[Clinical relevance of headache in cerebral ischaemia]. / Relevancia clínica de la cefalea en la isquemia cerebral.

TITLE: Relevancia clínica de la cefalea en la isquemia cerebral.

[The first Catalan Neurological Societies and their protagonists]. / Las primeras sociedades neurológicas catalanas y sus protagonistas.

INTRODUCTION: Little is known about the first Catalan neurological societies. Our aim was to analyse them from the formation of the pioneering Society of Psychiatry and Neurology of Barcelona founded in 1911. DEVELOPMENT: We performed a literature search using MEDLINE using the key words: neurological societies, using the doctoral thesis of MG Fabregas: «History of Neurology in Catalonia: from 1882 to 1949¼ and original historical bibliographical sources of the Library of the Academy of Sciences Mèdiques de Catalunya i Balears. The presence of neurological societies in Catalunya is relatively recent. The first society was established a century ago, and was the Society of Psychiatry and Neurology of Barcelona, founded by Artur Galcerán i Granés in 1911. This became the Catalan Society of Neurology and Psychiatry in 1934 under the presidency of Belarmino Rodriguez Arias. With the civil war, the society broke up and reappeared under the name Association of Psychiatry and Neurology presided over by José Córdoba Rodríguez (1941), emerging in 1968 as the Association of Neurological Sciences with Lluís Barraquer Bordas as President. In 1973 it assumed the current name of Catalan Society of Neurology under Agustí Codina Puiggrós. CONCLUSIONS: The Society of Psychiatry and Neurology of Barcelona founded in 1911 by Galcerán i Granés was the first neurological society and was a precursor of the Catalan Society of Neurology. It should be highlighted that in 2011 it will be 100 years since the founding of the first neurological society in Catalonia and Spain.

Diagnosis of CADASIL disease in normotensive and non-diabetics with lacunar infarct.

BACKGROUND: CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) is characterized by recurrent cerebral ischemic episodes of the lacunar subtype usually without traditional vascular risk factors. We investigated the frequency of CADASIL among selected patients with cerebral ischemia of the lacunar subtype. METHODS: we studied patients under 65 years old who presented cerebral ischemia of the lacunar subtype without hypertension, diabetes mellitus or other causes that explained the cerebral ischemia. On the skin biopsies, we performed immunostaining analysis on 5µm frozen sections with monoclonal antibody anti-Notch 3 (1E4). We also performed a genetic analysis of the Notch 3 gene (exons 3,4,5,6,11 and 19). RESULTS: of 1.519 patients analyzed, only 57 (3.7%) fulfilled the selection criteria, and 30 of them accepted to participated in the study. We studied 30 patients, mean age was 53 years (range 34 to 65), 50% were men and all patients suffered a lacunar stroke. Immunostaining analysis was positive in two patients (6.6%) and the genetic analysis confirmed a mutation characteristic of CADASIL in exon 4 nt 622C/T (Arg 182 Cys) and 694 T/C (Cys206Arg) respectively. CONCLUSIONS: CADASIL disease was present in 6.6% of patients younger than 65 years with a lacunar stroke and without hypertension or diabetes mellitus. Screening for CADASIL should be considered in these patients.

The neurological work of Artur Galcerán i Granés (1850-1919).

INTRODUCTION: To analyze the neurological work of Artur Galcerán i Granés (Girona 1850-Barcelona 1919) founder of the Society of Psychiatry and Neurology of Barcelona in 1911. METHODS: We performed a literature search using MEDLINE from the keywords"Galceran Granés" and "Society of Psychiatry and Neurology of Barcelona", using the doctoral thesis of M. G. Fabregas Camps: "History of Neurology in Catalonia. From 1882 to 1949 ", and original historical bibliographical sources of the Library of the Academy of Sciences Mèdiques de Catalunya i Balears. RESULTS: Artur Galcerán i Granés was a disciple of the school of psychiatry of Dr. Joan Giné i Partagàs. His highlighting neurological work was: 1) "Some static and dynamic inferences about the brain, which may serve to clarify the concept of localization", 2) "Treatment of epilepsy" and 3) "Neuropathology and General Psychiatry". He was editor of "Archivos de Terapeútica de las enfermedades nerviosas y mentales" and "Anales de la Sociedad de Psiquiatría y Neurología". He was director of the mental asylum in Sant Boi of Llobregat and Pere Mata of Reus. In 1911 he founded the first Catalan and Spanish neurological society in Barcelona. CONCLUSIONS: The neurological work of Artur Galcerán i Granes is remarkable and significant. He was the founder of the first Catalan and Spanish neurological society: The Society of Psychiatry and Neurology of Barcelona in 1911, the forerunner of the Catalan Society of Neurology.

Early treatment of obstructive apnoea and stroke outcome: a randomised controlled trial.

The aim of the present study was to assess the impact of nasal continuous positive airway pressure (nCPAP) in ischaemic stroke patients followed for 2 yrs. Stroke patients with an apnoea-hypopnoea index ≥ 20 events·h⁻¹ were randomised to early nCPAP (n = 71; 3-6 days after stroke onset) or conventional treatment (n = 69). The Barthel Index, Canadian Scale, Rankin Scale and Short Form-36 were measured at baseline, and at 1, 3, 12 and 24 months. The percentage of patients with neurological improvement 1 month after stroke was significantly higher in the nCPAP group (Rankin scale 90.9 versus 56.3% (p < 0.01); Canadian scale 88.2 versus 72.7% (p < 0.05)). The mean time until the appearance of cardiovascular events was longer in the nCPAP group (14.9 versus 7.9 months; p = 0.044), although cardiovascular event-free survival after 24 months was similar in both groups. The cardiovascular mortality rate was 0% in the nCPAP group and 4.3% in the control group (p = 0.161). Early use of nCPAP seems to accelerate neurological recovery and to delay the appearance of cardiovascular events, although an improvement in patients' survival or quality of life was not shown.

Microstructural white matter changes in metabolic syndrome: a diffusion tensor imaging study.

BACKGROUND: Although metabolic syndrome is associated with cardiovascular disease and stroke, limited information is available on specific brain damage in patients with this syndrome. We investigated the relationship of the syndrome with white matter (WM) alteration using a voxel-based approach with diffusion tensor imaging (DTI). METHODS: We compared fractional anisotropy (FA) and apparent diffusion coefficient (ADC) measurements of DTI in 19 patients with metabolic syndrome aged between 50 and 80 years and 19 age-matched controls without any vascular risk factors for the syndrome. RESULTS: Patients with metabolic syndrome showed an anterior-posterior pattern of deterioration in WM with reduced FA and increased ADC values compared with controls. WM changes were not related to any isolated vascular risk factor. CONCLUSION: Although the mechanism of this damage is not clear, the results indicate microstructural white matter alterations in patients with metabolic syndrome, mainly involving the frontal lobe.

[Impaired fasting glucose as a risk factor for atherothrombotic or lacunar cerebral infarction. A case-control study]. / La glucemia basal alterada es un factor de riesgo para el infarto cerebral aterotrombótico o lacunar. Estudio de casos y controles.

INTRODUCTION: Modifiable vascular risk factors (MVRF) for atherotrombotic or lacunar cerebral infarction have been clearly established, even though only a few population studies have been conducted and we do not know the risk of glycemic status prior to the diabetes mellitus (DM). This study has aimed to determine the relationship between impaired fasting glucose (IFG) and others MVRF with atherothrombotic or lacunar cerebral infarctions. METHODS: A population based case-control study was conducted in two urban health care centers. CASES: 236 patients with atherothrombotic or lacunar CI, diagnosed by computed tomography scan magnetic resonance imaging. Unusual, indeterminate and cardioembolic cerebral infarction and cerebral hemorrhage were excluded. CONTROLS: 441 patients without cerebral infarction, matched by age and gender, selected by means of simple random sampling. The odds ratios (OR) of IFG, DM, smoking, high blood pressure, hypercholesterolemia, hypertriglyceridemia, and obesity were measured with logistic regression. RESULTS: Mean age was 71.1 years old, 62 % being male. Prevalence in cases of MVRF was: IFG, 32.9%; DM, 49.6 %; smoking, 26.3%; high blood pressure, 78.8%; hypercholesterolemia, 29.3%; hypertriglyceridemia, 18.2%, and obesity, 63.5%. All MVRFs were associated in the crude analysis with increased risk of cerebral infarction. In the multivariate analysis, significant associations were found for IFG (OR: 3.2; 95 % confidence interval [CI]:1.1-7.9), DM (OR: 4.5; 95 % CI: 1.4-14.9), high blood pressure (OR: 2.6; 95 % CI: 1.5-4.5), hypercholesterolemia (OR: 2.3; 95 % CI: 1.4-3.9), and obesity (OR: 1.7; 95% CI: 1.0-2.9). CONCLUSIONS: Alterations of the glucose metabolism IFG and DM are important MVRF for atherothrombotic or lacunar cerebral infarction as seen by the high rate of OR and high prevalence in the population with cerebral infarction.

Higher severity of frontal periventricular white matter and basal ganglia hyperintensities in first-ever lacunar stroke with multiple silent lacunes.

BACKGROUND AND PURPOSE: We investigated whether patients with a lacunar infarct (LI) syndrome exhibiting unique LI or multiple LI on magnetic resonance imaging (MRI) examinations differed in terms of topography and severity of white matter hyperintensities (WMH) ratings. METHODS: Forty consecutive patients with a first-ever acute LI, who presented a lacunar syndrome according to Miller-Fisher's classification were recruited and were classified into a group presenting isolated LI on MRI (n = 17) or multiple LI (n = 23). RESULTS: Despite equivalent demographic, clinical and cognitive characteristics, patients with multiple LI had increased ratings of WMH in frontal, occipital and subcortical regions. No significant correlations could be evidenced between the number of LI and WMH ratings. CONCLUSIONS: Present findings provide support to previous hypothesis considering single and multiple LI MRI presentations of lacunar infarct patients as distinct entities.

[Validation of the Essen risk scale and its adaptation to the Spanish population. Modified Essen risk scale]. / Validación de la escala de riesgo de Essen y su adaptación a la población española. Escala de riesgo de Essen modificada.

INTRODUCTION: Our objective was to evaluate the risk of stroke or vascular event recurrence in the Spanish population according to the Essen risk scale (ERS) and suggest modifications to improve its prediction sensitivity and specificity. METHODS: Patients in the Real Action Guidelines in Stroke Care and Treatment Study (PRACTIC), a prospective registry of stroke patients admitted to 88 Spanish hospitals representing the three level of care, were followed- up for 6 months. Sensitivity and specificity in stroke or vascular event recurrence prediction were determined with the ERS and after modifications of this scale. RESULTS: Sensitivity and specificity for stroke recurrence prediction were 61.5 % and 45.3 % in high-risk patients (p=0.340), 3.8% and 99.3% in very high risk patients (p=0.017). Prediction, sensitivity and specificity were 67.5 % and 46.2 % (p=0.020) or 5% and 99.6% (p=0.017) for any vascular event, respectively. After risk dichotomization, patients scoring >3 points had sensitivity and specificity of 46.2% and 71% (p=0.009) for stroke recurrence and 46.3% and 71.7% for a new vascular event. These results can be optimized by adding the alcoholism variable to the scale, obtaining a sensitivity and specificity of 51.9% and 67% (p=0.005) or 53.8% and 68% (p=0.0001), respectively. We also reach a higher predictive power adding alcoholism: 61.2 % (52.9 %- 69.5 %) vs 56.7% (47.9%-65.6%) for stroke recurrence and 63.7% (57.0%-70.4%) vs 60.5% (53.5%-67.4%) for new vascular event. CONCLUSIONS: ERS has a low sensitivity and predictive power for stroke or new vascular event in the Spanish population. Dichotomization and adding the variable alcoholism improve its sensitivity and predictive power for stroke recurrence either for stroke or for any vascular recurrence. However it is still necessary to modify the risk scale to improve identification of the higher risk patients.

Recurrent lacunar infarction following a previous lacunar stroke: a clinical study of 122 patients.

OBJECTIVE: To determine clinical variables related to recurrent lacunar infarction following a previous lacunar stroke. METHODS: A total of 122 out of 733 consecutive patients with lacunar infarction collected from a hospital based registry between 1986 and 2004 were readmitted because of a recurrent lacunar infarction. In a subset of 59 patients, cognition was assessed using the Mini-Mental State Examination (MMSE). Predictors of lacunar infarction recurrence were assessed by logistic regression analysis. RESULTS: First lacunar infarction recurrence occurred in 101 patients (83%) and multiple recurrences in 21. The mean time between first ever lacunar infarction and recurrent lacunes was 58.3 months (range 2-240). In the subset of 59 patients in whom cognition was studied, cognitive impairment, defined as an MMSE score <24, was detected in 16% (8/49) of patients with first lacunar infarction recurrence and in 40% (4/10) of those with multiple lacunar infarction recurrences. In the multivariate analysis, hypertension (odds ratio 2.01, 95% CI 1.23 to 3.30) and diabetes (odds ratio 1.62, 95% CI 1.07 to 2.46) were significant predictors of lacunar stroke recurrence, whereas hyperlipidaemia was inversely associated (odds ratio 0.52, 95% CI 0.30 to 0.90). CONCLUSIONS: Hypertension and diabetes were significant factors related to recurrent lacunar infarction. Hyperlipidaemia appeared to have a protective role. Cognitive impairment was a frequent finding in patients with multiple lacunar infarction recurrences.

Haemorrhagic pure motor stroke.

To describe the clinical characteristics of haemorrhagic pure motor stroke (PMS). Twelve patients with haemorrhagic PMS were identified. Haemorrhagic PMS accounted for 3.2% of all cases of pure motor hemiparesis (n = 380) and 3.3% of intracerebral haemorrhage (n = 364) entered in the database. When compared with PMS of ischaemic origin, patients with haemorrhagic PMS were more likely to be younger (62.2 vs. 75.2 years, P = 0.003) and to have headache (33% vs. 6.3%, P =0.007) and thalamus involvement (25% vs. 2.4%, P = 0.005). Limb weakness (100% vs. 74.1%; P = 0.03), involvement of the internal capsule (50% vs. 17.3%, P = 0.012) and symptom free at discharge (25% vs. 3.7%, P = 0.012) were significantly more frequent in patients with haemorrhagic PMS than in the remaining cases of haemorrhagic stroke, whereas nausea and vomiting (0% vs. 25.9%, P = 0.03), altered consciousness (0% vs. 42.9%, P = 0.001), sensory symptoms (8.3% vs. 46.9%, P =0.007) and ventricular haemorrhage (0% vs. 26.1%, P = 0.028) were significantly less frequent. Haemorrhagic PMS is a very infrequent stroke subtype. Headache at stroke onset may be useful sign for distinguishing haemorrhagic PMS from other causes of lacunar stroke. There are important differences between haemorrhagic PMS and the remaining intracerebral haemorrhages.

Determinants of early outcome in spontaneous lobar cerebral hemorrhage.

OBJECTIVE: To identify determinants of early outcome in spontaneous lobar hemorrhage. MATERIALS AND METHODS: From 2500 acute stroke patients included in a prospective hospital-based stroke registry over a 12-year period, 97 cases of lobar hematoma were selected. Determinants of in-hospital mortality were studied in multiple regression models. RESULTS: Lobar hematomas accounted for 3.9% of all acute stroke patients and 35.9% of intracerebral hemorrhages. The presence of chronic obstructive pulmonary disease (COPD) was a significant predictive variable in the model based on demographic variables and vascular risk factors [odds ratio (OR): 17.18; 95% CI: 1.77-166.22] and in the model based on these variables plus clinical data (OR: 15.12; 95% CI: 1.27-179.59). Other predictive variables included altered consciousness, previous cerebral infarct and chronic liver disease. CONCLUSIONS: COPD appeared as the most important predictor of death during hospitalization after lobar cerebral hemorrhage, a finding not generally acknowledged earlier.