Contraindications to intravenous thrombolysis in prehospital triage of thrombectomy candidates.

BACKGROUND AND PURPOSE: The existence of contraindications to intravenous thrombolysis (IVT) is considered a criterion for direct transfer of patients with suspected acute stroke to thrombectomy-capable centers in the prehospital setting. Our aim was to assess the utility of this criterion in a setting where routing protocols are defined by the Madrid - Direct Referral to Endovascular Center (M-DIRECT) prehospital scale. METHODS: This was a post hoc analysis of the M-DIRECT study. Reported contraindications to IVT were retrospectively collected from emergency medical services reports and categorized into late window, anticoagulant treatment and other contraindications. Final diagnosis and treatment rates were compared between patients with and without reported IVT contraindications and according to anticoagulant treatment or late window categories. RESULTS: The M-DIRECT study included 541 patients. Reported IVT contraindications were present in 227 (42.0%) patients. Regarding final diagnosis no significant differences were found between patients with or without reported IVT contraindications: ischaemic stroke (any) 65.6% vs. 62.1%, ischaemic stroke with large vessel occlusion (LVO) 32.2% vs. 28.3%, hemorrhagic stroke 15.4% vs. 15.6%, stroke mimic 18.9% vs. 22.3% respectively. Amongst patients with LVO, endovascular thrombectomy (EVT) was performed less often in the presence of IVT contraindications (56.2% vs. 74.2%). M-DIRECT-positive patients had higher rates of LVO and EVT compared with M-DIRECT-negative patients independent of reported IVT contraindications. CONCLUSIONS: Reported IVT contraindications alone do not increase EVT likelihood and should not be considered to determine routing in urban stroke networks.

The Direct Referral to Endovascular Center criteria: a proposal for pre-hospital evaluation of acute stroke in the Madrid Stroke Network.

BACKGROUND AND PURPOSE: For patients with acute ischaemic stroke due to large-vessel occlusion, it has recently been shown that mechanical thrombectomy (MT) with stent retrievers is better than medical treatment alone. However, few hospitals can provide MT 24 h/day 365 days/year, and it remains unclear whether selected patients with acute stroke should be directly transferred to the nearest MT-providing hospital to prevent treatment delays. Clinical scales such as Rapid Arterial Occlusion Evaluation (RACE) have been developed to predict large-vessel occlusion at a pre-hospital level, but their predictive value for MT is low. We propose new criteria to identify patients eligible for MT, with higher accuracy. METHODS: The Direct Referral to Endovascular Center criteria were defined based on a retrospective cohort of 317 patients admitted to a stroke center. The association of age, sex, RACE scale score and blood pressure with the likelihood of receiving MT were analyzed. Cut-off points with the highest association were thereafter evaluated in a prospective cohort of 153 patients from nine stroke units comprising the Madrid Stroke Network. RESULTS: Patients with a RACE scale score ≥ 5, systolic blood pressure <190 mmHg and age <81 years showed a significantly higher probability of undergoing MT (odds ratio, 33.38; 95% confidence interval, 12-92.9). This outcome was confirmed in the prospective cohort, with 68% sensitivity, 84% specificity, 42% positive and 94% negative predictive values for MT, ruling out 83% of hemorrhagic strokes. CONCLUSIONS: The Direct Referral to Endovascular Center criteria could be useful for identifying patients suitable for MT.

[Endovascular treatment in acute ischaemic stroke. A stroke care plan for the region of Madrid]. / Tratamiento endovascular en el ictus isquémico agudo. Plan de Atención al Ictus en la Comunidad de Madrid.

INTRODUCTION: Endovascular therapies (intra-arterial thrombolysis and mechanical thrombectomy) after acute ischaemic stroke are being implemented in the clinical setting even as they are still being researched. Since we lack sufficient data to establish accurate evidence-based recommendations for use of these treatments, we must develop clinical protocols based on current knowledge and carefully monitor all procedures. DEVELOPMENT: After review of the literature and holding work sessions to reach a consensus among experts, we developed a clinical protocol including indications and contraindications for endovascular therapies use in acute ischaemic stroke. The protocol includes methodology recommendations for diagnosing and selecting patients, performing revascularisation procedures, and for subsequent patient management. Its objective is to increase the likelihood of efficacy and treatment benefit and minimise risk of complications and ineffective recanalisation. Based on an analysis of healthcare needs and available resources, a cooperative inter-hospital care system has been developed. This helps to ensure availability of endovascular therapies to all patients, a fast response time, and a good cost-to-efficacy ratio. It includes also a prospective register which serves to monitor procedures in order to identify any opportunities for improvement. CONCLUSIONS: Implementation of endovascular techniques for treating acute ischaemic stroke requires the elaboration of evidence-based clinical protocols and the establishment of appropriate cooperative healthcare networks guaranteeing both the availability and the quality of these actions. Such procedures must be monitored in order to improve methodology.

[Cardioembolic stroke: epidemiology]. / Ictus cardioembólico: epidemiología.

Approximately one in four ischemic strokes is of cardioembolic origin. Non-valvular atrial fibrillation accounts for 50% of these cases, followed by myocardial infarction, intraventricular thrombus, valvular heart disease and a miscellany of causes. The incidence of embolic heart disease in the population could be about 30 cases per 100,000 inhabitants per year, and its prevalence between 5 and 10 cases per 1,000 persons aged 65 years or older. Hospital mortality is high, and 5-year survival is only one out of every five patients. The recurrence rate of this type of stroke is about 12% at 3 months, higher than that of non-cardioembolic stroke. The severity of cardioembolic strokes and the resulting disability are greater than with non-cardioembolic stroke. Age, a history of stroke or transient ischemic attack, hypertension, diabetes and heart failure play a role in stroke with atrial fibrillation as additional risk factors for future embolisms. Stroke rates can reach over 20% per year and therefore the prevention and treatment of these events are of paramount importance.

Consistency of clinical diagnosis of dementia in NEDICES: A population-based longitudinal study in Spain.

BACKGROUND: Few longitudinal studies have verified the clinical diagnosis of dementia based on clinical examinations. We evaluated the consistency of the clinical diagnosis of dementia over a period of 3 years of follow-up in a population-based, cohort study of older people in central Spain. METHODS: Individuals (N = 5278) were evaluated at baseline (1994-1995) and at follow-up (1997-1998). The evaluation included a screening questionnaire for dementia and a neurological assessment. RESULTS: Dementia screening consisted of a 37-item version of the Mini-Mental State Examination (MMSE) and the Pfeffer Functional Activities Questionnaire (FAQ). Study neurologists investigated those participants who screened positively (N = 713) as well as 843 who had screened negatively to test the sensitivity of the screening instruments or because they had a positive screening for other chronic neurological diseases. We detected 295 patients among those who screened positive and 13 among those who screened negatively. Three years follow-up evaluation demonstrated 14 diagnostic errors at baseline (4.5%) leading to a final number of 306 patients with dementia. The corrected prevalence of dementia was 5.8% (95% confidence interval [CI] 5.2-6.5). CONCLUSIONS: The diagnosis of dementia was highly accurate in this population-based, Spanish cohort study, and our prevalence figures agree with other European surveys. Given the high cost and difficulties of population rescreening and its relatively low yield, we conclude that a single 2-phase investigation (screening followed by clinical examination) provides accurate information for most population-based prevalence studies of dementia.

Prevalence of stroke and transient ischemic attack in three elderly populations of central Spain.

OBJECTIVE: Our aim was to assess prevalence rates of cerebrovascular disease (CVD; stroke and transient ischemic attacks) according to age and gender in three populations in central Spain using data from the Neurological Disorders in Central Spain (NEDICES) study, a population-based survey of elderly participants. METHODS: Individuals from one suburban municipality of Greater Madrid (Las Margaritas neighborhood, Getafe), one urban district of Madrid (Lista) and one rural site (Arévalo county, Avila) were evaluated at baseline (n = 5,278). The evaluation included a screening questionnaire and a neurological assessment when possible. We used point prevalence with a reference date of May 1, 1994. RESULTS: Of the 5,278 subjects, there were 186 prevalent stroke cases and 71 cases of transient ischemic attacks. Prevalence rates, adjusted to the standard European populations, were 4.9% for CVD (95% confidence interval [CI] = 4.3-5.4), 3.4% for stroke (95% CI = 2.9-3.9) and 1.3% for transient ischemic attacks (95% CI = 1.0-1.6) in the total population. Age-specific prevalence rates of CVD, stroke and transient ischemic attacks increased exponentially with advancing age. The prevalence rates of CVD, stroke and transient ischemic attacks were higher for men than for women. Prevalence figures were higher in the suburban area of Margaritas compared to the rural region. CONCLUSIONS: In this study, the prevalence of stroke and transient ischemic attacks were higher in men and in urban areas. Central Spain would be a medium stroke prevalence zone.

Epidemiología del ictus cardioembólico y su asociación con la penetración de los ACOD en España: primer estudio poblacional 2005-2018 / Epidemiology of atrial fibrillation-related ischemic stroke and its association with DOAC uptake in Spain: first national population-based study 2005 to 2018

Introducción y objetivos: La prevalencia y la incidencia de la fibrilación auricular (FA), un importante factor de riesgo de ictus cardioembólico, han aumentado sustancialmente en los últimos años. Sin embargo, varios estudios europeos han observado una disminución en la tasa de ictus cardioembólico asociada con un aumento de la penetración de los anticoagulantes orales de acción directa (ACOD). Este estudio ecológico evalúa la asociación entre la penetración de los ACOD y la tasa de incidencia de ictus cardioembólicos en España. Métodos: Los datos se obtuvieron del Registro de Actividad Sanitaria Especializada del Ministerio de Sanidad de España (RAE-CMBD). Los ictus cardioembólicos se identificaron mediante códigos ICD. Las tasas de incidencia se estandarizaron por edad y se ajustaron a la población estándar europea de 2013. Se utilizaron modelos de regresión de Poisson para estimar la asociación entre la penetración de los ACOD y la tasa de ictus cardioembólico en pacientes de 65 o más años. Resultados: La tasa de incidencia ajustada (TI) del ictus cardioembólico aumentó desde 2005 (2,20/100.000 personas/año) hasta 2012 (2,67). A partir de 2012, tras la introducción de los ACOD para la prevención del ictus cardioembólico en España, la TI se ha mantenido constante o ha disminuido ligeramente (en 2018, 2,66). Los resultados del modelo de regresión de Poisson indican que la penetración de los ACOD tiene una influencia estadísticamente significativa en la tasa de ictus cardioembólicos de los mayores de 65 años (RDI=0,995; IC95%, 0,995-0,996). Conclusiones: Los resultados de este estudio muestran una asociación entre la penetración de los ACOD y una menor incidencia de ictus cardioembólicos. A pesar de que esta asociación no implica causalidad, indica que una mayor penetración de los ACOD podría llevar a un mayor beneficio clínico para los pacientes con FA en España (AU)

Introduction and objectives: The incidence and prevalence of atrial fibrillation (AF), a major risk factor for stroke, has increased substantially in the past few years. However, several studies have reported a decline in AF-related stroke rates associated with higher uptake of direct oral anticoagulants (DOACs). This ecological study evaluated the association between DOAC uptake in Spain and the incidence rate (IR) of AF-related ischemic stroke. Methods: Data were obtained from the Registry of Activity of Specialized Healthcare of the Spanish Ministry of Health (RAE-MDS). AF-related ischemic strokes were identified using International Classification of Diseases codes. IR were age-standardized and adjusted to the 2013 European standard population. Poisson regression models were used to identify the association between DOAC uptake and AF-related ischemic stroke in patients aged ≥ 65 years. Results: Before the use of DOACs, the adjusted IR of AF-related ischemic stroke increased steadily from 2005 (IR=2.20 per 100 000 person/y) to 2012 (IR=2.67). Upon DOAC uptake in Spain from 2012 onwards for AF-related ischemic stroke prevention, the IR remained constant or decreased slightly (IR in 2018=2.66). Poisson regression showed that DOAC uptake was a significant predictor for the rate of AF-related ischemic stroke in patients older than 65 years (IRR=0.995; 95%CI, 0.995-0.996). Conclusions: This study shows an association between DOAC use and a reduced incidence of AF-related ischemic stroke. While this association is based on aggregate data and cannot demonstrate causality, these findings suggest that higher DOAC uptake could improve health outcomes in AF patients in Spain (AU)

[An analysis of complaints received in a Neurology Service]. / Análisis de reclamaciones en un servicio de neurología.

AIMS: To determine the number of complaints received by the Neurology Service in one year, to carry out a qualitative analysis, and to examine how they are dealt with in order to provide patients with a solution. MATERIALS AND METHODS: The work involved a retrospective study of the complaints from patients in the Neurology Service throughout the year 2004, using the information provided by the Patient Advice and Liaison Service. The following quality indicators were used to evaluate how these claims were managed: the percentage of complaints that were attended in less than 30 days after being received and the percentage of complaints that were resolved. RESULTS: Throughout the period under study a total of 183 complaints were received: 1/478 hospital admissions (0.21%), 71/43,841 medical visits (0.16%), 110/5,522 neurophysiological studies (2%) and 3 due to other reasons. It was found that 90.2% of all complaints had to do with waiting lists, 3.3% were related to dealings with staff and the rest were due to other causes. 86.3% of the complaints were resolved, 10.2% were dismissed and the others were passed on or shelved. 77.5% of the claims were attended within 30 days (quality parameter), the mean delay being 21.3 days (standard deviation: 11.3). CONCLUSIONS: Our rate of complaints is low, although improvements must be introduced both quantitatively and in their management. Practically no data has been published to date concerning these aspects of clinical management in neurology services.

[Parkinsonism and Camptocormia with focal spinal myopathy: case report and responsiveness to treatment]. / Parkinsonismo y camptocormia con miopatia focal espinal: descripcion de un caso y respuesta al tratamiento.

INTRODUCTION: Camptocormia is characterised by extreme flexion of the thoracolumbar spine. It suffered an increase during walking and it is relieved in supine position. Camptocormia has been described in psychogenic disorders, but in other diseases, including Parkinson's disease as well. It has been recently described several cases with focal spinal myopathy, and we present a patient with this clinical association. CASE REPORT: This 82-year-old man had a 6-year history of parkinsonian symptoms, mostly of rigid-akinetic type. He was in stage 4 on Hoehn & Yahr scale, and he had reached 62 points on Unified Parkinson Disease Rating Scale. Over the past 6-8 months, he developed progressive forward flexion of the trunk with clinical features of camptocormia. He suffered flogotic symptoms and signs on her lower back, and there were no dystonic posture or clinical features. Lumbar computerised tomography showed fat replacement of the paravertebral L3 muscles. A surgical paravertebral muscle examination and biopsy were performed, showing diffuse fat replacement and only a marginal myopathic focus. It was made several therapeutic approaches, with levodopa dose increase, reduction, fractioning, and addition of dopa-agonists. All of these strategies failed. It was determined to try a steroid course, but there were no improvement, so physiotherapy and rehabilitation measures did. He finally was confined to wheelchair. CONCLUSIONS: Physiopathologic and therapeutic aspects of camptocormia in Parkinson's disease are unclear. Their relationship could be casual or causal. Patients with clear inflammatory myopathy could benefit from steroid therapy, but patients with end-stage myopathy probably do not so.

[Vertigo as an atypical symptom of intraspinal cord tumor]. / Vértigo como síntoma atípico de un tumor intramedular.

Vertigo is an unpleasant sensation of movement of the subject or of his surroundings. There are many causes of vertigo. Traditionally these are divided into 'central' and 'peripheral'. It is unusual to find it as a symptom of myelopathy. We describe the case of a 67 year-old woman with no significant previous clinical history who complained of the sudden onset of vertigo a few hours previously, which worsened on turning her neck towards the left. On examination, the vertigo recurred on turning her neck to the left after a latent period of a few seconds together with the appearance of ipsilateral conjugated nystagmus, which gradually disappeared. On neurological examination, there was amyotrophy of both arms with weakness, considerably reduced reflexes, except for clonus of the left wrist. There was slight paraparesia with bilateral cutaneoplantar flexion and a level of sensitivity at C2-C3. The sensitivity disorder was more marked in the arms with a bilateral distribution approximately at C5-C7 affecting predominantly thermoanalgesia. Cervical MRI showed a mass consistent with ependymoma. This was removed surgically 2 weeks after admission. The findings of the intraoperative biopsy confirmed the radiological diagnosis. The vertigo improved one week after admission, although the patient died of pneumonia one month after operation. Despite the vertigo was an atypical symptom, it was the clue that led to the diagnosis. Hypotheses about the cause of vertigo are discussed.

[Brachial presentation of spinal pseudochoreoathetosis. The result of proprioceptive information being processed in parallel]. / Seudocoreoatetosis espinal de presentación braquial. Resultado del procesamiento paralelo de la información propioceptiva.

INTRODUCTION: The term pseudochoreoathetosis is used to refer to the choreoathetoid movements that are produced by alterations in the proprioceptive sensitivity due to damage it has suffered at some point along its course. Proprioceptive sensitivity is considered to go up as far as the cortex along the posterior cords of the spinal cord, which means that if they are injured in the cervical region there should be a sensory deficit in both the upper (UL) and lower limbs (LL). CASE REPORTS: We describe five cases of transverse myelitis with localised cervical injury that selectively and mainly affected the posterior cords of the spinal cord. In the five patients there was selective involvement of the proprioceptive sensitivity in the UL respecting the LL and pseudochoreoathetoid movements of the limb that has been deafferented for proprioceptive sensitivity. The dissociation between the UL and the LL occurs because the spinocerebellar and spinocervical tracts take the proprioceptive information from the LL in parallel to the posterior cords, which receive the proprioceptive sensitivity from the UL. CONCLUSIONS: At present, the most widely accepted physiopathological mechanism explaining pseudochoreoathetosis consists in a failure in the integration of the sensory-motor afferences in the striatum, which causes faulty sensory-motor integration at this level and gives rise to pseudochoreoathetosis.

[HTLV-I myelopathy: presentation of a new case]. / Mielopatía por HTLV-I: presentación de un nuevo caso.

INTRODUCTION: HTLV-I is a human retrovirus which has been implicated in the genesis of tropical spastic paraparesis (HTLV-I-associated myelopathy). So far five cases of this illness have been detected in Spain, five of them in immigrants. We present a new case in Spain, with a characteristic chronic clinical picture. CASE REPORT: A 36-year-old black woman native of Ecuatorial Guinea, developed along 10 years a progressive paraparesis of asymmetric onset with important back pain, that arrives to paraplegic spastic phase at the present time. She presents distal amyotrophies, ulcers of decubitus and loss of control of sphincters, with normal mental status. Laboratory tests: blood, biochemistry and microbiologic studies: normal, or negative. She presented positive Western Blot serology for HTLV-I, confirmed by means of PCR technique. Cranial MRI: small and hyperintense subcortical lesions on T2 weighted images; spinal MRI: local atrophy at high thoracic level. A lumbar puncture was performed, with no cells, and with presence of oligoclonal bands, and a high IgG index. Urodynamic study: neurogenic spastic bladder. EMG: mild axonal polyneuropathy with prevalence in legs. CONCLUSIONS: In the differential diagnosis of progressive paraperesis, and mainly with epidemic antecedents, it is necessary to include a determination of HTLV-I between the diagnostic tests.

[MELAS syndrome masquerading as herpes encephalitis: genetic diagnosis]. / Síndrome MELAS que asemeja una encefalitis por virus herpes: diagnóstico genético.

INTRODUCTION: MELAS syndrome (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke like episodes) is a mitochondrial disease related to the mitochondrial DNA mutation. The tRNALeu(UUR) mutation at the base pair 3234 is associated to 80% of cases of MELAS syndrome. The onset with the stroke like episodes is often before the age 40. Herpes simplex encephalitis (HSE) presents as acute episodes of focal neurologic deficit that are often related to the temporal lobe. Occasionally MELAS syndrome and HSE may have a similar clinical presentation. CLINICAL CASE: A 33-year-old woman presented with seizures and a right parietotemporal syndrome of acute onset. The differential diagnosis between HSE and MELAS syndrome was established. MELAS syndrome was suspected based on her phenotype. The diagnosis of MELAS syndrome was confirmed by the presence of the mitochondrial tRNALeu(UUR) mutation at the base pair 3243. CONCLUSION: The clinical presentation of the MELAS syndrome may mimic that of the HSE, and antiviral treatment should be given until the diagnosis of MELAS syndrome is definitive. The study of the mitochondrial DNA helps diagnosing in a non invasive way many patients with MELAS syndrome.

[Gradenigo syndrome as the form of presentation of nasopharyngeal carcinoma]. / Síndrome de Gradenigo como forma de presentación de carcinoma nasofaríngeo.

INTRODUCTION: Nasopharyngeal carcinoma is a condition which usually has an insidious onset and non-specific features in the initial stages, so it is difficult to make an early diagnosis. The most usual presenting features are otological (serous otitis media) and involvement of adjacent cranial nerves. We report a case of Gradeningo's syndrome due to the tumour spreading towards the base of the skull. We review the literature on the aetiology of this syndrome. CLINICAL CASE: A 53 year old patient required neurological assessment for a clinical condition which was compatible with Gradenigo's syndrome that involved both right V and VI cranial nerves. This study permitted diagnosis of a nasopharyngeal carcinoma which had been undetected because of its non-specific features, until this complication occurred. Otorhinolaryngological assessment proved the presence of a neoplasm in the cavum. Biopsy of the lesion showed it to be a well-differentiated squamous cell carcinoma. Cranial magnetic resonance imaging showed extension of the tumour to the base of the skull, adjacent to the right sinus cavernosus. The cerebrospinal fluid was normal. Treatment by radiotherapy was indicated. CONCLUSIONS: Diagnosis of nasopharyngeal carcinoma requires a high index of suspicion in view of its initial, sparse, non-specific symptoms. Although ideally the disease should be detected in its early stages, we believe that it is useful to recommend that in cases of Gradenigo's syndrome a full systematic otorhinolaryngological exploration be made so as to effectively rule out this disorder.

[The clinico-microbiological diagnosis of encephalitis due to herpes zoster in an elderly patient: apropos a case]. / Diagnóstico clínico-microbiológico de la encefalitis por herpes zoster en el anciano: a propósito de un caso.

Varicella-zoster infection consists of well-recognized cutaneous manifestations. However, in several cases it is complicated with central nervous system disorders. We present a 79-year-old diabetic woman with zoster ophthalmicus, who developed an acute confusional syndrome. EEG, cranial computed tomographic, biochemical and haematologic and liquoral studies were performed. An increased in the CSF-IgG index was founded, and it was related with Varicella-Zoster Herpes antibodies. She was treated with intravenous acyclovir, and her encephalopathy was resolved.

[Rhabdomyolysis and lumbosacral plexopathy in intravenous drug addict: report of a case]. / Rabdomiolisis y plexopatía lumbosacra en paciente adicto a drogas por vía parenteral: a propósito de un caso.

There are several neuromuscular complications in the intravenous heroin addict (IHA). Someone may be due to direct toxic effect of the substance, but other ones may be associated to abuser's typical diseases (i.e. HIV infection). We present a 27 year-old IHA patient, HIV positive, that develop acute rhabdomyolisis with severe neuromuscular involvement, and consistent clinical and electrodiagnostic features of lumbosacral plexus neuropathy, forteen hours after an heroin inyection. Thirty months later, the patient is severely disabled, but her initial painfull and paretic picture have improved. The association of rhabdomyolisis-lumbosacral plexopathy (RLPS) is ocasionally reported. It has been proposed that RLSP is etiologically related to mecanic, toxic and immunologic factors.

Reflexiones sobre el tratamiento endovascular en el ictus isquémico agudo. Plan de atención al ictus en la Comunidad de Madrid / Reflections on endovascular treatment for ischaemic stroke. A stroke care plan for the Region of Madrid

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