Analysis of stroke care resources in Spain in 2012: have we benefitted from the Spanish Health System's stroke care strategy?

INTRODUCTION: The Spanish Health System's stroke care strategy (EISNS) is a consensus statement that was drawn up by various government bodies and scientific societies with the aim of improving quality throughout the care process and ensuring equality among regions. Our objective is to analyse existing healthcare resources and establish whether they have met EISNS targets. MATERIAL AND METHODS: The survey on available resources was conducted by a committee of neurologists representing each of Spain's regions; the same committee also conducted the survey of 2008. The items included were the number of stroke units (SU), their resources (monitoring, neurologists on call 24h/7d, nurse ratio, protocols), SU bed ratio/100,000 inhabitants, diagnostic resources (cardiac and cerebral arterial ultrasound, advanced neuroimaging), performing iv thrombolysis, neurovascular interventional radiology (neuro VIR), surgery for malignant middle cerebral artery (MCA) infarctions and telemedicine availability. RESULTS: We included data from 136 hospitals and found 45 Stroke Units distributed unequally among regions. The ratio of SU beds to residents ranged from 1/74,000 to 1/1,037,000 inhabitants; only the regions of Cantabria and Navarre met the target. Neurologists performed 3,237 intravenous thrombolysis procedures in 83 hospitals; thrombolysis procedures compared to the total of ischaemic strokes yielded percentages ranging from 0.3 to 33.7%. Hospitals without SUs showed varying levels of available resources. Neuro VIR is performed in every region except La Rioja, and VIR is only available on a 24h/7 d basis in 17 cities. Surgery for malignant MCA infarction is performed in 46 hospitals, and 5 have telemedicine. CONCLUSION: Stroke care has improved in terms of numbers of participating hospitals, the increased use of intravenous thrombolysis and endovascular procedures, and surgery for malignant MCA infarction. Implementation of SUs and telemedicine remain insufficient. The availability of diagnostic resources is good in most SUs and irregular in other hospitals. Regional governments should strive to ensure better care and territorial equality, which would achieve the EISNS objectives.

Clinical and neuroradiological signs in adults with type 1 neurofibromatosis.

INTRODUCTION: Type 1 neurofibromatosis is the most common neurocutaneous syndrome. Most published case series study the paediatric population. MATERIAL AND METHODS: Cross-sectional study of cases of type 1 neurofibromatosis from neurology departments that were recorded in a database. We analysed the different clinical variables providing the diagnosis as well as demographic and neuroradiological variables. RESULTS: We found a total of 31 patients with type 1 neurofibromatosis. The mean age was 28.9 years and 58.4% were women. Subjects with unidentified bright objects (UBOs) were younger than those without them (22.45±8.22 years vs. 32.5±10.64; P=.011). In contrast, subjects with neurofibromas were older than those without them (30.56±10.68 years vs. 18.25±4.34; P=.032). No sex differences were found in the presentation of clinical or radiological variables. Seven patients (22.6%) had tumours; 3 were optic pathway gliomas (1 bilateral), 3 were plexiform neurofibromas, and 1 was a pilocytic astrocytoma in the brainstem. CONCLUSIONS: Patients with type 1 neurofibromatosis presented both peripheral neurofibromas and tumorous lesions of the central nervous system. Subjects with neurofibromas were older than those who did not present them, while subjects with UBOs were younger than those without such lesions.

[Stroke in the very old. Care in neurology units versus others general medical ward]. / Ictus en pacientes muy mayores. Análisis comparativo entre una unidad de neurología y otros servicios de medicina.

INTRODUCTION: The aim of this study is to compare the diagnosis, management, clinical course and outcome of the very major patients with acute stroke in our sanitary area. METHOD: Retrospective collection of data from a hospital-based registry, between January 2002 and March 2004, 130 stroke patients aged 84 and older admitted consecutively. We compared the patients admitted to the neurology unit (NU) to those admitted to other services (GWs). Demographic analysis, risk factors, morbidity to hospital admission (dementia, cancer, previous stroke and laboratory variables), neurological deficit measured for Canadian Neurological Scale (CNS) score, diagnostic studies, length of stay, outcomes variables (in-hospital mortality, complications developed during hospitalization and Rankin scale at hospital discharge) and need for institutionalization were analyzed. RESULTS: from a total of 130 patients, 44 (34,1 %) admitted to NU and 85 (65,9 %) to GWs. No difference was seen in demographic analysis, risk factors, morbidity to hospital admission, neurological deficit and outcomes variables. Length of stay was 8,4 days; 5,5 in the NU and 12,87 days among patients in the GWs (p=0,0001). There are significant differences in diagnostic studies in favor to NU (p < 0,05). Among the patients admitted into GWs the percentage of institutionalization to the discharge was of 28,8 % opposite to 5,6 % in the NU (p=0,006). CONCLUSIONS: There are not evidences of age discrimination for access to neurological units for demographic, risk factors, morbidity or neurological deficit. The diagnostic process is more rigorous and less costly in the NU than in the GWs.

[Herpes simplex encephalitis in Cáceres. An analysis of the last five years]. / Encefalitis herpética en Cáceres. Análisis de los últimos cinco años.

INTRODUCTION: Herpes simplex encephalitis (HSE) is a rare disease, although it is still the most common serious viral infection of the central nervous system. Little is currently known about its epidemiology and clinical features in our area. This paper presents a retrospective description of the clinical, diagnostic and progressive characteristics of patients diagnosed with HSE in Cáceres General Hospital, and confirmed by means of a polymerase chain reaction (PCR) study for the DNA of the herpes simplex virus over the last 5 years. CASE REPORTS: We found four patients who had been diagnosed with HSE in the last 5 years (3.3 cases/million inhabitants/year; CI at 95% of 2.42-4.18), two males and two females, with an age interval between 58 and 75 years. All the patients had high temperatures and three of them also presented neurological focus. A computerised axial tomography scan of the head performed on admission was interpreted as being normal in all cases, while magnetic resonance imaging of the head carried out in two patients showed lesions compatible with HSE in both cases. Electroencephalographic studies were carried out in two patients and revealed focusing in one of them and severe generalised involvement in the other. Analysis of the cerebrospinal fluid (CSF) disclosed lymphocytic meningitis in four cases, although in one of them the study was normal on admission. In two of the patients, viral meningoencephalitis was suspected from the moment the patient was admitted to hospital. For this reason, early treatment with IV acyclovir was established and the clinical progression was good in both patients, although one of them was left with mild neurological sequelae. The other two cases, who died, had a severe underlying pathology and alternative clinical diagnoses that were reasonable on admission (extensive pneumonia and delirium tremens in one of them, and hypercapnic encephalopathy with severe chronic obstructive pulmonary disease in the other), and the clinical suspicion of HSE and the establishment of treatment were late. CONCLUSIONS: The incidence of HSE in our environment is in the upper interval of that reported in the literature. PCR analysis for the herpes simplex virus in CSF seems to have replaced brain biopsy studies as the diagnostic technique. The underlying severe chronic pathology makes it more difficult to diagnose and worsens the prognosis. A multicentre epidemiological study should be conducted to confirm these findings.

[SUNCT syndrome and neoplasms in the central nervous system. A new association]. / Síndrome SUNCT y neoplasias en el sistema nervioso central. Una nueva asociación.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is a rare form of primary headache disorder, although secondary causes are well known. A growing number of cases have been described since its description in 1978 up to now. We report a new case in a 72 year old woman suffering SUNCT syndrome secondary to two ipsilateral intracranial lesions in the basal portion of the left frontal lobe of the sphenoid wing and the left pontocerebellar angle, suggestive of meningiomas. The patient was successfully treated with carbamazepine. We discuss the differential diagnosis with other very brief headaches associated with cranial autonomic features and the therapeutics possibilities. We review the secondary cases previously reported. The possible pathophysiological mechanism in this case is discussed.