Response to Symptoms and Prehospital Delay in Stroke Patients. Is It Time to Reconsider Stroke Awareness Campaigns?

BACKGROUND: Despite recent advances in acute stroke care, reperfusion therapies are given to only 1%-8% of patients. Previous studies have focused on prehospital or decision delay. We aim to give a more comprehensive view by addressing different time delays and decisions. METHODS: A total of 382 patients with either acute stroke or transient ischemic attack were prospectively included. Sociodemographic and clinical parameters and data on decision delay, prehospital delay, and first medical contact were recorded. Multivariate logistic regression analyses were conducted to identify factors related to decision delay of 15 minutes or shorter, calling the Extrahospital Emergency Services, and prehospital delay of 60 minutes or shorter and 180 minutes or shorter. RESULTS: Prehospital delay was 60 minutes or shorter in 11.3% of our patients and 180 minutes or shorter in 48.7%. Major vascular risk factors were present in 89.8% of patients. Severity was associated with decision delay of 15 minutes or shorter (odds ratio [OR] 1.08; confidence interval [CI] 1.04-1.13), calling the Extrahospital Emergency Services (OR 1.17; CI 1.12-1.23), and prehospital delay of 180 minutes or shorter (OR 1.08; CI 1.01-1.15). Adult children as witnesses favored a decision delay of 15 minutes or shorter (OR 3.44; CI 95% 1.88-6.27; P < .001) and calling the Extrahospital Emergency Services (OR 2.24; IC 95% 1.20-4.22; P = .012). Calling the Extrahospital Emergency Services favored prehospital delay of 60 minutes or shorter (OR 5.69; CI 95% 2.41-13.45; P < .001) and prehospital delay of 180 minutes or shorter (OR 3.86; CI 95% 1.47-10.11; P = .006). CONCLUSIONS: Severity and the bystander play a critical role in the response to stroke. Calling the Extrahospital Emergency Services promotes shorter delays. Future interventions should encourage immediately calling the Extrahospital Emergency Services, but the target should be redirected to those with known risk factors and their caregivers.

[Intracranial atherosclerosis]. / Ateromatosis intracraneal.

Until recently, intracranial atheromatosis was a probably underdiagnosed clinicopathological entity that was rarely studied in depth. In the last years the advance and expansion in the use of non-invasive diagnostic tools have led intracranial atheromatosis to the front page among the most prevalent causes of stroke worldwide. Important efforts have been accomplished with the aim of identifying markers of poor outcome, which, besides the underlying mechanisms of cerebral ischemia in these patients, are the most important factors on which clinical and therapeutic decisions should be based. To date, the therapeutic armamentarium is scarce and far from optimun, regarding medical and endovascular measures. In this review we address the most important aspects of the natural history and cure treatment of intracranial atheromatosis.

Sonographic assessment of the optic nerve sheath diameter in the diagnosis of idiopathic intracranial hypertension.

OBJECTIVE: Sonographic assessment of the optic nerve sheath diameter (ONSD) is a useful technique in detecting raised intracranial pressure (ICP) in neurocritical care patients. Its utility in idiopathic intracranial hypertension (IIH) is less known. The aim of this study was to evaluate the diagnostic accuracy of ONSD for detecting IIH. MATERIAL AND METHODS: Ultrasound measurement of ONSD was performed in 19 patients with IIH and in 11 patients with different neurological diseases without raised ICP that required undergoing a lumbar puncture. The validity of this technique for diagnosing IIH was established with cerebrospinal fluid manometry values. RESULTS: Patients with IIH showed significantly enlarged ONSD than those without IIH. The best cut-off point for detecting raised ICP was 6.3 mms, with a sensitivity, specificity and positive likelihood ratio of 94.7%, 90.9% and 10.4, respectively. After a therapeutic lumbar puncture an 87% of cases had a partial reduction of ONSD values. CONCLUSION: Sonographic assessment of ONSD seems to be a useful and reliable technique for detecting raised ICP. While the spinal manometry is not replaced in usual clinical settings, transorbital sonography alternatively allows a suitable and harmless screening of patients with suspected IIH. It would be desirable to perform an internal validation of the technique in each hospital in order to get the optimal cut-off point.

[Acute posterior multifocal placoid pigment epitheliopathy. A rare cause of ischaemic stroke]. / Epiteliopatía pigmentaria placoide multifocal posterior aguda. Una rara causa de ictus isquémico.

INTRODUCTION: Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is a rare inflammatory disease, generally of unknown aetiology, affecting the choriocapillaris, the pigment epithelium and the outer retina. It predominantly affects young patients and in some cases may involve the central nervous system in the form of strokes or meningoencephalitis. We report the clinical case of a young female with APMPPE that was complicated by stroke and intracranial hypertension. CASE REPORT: Our patient was a 16-year-old female who began with intense headaches suggesting intracranial hyper-tension, as well as with an acute deficit in the left hemisphere. A magnetic resonance scan of the head revealed embolic or vasculitic lesions in different territories. No evidence of meningoencephalitis was found in the cerebrospinal fluid analysis, but signs of associated intracranial hypertension were observed. The presence of very specific lesions in the posterior pole of the eye led to a diagnosis of APMPPE complicated by ischaemic stroke, probably caused by a vasculitic mechanism. An extensive aetiological study failed to identify a clear precipitating factor underlying the process. Treatment with corticoids was established, with good clinical and radiological progression. CONCLUSIONS: APMPPE is an infrequent condition that generally has a good prognosis. In some cases, however, complications may arise owing to involvement of the central nervous system, and ischaemic stroke secondary to vasculitis is the most severe complication. In young patients with stroke who present visual symptoms and chorioretinital lesions, APMPPE must be considered in the aetiological diagnosis.

TITLE: Epiteliopatia pigmentaria placoide multifocal posterior aguda. Una rara causa de ictus isquemico.Introduccion. La epiteliopatia pigmentaria placoide multifocal posterior aguda (EPPMPA) es una enfermedad inflamatoria rara, generalmente de etiologia indeterminada, de la coriocapilar, el epitelio pigmentario y la retina externa. Afecta predominantemente a pacientes jovenes y en algunos casos puede involucrar al sistema nervioso central en forma de ictus o de meningoencefalitis. Presentamos el caso clinico de una mujer joven con EPPMPA complicada con ictus e hipertension intracraneal. Caso clinico. Mujer de 16 anos que comienza con cefalea intensa sugestiva de hipertension intracraneal, asi como con un deficit agudo hemisferico izquierdo. La resonancia magnetica craneal ponia de manifiesto lesiones embolicas o vasculiticas en diferentes territorios. No se evidenciaron datos de meningoencefalitis en el estudio del liquido cefalorraquideo, pero si de hipertension intracraneal asociada. La presencia de lesiones muy especificas en el polo ocular posterior permitio el diagnostico de EPPMPA complicada con ictus isquemico, probablemente por mecanismo vasculitico. Un amplio estudio etiologico fue negativo para identificar un factor desencadenante claro del proceso. Se inicio tratamiento corticoideo con buena evolucion clinica y radiologica. Conclusiones. La EPPMPA es una entidad rara que generalmente entrana buen pronostico; sin embargo, en algunos casos puede complicarse con afectacion del sistema nervioso central, y el ictus isquemico secundario a vasculitis es la complicacion mas grave. Ante un paciente joven con ictus que presente sintomatologia visual y lesiones coriorretinianas, debe considerarse la EPPMPA en su diagnostico etiologico.

Psoriasis during natalizumab treatment for multiple sclerosis.

Beta-interferon therapy is known to trigger psoriasis, but this effect has not been previously reported for other multiple sclerosis treatments, such as natalizumab. The following is a case report. A 31-year-old woman affected by psoriasis and relapsing-remitting multiple sclerosis suffered a severe worsening of psoriasis symptoms during natalizumab treatment and acquired a drug-resistant course. This case suggests that aggravation of psoriasis might be a rare side effect of natalizumab, and that clinicians should be aware of the possibility of paradoxical activation of autoimmune diseases during its treatment.

[The use of oral lacosamide in a patient with refractory partial epileptic status]. / Uso de lacosamida oral en un paciente con estado epiléptico parcial refractario.

INTRODUCTION: Generalised epileptic status is a medical emergency with a well-defined therapeutic algorithm. Nevertheless, in the partial status, treatment must be tailored to each patient and the risk of intensive treatment has to be assessed. Unlike generalised epileptic status, partial status is not considered a medical emergency, which means that when it comes to choosing a type of treatment the risk-benefit ratio must be carefully evaluated bearing in mind the characteristics of each particular case. CASE REPORT: A 72-year-old male with partial status secondary to an ischaemic lesion which was refractory to conventional treatment; treatment was established with lacosamide and his condition was rapidly inverted. This is the third case that has been reported of epileptic status being treated with this drug and the second in which it is employed orally. CONCLUSIONS: Although further research is required, lacosamide could be a good therapeutic option with few interactions and side effects.

Oftalmoplejía dolorosa recurrente secundaria a displasia fibrosa poliostótica del seno maxilar con afectación de la hendidura esfenoidal / Recurrent painful ophthalmoplegia secondary to polyostotic fibrous dysplasia of the maxillary sinuses with involvement of the superior orbital fissure

Introducción. La displasia fibrosa es una enfermedad ósea benigna que suele cursar con lesiones asintomáticas pero que en ocasiones puede dar manifestaciones neurológicas por afectación de los huesos craneofaciales. Caso clínico. Mujer de 25 años, con antecedentes de migraña, que consultó a los 18 años por un cuadro de dolor en la región maxilar y retrocular derecha de características diferentes de las de su migraña habitual y que asocia oftalmoparesia ipsolateral; presenta un curso autolimitado con buena respuesta a corticoides, aunque recidivante. La exploración puso de manifiesto un intenso dolor a la palpación en el seno maxilar derecho y parálisis incompleta del III par craneal ipsolateral con ptosis palpebral. Los estudios complementarios fueron normales, salvo la resonancia magnética craneal y la tomografía axial computarizada facial, donde se evidenció una lesión expansiva con afectación del seno maxilar superior derecho y el ala mayor del esfenoides, con probable afectación de la hendidura esfenoidal, compatible con el diagnóstico de displasia fibrosa, que fue confirmado mediante estudio anatomopatológico. Conclusiones. La displasia fibrosa es un trastorno óseo benigno cuya etiología se desconoce y que consiste en la sustitución del tejido óseo normal por tejido conjuntivo amorfo. En ocasiones, existe afectación craneofacial y se forma una masa ósea hipertrófica que puede ocupar los senos paranasales y la órbita, y dar lugar a exoftalmos y alteraciones visuales. Hasta el momento, no se ha descrito en la bibliografía científica la manifestación de esta enfermedad en forma de brotes de oftalmoparesia dolorosa recurrente con respuesta a corticoides, como ocurre en nuestra paciente (AU)

Introduction. Fibrous dysplasia is a bone disease that is usually accompanied by asymptomatic lesions but which may sometimes display neurological manifestations due to the involvement of the craniofacial bones. Case report. A 25-year-old female, with a history of migraines, who visited at the age of 18 due to pain in the right retro-ocular and maxillary region, although with characteristics that were unlike those of her usual migraines, and which was associated with ipsilateral ophthalmoparesis. The condition had a self-limiting course and responded well to corticoids, although it was recurring. Examination revealed intense pain on palpation of the right-hand maxillary sinus and incomplete paralysis of the ipsilateral oculomotor nerve with palpebral ptosis. Results of complementary studies were normal, except for magnetic resonance imaging of the head and computerised axial tomography of the face, which revealed an expansive lesion with involvement of the right superior maxillary sinus and the greater wing of the sphenoid bone, with probable compromise of the superior orbital fissure, consistent with the diagnosis of fibrous dysplasia, which was confirmed by means of a pathology study. Conclusions. Fibrous dysplasia is a benign bone disorder, of unknown causation, in which normal bone tissue is replaced by amorphous conjunctive tissue. There is sometimes craniofacial involvement and a hypertrophic bone mass is formed which can fill the paranasal sinuses and the orbit, resulting in exophthalmus and visual disorders. To date the scientific literature does not include any reports of this disease manifesting as bouts of recurrent painful ophthalmoparesis which responds to corticoids, as happened in the case of our patient (AU)

Uso de lacosamida oral en un paciente con estado epiléptico parcial refractario / The use of oral lacosamide in a patient with refractory partial epileptic status

Introducción. El estado epiléptico generalizado es una urgencia médica con un algoritmo terapéutico bien definido. Sin embargo, en el estado parcial, el tratamiento debe individualizarse y valorar el riesgo del tratamiento intensivo. A diferencia del estado epiléptico generalizado, el estado parcial no se considera una emergencia médica, por lo que en la elección de su tratamiento debe valorarse cuidadosamente y de modo individualizado la relación riesgo-beneficio.Caso clínico. Varón de 72 años con estado parcial secundario a lesión isquémica y refractario a tratamiento convencional, en el que se inicia tratamiento con lacosamida y se consigue su rápida reversión. Se trata del tercer caso de estado epiléptico publicado con este fármaco y del segundo en el que se emplea vía oral. Conclusión. Aunque se requieren más estudios la lacosamida podría representar una buena opción terapéutica con escasas interacciones y efectos secundarios (AU)

Introduction. Generalised epileptic status is a medical emergency with a well-defined therapeutic algorithm. Nevertheless, in the partial status, treatment must be tailored to each patient and the risk of intensive treatment has to be assessed. Unlike generalised epileptic status, partial status is not considered a medical emergency, which means that when it comes to choosing a type of treatment the risk-benefit ratio must be carefully evaluated bearing in mind the characteristics of each particular case. Case report. A 72-year-old male with partial status secondary to an ischaemic lesion which was refractory to conventional treatment; treatment was established with lacosamide and his condition was rapidly inverted. This is the third case that has been reported of epileptic status being treated with this drug and the second in which it is employed orally. Conclusions. Although further research is required, lacosamide could be a good therapeutic option with few interactions and side effects (AU)