Background Current literature highlights a gap in precise stroke cost data for Latin America. This study measures the real costs associated with acute ischemic stroke care in Latin America using Time-Driven Activity-Based Costing (TDABC). The findings aim to lay a solid foundation for adopting value-based healthcare (VBHC) strategies in the region. Methods The study is an observational, multicenter, international analysis of direct costs and outcomes for patients hospitalised with acute ischemic stroke from December 2021 to December 2022. Data from stroke centres in Argentina, Brazil, Chile, Colombia, Costa Rica, Mexico, Peru, and Uruguay were analysed. Costs were stratified by country. Factors such as favourable outcomes based on the modified Rankin Scale (mRS 0-2), clinical risk levels, and treatment interventions were considered for the analysis. Generalized Estimating Equation (GEE) models were utilised to assess the relationship of clinical variables with the total cost per patient. Findings A total of 1106 patients were included in the study. Among these patients, 74% received medical treatment alone, 18% received intravenous thrombolysis (IVT), 4% underwent mechanical thrombectomy (MT), and 3% received combined IVT plus MT. The mean cost per patient was I$ 12,203 (SD I$ 15,055), with 49% achieving a favourable functional outcome. Compared to medical treatment alone, MT incurred costs 3.1 times higher, with an incremental cost of I$ 20,418 per patient (p < 0.0001). Across all countries, costs increased according to patients' clinical risk and treatment options, with length of hospital stay emerging as the primary cost driver. Interpretation Our study highlights significant disparities in stroke costs across healthcare services in Latin America, influenced by variations in treatment accessibility, patient outcomes, and clinical risk profiles. These findings offer essential insights for shaping health policy decisions to enhance the long-term sustainability of stroke care in the region. Copyright (c) 2024 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Objective: Quality of performance after stroke in working-active survivors has been poorly studied.The aim of this study is to analyze work performance after stroke not only by the probability of being active in daily job activities but also by the survivor's ability to recover capability in different cognitive and motor areas.Material and methods: We developed a 15-item survey for stroke who had returned to their work activity.The survey evaluated 11 different domains (language, memory, attention, planning, calculating, writing, motor skills, gait, visual, mood, and self-perception).Internal consistency, test-retest reliability, item-scale correlation, and factor analysis were conducted.Results: A total of 100 ischemic stroke survivors were recruited (51 [51.0%] female patients, median age 42 years [interquartile range = 34.5-54.5 years]); median time to return to work was 4 months.Work performance after stroke was high in 16% of cases, good in 58% of cases, moderate in 24%, and low in 2%.Chronbach's alpha coefficient was 0.75 for the scale.The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.72 (p < 0.001).The test-retest reliability, as estimated by the intraclass correlation coefficients, was good.Memory, language, and attention explained 59.7% of the variance of the questionnaire in the extraction analysis.Conclusion: The WPQ-INNN is a reliable and valid tool for the assessment of performance quality in stroke survivors who returned to work.

Background: Intracranial hemorrhage (ICH) carries a significant morbidity and mortality burden; however, there is scarce information in Latin American. Objective: To analyze the functional prognosis and mortality rates among participants in the Latin American Stroke Registry (LASE). Methods: Eighteen centers across Latin American compiled data on demographics, vascular risk factors, clinical stroke description, ancillary tests, and functional outcomes in hospital stay of patients included from January 2012 to January 2017. All these variables were analyzed based on functional outcome at hospital discharge. Results: We included 495 patients with ICH, representing 10.3% of all collected stroke subtypes in LASE. The median in-hospital stay was 9 days (interquartile range, 1-30); 285 (57.6%) were male (median age, 62 years) and 210 female (median age, 65 years). A poor functional outcome (modified Rankin scale, 3-6) was observed in 214 (43.2%) patients, with 62.5% of women (p < 0.009). Mortality was documented in 12.5% of ICH patients. The Kaplan-Meier survival curves presented difference in mortality, with higher frequency in patients > 80 years (HR 1.89, 95%CI 1.07-3.35, p = 0.028), with GCS < 8 (HR 0.19, 95%CI 0.11-0.33, p = < 0.001), ventricular irruption (HR 1.88, 95%CI 1.09-3.24, p = 0.0282), and hematoma volume > 30 cc (HR 2.36, 95%CI 1.17 - 4.77, p = 0.016). Conclusions: Our study demonstrates a poor functional prognosis in 43.2% of ICH patients, with the risk factors for higher mortality being age over 80 years, higher GCS values, and ventricular irruption in the LASE. Our collaborative study contributes substantial insight into the factors influencing ICH occurrence, prognosis, and outcomes in Latin America.

Introduction: Except for RESILIENT, there is a paucity of randomized controlled trials (RCTs) for stroke from Latin America (LA), home to growing stroke burden. Comparison between stroke population typically suffers from baseline factor imbalances. Here, we developed outcome models from RCTs to compare Latin American Stroke Registry (LASE) with similar baselines. Methods: LASE is a registry of patients receiving tPA and thrombectomy from 17 centers in 9 countries. A systematic review identified RCTs that provided median NIHSS, mean age, percentage of patients receiving tPA, time-to-randomization, 90d mRS0-2, and mortality. Akaike Information Criterion (AIC), an information theory construct, was used to select the best model amongst 15 combinations of 4 variables. 90d outcomes of LASE and RESILIENT were compared at the baseline values against the selected model. Results: 34 RCTs with ~8300 subjects were identified. Models based on NIHSS and the percentage of tPA were considered the most optimum in terms of AIC. In the 3D models (Fig1), the middle surface defines the function and the bounding surfaces the ±90% intervals. The LASE registry has 950 patients that received tPA alone, 127 that received tPA & mechanical thrombectomy (MT), and 101 that received MT alone. LASE & RESILIENT outcomes were plotted onto the models at their baseline values. LASE tPA alone group was on the middle surface for mRS 0-2 (Fig1-A), indicating that outcomes were in line with the RCT-informed model. MT alone (0% tPA) and MT + tPA (100%), and the RESILIENT MT arm (68.5% tPA) were above the +90% surface, indicating superior efficacy compared to no-MT. The RESILIENT control arm (71.8% tPA) had > expected mortality, suggesting harm, while mortality of all other arms was within the ±90% intervals (Fig1-B). Conclusion: Functional outcomes and mortality of patients from the LASE that received MT and MT+tPA compared favorably to a 90-day functional and mortality predictive model.

Introduction: As acute stroke therapies expand to less well-resourced regions, it is imperative to study real-world data to assess outcomes and the quality of stroke care. The present study analyzes clinical, and imaging outcomes after acute IV thrombolysis (IV-tPA) compared to mechanical thrombectomy (MT) or combined therapy in the LASE. Methods: A retrospective analysis of consecutive acute ischemic stroke cases in 17 centers from 9 Latin American (LA) countries since 2012 was performed using weighted Euclidean matching of nearest neighbors in 3-D space of baseline NIHSS, age, and glucose. Results: 950 patients receiving only IV-tPA were matched to 127 treated with MT+IV-tPA. Matching resulted in 97 pairs well balanced for age (69.1 vs. 69.3), baseline NIHSS (17 vs. 17), and glucose (124.3 vs. 124.5), all p>0.2. 3-month mRS 0-1 (38.3% vs 29.8%, p=0.23) and mRS 0-2 (46.8% vs 41.5%, p=0.54) were non-significantly higher in the MT+IV-tPA group, with higher hemorrhage (26.6% vs 15.5%, p=0.05) and trends for higher death (15.1% vs 9.5%, p=0.40) and symptomatic hemorrhage (7.4% vs 6.2%, p=1.0). One hundred one patients receiving only MT were matched to 127 patients with MT+IV-tPA, resulting in 61 pairs; MT+IV-tPA showed trends for higher rates of 3-month mRS 0-1 (45.0% vs 35.6%, p=0.31), mRS 0-2 (48.3% vs 42.4%, p=0.54); with trends for lower rates of death (16.9% vs 20.0%, p=1.0) and symptomatic hemorrhage (8.3% vs 11.1%, p=0.75). Conclusions: In this real-world LA sample, trends for better functional outcomes were demonstrated with MT+IV-tPA compared to either treatment alone, as in non-LA populations. A trend for higher adverse events in the combined group requires further investigation.

Introduction Despite the significant stroke burden in the region, the RESILIENT trial remains the only randomized controlled trial (RCT) for stroke treatment in Latin America. Imbalances in baseline factors typically hamper comparisons between stroke populations. The Latin American Stroke Registry (LASE) is a registry of patients receiving tPA and thrombectomy from 17 centers across 9 countries. We compared the outcomes of LASE and RESILIENT at each cohort’s baseline characteristics against models derived from other RCTs. Methods A systematic search identified RCTs that provided median NIHSS, mean age, percentage of patients receiving tPA, time-to-randomization, 90-day mRS0-2, and mortality. Akaike Information Criterion (AIC) was used to select the best model amongst 31 combinations of 5 variables. 90-day outcomes of LASE and RESILIENT were compared at their baseline values against the selected model. Results 35 RCTs encompassing 8376 subjects were identified. Models based on baseline NIHSS and the percentage of intravenous thrombolysis (IVT) were considered the most optimum in terms of AIC. The LASE registry included 950 patients receiving IVT alone, 127 that received IVT and mechanical thrombectomy (MT), and 101 receiving only MT. LASE & RESILIENT outcomes were plotted onto the models at their baseline values. LASE IVT alone group outcomes were in line with the RCT-informed model. LASE MT alone and MT + IVT, and the RESILIENT MT arm (68.5% IVT) demonstrated superior efficacy compared to no-MT. The RESILIENT control arm (71.8% tPA) had higher-than-expected mortality, while mortality of all other arms was within the predicted range. Conclusion Functional outcomes and mortality of patients from the LASE and RESILIENT trial receiving MT and MT+IVT compared favorably to the 90-day functional and mortality outcomes predicted in a model derived from no-MT data from other stroke RCTs, indicating Latin American MT systems of care are comparable to those of more resourceful regions. Higher mortality from IVT in the RESILIENT trial requires further investigation.

Resumen: Antecedentes: El bloqueo interatrial avanzado (BIA-a) es considerado un factor de riesgo independiente para infarto cerebral (IC). Nuestro objetivo fue analizar si el BIA-a predice recurrencia de IC en pacientes con infarto cerebral embólico de origen no determinado (ESUS). Métodos: Ciento cuatro pacientes con diagnóstico confirmado de ESUS fueron seguidos durante una mediana de 15 meses (RIQ 10-48). Los datos clínicos, las características de la onda P y presencia de BIA en electrocardiograma realizado durante el evento índice, fueron registrados. La interpretación de los electrocardiogramas se realizó de forma centralizada y ciega en (XXXX2). La recurrencia de ESUS fue el desenlace primario. Resultados: La mediana de edad de los casos fue de 47 años (rango 19-85); 50% fueron mujeres. Se encontró BIA en 36 casos (34,6%); parcial (BIA-p) en 29 (27,9%) y BIA-a en 7(6,7%). Dieciséis pacientes (15,4%) presentaron IC recurrente; de los cuales 5 tenían BIA-p y 4 BIA-a (p=0,01;OR 9,44:IC 95% 1,88-47,46). La mediana de duración de la onda P fue mayor en pacientes con recurrencia (p=0,009). En el análisis multivariado de regresión logística, los factores de riesgo independientes para recurrencia de IC fueron: el BIA-a (p<0,001; OR 10,86:IC 95% 3,07-38,46), género masculino (p=0,028; OR 4,6:IC 95% 1,18-17,96) y la edad mayor a 50 años (p=0,039; OR 3,84:IC 95% 1,06-13,88); en riesgos proporcionales de Cox fueron: edad mayor a 50 años (p=0,002; HR 7,04:IC 95% 2,06–23,8) y duración de la onda P (por ms) p=0,007 (HR 1,02:IC 95% 1,01-1,04). Conclusiones: El BIA-a y edad mayor a 50 años predicen recurrencia de ESUS. Abstract: Background: Advanced interatrial block (IAB) is an independent risk factor for ischaemic stroke. This study aimed to analyse whether advanced IAB predicts recurrence of embolic stroke of undetermined source (ESUS). Methods: 104 patients with a confirmed diagnosis of ESUS were followed up for a median period of 15 months (interquartile range, 10-48). We recorded data on clinical variables, P-wave characteristics, and presence of IAB on the electrocardiogram. Electrocardiogram findings were interpreted by a blinded, centralised rater at (XXXX2). ESUS recurrence was the primary outcome variable. Results: Median age was 47 years (range, 19-85); 50% of patients were women. IAB was detected in 36 patients (34.6%); IAB was partial in 29 cases (27.9%) and advanced in 7 (6.7%). Sixteen patients (15.4%) presented stroke recurrence; of these, 5 had partial and 4 had advanced IAB (P = .01; odds ratio [OR] = 9.44; 95% confidence interval [CI], 1.88-47.46; relative risk [RR] = 4.62; 95% CI, 2.01-10.61). Median P-wave duration was longer in patients with stroke recurrence (P = .009). The multivariate logistic regression analysis identified the following independent risk factors for stroke recurrence: advanced IAB (P < .001; OR = 10.86; 95% CI, 3.07-38.46), male sex (P = .028; OR = 4.6; 95% CI, 1.18-17.96), and age older than 50 years (P = .039; OR = 3.84; 95% CI, 1.06-13.88). In the Cox proportional hazards model, the risk variables identified were age older than 50 years (P = .002; hazard ratio, 7.04; 95% CI, 2.06-23.8) and P-wave duration (per ms) (P = .007; hazard ratio, 1.02; 95% CI, 1.01-1.04). Conclusions: Advanced IAB and age older than 50 years predict ESUS recurrence.

Background and purpose To explore the prevalence, risk factors, time correlation, characteristics and clinical outcome of dural arteriovenous fistulas (dAVFs) in a cerebral venous thrombosis (CVT) population. Methods We included patients from the International CVT Consortium registries. Diagnosis of dAVF was confirmed centrally. We assessed the prevalence and risk factors for dAVF among consecutive CVT patients and investigated its impact on clinical outcome using logistic regression analysis. We defined poor outcome as modified Rankin Scale score 3-6 at last follow-up. Results dAVF was confirmed in 29/1218 (2.4%) consecutive CVT patients. The median (interquartile range [IQR]) follow-up time was 8 (5-23) months. Patients with dAVF were older (median [IQR] 53 [44-61] vs. 41 [29-53] years; p < 0.001), more frequently male (69% vs. 33%; p < 0.001), more often had chronic clinical CVT onset (>30 days: 39% vs. 7%; p < 0.001) and sigmoid sinus thrombosis (86% vs. 51%; p < 0.001), and less frequently had parenchymal lesions (31% vs. 55%; p = 0.013) at baseline imaging. Clinical outcome at last follow-up did not differ between patients with and without dAVF. Additionally, five patients were confirmed with dAVF from non-consecutive CVT cohorts. Among all patients with CVT and dAVF, 17/34 (50%) had multiple fistulas and 23/34 (68%) had cortical venous drainage. Of 34 patients with dAVF with 36 separate CVT events, 3/36 fistulas (8%) were diagnosed prior to, 20/36 (56%) simultaneously and 13/36 after (36%, median 115 [IQR 38-337] days) diagnosis of CVT. Conclusions Dural arteriovenous fistulas occur in at least 2% of CVT patients and are associated with chronic CVT onset, older age and male sex. Most CVT-related dAVFs are detected simultaneously or subsequently to diagnosis of CVT.

Purpose Endovascular treatment (EVT) has become a major option in management of infectious intracranial aneurysms (IIAs) complicating infective endocarditis. We report a retrospective, single-center series of consecutive patients with IIAs treated by EVT. Methods Patients were included from January 2009 to July 2020. IIAs were diagnosed on DSA. Each patient underwent a neurological assessment before and after EVT and was followed up by imaging within 15 days of EVT. Safety was assessed on the evolution of NIHSS score. A minor stroke was defined as a worsening of NIHSS < 4 points. Efficacy was defined as the absence of hemorrhagic event during cardiac surgery and the exclusion of the IIA on control imaging. Results Sixty-two IIAs (30 ruptured) were diagnosed in 31 patients. Fifty-six IIAs were diagnosed on the first DSA and 6 on the early control exploration. EVT was achieved in 55 IIAs by parent artery occlusion with glue in 52 distal IIAs and coils in 3 proximal IIAs. IIAs were located in 90.9% of cases on a fourth-division branch of a cerebral artery. The neurological examination remained unchanged in 29 patients (93.5%), and 2 patients suffered minor stroke. EVT was performed before cardiac surgery in 20/22 patients. All treated IIAs were excluded on follow-up imaging. No hemorrhage was observed during cardiac surgery or in the aftermath. Seven (11.3%) unruptured IIAs were not embolized. Conclusion EVT of IIAs by occlusion of the parent artery is effective in preventing rupture and carries no significant neurological risk.

Background and aim The diagnosis of embolic stroke of undetermined source (ESUS) is based on excluding other more likely stroke etiologies, and therefore diagnostic testing plays an especially crucial role. Our objective was to compare the diagnostic testing by region, sex, and age among the participants of NAVIGATE-ESUS trial. Methods Participants were grouped according to five global regions (North America, Latin America, Western Europe, Eastern Europe and East Asia), age (<60, 60-74, and >75 years), and sex. Frequencies of each diagnostic test within areas of echocardiography, cardiac rhythm monitoring, and arterial imaging were described and compared across groups. A multivariable logistic regression model for each diagnostic test was fit to assess the independent influence of each of region, age, and sex and likelihood of testing. Results We included 6985 patients in the analysis (918 from North America; 746 from Latin America; 2853 from Western Europe; 1118 from Eastern Europe; 1350 from East Asia). Average age (highest in Western Europe (69 years), lowest in Eastern Europe (65 years)), % females (highest in Latin America (44%) and lowest in East Asia (31%)), and use of each diagnostic test varied significantly across regions. Region, but not sex, was independently associated with use of each diagnostic test examined. Transesophageal echocardiography and either CT or MR angiogram were more often used in younger patients. Conclusion Diagnostic testing differed by region, and less frequently by age, but not by sex. Our findings reflect the existing variations in global practice in diagnostic testing in ESUS patients.

OBJECTIVE:To identify characteristics, predictors, and outcomes of acute symptomatic seizures (ASS) in cerebral venous thrombosis (CVT), we investigated 1,281 consecutive adult patients with CVT included from 12 hospitals within the International CVT Consortium. METHODS:We defined ASS as any seizure between symptom onset and 7 days after diagnosis of CVT. We stratified ASS into prediagnosis and solely postdiagnosis ASS. Status epilepticus (SE) was also analyzed separately. We analyzed predictors for ASS and the association between ASS and clinical outcome (modified Rankin Scale) with multivariable logistic regression. RESULTS:Of 1,281 eligible patients, 441 (34%) had ASS. Baseline predictors for ASS were intracerebral hemorrhage (ICH; adjusted odds ratio [aOR] 4.1, 95% confidence interval [CI] 3.0-5.5), cerebral edema/infarction without ICH (aOR 2.8, 95% CI 2.0-4.0), cortical vein thrombosis (aOR 2.1, 95% CI 1.5-2.9), superior sagittal sinus thrombosis (aOR 2.0, 95% CI 1.5-2.6), focal neurologic deficit (aOR 1.9, 95% CI 1.4-2.6), sulcal subarachnoid hemorrhage (aOR 1.6, 95% CI 1.1-2.5), and female-specific risk factors (aOR 1.5, 95% CI 1.1-2.1). Ninety-three (7%) patients had solely postdiagnosis ASS, best predicted by cortical vein thrombosis (positive/negative predictive value 22%/92%). Eighty (6%) patients had SE, independently predicted by ICH, focal neurologic deficits, and cerebral edema/infarction. Neither ASS nor SE was independently associated with outcome. CONCLUSION:ASS occurred in one-third of patients with CVT and was associated with brain parenchymal lesions and thrombosis of the superficial system. In the absence of prediagnosis ASS, no subgroup was identified with sufficient risk of postdiagnosis ASS to justify prophylactic antiepileptic drug treatment. We found no association between ASS and outcome.

BACKGROUND:Whether carotid artery web can be considered as a potential source of arterial thromboembolism in ischemic stroke remains uncertain. AIMS:In a large sample of individuals with large intracranial artery occlusion, we compared the prevalence of carotid artery webs between patients with and without embolic stroke of undetermined source. METHODS:In a single-center study of consecutive patients with anterior circulation ischemic stroke referred for mechanical thrombectomy, the presence of carotid artery web was systematically assessed by two independent readers. Thereafter, its prevalence was compared between patients with and without embolic stroke of undetermined source. RESULTS:Among 466 patients of whom 12% were considered to have had an embolic stroke of undetermined source, ipsilateral carotid artery web was detected in 1.9% (confidence interval 95% = 0.7-3.1). Ipsilateral carotid artery web was more frequent in embolic stroke of undetermined source than in the rest of the sample (10.7% (confidence interval 95% = 2.7-18.7] vs. 0.7% (0-1.5), P < 0.001). This difference remains significant after adjustment for sex, age, and vascular risk factor (odds ratio: 12.5 (2.1-72), P = 0.005) or after exclusion of patients with any other bulb wall thickening (P = 0.025). In contrast, the difference of prevalence of contralateral carotid artery web between the two groups did not reach statistical significance (2.4% vs. 1.9%, P = 0.6). CONCLUSIONS:Our results suggest that the presence of a carotid artery web might be considered as a potential source of large intracranial artery embolism. Longitudinal studies are needed to assess the exact risk of recurrence associated with these lesions.

Purpose Embolization of middle meningeal artery (MMA) has been proposed for postoperative recurrences and primary treatment of chronic subdural hematoma (CSDH). This endovascular intervention is safe only when MMA originates from the internal maxillary artery. The aim of this study was to report an unusual high frequency of MMA originating from the ophthalmic artery, which prohibits this treatment. Methods In this retrospective study, we reviewed the anatomical origin of the MMA in patients with CSDH who were referred to our center for endovascular treatment between January 2017 and May 2019 (42 patients with 58 CSDH). We compared the prevalence of this variant in a control group of 66 patients who underwent embolization for epistaxis during the same period. Results In CSDH group, MMA originated from the ophthalmic artery in 8 out of 58 internal carotid arteries (13.8%). In the control group, this variant was observed in only 1 case out of 131 internal carotid arteries (0.7%) (OR = 20; 95% CI 2.6 to 925.2, p = 0.0003). Conclusion In this study, we report an extremely high prevalence of MMA originating from the ophthalmic artery in CSDH. In the hypothesis of prospective studies, a priori recognition of this variant will be necessary in order to exclude patients in whom endovascular treatment will not be feasible.

Background Reports on sex differences in stroke outcome and risk factors are scarce in Latin America. Our objective was to analyze clinical and prognostic differences according to sex among participants in the LASE (Latin American Stroke Registry). Methods and Results Nineteen centers across Central and South America compiled data on demographics, vascular risk factors, clinical stroke description, ancillary tests, and functional outcomes at short‐term follow‐up of patients included from January 2012 to January 2017. For the present study, all these variables were analyzed according to sex at hospital discharge. We included 4788 patients with a median in‐hospital stay of 8 days (interquartile range, 5–8); 2677 were male (median age, 66 years) and 2111 female (median age, 60 years). Ischemic stroke occurred in 4293: 3686 as cerebral infarction (77%) and 607 as transient ischemic attack cases (12.7%); 495 patients (10.3%) corresponded to intracerebral hemorrhage. Poor functional outcome (modified Rankin scale, 3–6) was present in 1662 (34.7%) patients and 38.2% of women (P<0.001). Mortality was present in 6.8% of the registry, with 7.8% in women compared with 6.0% in men (P=0.01). Death and poor functional outcome for all‐type stroke showed a higher risk in female patients (hazard ratio, 1.3, P=0.03; and hazard ratio, 1.1, P=0.001, respectively). Conclusions A worse functional outcome and higher mortality rates occurred in women compared with men in the LASE, confirming sex differences issues at short‐term follow‐up.

Objective To examine the incidence, characteristics, treatment, and predictors of late seizures (LS) after cerebral venous thrombosis (CVT), we described these features in a registry of 1,127 patients with CVT. Methods We included consecutive adult patients from an international consortium of 12 hospital-based CVT registries. We excluded patients with a history of epilepsy or with 7 days after diagnosis of CVT. We used multivariable Cox regression to identify predictors of LS. Results We included 1,127 patients with CVT. During a median follow-up of 2.0 years (interquartile range [IQR] 1.0-6.3), 123 patients (11%) experienced >= 1 LS (incidence rate for first LS 30 per 1,000 person-years, 95% confidence interval [CI] 25-35). Median time to first LS was 5 months (IQR 1-16 months). Baseline predictors of LS included status epilepticus in the acute phase (hazard ratio [HR] 7.0, 95% CI 3.9-12.6), decompressive hemicraniectomy (HR 4.2, 95% CI 2.4-7.3), acute seizure(s) without status epilepticus (HR 4.1, 95% CI 2.5-6.5), subdural hematoma (HR 2.3, 95% CI 1.1-4.9), and intracerebral hemorrhage (HR 1.9, 95% CI 1.1-3.1). Eighty-five patients (70% of patients with LS) experienced a recurrent seizure during follow-up, despite the fact that 94% received antiepileptic drug treatment after the first LS. Conclusion During a median follow-up of 2 years, approximate to 1 in 10 patients with CVT had LS. Patients with baseline intracranial bleeding, patients with acute symptomatic seizures, and those who underwent decompressive hemicraniectomy were at increased risk of developing LS. The high recurrence risk of LS justifies epilepsy diagnosis after a first LS.

Intrahepatic lesions in adults, commonly named hepatic hemangioma, should be called Intrahepatic Venous Malformations (IHVM), or Giant Intrahepatic Venous Malformations (GIHVM) when larger than 10 cm according to the ISSVA classification (International society study group for vascular anomalies). Localized coagulation disorders (LIC) in patients with venous malformations are quite commonly associated in venous malformations, they result in decreased fibrinogen (< 2g/l) and elevated d-dimers (> 1500 ng/ml) and might be responsible of intralesional thrombotic, pain or bleeding episodes.We report a case report of a 41 y/o patient that presented with right hypochondrium pain episodes discovering an unknown GIHVM on ultrasound imaging with a prior history of uterine bleeding episodes and multiples miscarriages.On laboratory work up the patient presented an associated localized Intravascular Coagulation (LIC) with the GIHVM. As the patient desire to become pregnant was important our multidisciplinary clinic allowed a pregnancy with close clinical, biological and imaging monitoring and follow up. Early initiation of low molecular weighted heparin (LMWH) successfully allowed an uncomplicated term pregnancy and delivery. Intrahepatic lesion stability was achieved and prevented progression from LIC to diffuse intravascular coagulation disorder (DIC)..

Information about clinical outcome and reperfusion treatment in Latin-America is not widely known. Our aim was to determine this association and other clinical factors according to the initial clinical severity in functional outcome in the population from the Latin-America Stroke Registry (LASE). Methods: Data were collected prospectively from consecutive patients admitted from January 2012-January 2017 in 20 Latin-American centers. The initial clinical severity was stratified according to the baseline NIHSS; 0-3 minor, 4-7 mild, 8-14 moderate, and ≥15 severe. Clinical outcome was defined by mRS at 3 months, dichotomized in good (0-2) and poor (3-6) groups for univariate and logistic multivariate analysis. Results: Among 5381 patients, 823(15.3%) patients received any reperfusion treatment. Of these, 84.7% received I.V. fibrinolytic, 13.2% bridging therapy, and 0.9 % primary endovascular treatment. In overall, according to initial clinical deficit by NIHSS, reperfusion treatment was associated with good outcome in mild (82.8% Vs 66.1% p=0.005), moderate (55.9 % vs. 41.6% p=0.002) and severe deficits (29.4 Vs. 18.8% p=0.002). In patients with a baseline NIHSS ≥4, multivariate analysis showed that lower NIHSS (p<0.001 OR: 1,194 CI95%: 1,169-1,219), reperfusion treatment (p<0.001 OR: 2.132 CI95%: 1.625-2.797) and urban setting (p<0.001 OR: 2.310 CI95%: 1,702-3,134) were predictors for good outcome. In reperfusion treatment patients group, multivariate analysis showed that the presence of prior ischemic cardiopathy (p=0.009 RO: 4,304 CI95%: 1,430-12,953) and lower baseline NIHSS (p< 0.001 OR: 1,232 CI95%: 1,173- 1,293) were independent variables associated with a good outcome. Conclusion: In this study, the rate of reperfusion treatment in 20 stroke Latin-American centers is lower than that reported from other world regions. A significant association between reperfusion treatment and good clinical outcome was observed in mild up to severe baseline deficit in our study. The effect of ischemic cardiopathy in clinical outcome in reperfusion treated patients deserves further studies. Its association with recanalization, remote pre-conditioning ischemia and collateral circulation could be explored in our population.

La vasculopathie causée par le virus zona-varicelle (VZV) est une cause rare d'infarctus cérébral mais possiblement sous-estimée. Une patiente de 25 ans, sans facteurs de risque vasculaire, est hospitalisée pour l'apparition brutale d'une aphasie isolée 6 mois après une varicelle. En dehors de l'aphasie, l'examen clinique est normal. L'IRM cérébrale confirme le diagnostic d'infarctus cérébral aigu dans le territoire de l'artère cérébrale moyenne gauche. L'ARM montre une sténose serrée de la terminaison carotide gauche et de l'origine de l'artère cérébrale antérieure gauche avec sur l'IRM haute résolution une prise de contraste intense et circonférentielle de la paroi de ces artères en faveur d'une angéite. L'examen cytologique et biochimique du LCR est normal mais la PCR VZV est positive. Un bilan exhaustif ne retrouve pas d'autre cause à cet infarctus cérébral. Un traitement par prednisone 1 mg/kg pendant 3 jours et aciclovir intraveineux pendant 14 jours, puis valaciclovir orale pendant 7 jours est introduit sans nouvel épisode neurologique. Le diagnostic de vascularite à VZV est retenu. Chez l'enfant, le VZV est une cause fréquente d'artériopathie cérébrale unifocale touchant surtout la terminaison carotide, survenant dans l'an suivant une varicelle. Plus rare chez l'adulte, elle atteint les artères de gros et moyens calibres et/ou de petit calibre après une varicelle ou un zona ophtalmique. Le diagnostic repose sur des critères clinico-radiologiques, la positivité de la PCR VZV et/ou la synthèse intrathécale d'IgG anti-VZV. L'association d'un infarctus cérébral et d'une vasculopathie unilatérale des artères cérébrales de gros et moyen calibre doit faire évoquer le diagnostic de vascularite zostérienne chez l'enfant et l'adulte.