Selection of patients for percutaneous closure in nonlacunar cryptogenic stroke associated with patent foramen ovale. Data from the NORDICTUS cooperative registry.

INTRODUCTION: There is an extending use of percutaneous closure of patent foramen ovale (PFO) as therapy for PFO-associated cryptogenic strokes. The aim of our study was to investigate the clinical practice of percutaneous closure of PFO and to analyse the variables for decision-making on the selection of patients for this procedure. METHOD: A prospective observational multicentric survey was conducted using all the cases of cryptogenic stroke/transient ischaemic attack associated with PFO recorded in the NORDICTUS hospital registry during the period 2018-2021. Clinical data, radiological patterns, echocardiogram data and factors related to PFO-associated stroke (thromboembolic disease and paradoxical embolism criteria) were recorded. The indication for closure was analysed according to age (≤/> 60 years) and the characteristics of the PFO. RESULTS: In the group ≤ 60 years (n = 488), 143 patients (29.3%) underwent PFO closure. The most influential variables for this therapy were detection of a high-risk PFO (OR 4.11; IC 2.6-6.5, P < .001), criteria for paradoxical embolism (OR 2.61; IC 1.28-5.28; P = .008) and previous use of antithrombotics (OR 2.67; IC 1.38-5.18; P = .009). In the > 60 years group (n = 124), 24 patients had PFO closure (19%). The variables related to this option were history of pulmonary thromboembolism, predisposition to thromboembolic disease, paradoxical embolism criteria, and high-risk PFO. CONCLUSIONS: The detection of a high-risk PFO (large shunt, shunt with associated aneurysm) is the main criterion for a percutaneous closure-based therapy. Other conditions to consider in the eligibility of patients are the history of thromboembolic disease, paradoxical embolism criteria or the previous use of antithrombotics.

[Impact of the COVID-19 pandemic on the training of Spanish neurology residents]. / Repercusión de la pandemia por COVID-19 en la formación de los residentes de neurología españoles.

Introduction: The COVID-19 pandemic has transformed medical practice and severely disrupted the training of medical residents worldwide. The Spanish Society of Neurology conducted a study to assess its impact on the training of neurology residents in Spain. Methods: We performed a descriptive, cross-sectional study through a survey distributed by e-mail to all neurology residents belonging to the Society. The survey included questions on demographic variables, care activity, and personal and educational impact of the pandemic, as well as respondents' expectations for the future of their work in the post-pandemic era. Results: Of 422 surveys sent, we received a total of 152 responses (36%); 79 respondents (52%) were women and 73 (48%) were men. By year of residency, 51 respondents (33.6%) were in the fourth year, 45 (29.6%) in the third year, 28 (18.4%) in the second year, and 28 (18.4%) in the first year. A total of 139 respondents (90.8%) reported changes in hospital activity, and 126 (82.8%) considered the situation to have had a negative impact on their training, with 99 (64.7%) having lost non-recoverable rotations. Sixty-six percent of respondents (n=101) expressed a desire to extend their residency period. Conclusions: The pandemic has had an extremely severe impact on all areas of the health system, with trainee physicians being one of the most affected groups. Among neurology residents, the crisis has caused significant shortcomings in their training and clinical activities, through the suspension of specific rotations. A high percentage of respondents wished to extend the residency period.

[Constraint-induced movement therapy in the rehabilitation of hemineglect after a stroke]. / Terapia del movimiento inducido por restricción en la rehabilitación de la heminegligencia después de un ictus.

INTRODUCTION: Hemineglect produces a lower capacity for recovery after the stroke and so far there are no rehabilitation techniques that have proven to be effective at functional level. AIMS: The main objective of this work was to assess whether the modified constraint-induced movement therapy (mCIMT)for hemineglect produces greater benefits than conventional therapy on functional hemineglect. Secondary objectives were to assess whether mCIMT produces greater benefits on upper and lower limb function as well as on the degree of autonomy and disability of patients with in relation to conventional therapy. PATIENTS AND METHODS: We have recruited 30 patients with ischemic stroke and diagnosis of hemineglect randomly assigned to mCIMT group (n = 15) or conventional therapy group (n = 15). We used the Catherine Bergego Scale (CBS) for assessment hemineglect; Fugl-Meyer tests for the motor function of lower and upper limb, and Barthel index and modified Rankin scale for the rest of objectives. RESULTS: We have found significant differences in favour of mCIMT group in the CBS after treatment and three months later once finished. We have not found differences between groups for the rest of variables. CONCLUSIONS: mCIMT could be a more effective therapy than conventional therapy to improve the symptoms of hemineglect in the acute stroke. However, it may be clinically more recommended in patients with a certain motor function after stroke.

TITLE: Terapia del movimiento inducido por restricción en la rehabilitación de la heminegligencia después de un ictus.Introducción. La heminegligencia produce una menor capacidad de recuperación después del ictus y hasta el momento no existen técnicas de rehabilitación que hayan demostrado ser funcionalmente efectivas. Objetivos. El objetivo principal de este trabajo fue valorar si la terapia de movimiento inducido por restricción modificada (TMIRm) para la heminegligencia produce mayores beneficios que la terapia convencional sobre la heminegligencia funcional. Los objetivos secundarios fueron evaluar si la TMIRm produce mayores beneficios en la función del miembro superior y del miembro inferior, así como sobre el grado de autonomía y discapacidad de los pacientes con respecto a la terapia convencional. Pacientes y métodos. Se seleccionó a 30 pacientes con ictus isquémico y diagnóstico de heminegligencia, que fueron asignados aleatoriamente al grupo de TMIRm (n = 15) o al grupo de terapia convencional (n = 15). Se empleó la Catherine Bergego Scale (CBS) para la valoración de la heminegligencia; las pruebas Fugl-Meyer para la función motora del miembro inferior y del miembro superior, y el índice de Barthel y la escala de Rankin modificada para el resto de los objetivos. Resultados. Se hallaron diferencias significativas en favor del grupo de TMIRm para la CBS en la valoración después del tratamiento y a los tres meses de finalizado. No se encontraron diferencias entre grupos para el resto de las variables. Conclusiones. La TMIRm podría ser una terapia más efectiva que la convencional para mejorar la sintomatología de la heminegligencia en la fase aguda del ictus. Sin embargo, podría ser clínicamente más recomendable en pacientes con una determinada función motora después del ictus.

[Epidemiology of the subtypes of stroke in hospitalised patients attended by neurologists: results of the EPICES registry (I)]. / Epidemiologia de los subtipos de ictus en pacientes hospitalizados atendidos por neurologos: resultados del registro EPICES (I).

INTRODUCTION: Hospital-based population studies are a good way to determinate the number and features of strokes that occur in a given society. The major stroke subtypes have different patterns of incidence and outcome, for that reason information on the natural history of stroke subtypes is essential. AIM: To determine the incidence of the stroke subtypes and the prevalence of the major risk factors in the Spanish population. PATIENTS AND METHODS: EPICES is an observational, multicenter and prospective study. Methodology includes systematic review of consecutive medical records of hospitalized stroke patients in neurological care. 6,197 patients were included during the period April 2008 and January 2009. 3,544 (57.2%) were men. Mean age was 71.4 ± 12.8 years. RESULTS: Intracerebral haemorrhage was diagnosed in 771 patients (12.4%) and ischemic stroke in 5,426 (87.6%). 1,543 (28.4%) were classified as large-artery atherosclerosis, cardioembolic 1,424 (26.2%), small-vessel occlusion 1,202 (22.5%), undetermined etiology 1,125 (20.7%). Stroke of other uncommon origin was founded in 132 (2.4%). Hypertension is the most common risk factor in both ischemic stroke (67%) and intracerebral haemorrhage (69.1%). The different types of ischemic and hemorrhagic stroke showed differences in risk factors prevalence. CONCLUSIONS: The overall distribution of stroke subtypes are not significantly different from those of most Western countries. The frequency of vascular risk factors differs between stroke subtypes. Hypertension remains the most important modifiable risk factor.

Late onset multiple sclerosis.

INTRODUCTION: Late onset multiple sclerosis (LOMS) is an unusual entity, poorly characterised and difficult to diagnose. OBJECTIVE: To study a series of patients with LOMS (presentation of the first symptom of disease after the age of 50 years). PATIENTS AND METHODS: In this retrospective study we review demographic characteristics, first onset symptom, diagnostic delay, disability at the time of diagnosis (EDSS), disease course and findings in SCF, VEP and MRI studies. RESULTS: We included 18 patients (12 F and 6M) with LOMS (4.8% of the total). The most frequent first symptoms were motors deficits (33%), multisystem deficits (33%) and cerebellum disorder (16%). Clinical course (all the cases with a minimal follow-up of 5 years after the diagnosis): primary progressive-MS (62%), secondary progressive-MS (22%), relapsing-remitting-MS (16%). The initial EDSS score was higher than 4 points in one third of patients and diagnosis delay was over 5 years in two thirds of cases. The cerebral MRI study was abnormal and compatible with MS in all patients and fulfilled the Barkhof criteria in 12 (67% of cases). Oligoclonal IgG bands were positive in the 64% of patients in the CSF study and VEP were abnormal in the 73%. The most frequent wrong diagnoses were cerebrovascular disorders and spondyloarthritic cervical myelopathy. CONCLUSIONS: LOMS course is often primary, progressive and motor and multisystem symptoms are the most frequent. The diagnosis is usually delayed and when it is made patients have a high disability score. The findings of cerebral and spinal MRI, CSF and VEP studies are of high diagnostic yield. Cerebrovascular disorders and spondyloarthritic cervical myelopathy are the most important entities in the differential diagnosis of LOMS.

Recurrent leukoencephalopathy with microhemorrhages: gradient-echo MRI study diagnostic value in CNS primary angiitis.

Diagnosis of primary angiitis of the central nervous system (PACNS) is difficult in relation to variability in its clinical manifestations and absence of specific signs in neuroimaging. A young patient presented with a recurrent encephalopathic clinical course. T2 and fluid-attenuated inversion recovery-magnetic resonance imaging (FLAIR-MRI) showed hyperintense lesions in the cerebral white matter suggesting demyelination. Those lesions decreased or even disappeared after treatment with steroids and immunoglobulins. In echo gradient MRI (T2*-MRI), there were permanent cortical-subcortical petechial hypointense lesions (microhemorrhages). Definite diagnosis was established after cerebral biopsy. Intravenous cyclophosphamide was administrated with no new relapses in more than 18 months of follow-up. In a compatible clinical course, the finding of petechial hemorrhages in T2*-WI could play an important role in early diagnosis of PACNS.

[Past hepatitis B virus infection and demyelinating multiphasic disease: casual or causal relationship?]. / Infección remota por virus de la hepatitis B y enfermedad desmielinizante multifásica: ¿casualidad o causalidad?

INTRODUCTION: The relationship between hepatitis B virus and hepatitis B vaccine with central nervous system demyelinating diseases is controversial. CASE REPORTS: We describe two male patients, who in their 70's developed recurrent pictures of acute demyelinating diseases. The first one had recurrent acute disseminated encephalomyelitis (diplopia, paraparesis and urinary retention) and the second one recurrent transverse myelitis (paraparesis and urinary retention). RESULTS: The cerebrospinal fluid test showed mononuclear pleocytosis with negative oligoclonal bands in both patients. Visual evocated potentials were normal. Magnetic resonance imaging (T2-WI and FLAIR) showed hyperintense lesions located in the brain and spinal cord in the first case and only in the spinal cord in the second. With negative antigenemia, antibodies against hepatitis B core and hepatitis B surface antigens were positive in both patients. No patient had been vaccinated for nor had suffered symptomatic hepatic disease. In the second patient, there was an almost total remission of the symptoms with periodic treatment with immunoglobulins. CONCLUSIONS: We recommend hepatitis B virus infection investigation in all patients with central nervous system demyelinating disease.

[Widespread brainstem abscess resolved with medical therapy]. / Extenso absceso de tronco resuelto con tratamiento médico.

The brainstem is an uncommon site of a brain abscess. Such lesions, which were invariably fatal, changed with the arrival of computed tomography and magnetic resonance imaging (MRI). These not only helped in the diagnosis but also in treatment management. A 51-year old patient was diagnosed of widespread pontomesencephalic abscess. He was admitted with a clinical picture of dizziness, headache and involvement of multiple cranial nerves with near complete ophthalmoplegia and cerebellar syndrome in the side of the lesion and contralateral hemiplegia. Microbiologic investigations were negative and the medical management decided was broad spectrum antibiotic and periodic MRI controls. The length of the lesion decreased (from 4 cm in diameter to 0.5 cm) with progressive improvement of the neurological deficits. Treatment of large brainstem abscesses includes primary antibiotic therapy combined with stereotaxic drainage, but in individual cases empirical medical therapy can be effective. Sequential MRI examinations are very important for monitoring treatment efficacy.

[Brachial plexitis and myelitis and herpes-zoster lumbar plexus disorder in patient treated with infliximab]. / Plexitis lumbar por herpes zoster, mielitis y plexitis braquial en paciente tratada con infliximab.

Infliximab, a chimeric monoclonal antibody, is a TNF-a inhibitor approved for use in refractory rheumatoid arthritis and Crohn s disease. We present the case of a patient affected by severe rheumatoid arthritis who was successfully treated with infliximab. She suffered diverse neurological complications: brachial plexitis, asymptomatic thoracic myelitis with extensive lesions in MRI study, and herpes zoster lumbar plexitis. We review the neurological adverse effects of infliximab (aseptic meningitis, opportunistic germs infections, disseminated herpes zoster) and focus in their potential adverse effect to induce central and peripheral nervous system demyelination.

[Headache and fainting as initial symptoms of syringomyelia associated to Arnold-Chiari and facial angiomatous nevus]. / Cefalea y síncope como manifestaciones iniciales de siringomielia asociada a Arnold-Chiari y nevo angiomatoso facial.

INTRODUCTION: Syringomyelia and Arnold-Chiari malformation are two dysraphism that often appear together. Clinical manifestations are diverse although some patients remain asymptomatic for years. Syncope, supposedly due to a dysfunction of medulla baroceptors and spinal cord intermediolateral horn, is uncommon, particularly as the initial symptom. CASE REPORT: 34 year old woman, with a facial angiomatous nevus, presented with two episodes of headache followed by syncope; neurological examination was apparently normal. MRI showed mild supratentorial hydrocephalus, Arnold-Chiari malformation and cervical syringomyelia, with no vascular anomalies. CONCLUSION: This case, which shares some features with Sturge-Weber syndrome and PHACE syndrome, enhances the importance of the search for anomalies in patients with paroxistical symptoms and cutaneous lesions.

[Rapidly progressing dementia as the presenting symptom of Waldenstrom's macroglobulinemia: findings from magnetic resonance imaging of the brain in Bing Neel syndrome]. / Demencia rapidamente progresiva como presentacion de macroglobulinemia de Waldenstrom: hallazgos de la resonancia magnetica cerebral en el sindrome de Bing Neel.

CASE REPORT: A 68 year old male with no relevant clinical history was admitted to hospital because of symptoms of cognitive impairment (attentional deficit, short term memory disorders and behavioural disorders), accompanied by apraxia of gait and rectal and urinary incontinence. Results of a general clinical exploration were normal. In the MRI study of the brain numerous areas of hypersignal were observed in different arterial territories, which stood out in the T2, FLAIR and, above all, in diffusion weighted sequences. Analytical studies showed hypergammaglobulinemia with monoclonal IgM k and a bone marrow biopsy revealed infiltration by plasmatic cells. Bing Neel syndrome was diagnosed. CONCLUSIONS: We underline this exceptional form of presentation of Waldenstrom's macroglobulinemia and highlight the findings of diffusion weighted MRI, which suggested multiple infarcts for which a neoplastic vascular obstruction mechanism similar to that involved in malignant angioendotheliomatosis is posited.