[Cerebrovascular disease in a tertiary care hospital. The current situation and points to be improved]. / Patología cerebrovascular en un hospital terciario. Situación actual y puntos de mejora.

INTRODUCTION: Caring for patients suffering from a cerebrovascular diseases requires a large quantity of resources which must be optimised. The aim of this study is to analyse the management of stroke in a tertiary care hospital. PATIENTS AND METHODS: All admissions with a diagnosis of stroke were analysed retrospectively for the year 2003. Length of stay, computed tomography in the Emergency Room, origin, previous admissions during the last year, presence of vascular risk factors, stroke subtype, complications and mortality during admission and destination when discharged from hospital, were all recorded. RESULTS: 936 patients were admitted to hospital with a diagnosis of stroke. 80.22% corresponded to acute ischaemic strokes (27.14% lacunar, 18.57% transient ischaemic attacks, 10.25% cardioembolic, 15.44% aterothrombotic, 8.44% infarct of undetermined cause, 0.24% unusual aetiology) and 19.78% corresponded to haemorrhagic strokes (13.99% intraparenchymatous hemorrhage, 5.79% subarachnoid hemorrhage). Intra-hospital mortality was 5.3%. 11% suffered from complications while in hospital, and average length of stay was 10.4 days, being much longer for those patients discharged to a medium-long stay centre (17.5 days). Compared to other series, the incidence of cardioembolic and aterothrombotic subtypes of stroke is low. However, because of the inclusion of neurosurgical patients, an increase of cerebral haemorrhages is observed. CONCLUSIONS: Intra-hospital morbidity and mortality and average length of stay in our series are consistent with those from other centres of similar characteristics. A better coordination with medium-long stay centres along with the presence of neurologists on call, would certainly improve these variables.

[Problems of diagnosis and treatment in frontal epilepsies]. / Problemas diagnósticos y tratamiento de las epilepsias frontales.

OBJECTIVE: In this paper we review the anatomy, clinical features, problems of diagnosis and alternative treatment of the frontal epilepsies. DEVELOPMENT: A knowledge of the functional anatomy of the frontal lobe, the largest in the brain, is essential to understanding the varied features of the epileptic seizures arising in it. Unlike seizures arising in the temporal lobe in which the anatomicoclinical correlation is clearer since the rhinencephalum and especially the amygdala are almost always involved, in frontal seizures it is very difficult to systematize the relationship between the clinical signs and the organization of the discharge since there is wide cortico subcortical propagation, both homolateral and contralateral. There are therefore various types of frontal seizures which we define from a clinical point of view. They are the ones causing the greatest problems of differential diagnosis with epileptic pseudo seizures. A continuous video EEG recording is often necessary to differentiate them. Resonance imaging has meant a major advance in making an aetiological diagnosis of this type of seizure. It can show cortical dysplasia, heterotopia and small tumours or vascular malformations which are not visualized by other means. We give a brief description of the newly discovered genetic frontal epilepsies. Finally we review the different types of treatment indicated for them. CONCLUSIONS: Between 20% and 30% of all partial epilepsies start in the frontal lobe, and they form 30% of all surgical operations. The correct diagnosis of frontal seizures is still a challenge for the neurosurgeon. Advances in neurophysiology, neuro radiology and genetics have been, and still are, very important in better understanding of the disorder.

[Indications and results of nonpharmacological treatments of epilepsies: vagal stimulation, ketogenic diet and gamma rays]. / Indicaciones y resultados de los tratamientos no farmacológicos de las epilepsias: estimulación vagal, dieta cetógena y rayos gamma.

OBJECTIVES: In this paper we review alternative non pharmacological treatments for patients with epilepsy, both focal and generalized, which are resistant to the pharmacological treatment normally used. DEVELOPMENT: Vagal nerve stimulation (VNS) is a recently used palliative technique whose mechanism is not clearly understood. We analyze the clinical trials reported to date and the main indications and contra indications. Although the ketogenic diet (KD) has been used since the 1920s, recently there has been renewed interest in using it. Several papers have been published describing its use in children with epilepsy which was difficult to control. The complex metabolic and endocrine aspects of this type of diet make it difficult to select patients who may benefit from it. Gamma knife surgery is a new technique which has been discussed in this paper since it has been recently used in cases of refractory epilepsy, especially temporal medial epilepsy and hypothalamic hamartomas. CONCLUSIONS: VNS and KD are alternative treatments which may be used in patients whose condition cannot be satisfactorily controlled by pharmacological treatment and are not candidates for the surgery of epilepsy. Gamma knife surgery is a surgical technique which has recently been introduced for the treatment of these patients.

[Ambiguous epileptic syndrome: from the point of view of adults]. / Sindromes epilépticos ambiguos: perspectivas desde el adulto.

AIM: To review a series of neurological problems that we frequently encounter in our day-to-day clinical practice and which are difficult to diagnose correctly because of the type of presenting symptoms and clinical features they have. DEVELOPMENT: In spite of the fact that a good patient record and detailed neurological examination are still essential, use of long-term (LT) video-EEG monitoring is sometimes indispensable given the ambiguity of the clinical signs and symptoms. Selected subjects were young adult patients of both sexes who had been referred to the Epilepsy Unit at our hospital for study, due to the existence of doubts about their diagnosis. A detailed patient record was drawn up for each patient, and they were also submitted to a neurological examination and LT video-EEG monitoring, which lasted between two and six days. In some of these patients, the diagnosis was modified following their admission and important changes were introduced in their treatment. CONCLUSIONS: LT video-EEG is an important test when it comes to establishing a correct neurological diagnosis in patients with mixed or poorly defined clinical symptoms.

Indicaciones y resultados de los tratamientos no farmacológicosde las epilepsias: estimulación vagal, dieta cetógena y rayos gamma / Indications and results of non-pharmacological treatments of epilepsies: vagal stimulation, ketogenic diet and gamma rays

Objetivo. En el presente trabajo se revisan las alternativas de tratamiento, no farmacológico, en los casos de pacientes con epilepsias, tanto focales como generalizadas, que son refractarios al tratamiento farmacológico habitual. Desarrollo. La estimulación del nervio vago (VNS) es una técnica paliativa de reciente utilización, cuyo mecanismo de acción no se conoce bien. Se analizan los ensayos clínicos existentes hasta la actualidad y sus principales indicaciones y contraindicaciones. Aunque el uso de la dieta cetógena (DC) se remonta a los años 20, últimamente ha habido un resurgimiento en su utilización y se han publicado diversos trabajos realizados en niños con epilepsias de difícil control. Los complejos aspectos metabólicos y endocrinos de este tipo de dieta hacen difícil la selección de los pacientes posibles candidatos. La cirugía con gamma knife en realidad no es más que una técnica quirúrgica, que se ha revisado en este trabajo por su novedosa utilización en los casos de epilepsias refractarias, en especial epilepsias mesiales (mediales) temporales y hamartomas hipotalámicos. Conclusiones. La VNS y la DC son tratamientos alternativos para pacientes que no se controlan adecuadamente con tratamiento farmacológico y no son candidatos a cirugía de la epilepsia. La cirugía con gamma knife es una técnica quirúrgica de reciente utilización en estos pacientes. (AU)