[Gait and stability disorders of the elderly. Clinical analysis of a series of 259 patients older than 70 years]. / Trastornos del equilibrio y de la marcha en el anciano: análisis clínico de una serie de 259 casos mayores de 70 años.

INTRODUCTION: Gait and stability disorders of the elderly are frequent and a cause of disability, but studies on their clinical features and etiology are scarce, including the relationship between both disorders. OBJECTIVES: To evaluate an extensive series of patients with gait and stability disorders, its clinical variants and posible pathogenic significance. PATIENTS AND METHODS: 259 patients older than 70 years consulting for chronic gait and stability symptoms in an outpatients neurologic clinic were retrospectively reviewed. Several clinical and evolution data are analyzed. RESULTS: Mean age was 78.8 years and 61.8% were women. 52 % were hypertensive. 161 cases had disequilibrium, 91 a cautious gait and seven other types of gait abnormality. 11 % had associated dementia. 27 % showed subcortical white matter abnormalities on computed tomography scan. In 28 cases a specific cause could be established. In follow-up 33.5 % worsened. Significant differences between cases of disequilibrium and cautious gait were increased age, functional disability and turn abnormality in the latter. CONCLUSIONS: Disequilibrium and cautious gait of the elderly share some clinical features, have few specific causes and vary from mild cases to a disabling <>.

Time window for clinical effectiveness of mass evacuation in a rat balloon model mimicking an intraparenchymatous hematoma.

The purpose of this study is to evaluate in a rat model if the early removal of an experimental intracerebral mass mimicking an extensive subcortical hematoma improves neurological outcome. Fifty six male Wistar rats were studied. A balloon was placed sterotactically at the level of the striatum. The balloon was inflated to 100 microl for periods of 10, 60 or 120 min (with 10 animals in each group). In 10 animals the balloon was not deflated and there were four sham operated cases. Neurological deficit was evaluated by a blinded observer by means of a clinical scale from 0 to 8 points at 24 and 72 h after inflation. Three additional animals at each inflation period were sacrificed after 6 h for pathological study with hematoxylin-eosin staining. Death rate was 9/10 animals who had permanent inflation, 4/10 in those with 2 h inflation, 2/10 for 1 h inflation and 0/10 for 10 min inflation (P<0.01 in chi square test). Many animals developed a particular clinical syndrome not previously described. Mean 72 h clinical scores (0-8 points) were 7.6 (S.D.: 1. 2) for the permanent inflation group, 4.4 (S.D.: 3.2) for 2 h of inflation, 2.3 (S.D.: 3.2) for 1 h and 0.4 (0.9) for 10 min of inflation (P<0.01 in Kruskal Wallis test). In the pathological study the rate of damaged neurons was significantly higher in the permanent than in transient inflation groups. In conclusion, in this balloon model evacuation of an extensive acute expanding subcortical (hematoma-like) mass must be performed within a limited time window to prevent the development of irreversible neurological deficits or death.

[Estimation of the neurologic demand in a health care area of Madrid, Spain (area 11, University Hospital, 12 of October)]. / Estimación de la demanda neurológica en un área sanitaria de Madrid (area 11, Hospital Universitario 12 de Octubre).

OBJECTIVES: To analyse the demand for neurologic care and the neurological resources in a health district. PATIENTS AND METHODS: Demographic, medical care aspects, neurologic care demands and neurological resources of the health district 11 of Madrid (University Hospital "12 de Octubre"), referred to 1996, were reviewed. RESULTS: The rate of aging (17%) and the consulting rates in the National Health System (86%) versus private care were high in this health district. The neurologic care demands were 17.5-18.1 and 36 consultations respectively per 1,000 inhabitants/year. There were 2 patient-care neurologists and 3.7 neurologic beds per 100,000 inhabitants. CONCLUSIONS: The neurologic care was considered high and with a tendency to increase. The available neurological resources were judged to be insufficient.

[Reversible dementia in neurology outpatient clinics]. / Demencias reversibles en la consulta neurológica extrahospitalaria.

INTRODUCTION: The dementias are one of the commonest conditions seen in Neurology Clinics. Potentially reversible causes are described amongst the various aetiologies although there are doubts as to whether the use of indiscriminate testing to detect them is worthwhile. OBJECTIVE: In a group of demented persons to determine how many had a potentially reversible condition and how many improved, in a prospective, descriptive study in a Neurology Outpatient Clinic. PATIENTS AND METHODS: Using the Mini-Mental State Examination of Folstein and the DSM-III-R criteria for dementia, 121 demented patients were selected. An ordinary biochemical study was made (vitamin B12, thyroid hormones), serology (lues) and neuroimaging (cerebral CT), and when a potentially reversible condition was found, each case was treated. The patients treated were followed-up periodically for an average of 9.6 months (range 2 to 24 months). RESULTS: A potentially reversible condition was seen in 19.8% of the patients. On prospective evaluation only 3.3% had reversible symptoms and in no case were these completely reversed. Improvement was seen in conditions of depressive pseudo-dementia. CONCLUSIONS: Since some causes of dementia are reversible, the neurologist is obliged to investigate and seek these possible aetiologies. This study should be individualized according to clinical criteria to improve profitability of the complementary tests. Our results suggest that there are doubts as to the usefulness of indiscriminate investigation of possible reversible causes of the cases of dementia referred to Outpatient neurologists.

[Guidelines for headaches and dizziness for general physicians: analysis of their impact on visit frequency to outpatient neurological ambulatory services]. / Guías de actuación en cefaleas y mareos para médicos de familia: análisis de su repercusión en la frecuentación de una consulta extrahospitalaria de neurología.

BACKGROUND: The work of neurologists in the Public Health Service is absolutely determined by the demand of the general physicians, who have occasionally been considered to be not too selective. For this reason we have tried to change this demand. METHODS: In our outpatient clinic we have developed some guidelines for the general physicians to orientate them in the selection of patients referred with neurological disease. In this study the impact of the implementation of headache and dizziness guidelines on the annual frequentation from 1993 to 1997 is analysed. We also reviewed 200 cases of patients referred in 1996-1997 and assessed their adequacy to the guidelines, and inquired the general physicians after their demand and percentage of patients with neurologic disease that they referred to the neurologist. RESULTS: There were no significant changes on the demand of consultations on headache or dizziness. We found that 39% of patients referred with headache and 23% of those with dizziness didn't adequate to the guidelines. General physicians referred only 3.3% of the patients seen by them with headache, and 3.7% of those with dizziness. CONCLUSIONS: Sending guidelines to the general physicians has not demonstrated to be effective on improving their selection of patients, and a better implementation of guidelines should be studied, admitting that the care demand of headache and dizziness is high, and that general physicians make an important selective effort.

Early complete recanalization in internal carotid artery embolism treated with high-dose t-PA: a sequential angiographic study in a novel model of embolism in rats.

Complete early recanalization rate of human internal carotid artery embolic occlusion treated with thrombolytic drugs is low. To study factors related with this difficulty to recanalize we have developed a novel model of rat ica embolism using a fragment of human embolus. In 50 male Wistar rats the ica was embolized through the external carotid artery with a fragment of an embolus obtained from a human embolectomy passed through a catheter of 0.8 mm diameter. Recanalization was assessed by sequential angiograms from 15 to 120 min after embolization. Reperfusion was classified according to TIMI grades. Emboli of either 1 (group 1) or 2 mm (group 2) in length were cut. In group 1, four groups of nine animals each were treated, 15 min after embolization, with i.v. t-PA at doses of 1 mg/kg, 10 mg/kg and 20 mg/kg or saline. In group 2 there was one control group of seven animals treated with saline and another of seven animals treated with 10 mg/kg t-PA. Complete recanalization (TIMI grade 3) within the first 30 min was present in two animals treated with 10 and 20 mg/kg. Complete recanalization within the first 60 min was present in 0% of controls and animals treated with 1 mg/kg and in 44% of the 10 and 20 mg/kg groups (P<0.05 in chi-square test). Incomplete recanalization (TIMI grades 0, 1 and 2) occurred in 33%. In group 2 total recanalization occurred in 1/7 controls and in 3/7 animals receiving 10 mg/kg of t-PA. Early (60 min) complete i.v. t-PA induced internal carotid artery embolic recanalization is low with standard doses and increases moderately when high doses are used. Further increases in the dose do not improve recanalization rate, which is not clearly influenced by embolus size. Complete recanalization within 30 min, the period after which infarction develops in the rat, is uncommon in our model.

[Chronic disequilibrium in the older patient: investigation of reversible cases in a 22-patient series]. / Inestabilidad crónica en el paciente mayor. investigación de causas reversibles en una serie de 22 casos.

Chronic instability is a frequent complaint in elderly patients. As literature on the subject is scarce, we investigated reversible causes, evaluating patients over 65 years of age referred to a regional neurological practice for disequilibrium lasting longer than three months. Clinical features were analyzed. Computerized tomography (CT) of the brain, and thyroid hormone and cyanocobalamin (Cc) serum levels were studied for all patients, as was clinical course. No CT abnormalities were found. Low Cc levels were observed in 6 patients, and 2 were diagnosed of previously undetected hypothyroidism. During the mean follow-up period of 12 months, improvement was seen in 3 specifically-treated patients, one with hypothyroidism and two with Cc deficit. We conclude that chronic instability in the older patient cannot usually be traced to a specific cause, but that it is important to protocolize the assessment of such patients, including routine tests for thyroid hormone and Cc levels, in order to rule out treatable causes.

[Multiple cerebral hematomas: review of 7 cases]. / Hematomas cerebrales múltiples: revisión de 7 casos.

We present seven patients with multiple spontaneous cerebral haemorrhages, diagnosed by CT scan, in a 10-year period in the Hospital 12 de Octubre. The clinical presentation, radiologic features, and prognosis of this entity are analyzed, and the diverse etiologic factors are discussed. All of the patients in this series were over 50 years of age, the majority not hypertensive (57%, n = 4), and in almost half the cases (43%, n = 3) the brain haemorrhages were associated with diverse coagulation disorders. The localization of the haemorrhages was exclusively supratentorial. Four patients presented with a moderate global confusional state, and one patient with deep coma. All the patients had focal signs. The mortality was elevated, with three patients dying, but the clinical evolution and outcome of those who survived was favourable.

Benign Valsalva's maneuver-related headache: an MRI study of six cases.

Cough headache is not infrequent, but there have not been any series studied with current neuroimaging techniques, and effective therapy has seldom been reported. In a large series from an outpatient clinic of a general hospital, we have studied, with MRI, eight cases of headache related to situations provoking sudden increase of intrathoracic pressure (cough, straining, stooping), similar to that elicited by a Valsalva's maneuver. One case showed hindbrain herniation and another showed isolated hydrocephalus. Symptoms did not differ between these two cases and the six cases without MRI abnormality. Initial symptoms presented between 49 and 67 years of age, and headache was of variable location and duration, mostly global and short-lasting. During a mean follow-up of 13.3 months, one patient became spontaneously asymptomatic, one improved on indomethacin, and two improved after treatment with propranolol. We propose the eponym, benign Valsalva's maneuver-related headache (as more appropriate than the equivalent "cough headache"), for cases in which headache is related to such situations and structural lesions are excluded by MRI or similar tests.

[Temporal threshold for middle cerebral artery infarction]. / Umbrales de tiempo de infarto en el territorio de la arteria cerebral media. Utilidad del modelo de oclusión intravascular en la rata.

We describe a rat model for middle cerebral artery occlusion and discuss its usefulness for the study of structural consequences of various ischemic periods. We inserted 4/0 polyethylene sutures into the external carotid artery of 48 Wistar rats. The tips were rounded and coated with a thin layer of dental silicone. By inserting a section 18 mm long we assured that placement of the tip was between the origins of the middle and anterior cerebral arteries. The suture was withdrawn at predetermined times to allow complete reflux through the common carotid. The animals were sacrificed 24 hours after this procedure and tested for the presence of infarct by staining with 2,3,5 triphenyl-tetrazolium on 2 mm coronal cuts. We identified several differences regarding areas of infarction after the different occlusion periods, as shown by ANOVA and Newman-Keuls testing. Thus, occlusion for 15 minutes did not provoke infarction; occlusion of 30, 45 and 60 minutes produced selective infarction of the caudate nucleus and putamen; and finally, incomplete cortical infarction appeared after 90 minutes and was complete after 2 hours, at which time infarction was similar to that seen after 24 hours of occlusion. Intravascular occlusion is a reliable method for inducing focal cerebral ischemia, enabling us to confirm the existence of an infarction time threshold that is longer for the cortex than for the caudate nucleus and putamen.

Risk factors, diet and carotid atheromatosis in TIAs and minor ischemic strokes (MISs) in a Mediterranean country.

Eighty-two patients with transient ischemic attacks (TIAs) or minor ischemic strokes (MISs) were prospectively recruited from the emergency room of a general hospital within 1 month of the event with the aim of providing a group for comparison - regarding the pathogenetic profile - with similar series from Northern Europe and USA. Patients were asked a diet questionnaire, and serum lipid analysis, CT scan and carotid duplex were performed in each case. Relevant features were antecedents of hypertension in 61%, current smoking in 23.2% and ischemic heart disease in 13.5%; mean serum levels of cholesterol 6.2 mmol/l, LDL- C, 4.27, HDL-C, 1.24, triglycerides 1.45; and duplex evidence of severe extracranial carotid atheromatosis (hemodinamically significant stenosis or occlusion) in 14.4%. Relevant diet data were daily intake of energy, 7.2 MJ, fat 34% of energy and saturated fat 12.6%. Cases with severe carotid atheromatosis had significantly lower levels of HDL-C, higher levels of triglycerides and lower per cent of energy from monounsaturated fat (p < 0.05 Mann-Whitney test). When compared with series from Northern Europe and USA ours showed lower incidence of severe carotid atheromatosis and ischemic heart disease, lower levels of triglycerides and higher HDL-C, and lower mean diet energy and proportion of unsaturated fat We suggest that higher HDL-C and lower triglyceride serum levels could be protective against severe extracranial carotid atheromatosis and that a Mediterranean diet, with less saturated fat and more monounsaturated fat could account in part for this low incidence of severe carotid disease in our TIAs and MISs patients.

Acute headache of recent onset and subarachnoid hemorrhage: a prospective study.

Twenty-seven patients with acute severe headache of recent onset were prospectively recruited in the Emergency Room. Mean duration of headache was 61 hours. CT scan disclosed subarachnoid bleeding in 4 patients and spinal tap revealed subarachnoid hemorrhage (SAH) in 5 patients with normal CT scan. In most SAH cases pain was bilateral, very intense and involving the occipital region. Four of these patients had doubtful or no nuchal rigidity and in one, pain improved while in the Emergency Room. In every case with an intense acute severe headache of recent onset CT scan and (if normal) a lumbar puncture are warranted to help rule out a SAH.

[Acute confusional syndrome due to bilateral occlusion of the anterior cerebral artery]. / Síndrome confusional agudo por oclusión bilateral de arteria cerebral anterior.

We report a case of acute confusional state (ACS) resulted from bilateral occlusion of anterior cerebral artery. This case is outstanding because development of ACS was caused by a focal lesion, without the presentation of focal neurologic signs. Then, cerebrovascular disease must be included in differential diagnosis of ACS, despite the lack of clinically detectable deficit.

Long-term outcome of TIAs, RINDs and infarctions with minimum residuum. A prospective study in Madrid.

A group of patients with transient ischemic attacks (65 cases), reversible ischemic neurologic deficits (37 cases) and infarctions with minimum residuum (41 cases) was included in a prospective follow-up for a mean period of 5.2 years. Most of the patients were treated with acetylsalicylic acid or other antiplatelet agents, or with anticoagulants. Principal complications during follow-up were: cerebral infarction, 15 cases (10.4%); cerebral hematoma, 2 (1.3%); transient ischemic attacks, 17, (11.8%); reversible ischemic neurologic deficits, 9 (6.2%); myocardial infarction, 4 (2.7%); and death, 11 (7.6%). The cumulative incidence for stroke or death was 6.2% for the first year and 14% for the fifth year. There were no significant risk factors for the occurrence of stroke or vascular death on time-related multivariate analysis (Cox). Disabling stroke was less frequent after infarctions with minimum residuum than after transient ischemic attacks or reversible ischemic neurologic deficits.

[Acute confusional syndrome of unknown cause. Prospective study in the emergency room]. / Síndrome confusional agudo de causa no aparente. Estudio prospectivo en el área de urgencias.

In a prospective study conducted in the Emergency Area of a general hospital during a period of 6 months, the Neurology Service was consulted in 45 cases of acute confusional syndrome. Twenty nine of these patients had no immediate apparent etiology. Among the studied patients 5 had a subarachnoid hemorrhage, 4 suffered a central nervous system infection, 3 had a cerebral infarction, 3 presented a metabolic encephalopathy, and the remaining patients had variate etiologies. Clinical signs and symptoms were insufficient to establish the diagnosis and in several cases complementary tests were required (cerebral tomography and cerebrospinal liquid examination). Even in these cases the diagnosis could not be obtained in some patients. The clinical implications of the present findings were discussed.