Factors associated with in-hospital delays in treating acute stroke with intravenous thrombolysis in a tertiary centre. / Identificación de los factores que influyen en el retraso intrahospitalario del inicio de trombólisis intravenosa en el ictus agudo en un hospital terciario.

OBJECTIVE: This study aims to determine which factors are associated with delays in door-to needle (DTN) time in our hospital. This will help us design future strategies to shorten time to treatment with intravenous thrombolysis (IVT). METHODS: Retrospective analysis of a prospective cohort of patients with ischaemic stroke treated with IVT in our hospital between 2009 and 2012. We analysed the relationship between DTN time and the following variables: age, sex, personal medical history, onset-to-door time, pre-hospital stroke code activation, blood pressure and blood glucose level, National Institutes of Health Stroke Scale (NIHSS), computed tomography angiography (CTA) and/or doppler/duplex ultrasound (DUS) performed before IVT, time to hospital arrival, and day of the week and year of stroke. RESULTS: Our hospital treated 239 patients. Median time to treatment in minutes (IQR): onset-to-door, 84 (60-120); door-to-CT, 17 (13-24.75); CT-to needle, 34 (26-47); door-to-needle, 52 (43-70); onset-to-needle, 145 (120-180). Door-to-needle time was significantly shorter when code stroke was activated, at 51 vs. 72min (P=0.008), and longer when CTA was performed, at 59 vs. 48.5min (P=0.004); it was also longer with an onset-to-door time<90min, at 58 vs. 48min (P=0.003). The multivariate linear regression analysis detected 2 factors affecting DTN: code stroke activation (26.3% reduction; P<0.001) and onset-to-door time (every 30min of onset-to-door delay corresponded to a 4.7min increase in DTN time [P=0.02]). On the other hand, CTA resulted in a 13.4% increase in DTN (P=0.03). No other factors had a significant influence on door-to-needle time. CONCLUSIONS: This study enabled us to identify CTA and the «3-hour effect¼ as the 2 factors that delay IVT in our hospital. In contrast, activating code stroke clearly reduces DTN. This information will be useful in our future attempts to reduce door-to-needle times.

Spontaneous spinal epidural haematoma: a retrospective study of a series of 13 cases.

INTRODUCTION: Spontaneous spinal epidural haematoma (SSEH) has an estimated incidence of one per million inhabitants. It is classified as spontaneous when no identifiable cause can be linked to its onset. OBJECTIVE: To describe a sample of patients with SSEH and analyse variables related to its functional prognosis. PATIENTS AND METHODS: Retrospective study carried out in patients diagnosed with SSEH between 2001 and 2013 in our hospital. RESULTS: We included 13 subjects (7 men) with a mean age of 71 years. Of the total, 62% had hypertension and 54% were treated with oral anticoagulants; of the latter, 57% had an International Normalised Ratio above 3. The most frequent manifestation was spinal column pain (85%). Nearly all subjects presented an associated neurological deficit, whether sensory-motor (70%), pure motor (15%), or pure sensory (7%). Five patients underwent surgical treatment and 8 had conservative treatment. After one year, 3 of the patients treated surgically and 4 of those on conservative treatment had a score of 2 or lower on the modified Rankin Scale. Poorer prognosis was observed in patients with anticoagulant therapy, large haematomas, location in the lumbar region, and more pronounced motor disability at onset. CONCLUSIONS: Old age, hypertension, and anticoagulant therapy are the main risk factors for SSEH. The typical presentation consists of back pain with subsequent motor deficit. In patients with established motor symptoms, surgical treatment within the first 24hours seems to be the best option.

Workload of on-call emergency room neurologists in a Spanish tertiary care centre. A one-year prospective study.

INTRODUCTION: Population ageing, the rising demand for healthcare, and the establishment of acute stroke treatment programs have given rise to increases in the number and complexity of neurological emergency cases. Nevertheless, many centres in Spain still lack on-call emergency neurologists. METHODS: We conducted a retrospective study to describe the role of on-call neurologists at Hospital General Universitario Gregorio Marañón, a tertiary care centre in Madrid, Spain. Sociodemographic characteristics, most common pathologies, diagnostic tests, and destination of the patients attended were recorded daily using a computer database. Results were compared with the general care data from the emergency department. RESULTS: The team attended 3234 patients (3.48% of the emergency department total). The mean number of patients seen per day was 11.15. The most frequent pathologies were stroke (34%), epilepsy (16%) and headache (8%). The mean stay in the emergency department was 7.17 hours. Hospital admission rate was 40% (7.38% of emergency hospital admissions). The main destinations for admitted patients were the stroke unit (39.5%) and the neurology department (33%). Endovascular or thrombolytic therapies were performed on 76 occasions. Doctors attended 70% of the patients during on-call hours. CONCLUSIONS: Emergency neurological care is varied, complex, and frequently necessary. Neurological cases account for a sizeable percentage of both patient visits to the emergency room and the total number of emergency admissions. The current data confirm that on-call neurologists available on a 24-hour basis are needed in emergency departments.

[Epilepsy in cancer patients: primary prevention and the importance of high-risk patient screening]. / Epilepsia en el paciente oncológico: prevención primaria e importancia en la selección del paciente de alto riesgo.

INTRODUCTION: Epilepsy in cancer patients has a prevalence of 13%, and is especially high in patients with brain tumours, with a higher morbidity and mortality rate compared to non-tumour-related epilepsy. Its physiopathogenic mechanisms are distinct and include distortion of the cortical architecture and alteration of the glutamate-enhancing tumoural and peritumoural molecular microenvironment. Nevertheless, there is scarce and inconsistent scientific evidence on some fundamental aspects, such as primary post-operative prophylaxis, the ideal pharmacological profile or the withdrawal time of antiseizure drugs after their release. DEVELOPMENT: Characteristics such as low tumour grade, number/size of cortical lesions, location (frontal, cortical/subcortical or eloquent area), early seizures and molecular alterations, such as IDH1/2 mutation, are factors that favour the occurrence of seizures. Within the treatment, surgery will provide cytoreduction and seizure control by excision of the epileptogenic area, with 75-90% freedom from disabling seizures. Although still a controversial issue, the post-operative use of antiseizure drugs is contraindicated by the main scientific societies due to the scarce evidence and the wide spectrum of side effects. However, they are frequently used in daily clinical practice. CONCLUSIONS: All this forces us to establish a group of patients at 'high risk' of postoperative seizures, who will need to select the ideal antiseizure drug for primary prevention, with a route of administration that facilitates a rapid action effect and pharmacokinetics that prevents hepatic metabolism and CYP450 induction to achieve a lower number of interactions with chemotherapy, corticosteroids and radiotherapy. Despite this, drug resistance rates of 20-40% and relapse rates of 25-29% have been reported.

TITLE: Epilepsia en el paciente oncológico: prevención primaria e importancia en la selección del paciente de alto riesgo.Introducción. La epilepsia en el paciente oncológico presenta una prevalencia del 13%, especialmente elevada en pacientes con tumores cerebrales, así como una mayor morbimortalidad respecto de la epilepsia no tumoral. Sus mecanismos fisiopatógenos son diferenciadores, e incluyen la distorsión de la arquitectura cortical y la alteración del microambiente molecular tumoral y peritumoral favorecedor de glutamato. A pesar de ello, existe evidencia científica escasa e inconsistente acerca de aspectos fundamentales, como la profilaxis primaria postoperatoria, el perfil farmacológico idóneo o el tiempo de retirada de fármacos anticrisis tras la libertad de éstas. Desarrollo. Características como el bajo grado tumoral, el número/tamaño de las lesiones corticales, la localización (frontal, cortical/subcortical o área elocuente), las crisis tempranas y las alteraciones moleculares, como mutación IDH1/2, son factores favorecedores para la aparición de crisis. Dentro del tratamiento, la cirugía aportará citorreducción y control de crisis por escisión del área epileptógena, con libertad de crisis incapacitantes del 75-90%. Aunque sigue siendo un tema controvertido, el uso postoperatorio de fármacos anticrisis está contraindicado por las principales sociedades científicas por la escasa evidencia y el amplio espectro de efectos secundarios. Sin embargo, se emplean frecuentemente en la práctica clínica diaria. Conclusiones. Todo ello nos obliga a establecer un grupo de pacientes de 'alto riesgo' de crisis postoperatorias, que precisará seleccionar el fármaco anticrisis idóneo en prevención primaria, con una vía de administración que facilite un rápido efecto de acción y una farmacocinética que evite el metabolismo hepático y la inducción de CYP450 para conseguir un menor número de interacciones con quimioterápicos, corticoides y radioterapia. A pesar de ello, se describen tasas de farmacorresistencia del 20-40% y recidiva del 25-29%.

[Choreoathetosis after Herpes simplex encephalitis]. / Coreoatetosis tras encefalitis herpética.

After Herpes simplex encephalitis, 25% of cases may have a relapse, rarely as a choreoathetosic movement disorder. The anatomic basis for herpes simplex virus encephalitis-associated movement disorders remains poorly understood, but the hypothesis is that it may be due to a post-infectious immune-mediated process. We report an 8-month-old boy, with herpes simplex encephalitis type 1, who started with an extrapyramidal Syndrome, presenting with choreoathetosis and ballistic movements, three weeks after onset. These new symptoms were attributed to a post-infectious immune-mediated process. We treated our patient with corticosteroids at high dose and gamma-globulins, in addition to a new course of Acyclovir. Sedation was required to control the intense choreoathetosic movements. Tetrabenazine was also tried, unsuccessfully. We studied a mutation on the toll like receptors (TLR3), which has been related to susceptibility for the disease, which was negative.

[Temporal lobe epilepsy. Aetiological classification in 61 paediatric patients]. / Epilepsia del lóbulo temporal. Clasificación etiológica en 61 pacientes en edad pediátrica.

INTRODUCTION: There are very few studies on the aetiology of temporal lobe epilepsy (TLE) in childhood. The purpose of the present study is to analyse the data of 61 children diagnosed with TLE, in order to describe the aetiology of TLE in children seen in a neuropaedriatic clinic. We also discuss the currently proposed classification. PATIENTS AND METHODS: A retrospective analysis was carried out on patients diagnosed with TLE. Patients consisted of 61 children less than 15 years old. RESULTS: Patients were classified into three groups: Group 1 (symptomatic temporal lobe epilepsy) consisted of 25 patients (40.98 %) with any temporal lesion on neuroimaging (tumours, malformations or infections) or significant history; Group 2 (Mesial temporal sclerosis) consisted of 17 patients (27.86 %), a history of simple and complex febrile seizure were common in this group; and Group 3 (Cryptogenic epilepsy) consisted of 19 patients (31.15 %) with no abnormalities on neuroimaging or significant history. CONCLUSION: To our knowledge, this is the largest paediatric series of childhood new-onset TLE assessed only by MRI in the literature. We have modified the previous aetiological classification in order to make the groups more realistic.

[Doubts and confusions in the diagnosis and treatment of positional plagiocephaly. Management protocol]. / Enigmas y confusiones en el diagnóstico y tratamiento de la plagiocefalia posicional. Protocolo asistencial.

INTRODUCTION: Positional plagiocephaly is currently the most frequent cause of consultation at pediatric neurosurgical departments in Spain and other western countries. There is considerable confusion in the literature on the terminology and physiopathology of this deformity, as well as its differential diagnosis with true synostosis and treatment recommendations. OBJECTIVES: To clarify these concepts and present a protocol for the management of positional plagiocephaly, which was recently requested by the Health Administration of the Community of Madrid. PROTOCOL: The protocol aims to achieve coordination among pediatricians and neurosurgeons, as well as to provide precise information on this deformity for parents, pediatricians and neurosurgeons. MATERIAL AND METHODS: Previous consensus was reached on a series of data. Infants were classified into three categories of deformity (mild, moderate, severe) according to measurements on digital photographs. Diagnosis and treatment follows two phases: a pediatric phase (up to 5 months of age) and a neurosurgical phase (from 5 months onwards). Infants are referred to neurosurgical consultation only after being treated with postural changes and physiotherapy and only after reaching the age of 5 months. The reasons for this approach are explained in the protocol, which also defines the functions and responsibilities of each specialty. CONCLUSION: The treatment proposed in the protocol is staged, starting with postural changes and physiotherapy, followed by orthotic cranial devices and finally surgical treatment.

[Neurological impairment in children with HIV infection]. / Afectación neurológica en niños con infección VIH.

We retrospectively checked 53 paediatric patients suffering from infection with human immunodeficiency virus (HIV) registered in our Centre between the years 1987 and 1993, and evaluated the appearance of HIV encephalopathy. We noted important neurological signs in eleven patients (20.7%) ten of whom had HIV infection via vertical transmission and one as a result of contamination from haemoderivatives. In this review we give a detailed description of neurological signs, the moment of onset of these signs and their possible relationship with the state of the HIV infection. We also analyzed the resulting neuroradiological findings as well as any abnormalities in cerebrospinal fluid. Follow-up period ranged from one month to two and a half years from the moment of onset of the appearance of encephalopathy. Although most of our patients showed a clear improvement after oral or intravenous treatment with zidovudine, this improvement generally proved to be short-lived. The mortality rate in our HIV encephalopathy series was 81.8%, this figure being reached two and a half years after encephalopathy. The appearance of neurological signs in HIV patients therefore represents a very gloomy prognostic factor in the evolution of the disease.

[A robotic system for gait re-education in patients with an incomplete spinal cord injury]. / Sistema robotizado para la reeducación de la marcha en pacientes con lesión medular incompleta.

INTRODUCTION: A spinal cord injury involves the loss or alteration of motor patterns in walking, the recovery of which depends partly on the rearrangement of the preserved neural circuits. AIM. To evaluate the changes that take place in the gait of patients with incomplete spinal cord injuries who were treated with a robotic walking system in association with conventional therapy. PATIENTS AND METHODS: The study conducted was an open-label, prospective, descriptive trial with statistical inference in patients with C2-L3 spinal cord injuries that were classified as degrees C and D according to the American Spinal Injury Association (ASIA) scale. The variables that were analysed on the first and the last day of the study were: number of walkers, 10-m gait test, the Walking Index for Spinal Cord Injury scale revision, technical aids, muscle balance in the lower limbs, locomotor subscale of the measure of functional independence, modified Ashworth scale for spasticity and the visual analogue scale for pain. At the end, data were recorded from the impression of change scale. The analysis was conducted by means of Student's t, chi squared and Pearson's correlation; p < or = 0.05. RESULTS: Forty-five patients, with a mean age of 44 +/- 14.3 years, finished the study; 76% were males, injury was caused by trauma in 58% of cases, and the time of progression was 139 +/- 70 days. Statistically significant increases were observed in the number of subjects capable of walking, walking speed, less need for technical aids, strength in the lower limbs and independence in activities of daily living. CONCLUSIONS: Treatment using the robotic system in association with conventional therapy improves walking capacity in patients with incomplete spinal cord injuries.

[Intracranial venous thrombosis: reports on 11 paediatric cases]. / Trombosis venosa intracraneal:a propósito de 11 casos pediátricos.

INTRODUCTION: Intracranial venous thrombosis (IVT) is a rare condition at the paediatric age, with a wide variety of clinical features and causations. AIM: To describe the etiopathogenic factors, the presenting symptoms, diagnosis, treatment and progress of the cases of IVT diagnosed at the Hospital 12 de Octubre. PATIENTS AND METHODS: The descriptive retrospective study involved reviewing the records of patients who were admitted to hospital between 1989 and 2005, with ages ranging between 1 month and 16 years. Those who had been diagnosed as having IVT, confirmed by neuroimaging, were selected for the study. A review of their patient records was then carried out and associated etiopathogenic factors, clinical features and neuroimaging findings, treatment and progress were analysed. RESULTS: Eleven patients fulfilled clinical and radiological eligibility criteria. Most of them presented precipitating factors of an infectious origin (45%). The most frequent presenting symptoms were headache and diminished level of consciousness (45% for each case). The superior longitudinal was the most commonly affected venous sinus (72% of cases). Thrombophilic alterations were found in 27% of the patients. Magnetic resonance imaging of the brain was the most cost-effective diagnostic test. No haemorrhagic complications were recorded in patients receiving anti-clotting therapy. In most cases progress was favourable. CONCLUSIONS: Improved diagnostic methods allow IVT to be detected increasingly more often at the paediatric age. Anti-clotting therapy in the acute phase proved to be safe and effective in this series, although further studies are needed with patients at this age to confirm this finding.

[Biliary secretion. Significance of hypercholeresis from the surgical point of view]. / La secreción biliar. Significación de la hipercoleresis desde el punto de vista quirúrgico.

In patients carrying a Kehr tube choledochostomy, the surgeon may observe, but rarely, important hypercholeresis, non-bile-acid dependent, in people with severe advanced chronic hepatic diseases or persistent cholestasis. The amount of bile flowing to the outside can reach two liters and more daily. We have seen this in two patients with compensated hepatic disorders and in another suffering from light cholestasis produced by choledocholithiasis. We have also found the same in three other people with liver and the main biliary extrahepatic tract completely normal. This hypercholeresis is continuous and subject to rapid increases relative to the ingestion of food. Such increases are related to gastrointestinal hormones, specially secretin, which is produced when portions of gastric chyme enters the duodenum.

[Diencephalic syndrome: An uncommon cause of malnutrition]. / Síndrome diencefálico: una causa poco común de malnutrición.

Diencephalic syndrome (DS) is a complex of signs and symptoms related to hypothalamic dysfunction. Its main features are emaciation despite normal energy intake and an alert appearance. This syndrome has been described in association with space-occupying lesions of the hypothalamic-optic chiasm region, mainly low-grade glioma, and less often with tumors in the proximity of the IV ventricle. Two patients with DS are reported. The first patient was an 8-month old boy with classical features of DS. Extensive investigation of malabsorption revealed no abnormalities and the first neurologic sign was a rotatory nystagmus. Magnetic resonance imaging (MRI) showed evidence of a hypothalamic tumor, which was identified after surgical resection as a pilocytic astrocytoma. The second patient was an adolescent boy who presented a 20-kg weight loss over a 6-month period and psychological disturbances. Gastrointestinal disease was ruled out as a cause of malnutrition. Because of a polydipsia-polyuria syndrome, manifest while the patient was hospitalized with a suspected diagnosis of anorexia nervosa, MRI of the brain was performed. Multiple intracranial lesions were revealed, mainly in the hypothalamus, and were identified as a disseminated disgerminoma. No neurologic signs or symptoms were present. The patients died 2 years and 1 year after diagnosis, respectively. Although DS is rare, it should be considered in severe failure to thrive or emaciation despite adequate food intake and normal absorptive function of the small bowel.