Endovascular occlusion of pial arteriovenous macrofistulae, using pCANvas1 and adenosine-induced asystole to control nBCA injection.

Background In large-caliber pial macrofistulae (pMF), the combination of high blood flow velocity and large efferent artery diameter makes control over the endovascular vessel occlusion difficult and may result in the inadvertent venous passage of occlusive devices or embolic agents. Case descriptions Patient 1: A 27-year-old man presented with headache and ataxia. An infratentorial pMF supplied by both superior cerebellar arteries with venous ectasia was found. The first treatment attempt using balloons and coils failed since the position of either device could not be controlled because of a distal diameter of the feeding artery of 8 mm. In a second session a pCANvas1 (phenox) was deployed at the level of the arteriovenous connection and adenosine-induced asystole allowed the controlled injection of nBCA/Lipiodol with partial occlusion of the pMF. A remaining arteriovenous shunt was occluded under asystole in a third session. The procedures were well tolerated, the patient returned to normal and DSA confirmed the occlusion of the fistula. Patient 2: A 13-year-old boy with hereditary hemorrhagic teleangiectasia presented with an intracerebral hemorrhage from an aneurysm of the left MCA. Twelve weeks after the aneurysm treatment a feeding MCA branch (diameter 4.5 mm) of a right frontal pMF was catheterized. The macrofistula was occluded by deployment of a pCANvas1, followed by the injection of nBCAl/Lipiodol under adenosine-induced asystole. Conclusion pCANvas1 and adenosine-induced asystole allow a controlled injection of nBCA/Lipiodol for the endovascular occlusion of high-flow pMF without venous passage of the embolic agent.

Oclusión arterial de gran vaso diagnosticada por angiografía portomografía computarizada en el ictus isquémico agudo: frecuencia, factores predictores y seguridad / Large artery occlusion diagnosed by computed tomography angiography in acute ischaemic stroke: frequency, predictive factors, and safety

Introducción: Con la creciente disponibilidad de las terapias endovasculares, la demostración de oclusión arterial en el ictus isquémico agudo ha cobrado mayor relevancia. Este estudio evalúa la frecuencia de oclusión arterial y los factores asociados a la misma, así como las complicaciones derivadas del uso de angio-TC en el ictus agudo. Métodos: Se analizan retrospectivamente a los pacientes con ictus isquémico entre el 1 de julio y el 31 de diciembre del 2011. Resultados: Ciento cincuenta y siete pacientes (edad media de 74±11 años, NIHSS 5 [2-13]). Un 56,7% llegó al hospital con menos de 8 h de evolución. Se realizó angio-TC en 71 casos (45,2%), detectando oclusión de gran vaso en 37 (52,1%). La localización más frecuente fue M1 (40%). En el análisis univariante se halló asociación de la escala NIHSS (17 vs. 7, p < 0,001) y la fibrilación auricular (64% vs. 32%, p = 0,006) con la presencia de oclusión arterial. Posteriormente, se realizó una regresión logística, confirmando dicha asociación. No se observó ningún caso de nefropatía por contraste. El tiempo puerta-aguja para fibrinólisis intravenosa fue de 61,2 ± 24,5 min en los pacientes en que se realizó angio-TC y 53,5 ± 34,3 en los que no se realizó (p = 0,495). Conclusiones: La oclusión de gran vaso se detecta en el 23,6% de la muestra, especialmente en los pacientes traídos en las primeras horas. La escala NIHSS es un buen factor predictor

Introduction: Demonstrating artery occlusion in ischaemic stroke has gained importance due to the increasing availability of endovascular therapies. This study evaluates the frequency of artery occlusion, its associated factors, and complications following the use of CT-angiography in acute stroke. Methods: We retrospectively analysed a cohort of patients who suffered acute ischaemic stroke between July and-December 2011. Results: We included 157 patients (mean age, 74 ± 11; mean NIHSS score, 5 [2-13]). Of that total, 56.7% of the patients were admitted to hospital during the first 8 hours. CT-angiography was performed in 71 cases (45.2%); arterial large-vessel occlusion was detected in 37 (52.1%) of these cases, and the most frequent site was M1 (40%). Univariate analysis showed that the NIHSS score (17 vs 7, P < .001) and atrial fibrillation (64% vs 32%, P = .006) were associated with artery occlusion. A logistic regression analysis was performed subsequently, confirming theseassociations. There were no cases of contrast-induced nephropathy. Door-to-needle time for intravenous thrombolysis was 61.2 ± 24.5 minutes in patients who underwent CT-angiography, and 53.5±34.3 minutes in those who did not (P = .495). Conclusions: Arterial occlusions are seen in 23.6% of patients, especially in those who are admitted during the first few hours. NIHSS score serves as a useful predictive factor

Large artery occlusion diagnosed by computed tomography angiography in acute ischaemic stroke: frequency, predictive factors, and safety.

INTRODUCTION: Demonstrating artery occlusion in ischaemic stroke has gained importance due to the increasing availability of endovascular therapies. This study evaluates the frequency of artery occlusion, its associated factors, and complications following the use of CT-angiography in acute stroke. METHODS: We retrospectively analysed a cohort of patients who suffered acute ischaemic stroke between July and-December 2011. RESULTS: We included 157 patients (mean age, 74±11; mean NIHSS score, 5 [2-13]). Of that total, 56.7% of the patients were admitted to hospital during the first 8hours. CT-angiography was performed in 71 cases (45.2%); arterial large-vessel occlusion was detected in 37 (52.1%) of these cases, and the most frequent site was M1 (40%). Univariate analysis showed that the NIHSS score (17 vs 7, P<.001) and atrial fibrillation (64% vs 32%, P=.006) were associated with artery occlusion. A logistic regression analysis was performed subsequently, confirming these associations. There were no cases of contrast-induced nephropathy. Door-to-needle time for intravenous thrombolysis was 61.2±24.5minutes in patients who underwent CT-angiography, and 53.5±34.3minutes in those who did not (P=.495). CONCLUSIONS: Arterial occlusions are seen in 23.6% of patients, especially in those who are admitted during the first few hours. NIHSS score serves as a useful predictive factor.

Estenosis crítica de arteria basilar asociada a inestabilidad clínica: propuesta de una nueva indicación de tratamiento endovascular agudo / Critical stenosis of the basilar artery associated with clinical instability: new proposed indication for acute endovascular treatment

No disponible

Patient radiation dose management in the follow-up of potential skin injuries in neuroradiology.

BACKGROUND AND PURPOSE: Radiation exposure from neurointerventional procedures can be substantial, with risk of radiation injuries. We present the results of a follow-up program applied to potential skin injuries in interventional neuroradiology based on North American and European guidelines. MATERIALS AND METHODS: The following guidelines approved in 2009 by SIR and CIRSE have been used over the last 2 years to identify patients with potential skin injuries requiring clinical follow-up: peak skin dose >3 Gy, air kerma at the patient entrance reference point >5 Gy, kerma area product >500 Gy · cm(2), or fluoroscopy time >60 minutes. RESULTS: A total of 708 procedures (325 in 2009 and 383 in 2010) were included in the study. After analyzing each dose report, 19 patients (5.9%) were included in a follow-up program for potential skin injuries in 2009, while in 2010, after introducing several optimizing actions and refining the selection criteria, only 4 patients (1.0%) needed follow-up. Over the last 2 years, only 3 patients required referral to a dermatology service. CONCLUSIONS: The application of the guidelines to patient radiation dose management helped standardize the selection criteria for including patients in the clinical follow-up program of potential skin radiation injuries. The peak skin dose resulted in the most relevant parameter. The refinement of selection criteria and the introduction of a low-dose protocol in the x-ray system, combined with a training program focused on radiation protection, reduced the number of patients requiring clinical follow-up.

El acceso arterial humeral: una vía alternativa al acceso femoral en el tratamiento endovascular del ictus agudo / Humeral arterial access: an alternative route to the femoral artery in the endovascular treatment of acute stroke

No disponible

[From the evidence to the organisation of stroke care]. / De la evidencia a la organización de la atención al ictus.

INTRODUCTION: Acute stroke care in stroke units (SU) compared to care in general medicine wards provides benefits to the patient. DEVELOPMENT: Acute stroke care in an SU has shown benefits in reducing mortality, institutionalisation, dependency and costs compared to care in internal medicine wards, and even a lower risk of recurrence in the long term. The benefits are associated with specific treatments developed in the SU, such as thrombolytic therapy, development of clinical pathways, standardised procedures, and training and experience of professionals in the SU. This evidence should lead to the proper organisation of hospitals to ensure that all acute stroke patients may benefit from care in an SU. The introduction of SUs is a priority in Europe, although the number of stroke patients admitted to SUs is still low. CONCLUSIONS: Based on current evidence, acute stroke patients should be cared for in an SU due to the associated clinical benefits and hospitals should organise to provide this care to patients.

[Endovascular treatment for acute stroke: an open field to begin]. / Tratamiento endovascular del ictus agudo: un campo muy abierto que está por iniciar.

INTRODUCTION: The evidence that recanalization and reperfusion of the distal vascular bed in appropriately selected patients is crucial to achieve good functional outcome has triggered interest and research into endovascular treatment of acute ischemic stroke. DEVELOPMENT: Intravenous (iv) thrombolytic therapy is the treatment of choice in patients with acute ischemic stroke, however, it has certain limitations. Endovascular treatment is a promising alternative with theoretical advantages over iv therapy, such as an increased frequency of recanalization and longer therapeutic windows. Endovascular reperfusion strategies include intra-arterial fibrinolysis with drugs, or endovascular mechanical devices for thrombectomy or thrombus disruption, thromboaspiration, or thrombus entrapment in the vessel wall. The ideal of comprehensive treatment of acute stroke would provide specificity to treat an individual patient: with specific arterial occlusion and collaterals and a determined physiology of acute cerebral ischemia. With all this information, we would decide the best therapeutic strategy for the patient, and move from just a time-based approach to include a pathophysiology approach as well, and thus different patients could have different therapeutic windows. The endovascular treatment situation in Spain is heterogeneous and requires human and material resources to enable it to be implemented throughout the country. CONCLUSIONS: Endovascular treatment of stroke is a new therapeutic tool for achieving reperfusion safely in patients ineligible for Alteplase or who have failed reperfusion with an iv fibrinolytic.

Tratamiento endovascular del ictus agudo: un campo muy abierto que está por iniciar / Endovascular treatment for acute stroke: an open field to begin

Introducción: La evidencia de que la recanalización y la reperfusión del lecho vascular distal de pacientes adecuadamente seleccionados son fundamentales para lograr un buen pronóstico funcional ha disparado el interés y la investigación sobre el tratamiento endovascular del ictus isquémico agudo. Desarrollo: La fibrinólisis intravenosa (i.v.) es el tratamiento de elección en pacientes con ictus isquémico agudo, aunque presenta ciertas limitaciones. El tratamiento endovascular supone una alternativa prometedora con ventajas teóricas sobre el tratamiento i.v., como una mayor frecuencia de recanalización y mayor ventana terapéutica. Las estrategias de reperfusión endovascular incluyen fibrinólisis intraarterial con fármacos o tratamiento mecánico con dispositivos que permiten extracción, aspiración, disrupción o atrapamiento del trombo en la pared. El ideal del tratamiento integral del ictus agudo sería aportar especificidad al paciente individual: tratar una oclusión arterial con unas colaterales y con una fisiología de la isquemia cerebral aguda determinadas. Con todos estos datos, ante cualquier paciente podremos decidir la mejor estrategia terapéutica y pasar de un enfoque del paciente basado únicamente en el tiempo a un enfoque basado también en la fisiopatología; por lo tanto, distintos pacientes tendrían diferentes ventanas terapéuticas. La situación del tratamiento endovascular en España es heterogénea y precisa de recursos materiales y humanos para conseguir su implantación en todo el territorio. Conclusiones: El tratamiento endovascular del ictus supone una nueva herramienta terapéutica para lograr la reperfusión de una forma segura en los pacientes no candidatos a alteplasa o que no han conseguido reperfundir con el fibrinolítico i.v (AU)

Introduction: The evidence that recanalization and reperfusion of the distal vascular bed in appropriately selected patients is crucial to achieve good functional outcome has triggered interest and research into endovascular treatment of acute ischemic stroke.Development: Intravenous (iv) thrombolytic therapy is the treatment of choice in patients with acute ischemic stroke, however, it has certain limitations. Endovascular treatment is a promising alternative with theoretical advantages over iv therapy, such as an increased frequency of recanalization and longer therapeutic windows. Endovascular reperfusion strategies include intra-arterial fibrinolysis with drugs, or endovascular mechanical devices for thrombectomy or thrombus disruption, thromboaspiration, or thrombus entrapment in the vessel wall. The ideal of comprehensive treatment of acute stroke would provide specificity to treat an individual patient: with specific arterial occlusion and collaterals and a determined physiology of acute cerebral ischemia. With all this information, we would decide the best therapeutic strategy for the patient, and move from just a time-based approach to include a pathophysiology approach as well, and thus different patients could have different therapeutic windows. The endovascular treatment situation in Spain is heterogeneous and requires human and material resources to enable it to be implemented throughout the country. Conclusions: Endovascular treatment of stroke is a new therapeutic tool for achieving reperfusion safely in patients ineligible for Alteplase or who have failed reperfusion with an iv fibrinolytic (AU)

[Carotid artery disease and human immunodeficiency virus (HIV) infection]. / Enfermedad vascular carotídea e infección por virus de inmunodeficiencia humana.

INTRODUCTION: Human immunodeficiency virus (HIV) infection provides patients an increased vascular risk, related to traditional vascular risk factors and metabolic and vascular disease induced by antiretroviral treatment and HIV infection itself. METHODS: By reviewing current literature, this article analyses meaning and measurement of subclinical atherosclerosis in general population; factors inducing vascular risk in HIV infected patients; and published evidence about subclinical atherosclerosis in this population. RESULTS: Carotid ultrasound measurement of carotid intimamedia thickness and atherosclerotic plaques, as surrogate markers of vascular risk, allows non-invasive quantification of subclinical atherosclerosis and it predicts vascular risk, of acute myocardial infarction or stroke. Studies in HIV-infected patients show different results, due to methodological heterogeneity that difficults comparisons. Most studies found a higher degree and progression of subclinical carotid atherosclerosis in HIV positive patients, compared to non-infected HIV controls, and it is associated to classical vascular risk factors, antiretroviral treatment and HIV infection itself. CONCLUSION: Carotid ultrasound in HIV patients could stratify vascular risk in these patients and it represents an efficacious tool in atherosclerosis study.

Enfermedad vascular carotídea e infección por virus de inmunodeficiencia humana / Carotid artery disease and human immunodeficiency virus (HIV) infection

Introducción. La infección por virus de inmunodeficiencia humana(VIH) confiere a los pacientes un aumento del riesgo vascular,en relación con los factores de riesgo vascular tradicionales y la alteraciónmetabólica y vascular inducida por el tratamiento antirretroviraly la propia infección.Métodos. Tras revisión de la bibliografía se analiza el significadode arteriosclerosis subclínica en la población general y su medición,los factores que condicionan el riesgo vascular en los pacientes coninfección por VIH, y los estudios de arteriosclerosis subclínica en estapoblación.Resultados. La medición mediante ecografía carotídea del grosorde íntima media y placas arterioscleróticas, como marcadores subrogadosde riesgo vascular, permite cuantificar la arteriosclerosissubclínica y predecir riesgo vascular, de infarto agudo de miocardio oictus, de forma no invasiva. Los estudios realizados en pacientes coninfección por VIH muestran resultados diferentes, probablemente porla heterogeneidad metodológica que dificulta su comparación. Lamayoría de estudios demuestran un mayor grado de arteriosclerosissubclínica carotídea y una mayor progresión de la misma en la poblaciónVIH positiva respecto a controles no infectados por el VIH; yestá asociada a factores de riesgo vascular clásicos, al tratamientoantirretroviral y a la infección por VIH en sí misma.Conclusión. La ecografía carotídea en los pacientes con infecciónpor VIH permitiría estratificar el riesgo vascular en estos pacientesy constituye una herramienta eficaz en el estudio de la arteriosclerosis (AU)

Introduction. Human immunodeficiency virus (HIV) infectionprovides patients an increased vascular risk, related to traditionalvascular risk factors and metabolic and vascular diseaseinduced by antiretroviral treatment and HIV infection itself.Methods. By reviewing current literature, this article analysesmeaning and measurement of subclinical atherosclerosis ingeneral population; factors inducing vascular risk in HIV infectedpatients; and published evidence about subclinical atherosclerosisin this population.Results. Carotid ultrasound measurement of carotid intimamediathickness and atherosclerotic plaques, as surrogate markersof vascular risk, allows non-invasive quantification of subclinicalatherosclerosis and it predicts vascular risk, of acutemyocardial infarction or stroke. Studies in HIV-infected patientsshow different results, due to methodological heterogeneity thatdifficults comparisons. Most studies found a higher degree andprogression of subclinical carotid atherosclerosis in HIV positivepatients, compared to non-infected HIV controls, and it is associatedto classical vascular risk factors, antiretroviral treatmentand HIV infection itself.Conclusion. Carotid ultrasound in HIV patients could stratifyvascular risk in these patients and it represents an efficacioustool in atherosclerosis study (AU)

Churg-Strauss syndrome triggered by hyposensitization to Alternaria fungus.

Churg-Strauss syndrome is a systemic vasculitis of unknown ethiology. Exposure to putative triggers have been described. We report a case of Churg-Strauss syndrome developing after specific immunotherapy with Alternaria fungus.

An isolated pituitary metastasis as presentation of a differentiated hepatocellular carcinoma mimicking a nonfunctioning macroadenoma.

The differential diagnosis of sellar masses may be complex. Metastatic disease constitutes 1% of all pituitary lesions and sometimes mimics the clinical-radiological presentation of pituitary adenoma. The definitive diagnosis usually relies on histology, but occasionally even histological features of pituitary metastasis may resemble those of adenomas. We present a patient initially diagnosed with pituitary adenoma, but whose clinical course finally revealed pituitary metastasis of a hepatocellular carcinoma. The existing literature on this topic is reviewed.

[Neuropathic pain as the reason for visiting Neurology: an analysis of its frequency]. / El dolor neuropático como motivo de consulta en Neurología: análisis de su frecuencia.

INTRODUCTION: Neuropathic pain (NP) is defined as pain that begins with or is caused by a primary injury or by a dysfunction in the nervous system. AIMS: Our aim was to evaluate how often patients visit Neurology as outpatients with NP as the main reason for referral. PATIENTS AND METHODS: A descriptive, cross sectional study was carried out on the use of the health care services; patients attended for the first time in a Neurology Screening visit were included consecutively. The variables studied were the following: the number of first visits and the total number of patients attended per visiting session, rate of patients with NP per visiting day, the topography and probable causation of the NP, and the rate of patients referred to the monographic NP clinic; the different quantitative variables are expressed in terms of their mean and standard deviation (SD), whereas the qualitative variables are given as their absolute value and the percentage. A total of 1,972 patients were attended, of whom 1,422 (72.1%) were first visits, with an average of 17.5 (SD: 2.5) new patients per visiting session. RESULTS: In all 113 patients clinically diagnosed with NP were identified, which represents a rate of 7.95% of the first visits. CONCLUSIONS: NP may be among the most frequent causes of the demand for neurological ambulatory care. The most common causes of NP were found to be trigeminal neuralgia, post-herpes neuralgia and diabetic polyneuropathy.

El dolor neuropático como motivo de consulta en Neurología: análisis de su frecuencia / Neuropathic pain as the reason for visiting neurology: an analysis of its frequency

Introducción. El dolor neuropático (DN) se define como aquel dolor iniciado o causado por una lesión primaria o por una disfunción en el sistema nervioso. Objetivo. Evaluar la frecuencia con la que los pacientes con DN como motivo principal de derivación se remiten a una consulta ambulatoria de Neurología. Pacientes y métodos. Se trata de un estudio descriptivo, transversal sobreutilización de los servicios sanitarios; se incluyeron consecutivamente los pacientes atendidos por primera vez en una consulta de Neurología de selección; variables estudiadas: número de primeras visitas y número total de pacientes atendidos por sesión de consulta, tasa de pacientes con DN por día de consulta, la topografía y probable etiología del DN, y la tasa de pacientes remitidos a la consulta monográfica de DN; las diferentes variables cuantitativas se expresarán con su media y desviación estándar (DE), mientras que en las variables cualitativas esto se hará con su valor absoluto y el porcentaje. Se atendieron 1.972 pacientes, de los cuales 1.422(72,1%) fueron primeras visitas, con una media de 17,5 (DE: 2,5) pacientes nuevos por sesión de consulta. Resultados. Se identificaron113 pacientes con diagnóstico clínico de DN, lo que supone una tasa del 7,95% de las primeras visitas. Conclusiones. El DN puede estar entre las causas más frecuentes de demanda de asistencia neurológica ambulatoria. Las causas más frecuentes de DN fueron la neuralgia del trigémino, la neuralgia posherpética y la polineuropatía diabética (AU)

Introduction. Neuropathic pain (NP) is defined as pain that begins with or is caused by a primary injury or by a dysfunction in the nervous system. Aims. Our aim was to evaluate how often patients visit Neurology as outpatients with NPas the main reason for referral. Patients and methods. A descriptive, cross sectional study was carried out on the use of the health care services; patients attended for the first time in a Neurology Screening visit were included consecutively. The variables studied were the following: the number of first visits and the total number of patients attended per visiting session, rate of patients with NP per visiting day, the topography and probable causation of the NP, and the rate of patients referred to the monographic NP clinic; the different quantitative variables are expressed in terms of their mean and standard deviation (SD), whereas the qualitative variables are given as their absolute value and the percentage. A total of 1,972patients were attended, of whom 1,422 (72.1%) were first visits, with an average of 17.5 (SD: 2.5) new patients per visiting session. Results. In all 113 patients clinically diagnosed with NP were identified, which represents a rate of 7.95% of the first visits. Conclusions. NP may be among the most frequent causes of the demand for neurological ambulatory care. The most common causes of NP were found to be trigeminal neuralgia, post-herpes neuralgia and diabetic polyneuropathy (AU)

Estudio neurovascular en la paresia de nervios motores oculares / Neurovascular study in paresis of the ocular motor nerves

No disponible

No disponible