No association between migraine frequency, white matter lesions and silent brain infarctions: a study in a series of women with chronic migraine.

BACKGROUND AND PURPOSE: It has been suggested that silent infarctions (SIs) and hyperintense white matter lesions (WMLs) are related to migraine frequency. We studied their prevalence and anatomical distribution in patients with chronic migraine (CM). METHODS: A total of 96 women with CM [mean age 43 (range 16-65) years] and 29 women with episodic migraine (EM) [mean age 36 (range 16-58) years] underwent 1.5-T magnetic resonance imaging following the CAMERA protocol. The number, size and location of SIs and deep WMLs were recorded and a modified Fazekas scale was applied to assess periventricular WMLs. RESULTS: White matter lesions were found in 59 (61.5%) women with CM and 17 (58.6%) women with EM (odds ratio, 1.13; 95% confidence intervals, 0.48-2.62; P = 0.784). The majority (63% CM and 71% EM) were small deep WMLs. Exclusive periventricular WMLs were exceptional. Of the 739 WMLs seen in patients with CM, 734 (99.3%) were hemispheric and mostly frontal (81%). Posterior fossa WMLs were seen in only five (5.2%) women with CM (always in the pons) and two (6.9%) women with EM. Age >45 years was the only vascular risk factor associated with a higher WML number (median: 0 < 45 years and 3 > 45 years; P = 0.004). We found seven SIs in six women with CM (6.3%). CONCLUSIONS: As compared with the expected prevalence at this age, this study confirms that the prevalence of WMLs, in most cases small, deep and frontal, was increased in CM and EM. However, our results do not support an association of WMLs or SIs with a higher frequency of attacks, but with the presence of vascular risk factors and mainly age >45 years.

El código ictus de Asturias / Code stroke in Asturias

Introducción: La trombólisis intravenosa con alteplasa es un tratamiento efectivo para el ictus isquémico si se aplica dentro de las primeras 4,5 horas, pero al que acceden <15% de los pacientes. La trombectomía mecánica recanaliza más obstrucciones proximales en las grandes arterias, pero necesita una infraestructura que la hace menos disponible. Métodos: Se detalla la evolución del código ictus en el Principado de Asturias y la adaptación del mismo a los sucesivos recursos para la atención urgente al ictus en la región. Teniendo en cuenta dichos recursos, las circunstancias poblacionales y geográficas de nuestra región, se plantea la reorganización del código ictus buscando la optimización del tiempo y la adecuación a cada paciente. Resultados: Reparto de las ocho áreas sanitarias de Asturias para derivar los pacientes candidatos a tratamientos de reperfusión hacia los dos hospitales donde se dispone de Unidad de Ictus y guardia de Neurología, con posibilidad de aplicar la fibrinólisis IV. Este reparto se realizó en función de la proximidad y la gravedad de los mismos, derivando todos los casos más graves directamente al hospital que dispone de guardia de Neurorradiología Intervencionista. El cribado del paciente se realizó por los Servicios de Emergencias Extrahospitalarias según la escala NIHSS. Conclusiones: Las modificaciones en el código ictus de Asturias permiten ofrecer tratamientos recanalizadores con buenos resultados, buscando la equidad y optimizando el manejo del binomio gravedad-tiempo para ofrecer a cada paciente el tratamiento óptimo en el menor plazo de tiempo posible y en condiciones de seguridad

Background: Intravenous thrombolysis with alteplase is an effective treatment for ischaemic stroke when applied during the first 4.5 hours, but less than 15% of patients have access to this technique. Mechanical thrombectomy is more frequently able to recanalise proximal occlusions in large vessels, but the infrastructure it requires makes it even less available. Methods: We describe the implementation of code stroke in Asturias, as well as the process of adapting various existing resources for urgent stroke care in the region. By considering these resources, and the demographic and geographic circumstances of our region, we examine ways of reorganising the code stroke protocol that would optimise treatment times and provide the most appropriate treatment for each patient. Results: We distributed the 8 health districts in Asturias so as to permit referral of candidates for reperfusion therapies to either of the 2 hospitals with 24-hour stroke units and on-call neurologists and providing IV fibrinolysis. Hospitals were assigned according to proximity and stroke severity; the most severe cases were immediately referred to the hospital with on-call interventional neurology care. Patient triage was provided by pre-hospital emergency services according to the NIHSS score. Conclusions: Modifications to code stroke in Asturias have allowed us to apply reperfusion therapies with good results, while emphasising equitable care and managing the severity-time ratio to offer the best and safest treatment for each patient as soon as possible

Code stroke in Asturias.

BACKGROUND: Intravenous thrombolysis with alteplase is an effective treatment for ischaemic stroke when applied during the first 4.5 hours, but less than 15% of patients have access to this technique. Mechanical thrombectomy is more frequently able to recanalise proximal occlusions in large vessels, but the infrastructure it requires makes it even less available. METHODS: We describe the implementation of code stroke in Asturias, as well as the process of adapting various existing resources for urgent stroke care in the region. By considering these resources, and the demographic and geographic circumstances of our region, we examine ways of reorganising the code stroke protocol that would optimise treatment times and provide the most appropriate treatment for each patient. RESULTS: We distributed the 8 health districts in Asturias so as to permit referral of candidates for reperfusion therapies to either of the 2 hospitals with 24-hour stroke units and on-call neurologists and providing IV fibrinolysis. Hospitals were assigned according to proximity and stroke severity; the most severe cases were immediately referred to the hospital with on-call interventional neurology care. Patient triage was provided by pre-hospital emergency services according to the NIHSS score. CONCLUSIONS: Modifications to code stroke in Asturias have allowed us to apply reperfusion therapies with good results, while emphasising equitable care and managing the severity-time ratio to offer the best and safest treatment for each patient as soon as possible.

[Familial spontaneous intracranial hypotension]. / Síndrome de hipotensión intracraneal espontánea de presentación familiar.

INTRODUCTION: Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache and diffuse dural gadolinium enhancement on magnetic resonance imaging. Spontaneous intracranial hypotension is caused by spinal cerebrospinal fluid leaks and evidence for an underlying generalized connective tissue disorder is found in about two thirds of patients. There had been no familial cases reported to date. CASE REPORT: We describe the case report of three healthy female patients with spontaneous intracranial hypotension who belong to the same family. They have no cutaneous or articular stigmas of connective tissue disease. DISCUSSION: These familial cases of spontaneous SIH suggest that certain underlying genetic susceptibility, probably linked to lower resistance of the spinal meninges, could favor the development of spontaneous intracranial hypotension.

Síndrome de hipotensión intracraneal espontánea de presentación familiar / Familial spontaneous intracranial hypotension

Introducción. El síndrome de hipotensión intracraneal (SHI) espontánea se caracteriza por la existencia de cefalea ortostática asociada a engrosamiento con captación de gadolinio de la duramadre cerebral en los estudios de resonancia magnética. Su origen es la depleción de volumen de líquido cefalorraquídeo por una fuga dural espinal y en cerca de dos tercios de estos pacientes existe un posible trastorno subyacente del tejido conectivo. No se han descrito hasta la fecha casos familiares. Caso clínico. Describimos los casos clínicos de tres mujeres con un SHI espontánea pertenecientes a una misma familia y sin estigmas cutáneos o articulares de enfermedad del tejido conectivo. Discusión. La agrupación familiar de estas pacientes con SIH espontánea apoya la posibilidad de que cierta predisposición genética, probablemente ligada a una menor resistencia de las meninges espinales, podría favorecer el desarrollo del SHI espontánea (AU)

Introduction: Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache and diffuse dural gadolinium enhancement on magnetic resonance imaging. Spontaneous intracranial hypotension is caused by spinal cerebrospinal fluid leaks and evidence for an underlying generalized connective tissue disorder is found in about two thirds of patients. There had been no familial cases reported to date. Case report: We describe the case report of three healthy female patients with spontaneous intracranial hypotension who belong to the same family. They have no cutaneous or articular stigmas of connective tissue disease. Discussion: These familial cases of spontaneous SIH suggest that certain underlying genetic susceptibility, probably linked to lower resistance of the spinal meninges, could favor the development of spontaneous intracranial hypotension (AU)