P atients presenting with large ischemic strokes may develop uncontrollable, progressive brain edema that puts them at risk for compression of brain parenchyma and cerebral herniation. 23 There are a limited number of therapeutic options, but research has shown that operative procedures, such as decompressive hemicraniectomy (DH), decrease patient mortality.32 Malignant infarction treated only by conservative approaches results in a mortality rate of 80% within the 1st week of the stroke. 15Edema that does not respond to medical treatment necessitates DH as a life-saving procedure. Studies have demonstrated that DH surgery can result in a reduction of mortality rate to 30% and, if decompression is performed within 24 hours of stroke onset, to 10%. 7,12,18,24,32 While DH imabbreviatioNs BMI = body mass index; DH = decompressive hemicraniectomy; DVT = deep vein thrombosis; ICA = internal carotid artery; IVC = inferior vena cava; MCA = middle cerebral artery; MI = myocardial infarction; MLS = midline shift; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; tPA = tissue plasminogen activator. obJective Patients presenting with large-territory ischemic strokes may develop intractable cerebral edema that puts them at risk of death unless intervention is performed. The purpose of this study was to identify predictors of outcome for decompressive hemicraniectomy (DH) in ischemic stroke. methods The authors conducted a retrospective electronic medical record review of 1624 patients from 2006 to 2014. Subjects were screened for DH secondary to ischemic stroke involving the middle cerebral artery, internal carotid artery, or both. Ninety-five individuals were identified. Univariate and multivariate analyses were performed for an array of clinical variables in relationship to functional outcome according to the modified Rankin Scale (mRS). Clinical outcome was assessed at 90 days and at the latest follow-up (mean duration 16.5 months). results The mean mRS score at 90 days and at the latest follow-up post-DH was 4. Good functional outcome was observed in 40% of patients at 90 days and in 48% of patient at the latest follow-up. The mortality rate at 90 days was 18% and at the last follow-up 20%. Univariate analysis identified a greater likelihood of poor functional outcome (mRS scores of 4-6) in patients with a history of stroke .66]; p = 0.017), peak midline shift (MLS) > 10 mm ]; p = 0.011), or a history of myocardial infarction ]; p = 0.04). Multivariate analysis demonstrated elevated odds of poor functional outcome associated with a history of stroke .05]; p = 0.008), MLS > 10 mm ; p = 0.007), a history of diabetes .88]; p = 0.01), delayed time from onset of stroke to DH (OR 1.32 [95% CI 1.02-1.72]; p = 0.037), and evidence of pupillary dilation prior to DH .51]; p = 0.04). Patients with infarction involving the dominant hemisphere had higher odds of unfavorable functional outcome at 90 days ]; p = 0.014), but at the latest follow-up, cerebral dominance was not significantly related to outc...

OBJECTIVEThe Pipeline embolization device (PED) has become a valuable tool in the treatment of cerebral aneurysms. Although failures with PED treatment have been reported, the characteristics and course of these aneurysms remain a topic of uncertainty.METHODSElectronic medical records and imaging studies were reviewed for all patients treated with the PED between July 2010 and March 2015 to identify characteristics of patients and aneurysms with residual filling after PED treatment.RESULTSOf 316 cases treated at a single institution, 281 patients had a long-term follow-up. A total of 52 (16.4%) aneurysms with residual filling were identified and constituted the study population. The mean patient age in this population was 58.8 years. The mean aneurysm size was 10.1 mm ± 7.15 mm. Twelve aneurysms were fusiform (23%). Of the aneurysms with residual filling, there were 20 carotid ophthalmic (CO) aneurysms (20% of all CO aneurysms treated), 10 other paraclinoid aneurysms (16.4% of all paraclinoid aneurysms), 7 posterior communicating artery (PCoA) aneurysms (21.9% of all PCoA aneurysms), 7 cavernous internal carotid artery (ICA) aneurysms (14.9% of all cavernous ICA aneurysms), 4 vertebrobasilar (VB) junction aneurysms (14.8% of all VB junction aneurysms), and 3 middle cerebral artery (MCA) aneurysms (25% of all MCA aneurysms). Eleven patients underwent placement of more than one PED (21.2%), with a mean number of devices of 1.28 per case. Eight of 12 aneurysms were previously treated with a stent (15.4%). Nineteen patients underwent re-treatment (36.5%); the 33 patients who did not undergo re-treatment (63.5%) were monitored by angiography or noninvasive imaging. In multivariate analysis, age older than 65 years (OR 2.65, 95% CI 1.33–5.28; p = 0.05), prior stent placement across the target aneurysm (OR 2.94, 95% CI 1.15–7.51; p = 0.02), aneurysm location in the distal anterior circulation (MCA, PCoA, and anterior choroidal artery: OR 2.72, 95% CI 1.19–6.18; p = 0.017), and longer follow-up duration (OR 1.06, 95% CI 1.03–1.09; p < 0.001) were associated with incomplete aneurysm occlusion.CONCLUSIONSWhile the PED can allow for treatment of large, broad-necked aneurysms with high efficacy, treatment failures do occur (16.4%). Aneurysm size, shape, and previous treatment may influence treatment outcome.

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The rate of DVT and PE is remarkably high in patients with large hemispheric infarction undergoing decompressive hemicraniectomy despite prophylactic measures. We recommend routine screening for DVT in this population. Interventions beyond the standard prophylactic measures may be necessary in this high-risk group.

IntroductionWithin the various cultures and throughout the centuries has observed the relationship between emotional states and heart function, colloquially calling him “heartbroken”. Also in the medical literature are references to cardiac alterations induced by stress.ObjectiveTakotsubo is a rare cardiac syndrome that occurs most frequently in postmenopausal women after an acute episode of severe physical or emotional stress. In the text that concerns us, we describe a case related to an exacerbation of psychiatric illness, an episode maniform.MethodWoman 71 years old with a history of bipolar I disorder diagnosed at age 20. Throughout her life, she suffered several depressive episodes as both manic episodes with psychotic symptoms. Carbamazepine treatment performed and venlafaxine. He previously performed treatment with lithium, which had to be suspended due to the impact on thyroid hormones and renal function, and is currently in pre-dialysis situation.She requires significant adjustment treatment, not only removal of antidepressants, but introduction of high doses of antipsychotic and mood stabilizer change of partial responders. In the transcurso income, abrupt change in the physical condition of the patient suffers loss of consciousness, respiratory distress, drop in blood pressure, confusion, making involving several specialists. EEG was performed with abnormal activity, cranial CT, where no changes were observed, and after finally being Echocardiography and coronary angiography performed when diagnosed Takotsubo.Results/conclusionsIn this case and with the available literature, we can conclude that the state of acute mania should be added to the list of psychosocial/stressors that can trigger this condition.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionParkinson's disease is caused by decreased dopaminergic neurons of the substantia nigra. Psychosis occurs between 20 and 40% of patients with Parkinson's disease. Dopaminergic drugs act as aggravating or precipitating factor. Before the introduction of levodopa patients had described visual hallucinations but the frequency was below 5%.ObjectiveIllustrated importance of treatment, reassessment after its introduction and refractoriness to answer; as well as the importance of a differential diagnosis at the onset of psychotic symptoms later in life.MethodClinical case: female patient 75 years tracking Neurology by parkinsonism in relation to possible early Parkinson disease. She was prescribed rasagiline treatment. Begins to present visual and auditory hallucinations, delusional self-referential and injury. She had no previous psychiatric history. She went on several occasions to the emergency room, where the anti-Parkinson treatment is decreased to the withdrawal point and scheduled antipsychotics did not answer. Doses of antipsychotics are increased despite which symptoms persist and even increase psychotic symptoms. In this situation it is agreed to extend the study. Subsequently an NMR of the skull where the image is suggestive of a right occipital meningioma appears.Results/conclusionsWith the emergence of psychotic symptoms later in life it will be important to ask a broad differential diagnosis, since in a large number of cases will be secondary to somatic or to drug therapies.Parkinsonism can be a symptom of occipital meningioma, presenting in the psychotic clinic. Refractoriness, on one hand to the suspension of treatment for Parkinson's disease, such as poor response to antipsychotics, did extend the study, which ultimately gave us the diagnosis.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionSystemic lupus erythematosus is a chronic disease that can give neuropsychiatric episodes and systemic manifestations. About 57% of patients with SLE have neuropsychiatric manifestations in the course of their illness, however an initial presentation with neuropsychiatric clinic is rare.ObjectiveDescribe how patients receiving corticosteroids as part of their treatment can develop mental disorders but not only them.MethodIt will raise grounds with a case: 20-year-old woman recently diagnosed with SLE because of arthritis in his ankle. Treatment was initiated with prednisone 10 mg and chloroquine 200 MG. After 20 days the patient comes to the emergency after episode of turmoil at home with major affective clinical maniform. Presenting fever. The presence of fever downloads the possibility of a psychosis chloroquine or corticosteroids to be a small dose. Treatment was initiated with high doses of prednisone and immunosuppressants. In addition to associating specific anticonvulsant and antipsychotic drugs at usual doses for a manic episode.ResultsTreatment of psychosis in SLE is essentially empirical, and depends on the etiology. It usually responds to the use of high doses of corticosteroids combined with immunosuppressive drugs. Psychosis induced by corticosteroids requires lowering them. It is valid concomitant use of antipsychotics.ConclusionsThe presence of psychotic symptoms in a patient with systemic lupus erythematosus forces to distinguish between various etiological possibilities.Corticosteroids may cause a variety of psychiatric symptoms. And yet, in patients with SLE these syndromes are not always attributable to the use of corticosteroids.Disclosure of interestThe authors have not supplied their declaration of competing interest.