Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment.

OBJECTIVE: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

[The one and a half vertical syndrome as the only evidence of bilateral thalamo-subthalamic infarction]. / Síndrome del uno y medio vertical como única manifestación de un infarto talamosubtalámico bilateral.

INTRODUCTION: The one and a half vertical syndrome consists of paralysis of upward vertical conjugated gaze and monocular paralysis of downward gaze or vice-versa. It occurs as a consequence of a mesencephalodiencephalic lesion, either unilaterally or bilaterally, due to effects on structures such as the interstitial nucleus of Cajal, posterior commissure and rostral interstitial nucleus of the medial longitudinal bundle. The arterial supply of the structures involved in the supranuclear control of vertical gaze depends on the paramedian thalamic arteries (or posterior thalamo-subthalamic arteries) and the paramedian peduncular arteries. CLINICAL CASE: We present the case of a 58 year old woman with non-insulin dependent diabetes mellitus who presented with sudden onset of diplopia of vertical gaze. On examination there was paralysis of superior vertical conjugated gaze and monocular paralysis of ocular infraversion (one and a half syndrome) with no other pathological findings. Cerebral angioresonance and Doppler studies of the territory supplied by the posterior cerebral artery were normal. CONCLUSIONS: Both unilateral and bilateral mesencephalodiencephalic infarcts usually present clinically as disorders of consciousness and of conduct (the almost universal form of presentation), involvement of the pyramidal tract, the third cranial nerves and a supranuclear disorder of vertical gaze. The unusual feature of the case we present is a bilateral thalamo-subthalamic infarct which presented solely as a one and a half vertical syndrome with no clinically apparent effect on anatomically adjacent structures. We have not found any similar cases in the literature.

[Paramedian thalamo-mesencephalic infarct con triphasic waves]. / Infarto talamomesencefálico paramediano con ondas trifásicas.

Triphasic waves are usually associated with metabolic encephalopathies but have been reported in patients with other etiologies. The pathophysiology of this EEG pattern remains poorly understood, although they have been attributed to lesion in the connections between the thalamus and cortex. We report a case of top-of-the-basilar artery occlusion with selective paramedian thalamic-mesencephalic infarct in which triphasic waves were evident on the EEG during clinical hypersomnia. To our knowledge this is the first reported case of triphasic waves with selective paramedian thalamomesencephalic infarct. We conclude that triphasic waves are a nonspecific manifestation of diencephalic dysfunction, probably of the paramedian thalamomesencephalic reticular system.