Acute treatment costs of intracerebral hemorrhage and ischemic stroke in Argentina

Background and purpose – Stroke is the third leading cause of death in Argentina, yet little information exists on the acute treatment provided for stroke or its costs. This study estimates the national costs of the acute treatment of first‐ever intracerebral hemorrhage (ICH) and ischemic stroke (IS) in Argentina. Methods – Retrospective hospital‐based inception study design using data on resource use and costs from high‐volume stroke centers in Argentina, and published population‐based incidence data. Treatment provided at two large urban hospitals were evaluated in all patients admitted with a first‐ever stroke between 1 January 2004 and 31 August 2006, and costs were assigned using appropriate unit cost data for all resource use. Cost estimates in Argentinian pesos were converted to US dollars ($) using the 2005 purchasing power parity index. National costs of acute treatment for incident strokes were estimated by extrapolation of average costs estimates to national incidence data. Assumptions of the average cost of stroke treatment on a national scale were examined in sensitivity analysis. Results – The acute care of 167 patients with stroke was thoroughly evaluated from hospital admission to hospital discharge. Mean length of hospital stay was 35.4 days for ICH and 13.0 days for IS. Ninety‐one percent of the patients with ICH and 68% of the patients with IS were admitted to an ICU for a mean length of stay (LOS) of 12.9 ± 20.3 and 3.6 ± 5.9 days respectively. Mean total costs of initial hospitalization were $12,285 (SD ±14,336) for ICH and $3888 (SD ±4018) for IS. Costs differed significantly by Glasgow Coma Scale (GCS) score at admission, development of pneumonia and infections during hospitalization, and functional outcome at hospital discharge. Aggregate national healthcare expenditures for acute treatment of incident ICH were $194.2m (range 97.1–388.4) and $239.9m for IS (range 119.9–479.7). Conclusion – The direct hospital costs of incident ICH and IS in Argentina are substantial and primarily driven by stroke severity, in‐hospital complications and clinical outcomes. With the expected increase in the incidence of stroke over the coming decades, these results emphasize the need for effective preventive and acute medical care.     

Subclinical apoplexy in pituitary tumors]

Acute pituitary apoplexy is a rare event, even in patients with pituitary macroadenomas. On the other hand, the presence of necrotic/hemorrhagic areas, especially in macroadenomas, seems to be more common than earlier reported in the CT period. After the introduction of MR in the presurgical workup of these patients, these apopleptic areas have been more easily diagnosed preoperatively. Forty consecutive patients with pituitary macroadenomas were studied with high-resolution 1.5 T T1 coronal, sagittal and axial slices over the sellar region. Special attention was paid in the detection of necrotic, cystic and hemorrhagic areas within these tumors. Ten patients had hemorrhagic/necrotic areas within their tumors, without any sign or symptom of acute apoplexy. These areas varied from small (2 mm) to very large (30 mm) ones. Seven patients had non-secreting tumors, 2 GH and 1 prolactin secreting tumors, which is the same profile of secretory pattern for the whole series (40 patients). The clinical picture included (other than that caused by endocrine secretion) slowly progressive (but not acute) visual loss (n = 8) and headache (n = 3). After surgical decompression of the surrounding structures and visual apparatus, which was facilitated by the presence of the necrotic areas, there was visual improvement in 6 patients and headache resolution in 2. The presence of asymptomatic apopletic areas in these macroadenomas and their absence in microadenomas as can be seen in the literature suggest that they are related more to the size of the tumor than to its endocrine secretion pattern. This is in agreement with a vascular insufficiency hypothesis in the pathogenesis of these lesions.     

缺血性脑卒中的分型及与预后的关系

当缺血性脑卒中的诊断确立之后，进一步确定其亚型将有助于治疗病因和评估预后；有利于更具针对性地进行二级预防；同时也有利于对临床试验中的患进行分层，以便为个体化治疗提供详细的依据。因此，临床医师有必要了解目前临床常用的缺血性脑卒中的分型方法，以及TOAST(the Trial of     

出血性脑瘤卒中的临床与CT诊断

目的探讨出血性脑瘤卒中的临床与CT表现以获取早期诊断的依据。方法结合文献复习,回顾性分析12例出血性脑瘤卒中的临床与CT表现。结果出血性脑瘤卒中临床分型有:Ⅰ型以脑卒中为首发症状(6例);Ⅱ型为原有脑瘤症状加重(3例);Ⅲ型为头部外伤后脑卒中(3例)。CT表现为出血征象与肿瘤征象共存。结论出血性脑瘤卒中的临床表现多样,容易误诊为脑血管病出血或脑外伤出血;除详细询问病史外,细致的临床及CT检查是早期确诊的关键。     

出血性脑瘤卒中的临床与CT诊断

目的 探讨出血性脑瘤卒中的临床与CT表现以获取早期诊断的依据.方法 结合文献复习,回顾性分析12例出血性脑瘤卒中的临床与CT表现.结果 出血性脑瘤卒中临床分型有：Ⅰ型以脑卒中为首发症状（6例）;Ⅱ型为原有脑瘤症状加重（3 例）;Ⅲ型为头部外伤后脑卒中（3例）.CT表现为出血征象与肿瘤征象共存.结论出血性脑瘤卒中的临床表现多样,容易误诊为脑血管病出血或脑外伤出血;除详细询问病史外,细致的临床及CT检查是早期确诊的关键.     

Necrosis of a hypophyseal adenoma and ischemic cerebral vascular accident

A 78-year old man developed an acute intracranial hypertension followed by central left facial palsy. CT Scan and MRI revealed an ischemia within the right lenticulostriate arteries territory and a hemorrhagic infarction of a pituitary adenoma without extrinsic carotid artery compression. Neuroophthalmologic examination and hormonal screening were normal. Though pituitary apoplexy and stroke might represent a fortuitous association, several mechanisms underlying such clinical picture are advanced.     

急性缺血性脑卒中降纤治疗临床研究

由蛇毒提纯的降解血浆纤维蛋白原(fibrinogen，FIB)的蛋白制剂自20世纪60年代末开始陆续用于治疗周围血管病、深静脉血栓形成、肝素诱导的血小板减少症及其导致的血栓栓塞性疾病、急性冠状动脉综合征、经皮冠状动脉成形术及冠状动脉搭桥术、周围血管重建术、股骨颈骨折术后、弥漫性增生     

Associated ischemic lesions in intracranial hemorrhage: MRI study

Cerebral small-vessel disease is an important cause of a hemorrhagic stroke (HS) or a certain type of ischemic stroke (IS). Using magnetic resonance imaging, the frequency and the pattern of ischemic lesions between an HS group and an IS group were compared. Sixty-eight patients with HS and 104 patients with IS as a control group were enrolled in this study. The rate of grade 2 and 3 periventricular white matter lesions (WML) in the HS group was similar to that in the IS group. However, grade 2 and 3 lacunes (LAC) were more frequent in the HS group. These results show that the incidence of concomitant silent LAC is different from that of WML in HS patients. This suggests that the pathophysiology of WML and that of LAC is different and that the pathophysiology of HS is closely associated with that of LAC.     

Acute hypertension in intracerebral hemorrhage: pathophysiology and treatment

Non-traumatic or spontaneous intracerebral hemorrhage (ICH) is defined as intra-parenchymal bleeding with or without extension into the ventricles and rarely into the subarachoid space. Primary ICH in most cases is associated with chronic hypertension. Acute hypertension is associated with hematoma expansion, and poor neurological outcome. The treatment of hypertension in acute ICH is a topic of controversy. Experiments have shown an area of ischemia around the hematoma, with the reduction of regional cerebral blood flow (CBF) secondary to compression of microvasculature. Not all scientific results agree with the above findings. Recent studies have shown that CBF decreases in the perihematoma region but with concomitant reduction of cerebral metabolism, which would argue against an area of ischemia in the perihematoma region. Based on the above result, there have been several clinical trials looking at clinical outcome and decrease in hematoma expansion rates with reduction of blood pressure acutely after ICH. The parameters for the blood pressure control are still under investigation. The American Heart Association has put forward guidelines for blood pressure control which have been adopted in the centers around the country. We have described the protocol we use at our center for the blood pressure control in patients with acute ICH.     

Spontaneous hemorrhage in brain tumors

In a period of 15 months in a material of 235 surgically verified brain tumours in 8 cases (3.4%) hemorrhages into the tumour mass were found. In 3 of these cases the tumours were anaplastic astrocytomas, the remaining tumours were: oligodendroglioma, meningioma, pituitary adenoma and metastases of renal carcinoma and skin melanoma. The clinical manifestations associated with haemorrhage are discussed stressing that haemorrhage into the tumour worsened the prognosis.     

Acute monocular disturbances mimicking optic neuritis in pituitary apoplexy

Three patients with acute monocular central scotoma and headache had the initial diagnosis of optic neuritis. Computed tomography showed large pituitary adenomas with necrosis and cyst formation consistent with the clinical symptoms of a previous pituitary apoplexy. After transsphenoidal adenomectomy the visual disturbances disappeared.     

Pituitary apoplexy in a child presenting with massive subarachnoid and intraventricular hemorrhage.

A case of pituitary apoplexy in a child with massive subarachnoid and intraventricular hemorrhage is reported. The patient presented with a sudden onset of headache, diminution of visual acuity and a bitemporal visual field defect. Computerized tomography revealed a massive subarachnoid hemorrhage with extension of blood into the third ventricle. Angiography did not show an aneurysm. The patient was operated on and altered blood within a necrotic pituitary adenoma was decompressed. His vision and field defect improved along with resolution of headache in the postoperative period.     

Perineurial hemorrhage in ischemic nerve after anticoagulation

We report a 29-year-old woman who developed severe left leg ischemia after aortic dissection and left common iliac artery occlusion. Light microscopic studies revealed severe nerve and muscle ischemic changes at the calf level. Nerves also showed extensive perineurial hemorrhage, most likely secondary to heparin administration. Perineurial hemorrhage should be considered as one of the possible complications of anticoagulant therapy.