We found that recanalisation occurs over time, until month 11. Complete recanalisation may influence functional outcome.

Background: Bilateral emphysematous pyelonephritis is a life threatening condition usually occurring in diabetics. Management of this condition has traditionally been aggressive and surgery is considered mandatory. However, this is itself a hazardous intervention in a septic, unstable patient with circulatory or liver failure. When bilateral disease is present, the need for long-term dialysis is obviously unavoidable.

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Objective: Conventional treatment of cerebral venous sinus thrombosis (CVST) has been systemic heparinization. A small percentage of CVST present with subarachnoid hemorrhage (SAH). We retrospectively evaluated the efficacy and safety of anticoagulation in consecutive patients with SAH due to CSVT. Materials and Methods: A retrospective review of our stroke database from November, 1994 to August, 2010 identified 21 consecutive patients who had presented with SAH secondary to CVST. CVST was documented through angiography, venous angioTC or venous phase angioresonance. CVST was documented through CT scan or lumbar puncture when image was equivocal. Diagnosis was performed by a neurologist and confirmed by neuorradiologists. Patient histories were reviewed to collect data on presentation, presence of venous infarction or hemorrhagic transformation, affected sinus, treatment with anticoagulation, follow up, and functional outcome. Results: 21 patients were included for analysis. The mean patient age was 39years (20-83). Sixty-seven percent of patients were female. The initial symptom was thunderclap headache in 11 patients (52%), acute progressive headache in 9 patients (43%) and seizures in 1 patient (5%). 15 patients (71.4%) were treated with anticoagulants. 10 patients (48%) were treated with low molecular weight heparin, 5 patients (24%) with non fractioned heparin. All these patients continued treatment with oral anticoagulation. 3 patients (14.3% received treatment with antiplatelet agents. 3 patients (14%) received no treatment. No patients developed intracaranial or extracranial hemorrhagic complications after initial treatment. One patient died due to cerebral edema. All other patients had good functional outcome (modified Rankin Scale<2) regardless of treatment. Conclusion: Treatment with anticoagulant drug appear to be safe in the setting of CVST related HSA. Outcome appears to be good in most patients. Our study is not powered to detect the efficacy of treatment in these patients.

Introduction: Growing availability of advanced imaging studies (AdIS) has resulted in increasing use of studies other than non-contrast CT (NCCT) in the evaluation of acute ischemic stroke (AIS) patients. The diagnosis of AIS is mainly clinical, and thrombolysis in patients with stroke mimics is generally considered to be safe. However, the need for diagnostic certainty and timely detection of large vessel occlusion (LVO) may incline physicians to perform more AdIS. Hypothesis: Performing pre-treatment AdIS in all patients with AIS will prolong DNT without conferring clear benefits regarding treatment decisions. Methods: We reviewed a prospective registry of AIS patients arriving at the Neurologic Emergency Department. We obtained additional information from the patients’ clinical records, and all pertinent imaging studies were reviewed to confirm diagnosis and site of arterial occlusion. Results: We analyzed 128 AIS patients treated with IV thrombolysis. Mean Door to-Needle-Time (DNT) was 83 min. Only 46% of patients were thrombolysed in the first 60 minutes after arrival. AdIS were performed in 60 patients (48%) They were equally performed among patients with NIHSS scores below and above 10 points, a possible cutoff for the presence of LVO. They also were performed equally in patients with clinically mild, and severe strokes, when the clinical diagnosis of AIS was not in doubt. On bivariate analysis, factors associated with DNT<60 minutes were: female sex, posterior circulation stroke and whether only NCCT was performed. Exclusive use of NCCT was associated with a higher percentage of DNT<60 minutes (59 vs 34%, p=0.005). On multivariable analysis, NCCT use was independently associated with DNT<60 min (OR= 2.92, p<0.007) Regarding different imaging studies, DNT means were as follows: NCCT: 69 min, CTA:79 min, CTP: 125 min, MRI 108 min (Difference between groups p=0.007). No patients were excluded from thrombolytic treatment based on AdIS results. Conclusions: The pre-thrombolysis performance of AdIS carries the risk of prolonging DNT and lowering the possibility of benefit for AIS patients. Selection of patients for specific studies and deferring AdIS until after initiating alteplase should be pursued.

Introduction: Reperfusion therapies are the optimal treatment for acute ischemic stroke (AIS). Their effectiveness is highly time-dependent. Worldwide, organized stroke care has shown to improve efficiency and quality of attention in stroke management. Neither reperfusion therapies or stroke center care have been widely implemented in Mexico. The objective of this study is to describe whether the implementation of a Stroke Care Program (ABC Stroke Center) improved time to treatment and adherence to Get With The Guidelines parameters on patients who underwent IV thrombolysis for AIS. Hypothesis: Implementation of an institutional Stroke Program lowers door-to-needle time (DNT) and improves adherence to stroke quality measures in patients treated with IV thrombolysis. Methods: The study included all patients with AIS diagnosis treated with IV thrombolysis between January 2010 and May 2016. We then compared patients admitted before and after June 2014 (start of the Stroke Program). Results: A total of 56 patients were included, 30 (53.6%) were admitted preintervention and 26 (46.4%) postintervention. All of them were treated with IV thrombolysis. All time parameters related to quality of attention were shorter in patients after the Stroke Program started. DNT was 21 minutes shorter in the Stroke Program group (mean 65 vs 86 min, p<0.03), and the number of patients within the DNT time goal of 60 minutes was larger postintervention (44.8 vs 29.6%, (95%CI 0.76 - 2.6, p=0.24)]. Adherence to stroke quality measures was more common in the Stroke Program group. Patients included after the start of the stroke program had a higher NIHSS score upon discharge. The probability of a good outcome (mRS<3) upon discharge was higher in the Stroke Program group (61.1% vs 31.4%) [RR = 1.9 (95%CI 1.17 - 3.38)]. Conclusions: Implementation of a Stroke Care program diminished DNT significantly and improved adherence to stroke quality measures. This may result on better outcomes for AIS patients.

Background Internuclear ophthalmoplegia (INO) is an eye movement disorder caused by a lesion in the medial longitudinal fasciculus (MLF) located in the midbrain. Adduction paralysis of both eyes and bilateral abduction nystagmus are the main features of INO [ 1 ] . Case presentation A 29-year-old Hispanic woman was admitted to the emergency department complaining of an intense holocranial headache lasting 9 days, associated with nausea and vomiting. She was discharged home with resolution of the headache but persistence of symptoms. However, she subsequently developed horizontal diplopia and gait abnormalities. She was readmitted to hospital because of anomalous eye movements and conjugate gaze palsy, manifested as bilateral INO. Magnetic resonance angiography (MRA) findings were consistent with dissection of the left V4 vertebral artery with multiple brain infarcts in the superior cerebellar artery territory, comprising both MLF tracts. Conclusions In young adults, bilateral INO is normally caused by demyelinating disease. In other patients, common causes include trauma, infections and autoimmune diseases with neurological symptoms. Vascular disease is implicated in over a third of cases. LEARNING POINTS A vascular aetiology should be suspected when internuclear ophthalmoplegia (INO) presents with an intense headache. Almost a third of patients with bilateral INO have an identified vascular cause. Magnetic resonance imaging is the gold standard for investigating INO