induced occipital reflex focal seizuresPublication . Buque, Helena; Catamo, Deise; Felix, Catarina; AndrĆ©, Ana; Gil, InĆŖs; Nzwalo, HipĆ³litoA myriad of neurological manifestations can occur in association with ketotic and non ketotic hyperglycaemic states. Contrary to diabetic coma, which is a universal complication under relatively established metabolic circumstances, the pathophysiology beyond hyperglycaemicassociated positive neurological manifestations, including seizures, remains to be elucidated. The occurrence of symptomatic focal epilepsy as a manifestation of diabetes-related hyperglycaemia is seldom reported. Herein, we present a case of focal epilepsy with alternating positive and negative neurological manifestations as the initial manifestation of diabetes-related hyperglycaemia. The electroencephalogram confirmed the diagnosis of focal occipital seizures, and the brain magnetic resonance imaging depicted the associated typical transient imaging findings in the occipital lobe. Seizures were refractory to antiepileptics, and symptomatic control was achieved after achieving normoglycemia. On follow-up, complete clinical and imaging recovery occurred. Reflex focal epilepsy in the context of hyperglycaemic states is a rare condition, and the possibility of misdiagnosis is likely high. As reported in similar cases, seizures can be resistant to antiepileptics. An important message to highlight is that seizures associated with hyperglycaemic status can be resistant to antiepileptic treatment and only cease with glycaemic control.
- Prediction of short-term prognosis in elderly patients with spontaneous intracerebral hemorrhagePublication . Batista, AntĆ³nio; OsĆ³rio, Rui; Varela, Ana; Guilherme, PatrĆcia; Marreiros, Ana; Pais, Sandra; Nzwalo, HipĆ³litoAim The incidence of spontaneous intracerebral hemorrhage (SICH) increases with age. Data on SICH mortality in the very old are sparse. We aimed to describe the predictors of 30-day SICH mortality in the very elderly in southern Portugal. Methods A total of 256 community representative SICH patients aged >= 75 years (2009-2016) were included. Multiple logistic regression was used to identify predictors of 30-day mortality. Results Mean age was 82.1 years; 57.4% males. The 30-day case fatality was 38.7%. The frequency of patients taking anticoagulants (29.3% vs. 11.5%); comatose (46.9% vs. 2.5%); with hematoma volume >= 30 mL (64.6% vs. 13.4%); intraventricular dissection (78.8% vs. 27.4%) was higher in deceased patients (p < 0.05). Survivors were more often admitted to stroke unit (SU) (68.2 vs. 31.3%) and had lower mean admission glycaemia values (p < 0.05). The likelihood of death was increased in patients with higher admission hematoma volume (>= 30 mL) (OR: 8.817, CI 1.753-44.340, p = 0.008) and with prior to SICH history of >= 2 hospitalizations OR = 1.022, CI 1.009-1.069, p = 0.031). Having higher Glasgow coma scale score, OR: 0.522, CI 0.394-0.692, p < 0.001, per unit was associated with reduced risk of death. Age was not an independent risk factor of short-term death. Conclusions The short-term mortality is high in very elderly SICH. Prior to SICH history of hospitalization, an indirect and gross marker of coexistent functional reserve, not age per se, increases the risk of short-term death. Other predictors of short-term death are potentially manageable reinforcing the message against any defeatist attitude toward elderly patients with SICH. Key summary pointsAim Identification of predictors of short-term death after spontaneous intracerebral hemorrhage (SICH) in the elderly. Findings The short-term case fatality (38.7%) after SICH is high in the elderly. Hematoma volume, decreased level of consciousness and functional reserve, but not age per se, increase the risk of short-term death. Message Age per se should not justify any decision of withholding best treatment in elderly SICH patients. Offering the best acute treatment can potentially improve the clinical outcome.
- Predictors of pneumonia in patients with acute spontaneous intracerebral hemorrhage in Algarve, Southern PortugalPublication . Soares, Rita; Fernandes, Adriana; Taveira, Isabel; Marreiros, Ana; Nzwalo, HipĆ³litoIntroduction: Following the hyperacute phase of spontaneous intracerebral hemorrhage (SICH), the severest form of stroke, pneumonia emerges as the leading cause of morbidity and mortality. Prevention of stroke associated pneumonia (SAP) is fundamental to improve the prognosis of SICH patients. Aim: Identify clinical, sociodemographic and process of care factors associated with occurrence of SAP after SICH in Algarve, southern Portugal. Methods: Observational, retrospective study of community representative consecutive case series of patients with SICH admitted to the sole public hospital in the region. Logistic regression was used to identify predictors of SAP after SICH. Results: A total of 525 patients were included. The mean age was 71 ( +/- 13) years and 64% were men. SAP occurred in 165 (31.5%). Lower Glasgow Coma Scale score (GCS score): <= 8 (OR= 2.087; 95% CI= [1.027;4.424]; p = 0.042) and GCS 9-12 (OR= 1.775; 95% CI= [1.030;3.059]; p = 0.039); prolonged emergency room stay (OR= 8.066; 95%CI=[3.082;21.113]; p < 0.001) and hyperactive delirium (OR=2.860; 95% CI= [1.661;4.925]; p < 0.001) increased the likelihood of SAP. Being younger, = 59 years (OR= 0.391; 95% CI= [0.168; 0.911]; p = 0.029) and 60-71 years (OR= 0.389; 95% CI= [0.185; 0.818]; p = 0.013); and having less severe SICH/intracerebral hemorrhage score (ICH score) <= 2 (OR=0.601; 95% CI= [0.370; 0.975]; p = 0.039), decreased the risk of SAP. Conclusion: After SICH, SAP occurs in approximately a third of patients. Non preventable (admission severity, ageing) and potentially preventable (prolonged emergency room stay, hyperactive delirium) determine the occurrence of SAP. Intensification of preventive intervention in high-risk patients, delirium prevention and improvement of the process of care can potentially reduce the occurrence of SAP after SICH.
- 24-hour rhythmicity of seizures in refractory focal epilepsyPublication . Nzwalo, HipĆ³lito; Cordeiro, InĆŖs Menezes; Santos, Ana Catarina; Peralta, Rita; Paiva, Teresa; Bentes, CarlaThe occurrence of seizures in specific types of epilepsies can follow a 24-hour nonuniform or nonrandom pattern. We described the 24-hour pattern of clinical seizures in patients with focal refractory epilepsy who underwent video-electroencephalography monitoring. Only patients who were candidates for epilepsy surgery with an unequivocal seizure focus were included in the study. A total of 544 seizures from 123 consecutive patients were analyzed. Specific time of seizures were distributed along 3- or 4-hour time blocks or bins throughout the 24-hour period. The mean age of the subjects was 37.7 years, with standard deviation of 11.5 years, median of 37. The majority were females (70/56%). The majority of patients had a seizure focus located in the mesial temporal lobe (102/83%) and in the neocortical temporal lobe (13/11%). The remaining patients had a seizure focus located in the extratemporal lobe (8/6%). The most common etiology was mesial temporal sclerosis (86/69.9%). Nonuniform seizure distribution was observed in seizures arising from the temporal lobe (mesial temporal lobe and neocortical temporal lobe), with two peaks found in both 3- and 4-hour bins: 10:00-13:00/16:00-19:00 and 08:00-12:00/16:00-20:00 respectively (p = 0.004). No specific 24-hour pattern was identified in seizures from extratemporal location. The 24-hour rhythmicity of seizure distribution is recognized in certain types of epilepsy, but studies on the topic are scarce. Their replication and validation is therefore needed. Our study confirms the bimodal pattern of temporal lobe epilepsy independently of the nature of the lesion. However, peak times differ between different studies, suggesting that the ambient, rhythmic exogenous factors or environmental/social zeitgebers, may modulate the 24-hour rhythmicity of seizures. Characterization of these 24-hour patterns of seizure occurrence can influence diagnosis and treatment in selected types of epilepsy, such as the case of temporal lobe epilepsy, the most common drug-resistant epilepsy. (C) 2015 Elsevier Inc. All rights reserved.
- Clinicoepidemiological profile of cerebral venous thrombosis in Algarve, Portugal: a retrospective observational studyPublication . Nzwalo, HipĆ³lito; Rodrigues, Fatima; Carneiro, Patricia; Macedo, Ana; Ferreira, Fatima; Basilio, CarlosBackground: Cerebral venous thrombosis (CVT) is a very uncommon disorder with a wide variety of clinical manifestations. There are few studies describing the clinical and epidemiological profile of CVT in peripheral or rural areas. Over the last decades, the frequency in which this disease is diagnosed has increased due to greater awareness and availability of noninvasive diagnostic techniques. Materials and Methods: A hospital-based retrospective case review of adult (>= 15 years) patients with CVT between 2001 and 2012 is described. 31 patients with confirmed imagiological diagnosis of CVT were included. Statistical Analysis Used: Statistical analysis was performed using R version 2.15.2. Incidence rate was computed as number of new cases by time. Confidence interval (CI) was set at 95% and P < 0.05 was considered significant. Results: The average annual incidence was 0.84 (CI: 0.58-1.18) to 0.73 (CI: 0.5-1.02) per 100 000 cases for adult population. There were 23 (74%) women and 8 (26%) men. Predominant initial manifestations were headache, followed by altered mental status and seizures. Median diagnostic delay from onset of illness was 8 days. All patients were treated with unfractionated heparin or low-molecular heparin followed by warfarin. Complete recovery occurred in the majority of cases 22 (78.6%) but two patients died during hospitalization. Conclusions: Albeit with some particularities, the epidemiology and clinical manifestations we found are comparable to what has been reported in western studies.
- On the pathways of an imperfect chameleon: posterior reversible encephalopathy syndromePublication . FĆ©lix, Catarina; Nunes, NĆ”dia; FlorĆŖncio, AndrĆ©; Grande, Pablo; Gozabez, Beatriz; Milheiro, Miguel; Soleiro, Luis; Shamasha, Motassen; Nzwalo, HipĆ³litoPosterior reversible encephalopathy (PRES) is a rare clinicoradiological syndrome characterized by a variety of neurological manifestations such as acute encephalopathy, headache, seizures, visual loss, and focal neurologic signs in association with a reversible and predominantly posterior leukoencephalopathy [1,2]. Although precipitated by severe hypertension in most cases, other conditions such as eclampsia, autoimmune disorders, renal failure, and drugs, for example, are now recognized to cause PRES [3]. The number of publications of PRES in the last years reļ¬ects the increasing recognition of the syndrome and also the availability of brain magnetic resonance (brain MRI) for urgent or emergency situations. However, because of its pleotropic clinical and radiological manifestations, the possibility of misdiagnosis should be considered [4]. Therefore, we decided to review and discuss our clinical experience in the diagnosis and management of this rare entity.