BACKGROUND:Young adults account for up to 15% of all ischemic strokes, yet data from Latin America remain scarce. Understanding their clinical profile and outcomes is essential to inform targeted interventions and public health strategies. We aimed to characterize demographics, vascular risk factors, stroke etiology, access to acute reperfusion therapies, and 90-day outcomes in Argentine patients aged 18-50 years with ischemic stroke. METHODS:We conducted a retrospective multicenter cohort study including consecutive patients aged 18-50 years with ischemic stroke, enrolled between January 2015 and December 2023 across 26 centers in Argentina. Primary outcomes were functional dependence (modified Rankin scale (mRS) 3-5), stroke recurrence, and all-cause mortality at 90 days. RESULTS:Among 18,934 ischemic stroke patients, 1422 (7.5%) were young adults. Median age was 43 years (interquartile range (IQR) 36-47), and 53.7% (n = 763) were male. The most prevalent risk factors were hypertension (31.0% (n = 441)), smoking (29.3% (n = 417)), and obesity (18.8% (n = 267)). Median National Institute of Health Stroke Scale (NIHSS) on admission was 3 (IQR 1-8). Acute reperfusion therapy was administered in 18.9% (n = 269). Stroke etiology remained undetermined in 50.4% (n = 717) of cases; within this group, 26.1% (n = 312) fulfilled criteria for embolic stroke of undetermined source (ESUS), and 17.8% (n = 198) were cryptogenic strokes associated with patent foramen ovale. Arterial dissection accounted for 56.6% (n = 193) of other determined causes. At 90 days, functional dependence was observed in 12.1% (n = 110), stroke recurrence in 3.9% (n = 37), and mortality in 4.8% (n = 44). CONCLUSION:In Argentina, nearly 1 in 13 ischemic strokes occurs in young adults. Despite generally mild presentations, functional dependence and mortality remain substantial. The high rate of undetermined etiology underscores the need for standardized diagnostic protocols in this population, whose strokes carry a disproportionate individual and societal burden due to their early onset.

Introducción y objetivosEn los últimos años la distribución de subtipos de accidente cerebrovascular (ACV) se ha modificado. El control de factores de riesgo (FR) y nuevas terapias pudieron influir en ello. Nuestro objetivo fue describir características y subtipos etiológicos de una población de pacientes con ACV isquémico en el último período y compararlas con datos de un estudio similar realizado en la misma institución hace 20 años.Materiales y métodosEstudio retrospectivo. Revisión de historias de pacientes con ACV admitidos en un hospital público de la Ciudad de Buenos Aires; período enero/2015 a marzo/2019. Se consideraron datos demográficos, FR, subtipo de ACV y tratamiento. Los resultaron fueron comparados con un estudio del período julio/1997 a marzo/1999.ResultadosDe 549 pacientes analizados, 445 fueron isquémicos. Media de edad: 66±15 años. Varones 60%. FR más frecuentes: hipertensión arterial (65%), diabetes (22%), tabaquismo (22%). Etiología: 54% indeterminado (46% estudios incompletos), 20% cardioembólico, 12% gran vaso, 10% pequeño vaso, 4% otras causas. Comparativamente con el período anterior, la hipertensión arterial continúa siendo el FR principal. Aumentó la proporción de ACV de etiología indeterminada y disminuyó pequeño vaso.ConclusionesLas características demográficas de nuestra población no se han modificado. La reducción en la frecuencia de ciertos FR, principalmente de la hipertensión arterial, podría relacionarse con la menor proporción de enfermedad de pequeño vaso. La etiología indeterminada por estudios incompletos ha aumentado, quizás por un sesgo de la población, dado que el centro recibe pacientes que después del tratamiento agudo son contrarreferidos.

Introducción y objetivoEl accidente cerebrovascular (ACV) es una urgencia tiempo dependiente: las conductas de mayor impacto pronóstico dependen del tiempo trascurrido hasta la realización de la terapia. Actualmente la ventana para la trombólisis intravenosa es hasta 4,5 h. Nuestro objetivo es analizar las causas de la no realización de trombólisis sistémica en pacientes ingresados a la unidad de ACV.Materiales y métodosEstudio observacional, con datos obtenidos de historias clínicas de pacientes internados en la unidad de ACV entre agosto de 2015 y diciembre de 2019. Analizamos el número de tratamientos trombolíticos intravenosos (TTE), los motivos por los cuales los pacientes no recibieron TTE, el tiempo puerta-aguja y el tiempo inicio-aguja.ResultadosDe 472 pacientes internados, 216 (45,7%) llegaron fuera de la ventana terapéutica. De los pacientes que arribaron dentro de dicha ventana, no se realizó TTE en 122 (46,1%). Los motivos fueron: NIHSS bajo 41%, tener síntomas transitorios 31%, ACV hemorrágico 10%, hipertensión arterial no controlada 7%, ventana extendida asociada a criterio de riesgo elevado de sangrado 6%, otras causas 5%. El tiempo inicio-aguja y el tiempo puerta-aguja en 2019 fue de 142 y 47,9 min, respectivamente.ConclusionesLa llegada tardía a unidad de ACV es la causa más común por la que a un paciente no se le realiza TTE, punto de mejora con educación poblacional y médica continua, más la reducción de los tiempos de atención prehospitalarios. Los que llegan en ventana terapéutica, los ACV menores o con síntomas transitorios representan el mayor porcentaje de los que no reciben TTE, grupo en el que evaluar si para algunos pacientes la TTE sería más beneficiosa que la no trombólisis.

Background: Cerebral venous thrombosis (CVT) is a rare medical condition that primarily affects young adults. The clinical spectrum is broad and its recognition remains a challenge for clinicians. Limited information is available on CVT in Argentina. Our goal was to report the results of the first National registry on CVT in Argentina and to compare clinical presentation, predisposing factors and out comes with other international registries. Material and method: The Argentinian National Registry on CVT (ANR-CVT) is a multicenter retrospective cohort study comprising patients aged 18 and older with a diagnosis of CVT from January 2015 to January 2019. We evaluated demographics, predisposing factors, clinical presentation, and radiological characteristics (e.g. number of involved sinuses, venous infarction or hemorrhage on CT and MRI scans at admission), therapeutic interventions and functional outcomes at discharge and at 90 days. Our results were compared to a literature review of CVT registries. Results: Overall, one hundred and sixty-two patients met the inclusion criteria. The mean age was 42 (+/- 17) years; 72% were women. Seventy percent of patients were younger than 50 years. The most common presenting symptom was headache (82%). The transverse sinus was the most common site of thrombosis (70%) followed by the sigmoid sinus (46%). The main predisposing factor in women was contraceptive use (44%), 3% of the events occurred during pregnancy and 9% during the puerperium. Participants 50 years and older had a higher frequency on malignancy related (7.5% vs. 30%, p = 0.0001) and infections (2% vs. 11%, p = 0.001). The modified Rankin Scale (mRS) <= 2 at discharge was 81% and the rate of mortality at discharge was 4%. At 90 days, the mRS <= 2 was 93%. When the ANR-CVT was compared with larger registries from Europe and Asia, the prevalence of cancer among patients with CVT was two to five-fold higher (15% vs. 7% and 3%, respectively; p = 0.002 and p < 0.001). Anticoagulation rates at discharge were also higher (94%) compared to registries from Asia (ASCVT 68%) or Turkey (VENOST 67%). Conclusion: Participants in the first ANR-CVT had a low mortality and disability at 90 days. Clinical and radiological characteristics were similar to CVT from other international registries with a higher prevalence of cancer. There was a high variability in treatment adherence to guidelines as reflected by anticoagulation rates (range 54.5%-100%) at discharge. (c) 2020 Elsevier Inc. All rights reserved.

BACKGROUND:Pseudobulbar affect is defined by involuntary or exaggerated episodes of laughter or crying, subsequent to a specific disease. After-stroke pseudobulbar affect is reported in 11%-34% of patients. In our population is underdiagnosed. Our objective was to determine its frequency in a group of stroke patients.PATIENTS AND METHODS:Prospective observational study from June/2017 to June/2018. Two populations were evaluated: chronic stroke (Group A) and acute stroke (Group B). Patients with severe psychiatric illness, cognitive impairment and/or aphasia were excluded. PLACS ("pathological laughing and crying scale") and CNS-LS ("lability scale for pseudobulbar affect") scales were performed. Pseudobulbar affect was defined with diagnostic criteria plus both positive scales.RESULTS:Fifty patients were evaluated. Sixty-eight percent were men. Mean age: 65±12 years. Group A: 19 cases and group B: 31 cases. Positive PLACS: 21% group A and 29% group B. Positive CNS-LS: 58% group A and 26% group B. Both positive scales in 8 patients (2 in group A and 6 in group B). Three of them had associated depression.CONCLUSIONS:Pseudobulbar affect should be screened after stroke. Post-stroke depression is frequent and differential diagnose with emotional lability attributable to pseudobulbar affect must be ruled out. The administration of a single scale would not be sufficient for diagnostic guidance.

Introducción y objetivo: El síndrome pseudobulbar se define por episodios involuntarios o exagerados de risa o llanto, posteriores a una enfermedad específica. El síndrome pseudobulbar después del accidente cerebrovascular se reporta entre el 11%-34% de los pacientes. En nuestra población está subdiagnosticado. Determinamos su frecuencia en un grupo de pacientes post-ACV. Pacientes y métodos: Estudio observacional prospectivo desde junio/2017 a junio/2018. Se evaluaron dos poblaciones: ACV crónico (Grupo A) y ACV agudo (Grupo B). Se excluyeron pacientes con enfermedad psiquiátrica grave, deterioro cognitivo y/o afasia. Se realizaron las escalas PLACS (“pathological laughing and crying scale”) y CNS-LS (“Center for Neurologic Study-Lability Scale”). El síndromepseudobulbar se definió por criterios diagnósticos más ambas escalas positivas. Resultados: Cincuenta pacientes fueron evaluados. El 68% eran hombres. Edad media: 65±12 años. Grupo A: 19 casos y grupo B: 31 casos. PLACS positiva: 21% grupo A y 29% grupo B. CNS-LS positiva: 58% grupo A y 26% grupo B. Ambas escalas positivas en 8 pacientes (2 en crónico y 6 en agudo). Tres de ellos tenían depresión asociada. Conclusiones: El síndrome pseudobulbar debe examinarse cuidadosamente luego del ACV. La depresión post-ACV debe diferenciarse de la labilidad emocional por síndrome pseudobulbar. La administración de una sola escala no seríasuficiente para la orientación diagnóstica.

May 7, 2019April 9, 2019Free AccessPseudobulbar affect in patients with stroke (P3.3-028)María Constanza Segamarchi, Matias Alet, Santiago Claverie, Sandra Lepera, Leonardo Adrian Gonzalez, and Raul ReyAuthors Info & AffiliationsApril 9, 2019 issue92 (15_supplement)https://doi.org/10.1212/WNL.92.15_supplement.P3.3-028 Letters to the Editor

Key PointsQuestionCan a multifaceted quality improvement intervention increase the adherence to 10 evidence-based performance measures for patients with acute ischemic stroke and transient ischemic attack in Latin America? FindingsIn this cluster randomized clinical trial that included 1624 patients from 36 hospitals in 3 countries, hospitals in the intervention group had a composite adherence score of 85.3% for the evidence-based performance measures, and those in the control group had a score of 77.8%, a difference that was not statistically significant. In a planned secondary analysis, improvement in adherence to all 10 performance measures was greater in the intervention group than in the control group using an all-or-none approach for the outcome. MeaningIn this cohort of patients with acute ischemic stroke and transient ischemic attack, a multifaceted intervention did not demonstrate an overall improvement in adherence to evidence-based performance measures compared with standard of care, yet individual care elements improved. This cluster randomized clinical trial assesses the effect of a multifaceted quality improvement intervention compared with routine care on adherence to evidence-based therapy among patients with acute ischemic stroke and transient ischemic attack. ImportanceTranslating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging, especially in low- and middle-income countries. ObjectiveTo assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for care of patients with AIS and TIA. Design, Setting and ParticipantsThis 2-arm cluster-randomized clinical trial assessed 45 hospitals and 2336 patients with AIS and TIA for eligibility before randomization. Eligible hospitals were able to provide care for patients with AIS and TIA in Brazil, Argentina, and Peru. Recruitment started September 12, 2016, and ended February 26, 2018; follow-up ended June 29, 2018. Data were analyzed using the intention-to-treat principle. InterventionsThe multifaceted quality improvement intervention included case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster. Main Outcomes and MeasuresThe primary outcome was a composite adherence score for AIS and TIA performance measures. Secondary outcomes included an all-or-none composite end point of performance measures, the individual process measure components of the composite end points, and clinical outcomes at 90 days after admission (stroke recurrence, death, and disability measured by the modified Rankin scale). ResultsA total of 36 hospitals and 1624 patients underwent randomization. Nineteen hospitals were randomized to the quality improvement intervention and 17 to routine care. The overall mean (SD) age of patients enrolled in the study was 69.4 (13.5) years, and 913 (56.2%) were men. Overall mean (SD) composite adherence score for the 10 performance measures in the intervention group hospitals compared with control group hospitals was 85.3% (20.1%) vs 77.8% (18.4%) (mean difference, 4.2%; 95% CI, -3.8% to 12.2%). As a secondary end point, 402 of 817 patients (49.2%) at intervention hospitals received all the therapies that they were eligible for vs 203 of 807 (25.2%) in the control hospitals (odds ratio, 2.59; 95% CI, 1.22-5.53; P=.01). Conclusions and RelevanceA multifaceted quality improvement intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with AIS or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies. Trial RegistrationClinicalTrials.gov identifier: NCT02223273

El accidente cerebrovascular (ACV) es una de las principales causas de muerte y discapacidad. Es una urgencia tiempo dependiente, ya que las conductas de mayor impacto pronóstico se toman en las primeras horas. La reperfusión mediante trombólisis endovenosa o vía endovascular, junto al manejo en unidades de ACV, son el «patrón oro» del tratamiento. En el contexto de un plan piloto desarrollado en un hospital público de la Ciudad de Buenos Aires, que brinda este tratamiento y recibe pacientes de otras instituciones, se evaluaron los parámetros de la cadena asistencial. Estudio observacional, prospectivo, con datos obtenidos de historias clínicas de pacientes internados en la unidad, considerando variables demográficas, clínicas y tiempos de la cadena asistencial, entre agosto de 2015 y julio de 2016. Se compararon pacientes que consultaron directamente en la institución con los derivados. Se revisaron datos suministrados por la División Estadística del Ministerio de Salud de la Ciudad de Buenos Aires en relación con la enfermedad y su manejo. Fueron evaluados 251 pacientes, 83 internados en la Unidad. Veinticuatro (31,2%) ingresaron por derivación y 26 recibieron trombólisis intravenosa. Tiempos medios: primera consulta 50 minutos, puerta-aguja 81,4 minutos, inicio de síntomas a trombólisis 187 minutos. Aquellos derivados presentaron mayor demora. En este período recibió trombólisis en nuestro centro solo el 1% de los ACV ocurridos en la ciudad. La organización de unidades de ACV demostró mejorar la mortalidad e independencia de los pacientes. Mayor disponibilidad de instituciones capacitadas con una distribución estratégica permitiría aumentar el número de tratamientos. Stroke is one of the leading causes of death and disability. It is a time-dependent emergency. Arterial reperfusion through systemic thrombolysis or endovascular therapy, combined with the management at Stroke Units, is the gold standard of care. In the context of a program developed at a public hospital of Buenos Aires, which provides this treatment and receives patients referred from other helthcare centers, the parameters of the therapeutic process were evaluated. Observational and prospective study with data obtained from the clinical records of patients admitted to the Stroke Unit, taking into account demographics and clinical characteristics and timelines of the therapeutic process, between August 2015 and July 2016. Patients who came directly to our healthcare center were compared with those referred from other centers. We reviewed the stroke management data furnished by the Statistics Division of the Ministry of Health of Buenos Aires. A total of 251 patients were assessed, 83 were admitted to the Stroke Unit. 24 (31.2%) came from others healthcare centers. 26 were treated with systemic thrombolysis. Average times: arrival to the emergency room: 50 minutes; door to needle: 81.4 minutes; onset of symptoms to thrombolysis: 187 minutes. Patients referred from other healthcare centers presented increased delay in treatment. Only 1% of the stroke patients of the City received thrombolysis in our center. Setting up of Stroke Units has been associated with decreased mortality and increased patient independence. A greater availability of specialized centers with a strategic distribution network would help increase the number of acute stroke treatments.

OBJECTIVE:Chronic neurological disorders generate disabilities affecting multiple aspects of life, including sexuality.OBJECTIVE:To describe the presence of sexual dysfunction and comorbidities in a population with chronic neurological disorders. To analyze the relationship between disability and sexual dysfunction.METHODS:A cross-sectional case-control study was carried out. Patients with amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), Parkinson's disease (PD), and stroke of at least one year since the onset of symptoms were included, and compared with controls with no neurological disease, matched by age and sex.RESULTS:We included 71 participants: 29 controls, with a mean age of 49.4 years, and 42 patients with a mean age of 53.8 years. Sexual dysfunction was present in 22.5% of the controls and 77.5% of the patients. A statistically significant relationship between sexual dysfunction and disability was found in the logistic regression analysis (OR = 20.38, 95%CI: 2.5 -165.86).CONCLUSIONS:Disability proved to be the main variable related to the presence of sexual dysfunction. Patients with ALS had the worst rates of sexual dysfunction. Patients with MS were similar to the control group. As for the PD group, no patient had normal sexuality. Finally, in stroke patients, the presence of comorbidities and their treatment may have negatively influenced sexuality. These findings showed that patients with chronic neurological diseases have sexual dysfunction and underscore the need for neurologists to know and address this problem.

El ACV en jóvenes tiene múltiples etiologías, entre ellas, cardioembolia. Pueden asociarse malformaciones cardíacas, como foramen oval permeable (FOP), aneurisma del septo interauricular (ASIA) o defectos del septo interauricular (DSIA). Presentamos una paciente con ACV asociado a ASIA multifenestrado. Mujer, 28 años, uso de anticonceptivos. Presenta afasia mixta, hemianopsia y hemiparesia derechas. Tomografía: borramiento insular y ganglios basales izquierdos. Recibe trombólisis intravenosa. Resonancia magnética: infarto de cerebral media izquierda. El ecocardiograma muestra ASIA y DSIA multifenestrado. Se interpreta ACV cardioembólico por pasaje de émbolo y anticonceptivos como protrombótico. Inicia anticoagulación; el 30% de los ACV en jóvenes son cardioembólicos. La asociación de FOP de gran tamaño y ASIA multifenestrado puede tener riesgo de embolización paradojal y relación con el ACV. Su manejo es controvertido, optando entre anticoagulación o cierre de defectos complejos.

To evaluate the relationship between disability and chronic neurological disorders.

Las distrofias musculares son miopatías genéticas, con importantes alteraciones cardiacas y si bien estas son consideradas factores de riesgo para fenómenos tromboembólicos, es baja la incidencia reportada de ataques cerebrovasculares (ACV) en estos pacientes.

En el accidente cerebrovascular (ACV) de causa ateroembólica, las características de la placa de ateroma se correlacionan con el riesgo de isquemia. La compresión extrínseca del vaso puede desencadenar la rotura y la embolización. Dentro de las recomendaciones para la evaluación de pacientes que han presentado un accidente isquémico transitorio o un ACV, se indica la realización de una ecografía Doppler de vasos de cuello (EDVC). Dicha práctica se considera carente de riesgos, aunque durante la misma pueden producirse compresiones bruscas sobre la arteria carótida. Paciente de 83 años que durante la realización de una EDVC presenta una hemiparesia súbita derecha. En la tomografía de encéfalo se evidencia una lesión isquémica insular izquierda aguda. La EDVC mostró una estenosis significativa de la arteria carótida izquierda, con presencia de una placa fibrolipídica inestable. Presentamos este caso como ejemplo de un ACV isquémico secundario a compresión carotidea durante una EDVC. Una complicación de este tipo podría estar subestimada en la literatura e indicamos que ante la presencia o sospecha, durante o previo al estudio, de una placa inestable o con posibles complicaciones se extremen las medidas para que la compresión sobre la arteria carótida sea la menor posible. In a cerebrovascular accident of atheroembolic cause, the characteristics of the atheromatous plaque correlates with the risk of ischemia. Extrinsic carotid compression may trigger the plaque rupture and embolization. In the evaluation of patients with a transient ischemic attack or a stroke, is suggested the realization of a carotid Doppler ultrasound. This practice is considered without risk, although abrupt carotid compression could be done. We report an 83 years old man who in the course of a carotid Doppler ultrasound scanning presents a sudden right hemiparesis. Computed tomography scan evidenced an acute left insular ischemic brain injury. The ultrasound showed significant stenosis of the left carotid artery with the presence of a fibro-lipid and unstable plaque. We present this case as an example of a stoke secondary to carotid compression. Complications of this type may be underestimated in the literature. We suggest that extreme measures in the compression of the carotid artery should be taken if during or prior to the study an unstable or complicated plaque is suspected.

Objectives: To determine whether vascular and demographic factors predict worsening disability up to 8 years after lacunar stroke. Methods: SPS3 (Secondary Prevention of Small Subcortical Strokes) was a clinical trial in lacunar stroke patients with annual assessment of disability using the Older Americans Resources and Survey instrumental activities of daily living (IADL) scale (range 0–14). Generalized estimating equations modeled the likelihood of disability (IADL <14) over time, adjusting for demographics, medical risk factors, cognition, mood, stroke location, and geographic region in univariate and multivariable models. IADL assessments after recurrent stroke were censored. We stratified by study region and age quartile. Results: Among 2,820 participants, mean age was 63.4 years (SD 10.8), 63% were male, 36% had diabetes, 90% hypertension, and 10% prior stroke. Mean follow-up was 3.7 years. In multivariable models, female sex, education, diabetes, nonregular alcohol use, prior stroke, Cognitive Abilities Screening Instrument score, depression, mild cognitive impairment, and stroke location were associated with disability. The youngest age quartile had decreased odds of disability over time (odds ratio 0.90 per year, 95% confidence interval 0.85–0.95), whereas the oldest age quartile had increased odds (2.20, 95% confidence interval 1.75–2.75). Americans and Latin Americans had >2-fold greater odds of disability per year compared with Spaniards (p < 0.0001). Conclusions: In lacunar stroke patients, older age was associated with worsening long-term disability, even without recurrence. Worse long-term function was associated with diabetes, cognitive status, and prior stroke, and regional differences may be attributable to variations in health care delivery or scale interpretation.

La afección seudobulbar (APB) es la expresión de risa o llanto involuntario e incontrolable. La prevalencia en ELA es del 50%, en EP 11%, en EM 8% y en ACV 18%. No existen datos concluyentes sobre el tipo de APB prevalente en cada afección ni sobre las vías anatómicas involucradas en su génesis. Evaluar la frecuencia y el tipo de APB en dichas enfermedades. Se evaluó a 18 pacientes con ELA, 31 con EP, 22 con EM brote y remisión, y 20 con ACV isquémico no agudo que concurrieron a una consulta espontánea entre abril del 2012 y junio del 2013. Se les realizaron las escalas CNS-LS y PLACS diagnósticas de APB y se consignó la existencia de lesiones en neuroimágenes de tipo cortical, profundo o infratentorial. Se entrevistó a 48 hombres y a 43 mujeres. La media etaria ± desviación estándar fue: 54 ± 13,31 años en ELA, 61 ± 9,92 años en EP, 71 ± 16,59 años en ACV y 37 ± 12,14 años en EM. Se diagnosticó APB en 33 pacientes (36% ELA, 27% EP, 21% EP, 16% EM). En ellos, 14 (43%) tendían al llanto, 11 (33%) a ambos y 8 (24%) a la risa. Hubo igual predisposición a APB en los pacientes con lesiones corticales o subcorticales. La máxima frecuencia de diagnóstico fue encontrada en ELA. El tipo de APB más diagnosticado fue el llanto, aunque en ELA fue el tipo risa y llanto. No se pudo relacionar una zona anatómica con el desarrollo de APB. Pseudobulbar affect (PBA) is an affective desinhibition characterized by uncontrollable episodes of laughing or crying. The prevalence of PBA is: 50% in Amyotrophic Lateral Sclerosis (ALS), 8% in Multiple Sclerosis, 11% in Parkinson disease (PD) and 18% in stroke. There is no conclusive information about the affected pathways involved in its pathogenesis. to diagnose type and frequency of PBA in ALS, MS, PD and stroke. Thirty-one patients with PD, 20 with non acute stroke, 22 with MS remission-recurrence type and 18 patients with ALS were evaluated from April 2012 to June 2013 when attending to a spontaneous follow-up consult. The CNS-LS and the PLACS scale were performed. Pathological answers were classified in crying, laughing or crying and laughing. The characteristics of the CT SCAN or MRI were divided in normal or cortical, deep or infratentorial lesion. There were 48 men and 43 women. Mean age was 54 (±13.31) years for ALS, 37 (±12,14) for MS, 71 (±16,59) for stroke and 61 (±9,92) for PD. Thirty-three patients were diagnosed of PBA (27% PD, 36% ALS, 21% Stroke and 16% MS). Of them, 14 (43%) had crying tendency, 11 (33%) laughing tendency and 8 (24%) both. There was the same disposition to PBA between patients with cortical or subcortical lesions. PBA was most frequently diagnosed in ALS. Crying was the predominant emotion in these patients. However, the most diagnosed PBA type was laughing and crying. We could not find an anatomical relation between lesional zone and PBA development.

Objective: to analyze the overall bone mass, the one in the lower muscle strength region (affected region) and vitamin D levels in a series of patients with stroke, ALS and MS. Background: Osteoporosis is characterized by bone mass loss, and other factors associated with hypovitaminosis D. Osteoporosis caused by disuse is the result of lack of stimulation of muscle strength. Patients with stroke, amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) are predisposed to disuse osteoporosis associated with malnutrition and lower sun exposure, predisposing to fractures. Design/methods: We studied patients with diagnosis of stroke, ALS and MS muscle weakness over a year of evolution, ambulatory monitored. Anamnesis looking for osteoporosis risk factors was done, besides physical examination, bone mineral densitometry (BMD) in the affected area (forearms or hips) (AA) and in those with greater muscle strength (control region) (CR). Serum Vitamin D was assessed (normal value 蠅 30). SPSS software was used for statistical analysis. Results:13 patients: seven strokes, 3 ALS, 3 MS. 8 men, mean age: 57 years. 5 women, mean age 61.8 years. 5 history of fracture. none on steroids, 2 antiepileptic drugs. 57.1% of BMD were pathological in AA, 42.9% in CR. ELA Group 33.3% of BMD were pathological in AA, stroke group 71.4% and 66.7% MS. Mean total vitamin D 20.3 ± 7.8. Vitamin D media group stroke 17.78, 22.46 ALS group, and MS was 24 (p = NS). Conclusions: This study demonstrates greater commitment tendency to bone density in regions with weakness, compared to those without it, this could be related to disuse. This series had insufficient vitamin D. The neurologist should consider bone mass evaluation in patients with chronic muscle weakness.

Background Lowering of blood pressure prevents stroke but optimum target levels to prevent recurrent stroke are unknown. We investigated the effects of different blood-pressure targets on the rate of recurrent stroke in patients with recent lacunar stroke.Methods In this randomised open-label trial, eligible patients lived in North America, Latin America, and Spain and had recent, MRI-defined symptomatic lacunar infarctions. Patients were recruited between March, 2003, and April, 2011, and randomly assigned, according to a two-by-two multifactorial design, to a systolic-blood-pressure target of 130-149 mm Hg or less than 130 mm Hg. The primary endpoint was reduction in all stroke (including ischaemic strokes and intracranial haemorrhages). Analysis was done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT 00059306.Findings 3020 enrolled patients, 1519 in the higher-target group and 1501 in the lower-target group, were followed up for a mean of 3.7 (SD 2.0) years. Mean age was 63 (SD 11) years. After 1 year, mean systolic blood pressure was 138 mm Hg (95% CI 137-139) in the higher-target group and 127 mm Hg (95% CI 126-128) in the lower-target group. Non-significant rate reductions were seen for all stroke (hazard ratio 0.81, 95% CI 0.64-1.03, p=0.08), disabling or fatal stroke (0.81, 0.53-1.23, p=0.32), and the composite outcome of myocardial infarction or vascular death (0.84, 0.68-1.04, p=0.32) with the lower target. The rate of intracerebral haemorrhage was reduced significantly (0.37, 0.15-0.95, p=0.03). Treatment-related serious adverse events were infrequent.Interpretation Although the reduction in stroke was not significant, our results support that in patients with recent lacunar stroke, the use of a systolic-blood-pressure target of less than 130 mm Hg is likely to be beneficial.