Measurement of GFAP in nasal exudate in the differential diagnosis between ischemic and hemorrhagic stroke.

INTRODUCTION: Differential diagnosis between ischemic stroke (IS) and intracerebral hemorrhage (ICH) is a great challenge. Recently, the discovery of cerebral lymphatic drainage towards the nostrils suggested nasal exudate (NE) as a new source for measure biomarkers from neural damage. We sought to confirm whether glial fibrillary acidic protein (GFAP) levels in NE could identify ICH. METHODS: GFAP in nasal exudate (nGFAP) was studied in 5 IS and 5 ICH patients. All patients underwent neurological examination, brain computed tomography, laboratory tests and measurement of nGFAP and serum GFAP. RESULTS: We found higher concentrations in ICH patients (p=0.02). The area under the ROC curve for IS/ICH discrimination was 0.840, with a cut-off point of 0.06 pg/mg for 100% sensitivity and 80% specificity Conclusions: These findings suggest that nGFAP could be a useful biomarker for differential diagnosis between IS and ICH and opens a potential field of study for other biomarkers in NE in neurological disorders.

Serum Prealbumin Levels on Admission as a Prognostic Marker in Stroke Patients Treated with Mechanical Thrombectomy.

INTRODUCTION: Prealbumin is a marker of malnutrition and inflammation. It has been associated with poor prognosis in cardiovascular disease, but less is known in stroke patients. Our objective was to evaluate the association of prealbumin levels at admission with prognosis in patients with stroke treated with mechanical thrombectomy. METHODS: Retrospective study of a prospective database of consecutive patients treated with mechanical thrombectomy. Clinical, radiological, and blood parameters including serum prealbumin, and prognostic variables such as respiratory infection, in-hospital mortality, and the modified Rankin scale at 3 months were collected. RESULTS: We included 319 patients between 2018 and 2019. Prealbumin levels were significantly lower in patients older than 80 years, women, patients with a prestroke Rankin score >2, a glomerular filtrate rate <60 mL/min, and in those with atrial fibrillation. Regarding prognostic variables, prealbumin levels were not associated with respiratory infection. Low prealbumin levels were associated with poor functional prognosis (Rankin score >2), in-hospital mortality, and 3-month mortality. In multivariate analysis, prealbumin was an independent risk factor associated with mortality at 3 months, OR 0.92 [0.86-0.98], p = 0.019. CONCLUSION: Lower prealbumin levels at admission behaved as an independent predictor of long-term mortality in patients treated with mechanical thrombectomy. These results should be replicated in other cohorts.

Incidence and mortality of cerebrovascular disease in Spain: 1,600,000 hospital admissions between 2001 and 2015.

BACKGROUND: To analyze the incidence and mortality of cerebrovascular diseases (CeVD) in Spain from 2001 to 2015. METHODS: Retrospective study of hospital incidence, hospital case fatality and population mortality, with records from the Spanish Government Statistics. Days of hospital stay and risk of death (RD) during admission were estimated adjusting for age, sex, first stroke (FS), atrial fibrillation (AF), diabetes, hypertension, and smoking. RESULTS: There were 1,662,487 stroke cases older than 15 years of age admitted to hospital (1,096,748 FS), with a national incidence = 291/105 in this period (Murcia maximum (367/105), Canary Islands minimum (238/105)). Population mortality (-50%) decreased while case fatality remained stable (-3%), despite the increase in the age of patients (+2.29 years) and the incidence (+25%). Canary Islands had the youngest patients (-3.5 years for men and -6 years for women) and the longest hospital stay (+5.1 days). Andalusia (odds ratio (OR) = 1.21 (1.19; 1.22)) and the Canaries (OR = 1.18 (1.15; 1.21)) had the highest RD. The factors associated to the highest increases in RD were FS (OR = 1.34 (95% confidence interval (CI) = 1.33-1.35)) and AF (OR = 1.30 (95% CI = 1.29-1.31)). CONCLUSION: Population mortality due to CeVD was reduced by half in Spain between 2001 and 2015, but hospital incidence increased. Andalusia and the Canary Islands had the highest RD in the country. These islands presented the lowest incidence, but their patients were younger, and their hospital stay longer. FS and AF were the factors associated with a higher RD.

Iron Measured in Nasal Exudate Samples as a New and Useful Biomarker in the Differential Diagnosis of Patients with Acute Stroke.

INTRODUCTION: Differential diagnosis between ischemic and hemorrhagic strokes in the acute stage is one of the major challenges of neurovascular research. Several biomarkers have been studied, but attempts to date have focused on determining their blood levels. Recently, cerebral lymphatic drainage toward the nostrils has been discovered, giving us the chance to study nasal exudate looking for biomarkers of neural damage. We sought to confirm whether iron levels in nasal exudate could identify the hemorrhagic nature of acute stroke. METHODS: We studied iron nasal exudate levels in 32 ischemic and 43 hemorrhagic stroke patients. All patients underwent neurological examination assessed by the National Institutes of Health Stroke Scale (NIHSS), brain computed tomography to the differential diagnosis of stroke subtype, laboratory tests, and measurement of iron levels in nasal exudate. RESULTS: The iron levels in nasal exudate were higher in hemorrhagic stroke patients. The area under the receiver operating characteristic curve for ischemic/hemorrhagic stroke discrimination was 0.896 (95% confidence interval 0.823-0.970) and cutoff point of 0.078 nmol/mg (sensitivity 93%, specificity 73%). CONCLUSIONS: Our findings suggest that iron levels in nasal exudate may be useful in the acute stage for the differential diagnosis between ischemic and hemorrhagic damage in acute stroke patients. They also open a potential field to study other biomarkers in nasal exudate in several neurological disorders. Clinical studies must be performed to confirm our results.

Efficacy and Safety of Endovascular Treatment in Acute Tandem Carotid Occlusions: Analysis of a Single-Center Cohort.

INTRODUCTION: Acute ischemic strokes with tandem occlusions, which represent 10-20% of all ischemic strokes, have a particularly poor prognosis. Since emergent treatment of tandem lesions has not been specifically addressed in randomized trials, there is an absence of standardized management. OBJECTIVE: We sought to assess the efficacy and safety of acute endovascular treatment in stroke due to tandem occlusions in our center and compare the results with previous reports. METHODS: From a prospective registry we analyzed data of 99 consecutive patients (males: 77.7%, mean age ± SD: 67.5 ± 9.5 years) with stroke due to tandem occlusions who underwent treatment with emergent carotid stenting and intracranial mechanical thrombectomy. Successful recanalization was defined as a TICI score of 2b-3 and a good functional outcome was defined as a modified Rankin scale score ≤2 at 90 days. Symptomatic intracranial hemorrhage (sICH) was considered when associated with worsening on the National Institutes of Health Stroke Scale (≥4 points). RESULTS: A successful recanalization rate was achieved in 87.8 and 48.5% of the patients had a good functional outcome. sICH and mortality rates were 12.1 and 20.2%, respectively, and 21.2% of the patients received combined treatment with intravenous thrombolysis, which did not affect neither the prognosis nor the recanalization or sICH rates. The time from symptom onset to recanalization and the degree of recanalization were the main factors associated with prognosis and the occurrence of sICH. CONCLUSIONS: Our results suggest that endovascular treatment with emergent carotid stenting and intracranial thrombectomy in patients with acute stroke due to tandem occlusions is an effective and safe procedure.

Obtaining information from the brain in a non-invasive way: determination of iron in nasal exudate to differentiate hemorrhagic and ischemic strokes.

Background Differentiation between hemorrhagic and ischemic stroke is currently made by brain imaging or analyzing blood and cerebrospinal fluid (CSF) samples. After describing a new drainage route from brain to nasal mucosa, nasal exudate samples can be considered a new and promising source of biomarkers. Saliva can also be evaluated. Methods We determined iron in nasal exudate and saliva samples from patients of acute stroke during the first 48 h from onset. A simple, non-invasive sampling procedure was employed to obtain information from the brain. Samples were taken with a pre-weighed swab, solved in a 2% nitric acid solution and iron was measured by inductively coupled plasma-tandem mass spectrometry (ICP-MS/MS). Results A significant difference in the dispersion of results of iron concentration for both stroke subtypes was observed in nasal exudate samples. The interquartile range was 0.608 nmol mg-1 of iron for hemorrhagic strokes and only 0.044 nmol mg-1 for ischemic strokes. In saliva samples, however, the values were 0.236 vs. 0.157 nmol mg-1. A cut-off limit of 0.102 nmol of iron per mg of nasal exudate provides a methodology with a 90% of sensitivity and a 90% of specificity. The value of the area under (AUC) the receiver operating characteristic curve (ROC) for nasal exudate samples is 0.960, considered as very good in which regards to its predictive value. Conclusions Non-invasive samples of nasal secretion have allowed obtaining, for the first time, information from the brain. Determination of iron in nasal exudate by ICP-MS allowed differentiation between ischemic and hemorrhagic strokes.

Evolución de la atención al ictus en un hospital de tercer nivel / Evolution of care for stroke in a third-level hospital

Objetivo: conocer la evolución de los pacientes ingresados y tratados en la Unidad de Ictus (UI) de un hospital de tercer nivel siguiendo el modelo actual de tratamiento, en comparación con los que fueron ingresados y tratados anteriormente en una planta convencional de neurología. Método: estudio observacional retrospectivo, de pacientes atendidos en el Hospital Universitario Central de Asturias tras sufrir un ictus, en dos periodos: antes de la creación de la unidad de ictus (1 al 31 de enero de 2009) y después de la implementación de la unidad (1 al 31 de enero de 2014). Se diseñó un cuaderno de recogida de datos. Se usó el sistema de clasificación TOAST y las escalas NIHSS (gravedad del ictus) y la Rankin modificada (grado de discapacidad física tras un ictus). Revisión de historias clínicas electrónicas a través de Cerner Millenium. Análisis mediante paquete estadístico SPPS versión 22. Resultados: 152 pacientes en 2009 y 132 en 2014. Edad media 73,92 años, con predominio de varones (62,9%). Los días de hospitalización y la mortalidad durante el ingreso disminuyen entre 2009 y 2014. El número de activaciones del protocolo de Código Ictus se duplicó. La aplicación de tratamientos recanalizadores pasó del 16,1% al 20,4%. El inicio de la rehabilitación precoz desde la instauración de la UI se incrementó del 7% al 33%. Los pacientes que no precisaron rehabilitación pasaron del 42% al 80%. Conclusiones: la puesta en marcha de la UI y la activación del Código Ictus han contribuido a mejorar los resultados de identificación, clasificación, tratamiento, seguimiento y resultados al alta de los pacientes ingresados por ictus en el hospital

Objective: to learn about the evolution of patients hospitalized and treated at the Stroke Unit of a third-level hospital following the current model of treatment, compared with those patients previously hospitalized and treated in a conventional Neurology ward. Method: an observational retrospective study, on patients managed at the Hospital Universitario Central de Asturias after suffering a stroke, conducted in two stages: before the Stroke Unit was set up (January, 1st to 31st, 2009), and after implementing the unit (January, 1st to 31st, 2014). A notebook for data collection was designed. The TOAST classification system was used, as well as the NIHSS scale (for stroke severity) and the modified Rankin scale (level of physical disability after a stroke). A review of electronic clinical records was conducted through Cerner Millenium. Analysis was conducted with the SPPS statistical package, version 22. Results: the study included 152 patients in 2009 and 132 patients in 2014; their mean age was 73.92 years, and the majority were male (62.9%). There was a reduction in hospitalization days and mortality during admission between 2009 and 2014. There was a twofold increase in the number of activations of the Stroke Code protocol. The application of recanalization treatments increased from 16.1% to 20.4%. The early initiation in physical therapy increased from 7% to 33% since the creation of the Stroke Unit; those patients who did not require physical therapy increased from 42% to 80%. Conclusions: the implementation of the Stroke Unit and the activation of the Stroke Code have contributed to improve the results in identification, classification, treatment, follow-up and results at discharge, in patients hospitalized for stroke

Análisis de los costes directos asociados a la trombectomía mecánica y a la fibrinólisis intravenosa en el Hospital Universitario Central de Asturias / Analysis of the direct costs associated with mechanical thrombectomy and intravenous fibrinolysis in the Hospital Universitario Central de Asturias

Introducción. La ampliación de las indicaciones de la trombectomía mecánica y su implementación en los hospitales españoles hacen necesario conocer los costes relacionados con este tratamiento para racionalizar los recursos económicos y permitir una adecuada distribución de éstos. Objetivos. Analizar los costes directos asociados a los pacientes con ictus isquémico agudo tratados con fibrinólisis intravenosa y con trombectomía mecánica, y valorar la efectividad y seguridad de ambos tratamientos durante los primeros 90 días de evolución en el Hospital Universitario Central de Asturias. Pacientes y métodos. Se realizó un análisis retrospectivo en el que se incluyó a 44 pacientes que recibieron fibrinólisis intravenosa y a 61 pacientes tratados con trombectomía mecánica, en los que se analizaron una serie de variables clínicas y económicas. Resultados. El coste total final medio por paciente fue de 16.059 euros en los tratados con trombectomía y de 8.169 euros en los que se administró fibrinólisis intravenosa. El porcentaje de pacientes con buen pronóstico funcional a los 90 días fue del 63,93% en los tratados de forma endovascular y del 56,82% en los que recibieron fibrinólisis intravenosa. Las tasas de mortalidad fueron del 18,03% y 11,36%, respectivamente. Conclusiones. El coste medio del tratamiento con trombectomía mecánica, así como el coste medio total por paciente durante la fase aguda de la enfermedad asociado a esta técnica, es mayor que en el caso de la fibrinólisis intravenosa. Tanto la fibrinólisis intravenosa como la trombectomía mecánica se configuran en nuestro medio como tratamientos efectivos y seguros (AU)

Introduction. The increase in the indications for mechanical thrombectomy and its implementation in Spanish hospitals makes it necessary to determine the costs related to this treatment so as to be able to streamline economic resources and allow them to be distributed in an appropriate manner. Aims. To analyse the direct costs associated with patients with acute ischaemic stroke who are treated with intravenous fibrinolysis and with mechanical thrombectomy, and to assess the effectiveness and safety of both treatments during the first 90 days of progression in the Hospital Universitario Central de Asturias. Patients and methods. A retrospective analysis was performed that included 44 patients who received intravenous fibrinolysis and 61 patients treated with mechanical thrombectomy, in whom a series of clinical and economic variables were analysed. Results. The mean final total cost per patient was 16,059 euros in treatments with thrombectomy and 8,169 euros in those in which intravenous fibrinolysis was administered. The percentage of patients with a good functional prognosis at 90 days was 63.93% in those treated by endovascular means and 56.82% in those who received intravenous fibrinolysis. Mortality rates were 18.03 and 11.36%, respectively. Conclusions. The mean cost of treatment with mechanical thrombectomy, as well as the total mean cost per patient during the acute phase of the disease associated with this technique, is higher than in the case of intravenous fibrinolysis. In our setting, both intravenous fibrinolysis and mechanical thrombectomy are considered to be effective and safe (AU)

Endovascular reconstruction of internal carotid artery dissection in patients with acute ischemic stroke using the Wingspan stent.

OBJECTIVE: The purpose of this study is to demonstrate our experience in endovascular reconstruction of carotid dissections using the Wingspan Stent System™ (Boston Scientific, Natick, MA, USA), a device we use because of its high radial force and its navigation in extreme curves. METHODS: We treated 11 consecutive patients with acute ischemic stroke due to carotid dissection with the Wingspan stent, in the cervical carotid artery. RESULTS: Functional evaluation revealed that 10 of the 11 patients were independent at 3 months post surgery and that the 11 stents used were found to be patent at the 6-month follow-up digital subtraction angiography (DSA). CONCLUSIONS: The Wingspan stent is an alternative to classic carotid stents and flow diverters for the treatment of cervical internal carotid artery (ICA) dissection associated with ectasias or large loops. The device remains patent over the long term and it is not associated with arterial wall complications.

Diferencias de sexo en el abordaje integral del ictus en un área sanitaria rural de Asturias / Sex differences in the integrated stroke management in a rural healthcare area in Asturias

Introducción. Las diferencias de sexo y el carácter (rural o urbano) de las poblaciones determinan en gran medida el abordaje integral de patologías dependientes del tiempo, como el ictus, principal causa de hospitalización y mortalidad femenina en nuestro medio. Objetivo. Determinar si en un área sanitaria rural del Principado de Asturias se ponen de manifiesto las características diferenciales entre mujeres y hombres con ictus. Pacientes y métodos. Estudio descriptivo retrospectivo realizado en el Hospital de Jarrio. Se revisaron variables a través de las historias clínicas informatizadas de los pacientes que sufrieron ictus en 2013. Resultados. Se produjeron 126 altas totales, el 53,2% en las mujeres, que sufrieron la enfermedad con un retraso de cinco años (p < 0,008) en relación con los varones, los cuales fueron más fumadores y consumidores perjudiciales de alcohol (p < 0,000). La demora prehospitalaria no arrojó diferencias de sexo significativas. El trastorno del lenguaje fue el síntoma principal en el grupo femenino (p < 0,008), que registró una puntuación superior en la National Institute of Health Stroke Scale (p < 0,046). Los estudios complementarios, como el Holter (p < 0,04) y la ecografía de troncos supraaórticos (p < 0,02), se realizaron menos en las mujeres, que recibieron un tratamiento principalmente conservador con mayor hidratación parenteral (p < 0,017) y reposo. El grupo femenino sufrió más complicaciones, discapacidad al alta (p < 0,001) y a los tres meses (p < 0,004), y registró porcentajes más elevados de institucionalización posterior (p< 0,005). Conclusiones. Existen diferencias de sexo demográfi cas, en el perfi l de riesgo cerebrovascular, la presentación clínica, el manejo hospitalario y la comorbilidad del ictus en esta población rural, que sugieren áreas de mejora (AU)

Introduction. Sex differences and the (rural or urban) nature of populations largely determine the integrated management of time-dependent pathologies such as strokes, which is the main cause of female hospitalisation and mortality in our setting. Aim. To determine whether any differential characteristics can be observed between male and female stroke patients in a rural healthcare area in the Principality of Asturias. Patients and methods. A descriptive retrospective study was conducted at the Jarrio Hospital. Different variables were reviewed using the computerised medical records of patients who suffered a stroke in 2013. Results. Altogether 126 patients were discharged, 53.2% among females, who suffered the disease with a five-year delay (p < 0.008) with respect to males. These latter smoked more and also drank harmful amounts of alcohol (p < 0.000). The pre-hospital delay did not yield any significant sex differences. Language disorder was the main symptom in the female group (p < 0.008), who scored higher on the National Institute of Health Stroke Scale (p < 0.046). Complementary studies, such as Holter monitoring (p < 0.04) and ultrasound scanning of the supra-aortic trunks (p < 0.02), are conducted less often in females, who mainly received conservative treatment with greater parenteral hydration (p < 0.017) and rest. The female group suffered more complications, disability at discharge (p < 0.001) and at three months (p < 0.004), and recorded higher percentages of subsequent institutionalisation (p < 0.005). Conclusions. There are demographic sex differences in the cerebrovascular risk profi le, clinical presentation, hospital management and comorbidity of stroke in this rural population, which suggest that there are areas where there is room for improvement (AU)

Vitamin K antagonist-associated intracerebral hemorrhage: lessons from a devastating disease in the dawn of the new oral anticoagulants.

BACKGROUND: Intracerebral hemorrhage (ICH) is the most feared complication associated with vitamin K antagonists (VKAs). We performed a retrospective study on the clinicoradiologic characteristics that influence its outcome. METHODS: We reviewed the clinical histories and neuroimaging studies of all patients attended at the Hospital Universitario Central de Asturias in 2010-2011 who had an ICH while being on VKA and analyzed the differential characteristics between patients with acceptable versus poor outcomes attending to 3 end points: death, poor outcome (modified Rankin Scale [mRS] score ≥ 4) at discharge, and poor outcome 3 months later. Additionally, CHA2DS2-VASc and HAS-BLED scores (validated tools for prediction of the risk of stroke and major hemorrhage, respectively, in patients with atrial fibrillation) were calculated to assess a priori risk-benefit balance for anticoagulant therapy. RESULTS: Eighty patients entered the sample (median age of 79 years). A priori annual risk of major bleeding surpassed ischemic stroke risk-without anticoagulation-only in 4. Fifty percent of the patients had an initial Glasgow Coma Scale (GCS) score lower than 13; in 51.3%, initial international normalized ratio was above their therapeutic range. Median hematoma size was 24.75 cc(3); relevant growth (≥33%) occurred in 29.4% of patients with a second computed tomography scan. On multivariable analysis, overall in-hospital mortality (47.5%) was related to prior antiplatelet therapy (P = .008), GCS (P = .001), and perilesional edema size (P = .036). Baseline mRS (P = .058) and National Institutes of Health Stroke Scale (NIHSS) scores (P = .008) were associated with poor outcome at discharge (77.5%). Initial NIHSS (P = .005) and glycemia (P = .038) predicted 3-month poor outcome (68.3%). VKA reversal was performed in almost all patients, which prevented assessment of its therapeutic value. CONCLUSIONS: VKA-associated ICH presents in a particularly vulnerable population and has a poor prognosis that may be reliably predicted by several clinicoradiologic features.

Diagnóstico del ictus por cocaína y sus complicaciones / Diagnosis of stroke due to cocaine and its complications

Introducción. La cocaína es un factor de riesgo cerebrovascular independiente, tanto para eventos isquémicos como hemorrágicos, sobre todo entre los menores de 55 años. Caso clínico. A través de un caso clínico de ictus por consumo de cocaína, se revisa su fisiopatología y la complejidad en el manejo y diagnóstico de las complicaciones asociadas. Una de estas complicaciones descritas en relación con el consumo de cocaína es el vasoespasmo. Esta entidad comparte con otras entidades, como la hiperperfusión postisquémica precoz, los hallazgos en estudios ecográficos. Sin embargo, ambas presentan importantes diferencias en cuanto a tratamiento y pronóstico se refiere. Conclusiones. El consumo de cocaína se asocia con la enfermedad cerebrovascular a través de múltiples mecanismos, de los que se derivan diferentes complicaciones. Identificar estas complicaciones permite su correcto abordaje (AU)

Introduction. Cocaine is an independent cerebrovascular risk factor both for ischaemic and haemorrhagic events, above all among persons under 55 years of age. Case report. A case report of stroke due to the consumption of cocaine is used to review its pathophysiology and the complexity involved in the management and diagnosis of the associated complications. One of these complications reported in relation to the consumption of cocaine is vasospasm. This condition shares findings observed in ultrasound imaging studies with other conditions, such as early-onset post ischaemic hyperperfusion. Yet, there are important differences between the two as regards their treatment and prognosis. Conclusions. The consumption of cocaine is associated with cerebrovascular disease through a number of different mechanisms, which each give rise to different complications. By identifying these complications, correct management can be implemented (AU)

Tiempo sigue siendo cerebro: la pelota en el tejado del tratamiento intervencionista neurovascular / Time is still brain: the ball is in the court of neurovascular interventionist treatment

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[Migraine as a vascular risk factor]. / La migraña como factor de riesgo vascular.

INTRODUCTION: Migraine and stroke are associated with a higher frequency than expected. Numerous studies have shown a significant, but controversial, association between migraine and vascular disease, not only in cerebral but also in other arterial beds. The full spectrum of this relationship includes coexisting stroke and migraine, stroke with clinical features of migraine and migraine-induced stroke. Why migraine is a risk factor and how it leads to stroke is not entirely understood, possibly because the mechanisms involved are multiple, complex and interrelated. AIM: Emphasizing the most recent papers, we review critically the current knowledge about the causal relationship between migraine and vascular disease and discuss its pathophysiology. DEVELOPMENT: Migraine is an independent risk factor for stroke, especially for young women with frequent migraine with aura attacks, who smoke and use oral contraceptives. Migraine has also been associated with lesions in the white matter and in other vascular territories. Potential pathogenic mechanisms include endothelium and vascular smooth muscle dysfunction, hypercoagulability, cortical spreading depression, genetic factors, patent foramen ovale, unfavourable vascular risk profile, arterial dissection and migraine-specific treatment. CONCLUSION: Considering that cerebrovascular disease is a major cause of disability and mortality and that migraine is a risk factor for vascular disease, understanding the relationship between migraine and vascular disease is necessary to reduce risks and optimize management and treatment.

La migraña como factor de riesgo vascular / Migraine as a vascular risk factor

Introducción. Migraña e ictus se asocian con una frecuencia superior a lo esperable. Aunque controvertida, múltiples estudios demuestran una asociación significativa entre migraña y patología vascular no sólo cerebral, sino también en otros lechos arteriales. El espectro de la relación entre migraña e ictus comprende relaciones de coexistencia, semejanza y causalidad. Los mecanismos por los que la migraña llega a ser un factor de riesgo vascular y conduce al desarrollo de un ictus no son del todo conocidos, posiblemente porque sean múltiples, complejos e interrelacionados entre sí. Objetivo. Poniendo énfasis en los artículos más recientes, se revisa críticamente el estado actual acerca de la relación de causalidad entre migraña y enfermedad vascular, y se discute su fisiopatología. Desarrollo. La migraña es un factor de riesgo independiente de ictus, especialmente en el subgrupo de población comprendido por mujeres jóvenes, con migraña con aura, crisis frecuentes, fumadoras y en tratamiento con anticonceptivos orales. Además, se asocia con lesiones de la sustancia blanca y patología vascular en otros territorios arteriales. Disfunción del endotelio y musculatura vascular, hipercoagulabilidad, depresión propagada cortical, factores genéticos, foramen oval permeable, perfil desfavorable de riesgo vascular, disección arterial y el tratamiento específico de migraña se postulan como mecanismos patogénicos. Conclusiones. Si la enfermedad cerebrovascular es una importante causa de invalidez y mortalidad, y la migraña es un factor de riesgo de enfermedad vascular, comprender la relación entre migraña y enfermedad vascular es necesario para reducir riesgos y optimizar su manejo y tratamiento (AU)

Introduction. Migraine and stroke are associated with a higher frequency than expected. Numerous studies have shown a significant, but controversial, association between migraine and vascular disease, not only in cerebral but also in other arterial beds. The full spectrum of this relationship includes coexisting stroke and migraine, stroke with clinical features of migraine and migraine-induced stroke. Why migraine is a risk factor and how it leads to stroke is not entirely understood, possibly because the mechanisms involved are multiple, complex and interrelated. Aim. Emphasizing the most recent papers, we review critically the current knowledge about the causal relationship between migraine and vascular disease and discuss its pathophysiology. Development. Migraine is an independent risk factor for stroke, especially for young women with frequent migraine with aura attacks, who smoke and use oral contraceptives. Migraine has also been associated with lesions in the white matter and in other vascular territories. Potential pathogenic mechanisms include endothelium and vascular smooth muscle dysfunction, hypercoagulability, cortical spreading depression, genetic factors, patent foramen ovale, unfavourable vascular risk profile, arterial dissection and migraine-specific treatment. Conclusion. Considering that cerebrovascular disease is a major cause of disability and mortality and that migraine is a risk factor for vascular disease, understanding the relationship between migraine and vascular disease is necessary to reduce risks and optimize management and treatment (AU)

Controversia. Dabigatrán en el tratamiento preventivo del ictus embólico: en contra de su utilización como fármaco de primera línea / No disponible

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