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• Ischemic stroke in chagasic patients
  Antonio L. Teixeira Jr
  Published on: 16 April 2003

• Published on: 16 April 2003

  Ischemic stroke in chagasic patients

  • Antonio L. Teixeira Jr, Neurologist
  • Other Contributors:
    • Mauro M. Teixeira

  Dear Editor

  We read with interest the paper by Carod-Artal et al.[1] that showed the relevance of Chagas' disease as a stroke risk factor in patients of South American origin.

  They also confirmed a textbook view [2] (not demonstrated until this paper) that cardioembolism is the main cause of stoke in Chagas' disease (52%). This reflects in part the underlying chagasic cardiomyopathy, characterised by...

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  Dear Editor

  We read with interest the paper by Carod-Artal et al.[1] that showed the relevance of Chagas' disease as a stroke risk factor in patients of South American origin.

  They also confirmed a textbook view [2] (not demonstrated until this paper) that cardioembolism is the main cause of stoke in Chagas' disease (52%). This reflects in part the underlying chagasic cardiomyopathy, characterised by congestive heart failure and arrhythmias, that was present in 46% of chagasic patients, a greater percentage than in non-chagasic patients (25%).

  Despite not performing a comparison of stroke characteristics between both groups, one very interesting finding was the significant percentage of chagasic patients who developed stroke without any vascular risk factors and cardiopathy. As the authors stated, undetected cardiovascular disease could account for, at least, part of this finding. In fact, 25 % of the chagasic patients classified as possessing the indeterminate form of the disease (defined by the presence of infection confirmed by serological tests, the absence of symptoms and of electrocardiographic and radiologic abnormalities) may present significant structural and/or functional abnormalities when they are fully evaluated by more sensitive methods, such as ergometry and autonomic tests.[3] Another possible explanation proposed by the authors would be vasculitis phenomenon.

  Although there is good experimental evidence to suggest that changes in the microvasculature may contribute to chagasic heart disease,[4] there is much less known about the possible involvement of central nervous system microvasculature in Chagas' disease. Indeed, most studies point to an important role of endothelin in the pathogenesis of microvascular changes in chagasic heart [4,5] but we are unaware of similar studies in the central nervous system.

  The authors also suggest the need for primary prevention in all patients with Chagas' disease cardiomyopathy.[1] This is a strong recommendation as most patients derive from poor social economic backgrounds and have poor access to the health system. Chronic oral anticoagulant therapy is known to cause frequent clinical complications, especially bleeding. One alternative approach could be the use of low dose anticoagulant therapy that has been recently suggested for the treatment of deep vein thrombosis.[6] However, further studies are still needed to investigate this possibility specifically in Chagas' disease.

  References

  (1) Carod-Artal FJ, Vargas AP, Melo M, Horan TA. American trypanosomiasis (Chagas' disease): an unrecognised cause of stroke. J Neurol Neurosurg Psychiatry 2003; 74: 516-518.

  (2) Kirchhoff LV. Trypanosoma species (American trypanosomiasis, Chagas' disease). In: Principles and practice of infectious disease Mandell GL, Bennet JE, Dolin R, (Eds). New York: Churchill Livingstone, 1995: 2442-2449.

  (3) Rocha MOC, Ribeiro ALP, Teixeira MM. Clinical management of chronic Chagas cardiomyopathy. Frontiers in Bioscience 2003;8: 44-54.

  (4) Petkova SB, Huang H, Factor SM, et al. The role of endothelin in the pathogenesis of Chagas' disease. Int J Parasitol 2001; 31:499-511.

  (5) Camargos ERS, Machado CRS, Teixeira-Jr AL, et al. Role of endothelin during experimental Trypanosoma cruzi infection in rats. Clinical Science 2002; 103 (suppl): 64S-67S.

  (6) Ridker PM, Goldhaber SZ, Danielson E, et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous tromboembolism. N Engl J Med 2003; 348: 1425-1434.

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  Conflict of Interest:
  None declared.

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