Stroke mimics treated with thrombolysis: further evidence on safety and distinctive clinical features.

BACKGROUND: Patients who present with symptoms mimicking ischaemic stroke (IS), but have a different diagnosis, are known as stroke mimics (SM). The necessity for rapid administration of intravenous thrombolysis in patients with acute IS may lead to treatment of patients with conditions mimicking stroke. A variable proportion of patients with SM (1.4-14%) are currently treated with intravenous tissue plasminogen activator therapy (IV-tPA). The outcome of these patients is generally favourable and complications are rather infrequent. We aimed to determine the frequency, clinical features and prognosis of SM patients treated with IV-tPA in an experienced stroke centre. METHODS: A prospective registry was assembled with patients treated with IV-tPA at our stroke unit from January 2004 to December 2011. We recorded age, gender, baseline National Institutes of Health Stroke Scale (NIHSS) score, treatment delay, vascular risk factors, clinical syndrome and aetiology. We retrospectively analysed the clinical characteristics of SM, safety (symptomatic intracranial haemorrhage and mortality) and outcome measures (modified Rankin Scale at 3 months, mRS) and compared them with IS patients. RESULTS: 621 patients were treated with IV-tPA during the study period, 606 (97.5%) were IS and 15 (2.4%) were SM. The aetiology of SM was somatoform disorders (5), headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) syndrome (3), herpetic encephalitis (2), glial tumours (2), and migraine with aura, focal seizure and cortical vein thrombosis in single cases. SM were younger (72 ± 14 vs. 53.7 ± 16 years, p < 0.05), had a lower baseline deficit [NIHSS 13 (9-18) vs. 8 (5-10), p < 0.05], fewer vascular risk factors, and left hemisphere symptoms were predominant (80 vs. 52.4%, p < 0.05). Global aphasia without hemiparesis (GAWH) was the presenting symptom in 8 (54%) SM and 44 (7%) IS (p < 0.05). Multimodal computed tomography was performed in 3 SM patients and showed perfusion deficits in 2 of them. No intracranial haemorrhage or disability (functional outcome at 3 months, mRS >2) was recorded in any SM patient. CONCLUSIONS: The use of intravenous thrombolysis appears to be safe in our SM patients, and prognosis is universally favourable. Somatoform disorder and HaNDL syndrome were prominent causes, and GAWH the most common presentation. The safety of thrombolysis in SM suggests that delaying or withholding treatment may be inappropriate: the benefit of thrombolysis in case of IS may outweigh the risks of treating an SM. Further studies may assess the future role of multimodal computed tomography in the differential diagnosis between IS and SM.

[Perioperative management of Parkinson's disease]. / Manejo perioperatorio de la enfermedad de Parkinson.

One of the particular characteristics of Parkinson's disease (PD) is the wide clinical variation as regards the treatment that can be found in the same patient. This occurs with specific treatment for PD, as well as with other drug groups that can make motor function worse. For this reason, the perioperative management of PD requires experience and above all appropriate planning. In this article, the peculiarities of PD and its treatment are reviewed, and a strategy is set out for the perioperative management of these patients.

Los videojuegos: una afición con implicaciones neuropsiquiátricas / Video gaming: A hobby with neuropsychiatric implications

La difusión de los videojuegos ha aumentado exponencialmente en los últimos años. Un porcentaje de jugadores puede hacer un uso perjudicial con características de adicción. Se llevó a cabo una revisión de referencias bibliográficas (2009-2015) y su análisis. La mayor parte de los estudios se centran en población infantojuvenil, faltando datos recientes de población española. No existe una definición clínica consensuada de la adicción a videojuegos, aunque sí se han desarrollado instrumentos para detectar el uso perjudicial. Jugar a videojuegos tiene implicaciones neurobiológicas y psicosociales beneficiosas y perjudiciales. Un mal funcionamiento psicosocial parece el factor fundamental para el desarrollo de patrón adictivo de uso, que también se ha relacionado con el sexo masculino, juego online, tiempo de juego y factores sociofamiliares. Los resultados indican que a nivel preventivo es necesario concienciar a la población del riesgo de jugar a videojuegos de manera descontrolada. Asimismo, a nivel de intervención, es preciso saber detectar y abordar el uso perjudicial

Video gaming has increased worldwide over the last years. A subgroup of gamers may develop an unhealthy pattern of use with features of addiction. A literature review and analysis (2009-2015) was carried out. Most research is focused on children and adolescent, and recent data on Spanish population is lacking. There is no consensus definition of videogames addiction, although several tools have been developed to assess the unhealthy use. There are both positive and negative neurobiological and psychosocial implications of video-gaming. A poor psychosocial functioning seems the be a key factor for developing an addictive pattern of use. Being a male, online gaming, time spent playing, and socio-family factors have also been implicated. Conclusions reveal that, at a prevention level, society needs to be aware of the risk of uncontrolled gaming and, at a therapeutic level, clinicians need to be able to identify and treat unhealthy gaming

[Decompressive craniectomy in malignant middle cerebral artery infarction. Experience after the implementation of a response protocol]. / Craniectomía descompresiva en el infarto maligno de la arteria cerebral media. Experiencia tras la implantación de un protocolo de actuación.

INTRODUCTION: Descompressive craniectomy (DC) for treatment of malignant infarction of the middle cerebral artery (MIMCA) reduces mortality and increases the probability of favourable outcome. AIM: To present the experience in daily practice after implantation of a clinical protocol of DC. PATIENTS AND METHODS: Prospective register of patients with MIMCA treated with DC. Age, stroke severity -National Institute of Health Stroke Scale (NIHSS) score-, basal characteristics, delay until DC, mortality, modified Rankin Scale (mRS) score at three and twelve months and questionnaire of satisfaction are recorded. RESULTS: From February 2008 to December 2010, 15 patients were treated. Mean age: 60 years (range: 35-69); basal NIHSS, median (p25/p75): 17 (15.5/21), NIHSS before craniectomy: 20 (18/23.5). DC was performed within 48 hours in 8 patients (53.3%). 5 subjects (33.3%) died during in-hospital stay. Mortality was 25% among those treated within 48 hours and 42.9% among those treated later and 37.5% among patients <= 60 years vs 28.6% in older patients. All survivors scored <= 4 in the mRS at three months and expressed satisfaction with surgery despite sequelae. Rate of favourable outcome (mRS <= 3) was higher among patients under 60 (63%) and among those treated before 48 h (50%). CONCLUSION: DC is safe in clinical practice and reduces mortality after MIMCA, especially if it is performed within 48 hours from stroke onset. Benefit appears to be greater in younger patients, but older people may benefit also. The decision to perform DC should be made on an individual basis.

Craniectomía descompresiva en el infarto maligno de la arteria cerebral media. Experiencia tras la implantación de un protocolo de actuación / Decompressive craniectomy in malignant middle cerebral artery infarction. Experience after the implementation of a response protocoll

Introducción. Ensayos clínicos muestran que la craniectomía descompresiva (CD) en el infarto maligno de la arteria cerebral media reduce la mortalidad y aumenta la probabilidad de evolución favorable si se realiza precozmente (< 48 h) en sujetos jóvenes (< 60 años). Objetivo. Presentar la experiencia tras la implantación de un protocolo de CD. Pacientes y métodos. Registro prospectivo de pacientes con infarto maligno de la arteria cerebral media tratados mediante CD. Se recogieron edad, gravedad -National Institute of Health Stroke Scale (NIHSS)-, características basales, retraso hasta la craniectomía, mortalidad, escala de Rankin modificada (ERm) a los 3 y 12 meses y encuesta de satisfacción. Resultados. Desde febrero de 2008 hasta diciembre de 2010 se trató a 15 pacientes; edad media: 60 años (rango: 35-69 años); NIHSS basal, mediana (p25/p75): 17 (15,5/21); NIHSS antes de la craniectomía: 20 (18/23,5). La CD se realizó antes de 48 h en ocho pacientes (53,3%). Cinco sujetos (33,3%) fallecieron durante el ingreso. La mortalidad fue del 25% en los intervenidos antes de 48 h y del 42,9% en los tratados posteriormente, y del 37,5% en ≤ 60 años frente al 28,6% en > 60 años. Todos los supervivientes presentaron ERm ≤ 4 y satisfacción por haber sido intervenidos pese a las secuelas. La tasa de evolución favorable (ERm ≤ 3) fue mayor entre los sujetos < 60 años (63%) y tratados antes de 48 h (50%). Conclusiones. La CD es segura en la práctica clínica cotidiana y permite reducir la mortalidad secundaria al infarto maligno de la arteria cerebral media, especialmente si se realiza en las primeras 48 h, sin dejar supervivientes con gran dependencia. El beneficio parece mayor en sujetos más jóvenes, si bien la indicación debe individualizarse (AU)

Introduction. Descompressive craniectomy (DC) for treatment of malignant infarction of the middle cerebral artery (MIMCA) reduces mortality and increases the probability of favourable outcome.Aim. To present the experience in daily practice after implantation of a clinical protocol of DC. Patients and methods. Prospective register of patients with MIMCA treated with DC. Age, stroke severity -National Institute of Health Stroke Scale (NIHSS) score-, basal characteristics, delay until DC, mortality, modified Rankin Scale (mRS) score at three and twelve months and questionnaire of satisfaction are recorded.Results. From February 2008 to December 2010, 15 patients were treated. Mean age: 60 years (range: 35-69); basal NIHSS, median (p25/p75): 17 (15.5/21), NIHSS before craniectomy: 20 (18/23.5). DC was performed within 48 hours in 8 patients (53.3%). 5 subjects (33.3%) died during in-hospital stay. Mortality was 25% among those treated within 48 hours and 42.9% among those treated later and 37.5% among patients ≤ 60 years vs 28.6% in older patients. All survivorsscored ≤ 4 in the mRS at three months and expressed satisfaction with surgery despite sequelae. Rate of favourable outcome (mRS ≤ 3) was higher among patients under 60 (63%) and among those treated before 48h (50%). Conclusion. DC is safe in clinical practice and reduces mortality after MIMCA, especially if it is performed within 48 hoursfrom stroke onset. Benefit appears to be greater in younger patients, but older people may benefit also. The decision to perform DC should be made on an individual basis (AU)

Manejo perioperatorio de la enfermedad de Parkinson / Perioperative management of Parkinson’s disease

Una de las características singulares de la enfermedad de Parkinson (EP) es la gran variabilidad clínica en relación con el tratamiento que puede acontecer en un mismo paciente. Esto sucede tanto con el tratamiento específico para la EP como con otra serie de fármacos que pueden empeorar la función motora. Por esta razón, el manejo perioperatorio de la EP requiere experiencia y sobre todo una planificación adecuada. En este artículo se revisan las peculiaridades de la EP y su tratamiento, y se plantea una estrategia para el perioperatorio de estos pacientes (AU)

One of the particular characteristics of Parkinson’s disease (PD) is the wide clinical variation as regards the treatment that can be found in the same patient. This occurs with specific treatment for PD, as well as with other drug groups that can make motor function worse. For this reason, the perioperative management of PD requires experience and above all appropriate planning. In this article, the peculiarities of PD and its treatment are reviewed, and astrategy is set out for the perioperative management of these patients (AU)