Gadolinium-enhanced brain lesions in multiple sclerosis relapse.

OBJECTIVE: To study the clinico-radiological paradox in multiple sclerosis (MS) relapse by analyzing the number and location of gadolinium-enhanced (Gd+) lesions on brain MRI before methylprednisolone (MP) treatment. METHODS: We analyzed brain MRI from 90 relapsed MS patients in two Phase IV multicenter double-blind randomized clinical trials that showed the noninferiority of different routes and doses of MP administration. A 1.5- or 3-T brain MRI was performed at baseline before MP treatment and within 15 days of symptom onset. The number and location of Gd+ lesions were analyzed. Associations were studied using univariate analysis. RESULTS: Sixty-two percent of patients had at least 1 Gd+ brain lesion; the median number was 1 (interquartile range 0-4), and 41% of patients had 2 or more lesions. The most frequent location of Gd+ lesions was subcortical (41.4%). Gd+ brain lesions were found in 71.4% of patients with brainstem-cerebellum symptoms, 57.1% with spinal cord symptoms and 55.5% with optic neuritis (ON). Thirty percent of patients with brain symptoms did not have Gd+ lesions, and only 43.6% of patients had symptomatic Gd+ lesions. The univariate analysis showed a negative correlation between age and the number of Gd+ lesions (p=0.002). CONCLUSION: Most patients with relapse showed several Gd+ lesions on brain MRI, even when the clinical manifestation was outside of the brain. Our findings illustrate the clinico-radiological paradox in MS relapse and support the value of brain MRI in this scenario.

Comparison of two high doses of oral methylprednisolone for multiple sclerosis relapses: a pilot, multicentre, randomized, double-blind, non-inferiority trial.

BACKGROUND AND PURPOSE: Oral or intravenous methylprednisolone (≥500 mg/day for 5 days) is recommended for multiple sclerosis (MS) relapses. Nonetheless, the optimal dose remains uncertain. We compared clinical and radiological effectiveness, safety and quality of life (QoL) of oral methylprednisolone [1250 mg/day (standard high dose)] versus 625 mg/day (lesser high dose), both for 3 days] in MS relapses. METHODS: A total of 49 patients with moderate to severe MS relapse within the previous 15 days were randomized in a pilot, double-blind, multicentre, non-inferiority trial (ClinicalTrial.gov, NCT01986998). The primary endpoint was non-inferiority of the lesser high dose by Expanded Disability Status Scale (EDSS) score improvement on day 30 (non-inferiority margin, 1 point). The secondary endpoints were EDSS score change on days 7 and 90, changes in T1 gadolinium-enhanced and new/enlarged T2 lesions on days 7 and 30, and safety and QoL results. RESULTS: The primary outcome was achieved [mean (95% confidence interval) EDSS score difference, -0.26 (-0.7 to 0.18) at 30 days (P = 0.246)]. The standard high dose yielded a superior EDSS score improvement on day 7 (P = 0.028). No differences were observed in EDSS score on day 90 (P = 0.352) or in the number of T1 gadolinium-enhanced or new/enlarged T2 lesions on day 7 (P = 0.401, 0.347) or day 30 (P = 0.349, 0.529). Safety and QoL were good at both doses. CONCLUSIONS: A lesser high-dose oral methylprednisolone regimen may not be inferior to the standard high dose in terms of clinical and radiological response.

The Mataró Stroke Registry: a 10-year registry in a community hospital.

INTRODUCTION: A prospective stroke registry leads to improved knowledge of the disease. We present data on the Mataró Hospital Registry. METHODS: In February-2002 a prospective stroke registry was initiated in our hospital. It includes sociodemographic data, previous diseases, clinical, topographic, etiological and prognostic data. We have analyzed the results of the first 10 years. RESULTS: A total of 2,165 patients have been included, 54.1% male, mean age 73 years. The most frequent vascular risk factor was hypertension (65.4%). Median NIHSS on admission: 3 (interquartile range, 1-8). Stroke subtype: 79.7% ischemic strokes, 10.9% hemorrhagic, and 9.4% TIA. Among ischemic strokes, the etiology was cardioembolic in 26.5%, large-vessel disease in 23.7%, and small-vessel in 22.9%. The most frequent topography of hemorrhages was lobar (47.4%), and 54.8% were attributed to hypertension. The median hospital stay was 8 days. At discharge, 60.7% of patients were able to return directly to their own home, and 52.7% were independent for their daily life activities. After 3 months these percentages were 76.9% and 62.9%, respectively. Hospital mortality was 6.5%, and after 3 months 10.9%. CONCLUSIONS: Our patient's profile is similar to those of other series, although the severity of strokes was slightly lower. Length of hospital stay, short-term and medium term disability, and mortality rates are good, if we compare them with other series.

Rapid assessment of transient ischaemic attack in a hospital with no on-call neurologist.

BACKGROUND: Risk of stroke soon after a transient ischaemic attack (TIA) is high. Urgent care can reduce this risk. Our aim is to describe and evaluate the efficacy of rapid assessment of TIA patients in a hospital without a neurologist available 24 hours a day. METHODS: In February 2007, we set up a protocol of rapid management of patients with symptoms consistent with acute TIA, with the aim of prioritising urgent care and reducing hospital admissions, without increasing risk of recurrences. We analyse our results since the protocol was implemented with particular focus on the analysis of delay in neurological and neurovascular assessment, percentage and reasons for hospitalisation, and stroke recurrence rates after 3 months. RESULTS: Four hundred and eleven patients were studied, with a final diagnosis of TIA in 282 (68.6%). Among other diagnoses, the most frequent were a vasovagal reaction (5.6%) and confusional syndrome (4.6%). Delay between emergency arrival and neurovascular assessment was <24h in 82% of the cases, and <48 h in 93%. After neurological evaluation, 28.7% of the patients were immediately admitted to hospital (most common causes: severe stenosis of a large artery and crescendo TIA). The incidence of ischaemic stroke in TIA patients was 3.55% after 3 months and 70% of them suffered the recurrence within the first week after the initial TIA. CONCLUSIONS: In a hospital without a neurologist available 24 hours a day, early assessment and management of TIA patients can be carried out in accordance with the guidelines, and may avoid hospitalisation in most cases without increasing recurrence rates.

[Cryptogenic infarct. A follow-up period of 1 year study]. / Infartos criptogénicos. Estudio de 1 año de seguimiento.

OBJECTIVE: To analyze the outcome of patients with a cryptogenic infarct (CI) after a follow-up period of 1 year. METHODS: From our prospective registry of stroke, during a 4-year period, we've identified 121 consecutive patients with a CI (15.1% of all infarcts). They have been followed up for 1 year and we have registered stroke recurrence, cardiovascular events and other incidences. RESULTS: Mean age 70.6 years-old, 53% male. Middle cerebral artery (MCA) was the most often involved territory (52 cases), 70% of them with cortical involvement. No patient died during admission, 95.8% received antiplatelet therapy and 4.1% oral anticoagulant. Fourteen patients were lost of follow-up. During 1-year period, atrial fibrillation (AF) was detected in 7 patients (6.54%), their mean age was 75 years-old, in 5 of them the CI was in MCA territory (4 with cortical involvement, 1 only deep infarct). Three patients (2.76%) suffered a recurrent ischemic stroke, in weeks 15, 16 and 44 after the CI. In all 3 cases the infarct was considered cryptogenic again. Two patients suffered a myocardial infarction and 4 died during follow-up period. CONCLUSION: In our series rate of stroke recurrence and cardiovascular events after a CI was low. An 11% of patients with a CI involving cortical MCA territory developed FA during the following year.

[Intracranial stenosis. Study and follow-up of 38 patients]. / Estenosis intracraneales. Estudio y seguimiento de 38 pacientes.

INTRODUCTION: To describe vascular risk factors of patients harboring intracranial arterial stenosis (IAS) as well their final outcome. METHODS: We reviewed clinical reports of all patients admitted to our Institution from April 1, 1999 to November 30, 2001 with the diagnosis of IAS. Diagnosis was made by means of magnetic resonance angiography (MRA) or four-vessels digital subtraction angiography. Thirty-eight patients harboring 56 IAS were identified. Mean follow-up was 18 months. Two control groups were selected: one was a group of 44 patients with stroke and embolic cardiopathy (EC) and the other was a group of 67 patients with stroke and extracranial stenosis without IAS. RESULTS: Mean age was 69.7 years, with male preponderance (76.3 %). Seventeen cases (44.7 %) had associated extracranial carotid stenosis greater than 50 %. Multiple IAS were found in 12 patients. Diabetes mellitus was significantly more frequent in the IAS group than in both control groups. On the other hand, cigarette smoking was more common in the IAS group with respect to the EC group. IAS was symptomatic in 25 cases, whereas in 13 patients IAS was found in the work-up for cerebral ischemia in another territory. From the group of symptomatic patients, 22 (88 %) had a Rankin scale 2 or lower on discharge and, in the long term follow-up, their incidence rate of recurrent ischemic stroke was 15 per 100 patients/year. CONCLUSIONS: Diabetes mellitus was the most specific risk factor for IAS. IAS was multiple in 32% of patients and in extracranial stenosis from moderate to severe degree was found in 44.7% of the cases. Stroke secondary to IAS caused a low dependency level at discharge. Incidence rate of recurrent ischemic stroke was 15 % patients/ year.