-Spontaneous cervical arterial dissection (SCAD) is a non-traumatic tear or disruption in the wall of the internal carotid arteries or the vertebral arteries. It accounts for about 25% of strokes in patients aged under 45 years. Awareness of its clinical features and advances in imaging over the last two decades have contributed to earlier identification of this condition. SCAD has become the commonest form of vascular lesion identified in the cervical carotid and vertebral arteries, second only to atherosclerosis. This review is an update on the epidemiology, vulnerable arterial segments, risk factors, clinical features, diagnosis, current treatment and prognosis of SCAD.Key worDS: dissection, carotid, vertebral artery, stroke, angiography. Dissecção espontânea da artéria cervical: atualização sobre aspectos clínicos e diagnósticosResumo -Dissecção arterial cervical espontânea (DACe) é uma laceração ou ruptura na parede de artérias cervicais responsáveis pela irrigação sanguínea cerebral: artérias carótidas internas e artérias vertebrais. É responsável por cerca de 25% dos acidentes vasculares cerebrais isquêmicos em pacientes abaixo de 45 anos de idade. Ao longo das duas últimas décadas, com a maior conscientização sobre suas manifestações clínicas e o avanço das técnicas de neuroimagem, a DACe tem sido diagnosticada mais precocemente, tornando-se o tipo de lesão vascular mais comumente identificado nas artérias cervicais, sendo superada apenas pelas lesões ateroscleróticas. esta revisão é uma atualização sobre a epidemiologia, segmentos arteriais mais vulneráveis, fatores de risco, manifestações clínicas, diagnóstico, tratamento e prognóstico da DACe.PAlAvrAS-ChAve: dissecção, artéria vertebral, acidente vascular cerebral, arteriografia.

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Paraíba do Sul River is located at a very densely inhabited region of Brazil crossing the three most industrialized states of the country (São Paulo, Minas Gerais and Rio de Janeiro states). As a result, industrial and farming residues as well as urban sewage are frequently disposed without appropriate treatment. The current study aimed at investigating the water quality in three reservoirs along the Paraíba do Sul River (Ilha dos Pombos, Santa Cecília and Santa Branca), through physiological, morphological, biochemical, and genetic biomarkers. The bioindicator chosen was the catfish Pimelodus maculatus, sampled during the dry (June 2008) and rainy (February 2009) seasons. Also, some water physicochemical parameters were analyzed from the sampling sites, but displayed no alterations according to the Brazilian Agency for Water Quality Legislation. Branchial carbonic anhydrase activity was inhibited in the dry season, while renal carbonic anhydrase activity was inhibited in the rainy season in the Santa Branca reservoir, indicating disturbance of osmoregulatory and acid-base regulation processes. Histopathological alterations were observed in the gills (neoplasic and tissue hyperplasia processes) and liver (necrosis), indicating serious damage to the functional integrity of these organs. A high incidence of melanomacrophage centers was observed in the liver, suggesting an intense immune response in all reservoirs. Acetylcholinesterase and catalase activity showed also differences corroborating some morphological results. Likewise, the induction of the micronucleus and DNA damage indicate genotoxicity, but mainly in the Santa Branca reservoir. Thus, the health status of P. maculatus warrants caution in the use of the water from the 3 reservoirs for direct human consumption, particularly after the accidental spill of endosulfan in November 2008, three months before the rainy season sampling.

Ischemic stroke (IS) in young adults is reported as uncommon, comprising less than 10% of all stroke patients 1 . However, In our clinical practice, we are faced not infrequently with patients aged less than 45 years who suffered a stroke, many of them with no risk factors for atherosclerosis and no ultimate clear etiological diagnosis even after a thorough investigation. This diagnostic challenge is one of the main scopes of studying and researching mechanisms of brain ischemia in young adults in addition to the dramatic personal, familial, and socio-economic consequences by affecting individuals at the top of their productive age.Although cardioembolism and cervicocephalic arterial dissection have been established as principal etiological factors of IS in young adults 2 , a systematic diagnostic approach must be applied to all patients, regarding the great number of potential causes in this group and the multifactorial nature in many of these patients.Despite more accurate diagnostic tools recently acquired in vascular imaging, hematological and genetic studies, currently, the number of young patients with cryptogenic IS remains high, performing 30-40% 3,4 . Considered an unusual cause of IS in the young two decades ago 5 , atherosclerosis has gaining projection by recent reports of significant raise in traditional risk factors as hypertension, diabetes, obesity, dyslipidemia and tabagism among hospitalized adolescents and young adults 6. Table 1 shows the main categorizations of etiologic subtypes of IS in young adults that must be considered in every young patient with IS. NoNAthERoSclERotIc ANgIopAthIES AbStRActStroke affects mainly people aged over 65 years, and atherosclerosis predominates as the main etiopathogenic factor in ischemic stroke (IS). On the other hand, cardiac embolism and arterial dissection are the most frequent causes of IS in patients aged less than 45 years. However, inappropriate control of traditional vascular risk factors in young people may be causing a significant increase of atherosclerosis-related IS in this population. Furthermore, a variety of etiologies, many of them uncommon, must be investigated. In endemic regions, neurocysticercosis and Chagas' disease deserve consideration. Undetermined cause has been still reported in as many as one third of young stroke patients.Key words: stroke, brain ischemia, young adult. RESumoA doença aterosclerótica é o fator etiopatogênico mais importante no acidente vascular cerebral isquêmico (AVCI), afecção que acomete predominantemente pessoas acima da sétima década de vida. Entretanto, nos adultos jovens a aterosclerose exibe frequência menor, sendo a embolia de origem cardíaca e as dissecções arteriais as causas mais comuns de AVCI em pacientes com até 45 anos de idade. Porém, o controle inadequado dos fatores de risco vascular nas faixas mais jovens da população pode estar levando à elevação significativa no nú-mero de infartos cerebrais associados à aterosclerose nessa faixa etária.Uma ampla gama de fatores etiológicos, muitos deles rar...

Heart valve calcifications are rarely recognized as a potential source for cerebral embolism. Previous studies have identified mitral, but not aortic, valve calcifications to be risk factors for stroke. Based on these studies, heart surgery is unlikely to be indicated in patients who present with a stroke and an ‘incidental’ aortic valve calcification. We report a case of a 46-year-old man presenting with acute onset of left-sided weakness and numbness. A previous smoking history was the only cardiovascular risk factor found. Head CT scan revealed a right middle cerebral artery territory infarct and an adjacent high-density lesion. CT angiography demonstrated the presence of calcific embolic material in the middle cerebral artery. A search for embolic sources revealed a calcific aortic stenosis (CAS). Initially placed on coumadin, the patient developed silent myocardial infarction 2 months later, presumed to be also embolic in origin from the CAS. After aortic valve replacement, the patient has been symptom-free during a 2-year follow-up. In conclusion, CT angiography may be the method of choice for detecting calcific cerebral emboli, and demonstration of a causal relationship between CAS and an embolic stroke by CT angiography may be an important adjunct in surgical decision-making.

intROduçãOEmbora estime-se que dois terços das mortes por acidente vascular cerebral (AVC) ocorram em países em desenvolvimento, informações sobre epidemiologia, manejo e prognóstico nestes países são escassas 1,2 . Nos últimos anos, o AVC tem sido identificado como a primeira causa de morte no Brasil 3,4 . Em estudos brasileiros, o tipo mais frequente de AVC é o acidente vascular cerebral isquêmico (AVCI) 5,6 . Complicações médicas intrahospitalares são comuns no AVCI e contribuem significativamente para a morbimortalidade desta doença. Foi estimado que 75% a 95% dos doentes apresentem ao menos uma complicação após um AVCI, sendo que 24% desses pacientes apresentam alguma complicação que requer um tratamento imediato ou resulta em aumento do tempo de internação ou óbito [7][8] .Os objetivos deste trabalho foram: analisar as complicações e o tempo de internação de doentes internados por AVCI na fase aguda ou subaguda em uma enfermaria de neurologia geral; investigar a influência de idade, fatores de risco para doença vascular, território arterial acometido e etiologia sobre as complicações e o tempo de internação.

-Subclavian steal syndrome refers to the association of neurological symptoms related to vertebrobasilar insufficiency and the phenomenon of subclavian steal. We report the case of a 63 year-old male patient that presented subclavian steal syndrome and severe proximal (80%) stenosis of the left subclavian artery. The patient was submitted to percutaneous transluminal angioplasty and stenting on the left SA. The procedure was well tolerated and immediately afterwards, there was complete remission of the symptoms and of the phenomenon of subclavian steal evaluated by angiography and transcranial doppler. We propose that percutaneous transluminal angioplasty with stenting placement is a good therapeutic option for subclavian steal syndrome.

, Milberto Scaff 4 RESUMO -Objetivo: Dada a ausência de estudos de séries brasileiras de pacientes com dissecção arterial cervical espontânea, com o objetivo de descrever os fatores de risco, sintomas precedentes, manifestações clínicas, resultados da investigação, tratamento e evolução. Método: realizamos a análise retrospectiva dos prontuários e laudos radiológicos [angiografia digital(AD), ressonância magnética(RM) e ângio-ressonância(ARM)] dos pacientes com esse diagnóstico atendidos no Serviço de Neurologia do HC/USP entre 1997 e 2003. Resultados: 48 pacientes (24 homens), média de idade 37,9 anos; 26 pacientes com dissecção carotídea (DC) unilateral, 15 com vertebral (DV) unilateral e 7 com multiarterial, todos com déficits neurológicos. Os principais fatores de risco para doença vascular foram hipertensão arterial, tabagismo e dislipidemia. Mais de 80% apresentaram pelo menos um sintoma precedente, na maioria cefaléia têmporo-parietal. Cervicalgia foi referida por 44% dos pacientes com DV e por 3,4% dos com DC. O tempo médio entre o primeiro sintoma e o déficit foi 5,4 dias para as DC e 13,5 para as DV.AD foi o principal método diagnóstico (93%), associado a RM e ARM em 42% dos casos. Em 3 pacientes a RM cervical com supressão de gordura foi isoladamente suficiente. 75% dos pacientes receberam anticoagulação. Dois pacientes fizeram trombólise endovenosa sem complicações. A evolução foi boa, exceto por dois óbitos (DC bilateral). Conclusão: Os resultados são semelhantes aos da literatura, exceto pela baixa freqüência de cervicalgia nos casos de DC e pelo predomínio de cefaléia têmporo-parietal nas dissecções arteriais cervicais. Fatores de risco para doença vascular isquêmica foram frequentes. PALAVRAS-CHAVE: dissecção arterial, artéria carótida interna, artéria vertebral, angiografia, ressonância magnética. Spontaneous cervical carotid and vertebral arteries dissection -Study of 48 patientsABSTRACT -Objective: To report a Brazilian series of spontaneous cervical arterial dissections, risk factors, warning symptoms, clinical manifestations, diagnostic tests, treatment and prognosis. Method: We performed the retrospective analysis of clinical and neuroradiological records (MRI, A-MRI and Angiography) of patients with this diagnosis who were evaluated in a tertiary hospital for the period of 1997-2003. Results: 48 patients (24 men) with median age 37.9 years: 26 patients with unilateral internal carotid dissection (ICAD), 15 with unilateral vertebral artery dissection (VAD) and 7 with multivessel dissections. All patients presented neurological deficits. Hypertension, smoking and dyslipidemia were the main risk factors. More than 80% of patients presented at least one initial symptom, most of them temporoparietal headache. 44% of patients with VAD and only 3.4% of patients with ICAD had neck pain. The median interval between the onset of symptom and the appearance of neurological deficit was 5.4 days for ICAD and 13.5 days for VAD. Five patients with ICAD presented preceding TIA. Angiography was performed in...