So, we made physical therapy in groups of three or more patients each, in 70 stroke patients all of them with middle cerebral artery infarct -50 walked and 20 did not walk in the beginning of treatment. The physical therapy in group was applied for three months. They all started treatment in acute phase of stroke.The results obtained after the physical therapy in group were analysed through both: 1 .The following measure tools: the Barthel Index, the Rivermead Mobility Index, the Canadian Neurological Scale, the Orgogozo Unifed Form for Neurological Stroke Scales, Motricity Index. 2.The notes about: the relative's participation in the rehabilitation program; both the patient's and the relative's understanding of the disease; the adherence to the clinical treatment and physical therapy; the patient's expectation of a good quality of life and the patient's interaction with both his family and society.The results suggest that this kind of treatment may be good for public health services. This therapy was not sufficient for those who did not walk, perhaps because of the short time of therapy. This mean that they were not adapted to the daily living activity after the threrapy. However, to most of the walking patients, the physical therapy in group was enough.

Vascular cognitive impairment (VCI) has superseded vascular dementia and multi-infarct dementia as the concept to be used in cognitive decline secondary to cerebrovascular disease 1 . The prevalence of dementia increases with age, and the prevalence of vascular dementia in epidemiological studies varies between 22 and 26.28% 2,3 . An epidemiologic study in Brazil showed a prevalence of 9.3% for vascular dementia (VaD) among demented participants aged 64 years and older 4 . Studies in tertiary outpatient clinics report a prevalence of vascular dementia between 24.9 and 32.25% 5,6 , and of 36.9% in a sample with presenile dementia 7 . VCI is a risk factor for the development of dementia. Wentzel 8 observed that half of the subjects with vascular cognitive impairment with no dementia (VCIND) developed dementia over a five-year period. The current findings suggest that poor mental flexibility and verbal retrieval in the context of preserved function in other domains may characterize the prodromal stage of ABSTRACTVascular cognitive impairment (VCI) is characterized by cognitive compromise predominantly of executive dysfunction. Objectives: To assess cognitive functions in VCI, focusing on executive functions, to observe functional losses in relation to activities of daily living (ADLs) and to detect early symptoms prior to the onset of dementia. Methods: We evaluated healthy subjects matched for gender, education and age to patients with diagnosis of subcortical vascular disease who had a stroke classified into three groups: 1) vascular lesions and no impairment; 2) vascular cognitive impairment with no dementia (VCIND); 3) vascular dementia (VaD). Results and discussion: The performance on neuropsychological tests differed among groups, worsening with increased impairment level. The probable VaD group demonstrated impaired performance in memory, processing speed and verbal production, while the VCIND group showed attention deficits. Conclusion: Impairment in executive functions and difficulties in ADLs allow us to differentiate levels of impairment in groups of subcortical vascular disease.Key words: cognitive impairment, vascular dementia, neuropsychological assessment, activities of daily living. RESUMOO comprometimento cognitivo vascular (CCV) é caracterizado por comprometimento cognitivo predominantemente sob a forma de disfunção executiva. Objetivos: Avaliar as funções cognitivas no CCV, enfocando as funções executivas, observar as perdas funcionais em relação às atividades cotidianas (AVDs) e detectar os primeiros sintomas antes do início da demência. Métodos: Foram avaliados indivíduos controles saudáveis pareados por sexo, escolaridade e idade com pacientes com diagnóstico de doença vascular subcortical que sofreram derrame classificados em três grupos: 1) lesões vasculares sem déficit; 2) comprometimento cognitivo vascular sem demência (CCVSD); 3) demência vascular (DV). Resultados e discussão: O desempenho em testes neuropsicológicos diferiu entre os grupos, sendo o desempenho tanto pior quanto maior o c...

-Celiac disease (CD/ Nontropicalsprue, gluten-sensitive enteropathy) is a malabsortive condition in which an allergic reaction to the cereal grain-protein gluten (present in wheat, rye and barley) causes small intestine mucosal injury. The onset is in the first four decades of life, with a female to male ratio of 2:1. It may be associated with a wide spectrum of neurological manifestations including cerebellar ataxia, epileptic seizures, dementia, neuropathy, myopathy and multifocal leucoencephalopathy. We report three patients with neurological manifestations related with CD: one with cerebellar ataxia, one with epilepsy and one with cognitive impairment. The diagnosis of CD was confirmed by serologic tests (antiendomysial and antigliadin antibodies) and biopsy of the small intestine. In two patients the neurological symptoms preceded the gastrointestinal abnormalities and in all of them gluten restriction failed to improve the neurological disability. Conclusion: CD should be ruled out in the differential diagnosis of neurological dysfunction of unknown cause, including ataxia, epilepsy and dementia. A gluten free diet, the mainstay of treatment, failed to improve the neurological disability.KEY WORDS: celiac disease, cerebellar ataxia, epilepsy, cognitive impairment. Manifestações neurológicas da doença celíacaRESUMO -A doença celíaca (DC, enteropatia sensível ao glúten) é desordem caracterizada por mal absorção causada por reação alérgica ao glúten, proteína presente em diversos cereais. As manifestações iniciais ocorrem nas primeiras quatro décadas de vida, sendo cerca de duas vezes mais freqüente no sexo feminino. DC pode estar associada a largo espectro de manifestações neurológicas incluindo ataxia cerebelar, epilepsia, demência, neuropatia, miopatia e leucoencefalopatia multifocal. Relatamos três casos de pacientes com manifestações neurológicas da DC: um com ataxia cerebelar, outro com epilepsia e o último com déficit cognitivo. O diagnóstico de DC foi estabelecido com base em testes sorológicos (anticorpos antiendomí-sio e antigliadina) e biópsia intestinal. Em dois pacientes as alterações neurológicas precederam as gastrointestinais. Em todos os casos a dieta livre de glúten não influenciou o quadro neurológico. Concluímos que o diagnóstico de DC deve ser considerado em pacientes com alterações neurológicas de etiologia indeterminada, incluindo ataxia, epilepsia e demência. Uma dieta sem glúten, a base do tratamento das manifestações gastrointestinais, não foi eficiente em melhorar os sintomas neurológicos em nossos pacientes.

So, we made physical therapy in groups of three or more patients each, in 70 stroke patients all of them with middle cerebral artery infarct -50 walked and 20 did not walk in the beginning of treatment. The physical therapy in group was applied for three months. They all started treatment in acute phase of stroke.The results obtained after the physical therapy in group were analysed through both: 1 .The following measure tools: the Barthel Index, the Rivermead Mobility Index, the Canadian Neurological Scale, the Orgogozo Unifed Form for Neurological Stroke Scales, Motricity Index. 2.The notes about: the relative's participation in the rehabilitation program; both the patient's and the relative's understanding of the disease; the adherence to the clinical treatment and physical therapy; the patient's expectation of a good quality of life and the patient's interaction with both his family and society.The results suggest that this kind of treatment may be good for public health services. This therapy was not sufficient for those who did not walk, perhaps because of the short time of therapy. This mean that they were not adapted to the daily living activity after the threrapy. However, to most of the walking patients, the physical therapy in group was enough.

In studies about cerebral infarcts in children, despite many different methodologic approach, a common observation is the wide diversity of etiologies. According to the Pan American Health Organization, in the last decade the mortality rate for Brazilian children under one year was 6 times higher than the rates reported by developed countries 1 . We hypothesized that the high morbidity condition of the disease in Brazil is a consequence of distinctive characteristics in the distribution of the causes of cerebral infarcts.Thus, the objective of the present investigation was to identify cerebral infarcts in children aged zero to 15 years attended at a tertiary hospital, ABSTRACT -Cerebral infarcts in children present peculiar characteristics either due to their diversity of causes or due to the unknown nature of the causes. The etiologies of cerebral infarct were reviewed in children from zero to 15 years old, attended at a tertiary hospital, in Ribeirão Preto (Brazil), from 1990 to 1997, adopting the modified Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria of classification; 1 -Atherosclerosis in large arteries; 2 -Cardioembolic; 3 -Occlusion of small vessels; 4 -Other etiologies; 5 -Undetermined cause. Thirty-nine children were included, 18 males and 21 females, aged 2 months to 15 years, mean age 5.67. The largest group, N=22 (56.4%), included children with "other etiologies", 7 of them aged under two years. The most common etiology was dehydration and septic shock leading to brain hypoperfusion and watershed infarcts. Nine (23%) children had "Undetermined etiology", 7 (17,9%) cardioembolic subtype and none had atherosclerosis. Laboratory improvement is needed for the large number of patients without a defined cause, and the high proportion of children with dehydration in the group with a determined cause emphasizes the need for preventive health actions among infants and children. CEREBRAL INFARCT IN CHILDREN AGED ZERO TO FIFTEEN YEARSKEY WORDS: cerebrovascular disease, cerebral infarct, stroke, children, infants, etiology. Infarto cerebral em crianças de zero a quinze anos de idadeRESUMO -Infartos cerebrais em crianças apresentam peculiaridades, como grande variedade de causas e alta freqüência sem etiologia definida. Foram revistos os diagnósticos etiológicos em crianças de zero a 15 anos, atendidas durante o ictus e com imagens cerebrais sugestivas de infarto, entre 1990 e 1997 em hospital terciário de Ribeirão Preto (SP). Adotou-se o critério de classificação modificado do Trial of ORG 10172 in Acute Stroke Treatment (TOAST): 1 -Arterioesclerose de grandes artérias, 2 -Cardioembólico, 3 -Oclusão de pequenos vasos, 4 -Outras etiologias, 5 -Não determinada. Trinta e nove crianças foram incluídas, 18 do sexo masculino e 21 do feminino, com idade variando entre 2 meses e 15 anos e média de 5,67. O maior grupo, com 22 crianças (56,4%), foi o de "Outras etiologias", 7 das quais com idades entre 2 meses e um ano. A etiologia mais freqüente foi desidratação e choque séptico, levando a hipoperfusão ce...

. O fórum de "Opinião Nacional" foi realizado em São Paulo-SP, no dia 1º de julho de 2004. Os temas de trabalho foram divididos para análise inicial por grupos de 5 a 6 neuro l o g i s t a s . Os coordenadores do presente tema foram os Drs. Cesar N. Raffin e Jefferson Gomes Fernandes. Um esboço de texto foi proposto para análise em plenário em leitura pública. Comentários, críticas e sugestões de mudanças foram amplamente debatidos por este plenário e incorporados ao texto final, redigido pelo grupo responsável pelo tema. RESUMO -Este artigo apresenta as conclusões sobre revascularização clínica e intervencionista no acidente vascular cerebral isquêmico agudo, um dos temas discutidos na reunião "Opinião Nacional sobre o Tr a t a m e n t o do AVC". Tratou-se de reunião promovida e coordenada pela Sociedade Brasileira de Doenças Cere b ro v a s c u l a re s , com neurologistas especializados em doenças cere b ro v a s c u l a res, que analisaram e discutiram as evidências e experiências atuais sobre o uso de trombólise e técnicas intervencionistas em pacientes com acidente vascular c e rebral isquêmico agudo.PALAVRAS-CHAVE: acidente vascular cerebral agudo, trombólise, opinião nacional. Clinical and interventional revascularization in the acute ischemic stroke: national opinionABSTRACT -The Brazilian Stroke Society constituted a committee composed by specialists from diff e rent are a s of Brazil that emitted a viewpoint called "National Opinion" , considering the interventional pro c e d u res and t h rombolysis in the treatment of the acute ischemic stroke. This study presents the conclusions of this committee.KEY WORDS: ischemic stroke, thrombolysis, national opinion.nos Estados Unidos da América, em junho de 1996, do ativador do plasminogênio tissular re c o m b i n a n t e (rt-PA) como trombolítico para o uso em casos selecionados de acidente vascular cerebral (AVC) isquê-mico agudo, veio reforçar a estratégia estabelecida nos últimos anos de considerar o AVC como uma emergência médica 4,5 . Existe uma "janela terapêutica" para o tratamento do AVC, ou seja, um momento ótimo para interv i r nos processos patológicos desencadeados pela isquemia cerebral no sentido de minimizar o dano ao sistema nervoso central 6 . Esta janela terapêutica, na maAs doenças cere b ro v a s c u l a res têm um grande impacto sobre a saúde da população, situando-se, conf o rme o ano e o Estado da Federação, entre a primeira e terceira principal causa de mortalidade no Brasil 1 . Estas doenças são compostas por um grupo heterogêneo de transtornos vasculares de diferentes etiol o g i a s 2 . Estima-se que cerca de 85% dos acidentes v a s c u l a res encefálicos sejam de origem isquêmica e 15% hemorrágicos. Dentre os hemorrágicos, cerc a de 10% são hemorragias intraparenquimatosas e 5% hemorragias subaracnóideas 3 . A aprovação pela "Federal Drug Administration",

RESUMO -Os anticorpos antifosfolípides (aFLs) têm sido associados a várias síndromes neurológicas, destacando-se a grande incidência os infartos celebrais. Os mecanismos responsáveis pelo comprometimento vascular encefálico em pacientes com títulos elevados de aFLs permanecem em discussão. A existência de vasculopatia relacionada a este grupo heterogêneo de imunoglobulinas é, no entanto, inquetionável. Relatamos dois casos de síndrome do anticorpo antifosfolípide primário que apresentaram enfartos cerebrais. Os achados angiográficos no primeiro sugeriam vasculite intracraniana, embora houvesse também estenose proximal sugestiva de trombose "in situ". No segundo paciente a angiografia mostrava obstrução de carótida interna, sem sinais de aterosclerose, e na necrópsia foi confirmada a hipótese de vasculopatia trombótica em múltiplos sítios. Nossos achados servem de modelo para discutirmos as controvérsias existentes a respeito da patogênese deste tipo de vasculopatia. Ou seja, se a lesão primária seria vasculite, trombose ou ambas. PALAVRAS-CHAVE: vasculopatia cerebral, infarto cerebral, anticorpos antifosfolípedes.Cerebral vasculopathy in the primary antiphospholipid syndrome: report of two cases ABSTRACT -The antiphospholipid antibodies are associated with a large number of neurologic syndromes, cerebral infarct (CI) being the most common of them. In these cases the pathogenesis of the CI is poorly understood and remains controversial; however, the existence of a vasculopathy is indubitable. We report the cases of two young patients with CI and diagnosis of primary antiphospholipid syndrome who were submitted to cerebral angiograms, and one of them to necropsy. In one case the angiographic findings were similar to those of vasculitis in intracranial vessels. In the other case we observed obstruction in internal carotid artery at the angiography that looked like thrombosis in situ; at necropsy we found non-atherosclerotic obstruction in coronary arteries. In summary, is the primary lesion vasculitis, thrombosis, or both? These cases ilustrate the discussion and demonstrate that vasculitic mechanisms may be involved in the vasculopathy of primary antiphospholipid syndrome eventhough trombosis occur more frequently.KEY WORDS: cerebral vasculopathy, cerebral infarct, antiphospholipid antibodies.A síndrome do anticorpo antifosfolípide (SaFL) foi proposta inicialmente para pacientes com lupus eritematoso sistêmico (LES) ou outras doenças do tecido conjuntivo que tivessem títulos elevados deste anticorpos (aFLs) e manifestações clínicas relacionadas aos seus efeitos (trombose venosa, oclusão arterial, trombocitopenia, anemia hemolítica, perda fetal de repetição, úlceras nas

Pemphigus vulgaris is a systemic auto-immune medical condition that mainly manifests with changes in skin and vasculopathy. This is a case report of a 69-year-old male with confirmed histopathologic diagnosis of Pemphigus vulgaris presenting ulterior Cognitive Impairment, mostly in executive function. The patient was treated using steroids, immunomodulatory therapy, fluoxetine and galantamine. Neuropsychological testing and magnetic resonance (MRI) were performed. This is the first report of correlational cognitive impairment with Pemphigus vulgaris in the literature. Physicians should be aware of vascular causes for cognitive impairment in patients presenting auto-immune conditions.