RESUMO -Realizamos análise epidemiológica de 164 pacientes com AVC, cujo primeiro episódio ocorreu entre 15 e 49 anos de idade através de um estudo retrospectivo de pacientes ambulatoriais. O principal tipo de apresentação foi AVC isquêmico (AVCI) em 141 pacientes, ocorrendo AVC hemorrágico (AVCH) em16 casos e 7 pacientes com trombose venosa. A presença de fatores de risco aterotrombóticos foi prevalente, em 48,22% dos pacientes com AVCI sendo que a hipertensão arterial sistêmica (HAS), nos casos de AVCH, foi a etiologia mais frequente. Em 32% dos casos não se pode determinar a sua causa. Embora a população jovem possua determinantes diferentes e geralmente deva ter uma investigação etiológica mais abrangente, no grupo estudado foram prevalentes os fatores de risco conhecidos e potencialmente controláveis, sugerindo que campanhas de prevenção e detecção precoce devam ser incentivados.PALAVRAS-CHAVE: acidente vascular cerebral, fatores de riscos, epidemiologia. Stroke in young adults: analysis of 164 patientsABSTRACT -We retrospectively analyzed the epidemiological features of 164 out-clinic patients with a firstonset stroke between 15 and 49 years old. Ischemic stroke occurred in 141 patients, hemorrhagic stroke in 16 patients, and venous thrombosis in 7 patients. .orty-eight percent of ischemic strokes were atherothrombotic, but no etiology was found in 32% of patients with ischemic stroke. Systemic arterial hypertension was the most frequent etiology in the hemorrhagic stroke group. The most frequent risk factors were systemic arterial hypertension, smoking, hypercholesterolemia, alcoholism and diabetes mellitus. Although stroke in young adults deserves some specific etiological investigation, we found that ordinary risk factors such as hypertension, tabacco use, hypercolesteremia and diabetes were prevalent in our population. It seems that prevention campaigns should be the target of our work.

Neuroleptic malignant syndrome (NMS) is a potentially fatal adverse event associated with the use of antipsychotics (AP). The objective of this study was to investigate the profile of cases of NMS and to compare our findings with those published in similar settings. A series of 18 consecutive patients with an established diagnosis of NMS was analyzed, gathering data on demography, symptoms and signs. Two thirds of all cases involved woman with a past medical history of psychiatric disorder receiving relatively high doses of AP. The signs and symptoms of NMS episodes were similar to those reported in other series and only one case had a fatal outcome, the remaining presenting complete recovery. As expected, more than two thirds of our cases were using classic AP (68%), however the clinical profile of these in comparison with those taking newer agent was similar. Newer AP also carry the potential for NMS. Key words: atypical antipsychotics, typical antipsychotics, neuroleptic malignant syndrome.Síndrome neuroléptica maligna RESUMO A síndrome neuroléptica maligna (SNM) é um evento adverso potencialmente fatal associado ao uso de antipsicóticos (AP). O objetivo deste estudo foi investigar as características clínicas de cases da SNM e comparar nossos resultados com os publicados na literatura. Uma série de 18 pacientes com diagnóstico confirmado de SNM foram analisados, associando dados demográficos, apresentação clínica, diagnóstico e tratamento. Dois terços dos casos envolveram mulheres com antecedentes psiquiátricos que recebeceram doses relativamente altas de AP. Os sinais e sintomas foram semelhantes àqueles já relatados na literatura e a maioria dos pacientes teve uma recuperação completa, exceto por um caso com desfecho fatal. Houve predomínio de pacientes que usam medicamentos neurolépticos clássicos (68%), porém não houve diferença nas manifestações destes casos em relação àqueles que usavam AP novos. AP mais novos também têm o potencial de causar SNM. Palavras-Chave: neurolépticos atípicos, neurolépticos típicos, síndrome neuroléptica maligna.

Our results suggest using the parameters of all of the 16 KPIs required by the Ministry of Health of Brazil, and the present results for the two stroke units for future benchmarking.

The purpose was to describe the main features of headache incidence in a hospital community, its frequency and the most requested medical investigation. Due to the stressful work environment, hospital is considered to hold a high-risk population. Interviews and questionnaires were utilized. Of a 1006 files, which were randomly filled out, 987 could be analyzed. Of all, 38.5% were from headache sufferers. By using a table of pain symptoms taken from the International Headache Society classification as a pattern, headaches were assigned as migraine, tension-type and other. The mean age was 31.18 and the frequency in females was higher than in males, at any type. Family occurrence in first-degree relatives was 76.8%. Frontal location, medium intensity and pulsation were the most described features. Stress was the most frequently mentioned trigger factor. A physician was consulted only by 41.3%. Cranium X-ray was the most frequently requested exam.

Neurological diseases are prevalent in the emergency room (ER). The aim of this study was to compare the neurological diagnoses between younger and older patients evaluated in the ER of a tertiary care hospital. Method: Patients admitted to the ER who required neurological evaluation in the first 24 hours were separated into two groups based on age, ≤50 years old and >50 years old. Results: Cerebrovascular disease (59.6% vs. 21.8%, p<0.01) was most frequent in the >50 years old group. Seizures (8.1% vs. 18.6%, p<0.01) and primary headache (3.7% vs. 11.4%, p<0.01) were most frequent in the ≤50 years old group. Conclusion: The current study demonstrated that these three neurological diagnoses represented the majority of the neurological evaluations in the ER. National guidelines for ER teams that treat these prevalent disorders must be included in clinical practice and training. Key words: nervous-system disease, stroke, headache, seizures, emergency medical services, health services epidemiology.Diagnósticos neurológicos na sala de emergência: diferenças entre pacientes jovens e idosos RESUMO Doenças neurológicas são prevalentes na sala de emergência (SE). O objetivo deste estudo é comparar a ocorrência de diagnósticos neurológicos entre pacientes jovens e idosos atendidos na SE de um hospital terciário. Método: Pacientes admitidos na SE que necessitaram avaliação neurológica nas primeiras 24 horas após a admissão foram separados em dois grupos baseados na idade, ≤50 anos de idade e >50 anos de idade. Resultados: Doença cerebrovascular foi o diagnóstico mais comum nos pacientes >50 anos (59,6% vs. 21,8%, p<0,01). Convulsões (8,1% vs. 18,6%, p<0,01) e cefaléias primárias (3,7% vs. 114%, p<0,01) foram mais frequentes no grupo ≤50 anos. Conclusão: O presente estudo demonstrou que esses três diagnósticos neurológicos representam a maioria das avaliações neurológicas na SE. Diretrizes nacionais para os profissionais emergencistas que tratam estas doenças devem ser incluídos na prática clínica e no treinamento médico. Palavras-chave: doença do sistema nervoso, AVC, cefaléia, convulsões, serviço médico de emergência, epidemiologia em serviços de saúde.

-Ten percent of all strokes are due to spontaneous cerebral hemorrhages. They are associated to drugs (licit and illicit) in 9.5% of all cases in young adults. This is a case report of a 44-year-old man, without previous morbidities, who presented a sudden onset headache and arterial hypertension 24 hours after use of naphazoline as nasal decongestant. Cranial tomography showed right thalamus hemorrhage. Cerebral angiography showed no aneurisms, vascular malformations or vasculitis. No other risk factors were found during investigation in this patient and the stroke was attributed to naphazoline exposition.KEY WORDS: hemorrhagic stroke, naphazoline, sympathomimetic drug.Acidente vascular encefálico hemorrágico após exposição à nafazolina: relato de caso RESUMO -Dez por cento de todos os eventos vasculares encefálicos são devido às hemorragias intracerebrais espontâneas, associados a drogas (lícitas e ilícitas) em 9,5% de todos os casos em adultos jovens. Relatamos o caso de um homem de 44 anos de idade, sem doenças prévias, que apresentou cefaléia súbita e hipertensão arterial 24 horas após o uso de congestionante nasal contendo nafazolina. A tomografia de crânio evidenciou hemorragia talâmica. Durante a investigação não foram encontrados outros fatores de risco e a hemorragia foi atribuída à exposição à nafazolina. PALAVRAS-CHAVE: doença vascular encefálica hemorrágica, nafazolina, droga simpaticomimética.Cerebrovascular diseases occur more frequently in elderly people. Peak incidence is between 7 th and 8 th decades 1,2 . Before age 55, incidence is 10% 3,4 and before 45 it falls to 3.9% 5 .Ten percent of all cerebrovascular events are due to hemorrhage 6 . Its estimated incidence in United States of America is 0.3/100000 in younger than 35 years old 7 . Main etiologies are vascular malformations, arterial hypertension and exposition to drugs (amphetamines, sympathomimetics and illicit drugs) 8,9 . In young adults, drugs are associated to 9.5% of ischemic and hemorrhagic stroke 10 .We report a case of exposition to sympathomimetic drug naphazoline followed by thalamic hemorrhage. CASEA 44 year-old previously healthy man, with no history of arterial hypertension, was admitted to the emergency department of Hospital de Clinicas, Federal University of Parana, complaining of headache and left arm weakness. Five days before he had had some flu-like symptoms and naphazoline nasal decongestant was prescribed. In the following day he had a sudden onset headache associated to nausea and vomiting. He then looked for medical attention. Blood pressure was 190/120 mmHg and captopril 50 mg as a single dose was prescribed. A couple of days latter he developed left hemiparesia that made him seek for our emergency department. There was no previous history of thrombotic disorders and there were no familiar stroke cases.On physical examination vital signs were normal including blood pressure (120/70 mmHg), with no positive signs on cardiopulmonary and abdominal examination. Neurological examination revealed an oriented ...

-The case of a 70 year-old, previously healthy woman who developed a severe bleeding diathesis shortly after touching a Lonomia obliqua caterpillar and finally died from multiple intracerebral hemo rrhages is described. Brain hemorrhages are the leading cause of death in patients envenomed by the Lonomia species. The pertinent literature is reviewed and the most relevant clinical features highlighted, with emphasis on diagnosis. The use of new therapeutic options such as anti-Lonomia serum is discussed.KEY WORDS: intracerebral hemorrhage, Lonomia obliqua, caterpillar envenoming.Hemorragia intracerebral fatal causada por acidente com Lonomia obliqua: relato de caso RESUMO -O caso de uma mulher de 70 anos, previamente hígida, que desenvolveu diátese hemorrágica grave após contato com uma lagarta Lonomia obliqua, resultando em óbito por hemorragia intracere b r a l é relatado. Hemorragias cerebrais são uma das causas de morte em acidentes por Lonomia. A literatura p e rtinente é revisada, sendo as características clínicas e laboratoriais mais relevantes discutidas com ênfase para o diagnóstico, e o uso de novas abordagens terapêuticas como o soro anti-Lonomia. PALAVRAS-CHAVE: hemorragia intracerebral, Lonomia obliqua, envenenamento, lagartas urticantes.First described by Arocha-Pinango and Layrisse in Venezuela in 1967 1 , the hemorrhagic diathesis caused in humans by touching the Lonomia species begins with inflammatory changes at the site of envenoming, followed by systemic symptoms such as headache, f e v e r, vomiting and malaise. After 24 hours, a severe bleeding disorder ensues, leading to echimosis, hematuria, pulmonary and intracranial hemorrhages, and acute renal failure 2 . Two species of Lonomia a re known to cause the hemorrhagic syndrome, L o n o m i a achelous, found in Venezuela and the north of Brazil, and Lonomia obliqua, found in the south of Brazil 1 , 3 , 4 . Although there are diff e rences in the effect of the venom of both species, both venoms may lead to intense fibrinolytic activity associated with consumption coagulopathy, resembling a diffuse intravascular coagulation 5 -7 . A case of accidental Lonomia obliqua envenoming is described, and its implications a re discussed. The re p o rt was approved by the institutional regulatory committee. CASEA 70 year-old, previously healthy woman developed a sudden coma. Four days before, she had started to pre s e n t hematuria. Shortly after admission, her coma was rated as Glasgow 3. Physical examination revealed several skin hemo rrhages, and gross hematuria was present. Based on information in a note left by the patient, two small hyperemic lesions were identified on the tip of her left toe. Along with the note w as the the green caterpillar (Fig 1) which was hidden inside of her slipper. CT-scan imaging re v e a l e d multiple intracerebral hemorrhages (Fig 2). She died seven days after being envenomed. Her laboratory data is summarized in the Table. DISCUSSION P resentation of the symptoms of caterpillar envenoming can generally be...

Population-Based Study of Capsular Warning Syndrome and Prognosis After Early Recurrent TIA Paul NN, Sinoni M, Schandratheva A, et al. Neurology 2012:79:1356 Conclusions: Capsular warning syndrome comprises 1.5% of transient ischemic attack (TIA) presentations but has a poor prognosis, with a 7-day stroke risk of 60%. With the exception of capsular warning syndrome, recurrent TIAs Յ7 days are not associated with a greater stroke risk than a single TIA.Summary: Stroke risk after TIA is highest within the first 7 days (Hill MD et al, Neurology 2004;62:2015-20). In addition, many guidelines recommend urgent evaluation for carotid stenosis for patients with more than two TIAs Յ7 days (Johnston SC et al, Ann Neurology 2006;60:301-13). Capsular warning syndrome, manifested by multiple stereotype motor TIAs, is thought to place patients at particular risk and precedes capsular infarction (Donnan GA et al, Neurology 1993;43:957-62). However, it is unclear whether patients with multiple TIAs have relatively untreatable or treatable underlying pathologic conditions such as carotid stenosis or atrial fibrillation. The authors used data from the Oxford Vascular Study (OXVASC) to delineate whether patients with multiple TIAs are at high early stroke risk and whether a treatable underlying condition is more common in patients with multiple TIAs. They studied clinical characteristics, acute STROKE treatment (TOAST) classification, and risk of stroke in 1000 consecutive patients with incident and recurrent TIAs as part of the prospective, population-based Oxford Vascular Study. Of the 1000 patients with TIAs, 170 had a further TIA Յ7 days (105 Յ24 hours). Multiple TIAs were not associated with carotid stenosis or atrial fibrillation. Much of the 10.6% (95% confidence interval [CI], 6.5%-15.9%) risk of stroke in the first 7 days after the an initial TIA was due to patients with small-vessel disease (SVD) etiology (10 of 24 vs 8 of 146; odds ratio, 12.3; 95% confidence interval, 3.7-41.9; P ϭ .0001), particularly in those with motor weakness (ie, capsular warning syndrome) compared with hemisensory events (9 of 15 [60%], 95% CI, 35.3-84.7 vs 1 of 9 [11.1%], 95% CI, 0-31.7; P ϭ .03). The 7-day risk of stroke after recurrent TIA was similar to the risk after a single TIA in patients with non-SVD TIA (8 of 146 [5.5%] vs 76 of 830 [9.2%]; odds ratio, 0.58; 95% CI, 0.25-1.3; P ϭ .20). All of the nine patients with stroke after a capsular warning syndrome had recurrent TIA Յ24 hours after the first TIA, and the subsequent stroke occurred Յ72 hours of the second TIA in eight patients. The ABCDE2 scores of all preceding TIAs were Յ4 in all nine patients with capsular warning syndrome before their stroke.Comment: The data point out that not all TIAs have the same prognosis for stroke. In particular, multiple TIAs without association with large-vessel disease may have the worst prognosis of all. The implication is that the emphasis on recurrent TIAs in many societal guidelines scores may not be justified. At least in this study, multiple T...