The second part of these Guidelines covers the topics of antiplatelet, anticoagulant, and statin therapy in acute ischemic stroke, reperfusion therapy, and classification of Stroke Centers. Information on the classes and levels of evidence used in this guideline is provided in Part I. A translated version of the Guidelines is available from the Brazilian Stroke Society website (www.sbdcv.com.br).

The epidemiological transition in Latin America toward older urban dwelling adults has led to the rise in cardiovascular risk factors and an increase in morbidity and mortality rates related to both stroke and myocardial infarction. As a result, there is an immediate need for effective actions resulting in better detection and control of cardiovascular risk factors that will ultimately reduce cardiovascular disease burden. Data from case-control studies have identified the following risk factors associated with stroke: hypertension; smoking; abdominal obesity; diet; physical activity; diabetes; alcohol intake; psychosocial factors; cardiac causes; and dyslipidemia. In addition to its high mortality, patients who survive after a stroke present quite frequently with marked physical and functional disability. Because stroke is the leading cause of death in most Latin American countries and also because it is a clearly preventable cause of death and disability, simple, affordable, and efficient strategies must be urgently implemented in Latin America.

RESUMO -A dissecção espontânea das artérias carótidas e vertebrais (DEACV) é considerada uma causa rara de acidente vascular cerebral, particularmente em países com população multiétnica. O objetivo desse estudo foi avaliar características clínicas e de neuroimagem dos pacientes com DEACV em uma população multiétnica. Foram estudados 66 pacientes com diagnóstico de DEACV em dois hospitais terciários de São Paulo. Aplicou-se um questionário inicial e os pacientes foram seguidos prospectivamente. Dos pacientes estudados, 82% eram brancos, 53% eram homens e a média de idade foi 41,7 anos. Os fatores de risco cardiovasculares mais freqüentes foram hipertensão arterial e tabagismo. Outros aspectos avaliados foram histó-ria prévia de enxaqueca, tratamento inicial e prognóstico. Concluiu-se que apesar da população estudada ser multiétnica, houve um marcante predomínio de brancos. A análise das características clínicas e de neuroimagem dos pacientes com DEACV possibilita um melhor conhecimento da doença, levando a um diagnóstico precoce e tratamento mais adequado.PALAVRAS-CHAVE: dissecação da artéria vertebral, dissecação da artéria carótida interna, acidente cerebrovascular, grupos étnicos. Spontaneous carotid and vertebral arteries dissection in a multiethnic populationABSTRACT -Spontaneous dissection of the carotid and vertebral arteries (SDCVA) is considered a rare cause of stroke, particularly in countries with multiethnic population. The objective was to evaluate the clinical and neuroimaging features of patients with SDCVA from a multiethnic population. Sixty-six patients diagnosed with SDCVA were studied at two tertiary hospitals at São Paulo. An initial questionnaire was completed and patients were followed prospectively. Among the patients studied, 82% were caucasian, 53% were male and the average age was 41.7 years old. The most frequent cardiovascular risk factors found were systemic hypertension and tobacco use. Other aspects evaluated were history of previous migraine, initial treatment and prognosis. In conclusion, although the population studied was multhiethnic, there was a marked predominance of caucasians. The analysis of clinical and neuroimaging data from patients with SDCVA allows a better understanding of the disease, leading to an earlier diagnosis and more appropriate treatment.KEY WORDS: vertebral artery dissection, carotid artery internal dissection, cerebrovascular disorder, ethnic groups. A dissecção espontânea das artérias carótidas e vertebrais (DEACV) caracteriza-se pela sua ruptura não traumática, entre as camadas arteriais, levando à redução do diâmetro da luz da artéria ou à formação de dilatação aneurismática . Novos estudos são necessários para o esclarecimento de dúvidas que ainda persistem quanto à etiologia, diagnóstico, tratamento e prognóstico dos pacientes com DEACV, especialmente em populações multiétnicas. O objetivo deste estudo foi descrever, a partir de uma série de casos, as características clínicas e os achados de neuroimagem mais freqüentemente observados nos pacientes ...

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O Acidente Vascular Cerebral (AVC) é a doença neurológica que mais incapacita os adultos. A respiração, a postura e a deglutição possuem uma relação direta nesta doença, necessitando assim de uma intervenção multidisciplinar. O objetivo do presente estudo foi realizar uma avaliação clínica integrada para analisar a relação entres estas disfunções. Trata-se de uma paciente do sexo feminino com 37 anos, com seis anos de diagnóstico de AVC isquêmico com hemiparesia completa à direita de predomínio crural, hipertensão arterial sistêmica, disfagia e disartrofonia. Na anamnese, relatou sintomas referentes à dispnéia, dores na coluna lombar, presença de tosse e engasgos à alimentação e escape anterior de saliva, principalmente durante a fala. A paciente apresenta escoliose, hipercifose torácica e fraqueza dos músculos abdominais. A avaliação respiratória evidenciou uma força expiratória abaixo do limite esperado. O pico de fluxo da tosse está abaixo do esperado, demonstrando não possuir força para tossir. A investigação fonoaudiológica evidenciou alterações no tempo aumentado para se alimentar, necessidade de ingerir líquidos para ajudar na deglutição de sólidos, eventuais escapes anteriores de alimento, necessidade de deglutições múltiplas devido à sensação de estase em cavidade laringo-faríngea e diminuição do paladar, bem como saliva grossa e viscosa. Utilizando-se das avaliações fisioterápicas e fonoaudiológicas, foi possível concluir que uma paciente com AVC na fase crônica apresenta alterações respiratórias que podem impedi-la de proteger com eficiência as vias aéreas inferiores, o que, somado às alterações posturais e na deglutição demonstram a importância da avaliação integrada para futuras intervenções terapêuticas mais eficazes.

Cluster headache (CH) is a clinical entity characterized by strictly unilateral head pain attacks accompanied by ipsilateral autonomic phenomena. The attacks are severe, short-lasting (15-180 minutes), and may occur several times a day 1 . Symptomatic CH cases have been described in association with different kind of lesions located in the middle fossa, near the sellar or parasellar structures although lesions of the internal carotid artery (ICA) were also described: aneurysma of ICA and internal carotid artery dissection (ICAD) 2 . We report a patient with symptomatic CH secondary to ICAD, and complete remission of his symptoms with usual treatment for CH. We obtained informed constent from the patient for publication. CaSeA 53-year-old white man presented to the emergency room of Hospital Israelita Albert Einstein with 10-day history of recurrent right peri-orbital headache. Headaches were sudden, severe, pulsating, of thirty minutes duration and occurred once or twice a day. Headache was accompanied by ipsilateral ptosis, conjunctival injection, lacrimation and nasal stuffiness. He was on treatment for mild hypertension with hidroclorotiazide 25 mg once a day. Examination during headache revealed right Horner's syndrome with partial ptosis and miosis, accompanied by ipsilateral lacrimation, eyelid edema and conjunctival injection. After this episode, he remained with mild right ptosis. The remaining cranial nerves and neurological examination were normal.The above features satisfied criteria "A to D" for CH of the International Classification of Headache Disorders (number, site and duration, accompanying symptoms, frequency of headaches) 1 . Criterion E stipulates that other causes for the headache must be ruled out. We therefore performed further investigations. Computed tomographic imaging of the brain was normal. Fat supression T1-weighted magnetic resonance imaging of the carotid canal level displayed high signal compatible with blood products within the wall of the right internal carotid what was sugestive of arterial dissection (Figure).He was admitted in our critical care unit and complementary investigation was performed. Blood cell count, erythrocyte sedimentation rate, coagulogram, protein C and protein S, lipidogram were normal. Results from a heart survey, including Holter's monitor and echocardiography, were normal.The patient was anti-coagulated. Verapamil and prednisone were initiated as prophylactic therapy for cluster headache in our patient. There was complete resolution of headaches in one week and the patient was entirely asymptomatic at follow-up six months later.

CONTEXT: Meningoencephalitis early in life, of any etiology, is a risk factor for development of subsequent sequelae, which may be of physical, psychiatric, behavioral or cognitive origin. Anomia is a language abnormality frequently found in such cases, and other language deficits are rarely described. The aim of this study was to describe the cognitive and linguistic manifestations following a case of herpetic meningoencephalitis in a 13-year-old patient with eight years of schooling. CASE REPORT: The patient underwent a speech-language audiology assessment nine months after the neurological diagnosis. The battery of tests included the Montreal-Toulouse Language Assessment test protocol (MT Beta-86, modified), the description from the Cookie Theft task of the Boston Diagnostic Aphasia Examination (BDAE), an informal assessment of the patient's logical and mathematical reasoning, and the neuropsychological subtests from the WAIS-III scale, which assess working memory. The patient presented mixed aphasia, impairment of short-term memory and working memory, and dyscalculia. This case also presented severe cognitive and linguistic deficits. Prompt diagnosis is crucial, in order to enable timely treatment and rehabilitation of this neurological infection and minimize the cognitive deficits caused by the disease.

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