ABSTRACT Autoimmune encephalitis with antibodies against the N-methyl-D-aspartate receptor (anti-NMDAR) is a disorder mediated by antibodies against neural surface antigens, whose early diagnosis and timely treatment improve the prognosis of the disease. Four cases with the definitive diagnosis of autoimmune encephalitis by anti-NMDAR are presented, treated at the National Institute of Neurological Sciences in Lima-Peru. All patients had epileptic seizures and three cases developed a refractory epileptic state. In addition, three patients presented neuropsychiatric alterations, dyskinesias, and dysautonomia. Two cases required ventilatory support. All presented an abnormal electroencephalogram; two cases had pleocytosis in cerebrospinal fluid, and only one showed brain abnormalities on MRI. Regarding treatment, all patients received methylprednisolone immunotherapy and only two of them required plasma exchange for an ineffective response to corticosteroid treatment. After 12 months of hospital discharge, three patients were free of epileptic seizures and only one case did not achieve functional independence. These cases show that anti-NMDAR encephalitis is a treatable condition and its early recognition together with appropriate treatment (immunotherapy/plasmapheresis) are essential for a favorable evolution.

RESUMEN La encefalitis autoinmune por anticuerpos contra el receptor N-metil-D-aspartato (anti-NMDAR) es un desorden mediado por anticuerpos contra antígenos de superficie neuronal, cuyo diagnóstico temprano y tratamiento oportuno mejoran el pronóstico de la enfermedad. Se presentan cuatro casos con el diagnóstico definitivo de encefalitis autoinmune por anti-NMDAR, tratados en el Instituto Nacional de Ciencias Neurológicas en Lima-Perú. Todos los pacientes presentaron crisis epilépticas y tres casos desarrollaron un estado epiléptico refractario. Asimismo, tres pacientes presentaron alteraciones neuropsiquiátricas, discinesias y disautonomías. Dos casos requirieron soporte ventilatorio. Todos presentaron un electroencefalograma anormal, dos casos tuvieron pleocitosis en líquido cefalorraquídeo, y sólo uno mostró anormalidades cerebrales en la resonancia magnética. Respecto al tratamiento, todos los pacientes recibieron inmunoterapia con metilprednisolona y sólo dos de ellos requirieron plasmaféresis por respuesta ineficaz al tratamiento con corticoides. A los 12 meses del alta hospitalaria, tres pacientes quedaron libre de crisis epilépticas y sólo un caso no logró la independencia funcional. Estos casos muestran que la encefalitis anti-NMDAR es una condición tratable y su reconocimiento temprano junto con un tratamiento adecuado (inmunoterapia/plasmaféresis) son esenciales para una evolución favorable.

Autoimmune encephalitis with antibodies against the N-methyl-D-aspartate receptor (anti-NMDAR) is a disorder mediated by antibodies against neural surface antigens, whose early diagnosis and timely treatment improve the prognosis of the disease. Four cases with the definitive diagnosis of autoimmune encephalitis by anti-NMDAR are presented, treated at the National Institute of Neurological Sciences in Lima-Peru. All patients had epileptic seizures and three cases developed a refractory epileptic state. In addition, three patients presented neuropsychiatric alterations, dyskinesias, and dysautonomia. Two cases required ventilatory support. All presented an abnormal electroencephalogram; two cases had pleocytosis in cerebrospinal fluid, and only one showed brain abnormalities on MRI. Regarding treatment, all patients received methylprednisolone immunotherapy and only two of them required plasma exchange for an ineffective response to corticosteroid treatment. After 12 months of hospital discharge, three patients were free of epileptic seizures and only one case did not achieve functional independence. These cases show that anti-NMDAR encephalitis is a treatable condition and its early recognition together with appropriate treatment (immunotherapy/plasmapheresis) are essential for a favorable evolution.

La encefalitis autoinmune por anticuerpos contra el receptor N-metil-D-aspartato (anti-NMDAR) es un desorden mediado por anticuerpos contra antígenos de superficie neuronal, cuyo diagnóstico temprano y tratamiento oportuno mejoran el pronóstico de la enfermedad. Se presentan cuatro casos con el diagnóstico definitivo de encefalitis autoinmune por anti-NMDAR, tratados en el Instituto Nacional de Ciencias Neurológicas en Lima-Perú. Todos los pacientes presentaron crisis epilépticas y tres casos desarrollaron un estado epiléptico refractario. Asimismo, tres pacientes presentaron alteraciones neuropsiquiátricas, discinesias y disautonomías. Dos casos requirieron soporte ventilatorio. Todos presentaron un electroencefalograma anormal, dos casos tuvieron pleocitosis en líquido cefalorraquídeo, y sólo uno mostró anormalidades cerebrales en la resonancia magnética. Respecto al tratamiento, todos los pacientes recibieron inmunoterapia con metilprednisolona y sólo dos de ellos requirieron plasmaféresis por respuesta ineficaz al tratamiento con corticoides. A los 12 meses del alta hospitalaria, tres pacientes quedaron libre de crisis epilépticas y sólo un caso no logró la independencia funcional. Estos casos muestran que la encefalitis anti-NMDAR es una condición tratable y su reconocimiento temprano junto con un tratamiento adecuado (inmunoterapia/plasmaféresis) son esenciales para una evolución favorable.

Persistent trigeminal artery is a rare vascular disorder and represents the permanence of the communication between the carotid system and vertebrobasilar system after birth. This persistence has been associated with the existence of other alterations of brain vascular morphology and different clinical conditions. We report three cases of persistent trigeminal artery, two incidental findings in patients with transient symptoms and one in a patient with subarachnoid hemorrhage, identified by three-dimensional reconstruction of images obtained by angiotomography.

La persistencia de la arteria trigeminal es una alteración vascular infrecuente y representa la permanencia, después del nacimiento, de la comunicación entre el sistema carotideo y el sistema vertebro-basilar. Esta persistencia se ha asociado a la existencia de otras alteraciones de la morfología vascular cerebral y a condiciones clínicas variadas. Reportamos tres casos de persistencia de la arteria trigeminal, dos como hallazgo incidental en pacientes con sintomatología transitoria y uno en un cuadro de hemorragia subaracnoidea, identificados mediante reconstrucción tridimensional de imágenes obtenidas por angiotomografía.

Traumatic brain injury (TBI) is a common cause of morbidity and mortality in our cities, and the high incidence of traffic accidents raise the frequency of occurrence of this condition. It is important to take into account the initial treatment for stabilizing patients, including airway management, hemodynamic stabilization, initial treatment of intracranial hypertension (ICH), sedation and analgesia, anticonvulsant use, and prophylaxis of venous thromboembolic events, avoiding secondary complications and improving the prognosis of this condition.

El traumatismo encéfalo-craneano (TEC) es una causa frecuente de morbi-mortalidad en nuestro medio y la alta incidencia de accidentes de transito elevan la frecuencia de presentación de esta enfermedad. Es importante tener en cuenta la terapéutica inicial para estabilizar al paciente la que incluye el manejo de la vía aérea, estabilización hemodinámica, terapéutica inicial de la hipertensión endocraneana (HIC), sedación y analgesia, uso de anticonvulsivantes y profilaxis de eventos tromboembólicos venosos; evitando las complicaciones secundarias y mejorando el pronóstico de la enfermedad.

Background: Type B aortic dissection is usually managed by intensive care medical therapy and surgery is reserved for treating the complications that can occur during the evolution of a case. Aim: To assess the endovascular management of acute complications of type B aortic dissection and the closure of the intimal defect and aortic false lumen. Material and Methods: Retrospective analysis of 8 consecutive patients aged 40 to 57 years (seven males) treated for acute complications in the initial episode of a type B aortic dissection between August 2006 and July 2008. Results: Six/eight were known hypertensive patients. The indications for surgery were intractable pain in one, hypertension refractory to treatment in two and distal hypoperfusion in fve. Five patients required covering of the left subclavian artery ostium, without need for surgical repair. One patient was subjected to renal angioplasty and stenting. Technical success was achieved in all cases, with complete closure of the proximal aortic tear and thoracic aortic false lumen, although 7 of patients had a persistent distal aortic false lumen. One case had a transient lower limb paraparesis. No patient died. Conclusions: Endovascular treatment is effective in closing the aortic tear as well as the thoracic aortic false lumen in aortic type B dissections with a low complication rate. Due to the high frequency of distal aortic false lumen persistence, it is not a defnitive treatment for this condition but it is useful for the acute complications of the initial phase of type B aortic dissection.

Popliteal artery entrampment is a rare condition, occurring in young subjects, that causes ischemia of the extremity. The anatomical background is the compression or occlussion of the popliteal artery caused by forced plantar or dorsal flexion. We report a 32 year-old sportsman who presented with gangrene of the right first toe and a history of three months of progressive claudication. The Ankle-Brachial index and pulse volume curve registries showed a severe ischemia below the knee. Angiography showed a medial deviation of the popliteal artery associated to stenosis and aneurysm formation. A CT scan of the contralateral artery was normal. The patient was operated using a posterior approach, performing a reverse saphenous vein bypass graft and excising the popliteal artery. The postoperative period was uneventful

During 1994 and 1995, a cross-sectional study was carried out to investigate the concentrations of lead in the blood of inhabitants of four Peruvian cities (Lima, Huancayo, La Oroya, and Yaupi) with different population densities and degrees of industrial development. In a random sample of 180 men and 180 women without occupational exposure to lead, blood lead levels were measured by the atomic absorption method with a Perkin Elmer 603 spectrophotometer without a graphite oven. The results revealed blood lead concentrations of 269 ± 63 micrograms per liter (mug/L) in Lima, 224 ± 47 (mug/L in Huancayo; 348 ± 40 mug/L in La Oroya, and 140 ± 27 mug/L in Yaupi. It was concluded that blood lead levels in the inhabitants of these cities were related to the degree of industrialization and the population density of each locality.

Con objeto de conocer las concentraciones de plomo sanguíneo de los habitantes de ciudades peruanas de diferente densidad poblacional y grado de desarrollo industrial, durante 1994 y 1995 se efectuó un estudio transversal con una muestra aleatoria de 180 hombres y 180 mujeres sin exposición ocupacional al plomo y procedentes de Lima, Huancayo, La Oroya y Yaupi. Se midió el plomo sanguíneo por el método de absorción atómica con espectrofotómetro Perkin Elmer 603 sin horno de grafito. Los resultados revelaron concentraciones de plomo en sangre de 269 ± 63 µg por litro (µg/L) en Lima, 224 ± 47 µg/L en Huancayo; 348 ± 40 µg/L en La Oroya, y 140 ± 27 µg/L en Yaupi. Se saca la conclusión de que las concentraciones de plomo sanguíneo de los habitantes de estas ciudades guardan relación con el grado de industrialización y la densidad poblacional de cada localidad.