[Management and improvement of the process of outpatient treatment of transient ischemic attacks in Neurology departments]. / Gestión y mejora del proceso de tratamiento ambulatorio del accidente isquémico transitorio en consultas de Neurología.

AIMS: To describe our experience in the ambulatory treatment of transient ischemic attacks (TIA) in a second-level hospital with the implementation of an example of process management within the different services involved in attending such conditions. PATIENTS AND METHODS: The following aspects of the process--mission, limits, flowchart, eligibility criteria and performance indicators (process, sentinel and effectiveness)--were defined by multidisciplinary consensus (Emergency, Vascular Surgery, Cardiology, Neurology and Radiology departments). This process was implemented from April 2002 to May 2004, and monthly assessments were carried out to check for problems and to introduce corrective measures. After ending the process, patients with TIA were admitted as inpatients for a hospital study. RESULTS: Definition of the process: medical care (diagnosis and treatment) of TIA patients who are eligible for a complete outpatient study within seven days. Patients evaluated: 254. Indicator 1 (percentage of suitable referrals): 2002: 53%, 2003: 75%, 2004: 73%. Indicator 2 (percentage of complete studies in less than one week): 2002: 35%, 2003: 57%, 2004: 50%; hospitalised: 90%. Indicator 3 (infarcts during the study): 2002: 4.3%, 2003: 0%, 2004: 0%; hospitalised: 0%. Indicator 4 (percentage of adjustments made to treatment): 2002: 39%, 2003: 31%, 2004: 62%; hospitalised: 72%. Mean delay before visit: in February 2002: 90 days, in April 2002: 7.67 days and in April 2003: 5.37. Problems detected: delays in referrals, failure to fit hospitalisation criteria, delays in carrying out examinations not included in the protocol, unsuitable indicator design. Steps taken: redefinition of indicators, modification of the referral system, adjustments made to the circuits involved in carrying out tests, review of hospitalisation criteria. CONCLUSIONS: Process management is an ideal tool for achieving ongoing improvements in clinical praxis. Early monitoring makes it possible to detect problems and to implement corrective measures. In our area, the study of TIA must be performed in a hospital inpatient regimen in order to comply with the guidelines for clinical practice.

Gestión y mejora del proceso de tratamiento ambulatorio del accidente isquémico transitorio en consultas de Neurología / Management and improvement of the process of outpatient treatment of transient ischemic attacks in neurology departments

Objetivo. Experiencia del tratamiento ambulatorio del accidente isquémico transitorio (AIT) en un hospital de segundo nivel con la puesta en marcha de un ejemplo de gestión por procesos entre todos los servicios implicados en su atención. Pacientes y métodos. Se definieron: misión, límites, diagrama de flujo, criterios de inclusión e indicadores de monitorización (de proceso, centinela y efectividad) del proceso por consenso multidisciplinar (Urgencias, Cirugía Vascular, Cardiología, Neurología y Radiología).Este proceso se implantó desde abril de 2002 hasta mayo de 2004,y se llevó a cabo una monitorización mensual para la detección de problemas y la introducción de medidas correctoras. Tras suspender el proceso, los pacientes con AIT ingresaron para un estudio hospitalario. Resultados. Definición del proceso: atención médica (diagnóstico y tratamiento) del paciente con AIT susceptible de realizar un estudio completo ambulatorio antes de siete días. Pacientes valorados: 254. Indicador 1 (porcentaje de remisiones apropiadas):2002: 53%, 2003: 75%, 2004: 73%. Indicador 2 (porcentaje de estudios completos en menos de una semana: 2002: 35%,2003: 57%, 2004: 50%; ingresados: 90%. Indicador 3 (infartos durante el estudio): 2002: 4,3%, 2003: 0%, 2004: 0%; ingresados:0%. Indicador 4 (porcentaje de ajustes del tratamiento): 2002:39%, 2003: 31%, 2004: 62%; ingresados: 72%. Demora media de cita: en febrero de 2002: 90 días, en abril de 2002: 7,67 días y en abril de 2003: 5,37. Problemas detectados: retraso en las citaciones, falta de ajuste a los criterios de ingreso, demora en exploraciones no incluidas en protocolo, diseño inadecuado de indicadores. Medidas adoptadas: redefinición de indicadores, modificación del sistema de citación, reajustes de los circuitos de realización de pruebas, revisión de los criterios de ingreso. Conclusiones. La gestión por procesos constituye la herramienta ideal para la mejora continua de la práctica clínica. La monitorización precoz permite detectar problemas e implantar medidas correctoras. En nuestro ámbito, el estudio del AIT debe realizarse en un régimen de ingreso hospitalario para ajustarnos a las recomendaciones de práctica clínica (AU)

Aims. To describe our experience in the ambulatory treatment of transient ischemic attacks (TIA) in a second-level hospital with the implementation of an example of process management within the different services involved in attending such conditions. Patients and methods. The following aspects of the process –mission, limits, flowchart, eligibility criteria and performance indicators (process, sentinel and effectiveness)– were defined by multidisciplinary consensus (Emergency, Vascular Surgery, Cardiology, Neurology and Radiology departments). This process was implemented from April 2002 to May 2004, and monthly assessments were carried out to check for problems and to introduce corrective measures. After ending the process, patients with TIA were admitted as inpatients for a hospital study. Results. Definition of the process: medical care (diagnosis and treatment) of TIA patients who are eligible for a complete outpatient study within seven days. Patients evaluated: 254.Indicator 1 (percentage of suitable referrals): 2002: 53%, 2003: 75%, 2004: 73%. Indicator 2 (percentage of complete studies inless than one week): 2002: 35%, 2003: 57%, 2004: 50%; hospitalised: 90%. Indicator 3 (infarcts during the study): 2002: 4.3%,2003: 0%, 2004: 0%; hospitalised: 0%. Indicator 4 (percentage of adjustments made to treatment): 2002: 39%, 2003: 31%,2004: 62%; hospitalised: 72%. Mean delay before visit: in February 2002: 90 days, in April 2002: 7.67 days and in April 2003:5.37. Problems detected: delays in referrals, failure to fit hospitalisation criteria, delays in carrying out examinations not included in the protocol, unsuitable indicator design. Steps taken: redefinition of indicators, modification of the referral system, adjustments made to the circuits involved in carrying out tests, review of hospitalisation criteria. Conclusions. Process management is an ideal tool for achieving ongoing improvements in clinical praxis. Early monitoring makes it possible to detect problems and to implement corrective measures. In our area, the study of TIA must be performed in a hospital inpatient regimen in order to comply with the guidelines for clinical practice (AU)

[Neuro-otological manifestations as presentacion of type I Chiari malformation]. / Manifestaciones otoneurológicas como presentación de la malformación de Chiari tipo I.

The type I Chiari malformation consists of an caudal descent of the cerebellar tonsils through the foramen magno towards the spinal cervical channel. The usual clinical presentation are occipital headaches and cervical pain, as well as some otoneurological symptoms. Among them are common dizziness and crisis of central positional vertigo in which down beating nystagmus can be observed. We present our experience with three cases presenting with neurotological manifestations in which MRI showed a type I Chiari malformation. Case 1: a patient of 24 years that had frequent instability, and common crisis ofpositional vertigo. It was possible to see the presence of positional down-beating nystagmus, of central characteristics, that improved after neurosurgical treatment. Case 2: patient of 11 years who suffered from occasional headaches, dizziness and positional vertigo, without severe handicap, and did not need surgery. Case 3: lady of 63 years who had common episodes of vertigo with head tilt, and unsteadiness during walks. Due to the coexistence of hydrocephalus and syringomyelia, surgery was indicated. A revision is done on otoneurological presentation of type I Chiari malformation, especially as differential diagnosis on central positional vertigo.

Manifestaciones otoneurológicas como presentación de la malformación de Chiari tipo I / Neurotological manifestation as presentation of type 1 Chiari malformation

La malformación de Chiari tipo I consiste en un desplazamiento caudal de las amígdalas cerebelosas a través del foramen magno hacia el canal cervical espinal. La presentación clínica habitual de esta anomalía son las cefaleas y dolores cervicales, así como algunos síntomas otoneurológicos. Entre ellos son comunes los cuadros de inestabilidad y episodios de vértigo posicional central en los que se objetiva nistagmo vertical hacia abajo. Presentamos nuestra experiencia en tres casos con alteraciones otoneurológicas en los que la resonancia magnética craneal demostró el diagnóstico de malformación de Chiari tipo I. En primer lugar, una paciente de 24 años que consultó por un cuadro de inestabilidad habitual y frecuentes episodios de vértigo posicional, en los que presentaba nistagmo posicional hacia abajo, que mejoraron tras tratamiento neuroquirúrgico. En segundo lugar, un paciente de 11 años que presentó episodios esporádicos de cefalea, asociada a inestabilidad y vértigo posicional, sin incapacidad evidente, por lo que no se derivó para tratamiento quirúrgico. En tercer lugar, una paciente de 63 años que padecía crisis de vértigo con los movimientos cefálicos, así como inestabilidad en la marcha. Ante la coexistencia de hidrocefalia y siringomielia, se derivó a la paciente para tratamiento neuroquirúrgico. Realizamos una revisión de las alteraciones otoneurológicas con las que puede presentarse la malformación de Chiari tipo 1, especialmente como diagnóstico diferencial dentro de los cuadros de vértigo posicional central

The type I Chiari malformation consists of an caudal descent of the cerebellar tonsils through the foramen magno towards the spinal cervical channel. The usual clinical presentation are occipital headaches and cervical pain, as well as some otoneurological symptoms. Among them are common dizziness and crisis of central positional vertigo in which down beating nystagmus can be observed. We present our experience with three cases presenting with neurotological manifestations in which MRI showed a type I Chiari malformation. Case 1: a patient of 24 years that had frequent instability, and common crisis of positional vertigo. It was possible to see the presence of positional down-beating nystagmus, of central characteristics, that improved after neurosurgical treatment. Case 2: patient of 11 years who suffered from occasional headaches, dizziness and positional vertigo, without severe handicap, and did not need surgery. Case 3: lady of 63 years who had common episodes of vertigo with head tilt, and unsteadiness during walks. Due to the coexistence of hydrocephalus and syringomyelia, surgery was indicated. A revision is done on otoneurological presentation oftype I Chiari malformation, especially as differential diagnosis on central positional vertigo

[Is progressive anarthria a clinical form of Pick complex?]. / Anartria progresiva: forma clínica del complejo Pick?

INTRODUCTION: Progressive anarthria is defined as a clinical entity with a degenerative origin consisting in progressive difficulty in articulating while grammatical, semantic and graphic aspects of language are preserved. It is included within the group of processes affecting restricted areas of the brain although its exact nosological location is not clear. We report two cases that progressed clinically towards frontotemporal dementia and corticobasal degeneration, respectively. CASE REPORTS: Case 1: a male who, at the age of 72, began with speech difficulties while comprehension and reading/writing skills were preserved. Three years later he developed apathy, bulimia, sexual indiscretions and aggressiveness, with preservation of visual memory, visual-constructional capacity and elementary writing skills. Case 2: a male who, at the age of 70, began with speech disorders, which were associated two years later to generalised slowness with Hoehn and Yahr stage II akinetic-rigid symptoms; another two years later, he developed a dystonic attitude and melokinetic apraxia in the left upper limb. CONCLUSIONS: The two cases, which were initially compatible with progressive anarthria, progressed clinically towards frontotemporal dementia and corticobasal degeneration, which are entities that are included in 'Pick complex'. This is a concept that we believe to be useful from a clinical point of view, given the variability that exists in the histology of the entities that have been proposed as members of this syndrome group, together with the progression of the cases described in the literature and the ones we have reported in this work.

Anartria progresiva: ¿forma clínica del complejo Pick? / Is progressive anarthria a clinical form of pick complex?

Introducción. La anartria progresiva se define como una entidad de origen degenerativo consistente en dificultad articulatoria progresiva con los aspectos gramaticales, semánticos y gráficos del lenguaje conservados. Enmarcada en los procesos que afectan a áreas cerebrales restringidas, su ubicación nosológica no está clara. Se comunican dos casos que evolucionaron clínicamente hacia demencia frontotemporal y degeneración corticobasal, respectivamente. Casos clínicos. Caso 1: varón, que debutó a los 72 años con dificultad en el habla, con comprensión y lectoescritura conservadas; tres años después desarrolló apatía, bulimia, indiscreciones sexuales y agresividad, con memoria visual, capacidad visuoconstructiva y escritura elemental conservadas. Caso 2: varón, que debuta a los 70 años con problemas en el habla, asociado dos años después a lentitud generalizada, con cuadro rígido acinético en II de Hoehn yYahr; dos años más tarde, desarrolló actitud distónica y apraxia melocinética en el miembro superior izquierdo. Conclusiones. Ambos casos, compatibles inicialmente con anartria progresiva, evolucionaron clínicamente hacia demencia frontotemporal y degeneración corticobasal, entidades incluidas en el 'complejo Pick', concepto que pensamos que es útil desde el punto de vista clínico, dada la variabilidad en la histología de las entidades que se proponen como integrantes de dicho grupo sindrómico, así como la evolución de los casos descritos en la literatura y los nuestros propios comunicados en este trabajo (AU)

Introduction. Progressive anarthria is defined as a clinical entity with a degenerative origin consisting in progressive difficulty in articulating while grammatical, semantic and graphic aspects of language are preserved. It is included within the group of processes affecting restricted areas of the brain although its exact nosological location is not clear. We report two cases that progressed clinically towards frontotemporal dementia and corticobasal degeneration, respectively. Case reports. Case 1: a male who, at the age of 72, began with speech difficulties while comprehension and reading/writing skills were preserved. Three years later he developed apathy, bulimia, sexual indiscretions and aggressiveness, with preservation of visual memory, visual-constructional capacity and elementary writing skills. Case 2: a male who, at the age of 70, began with speech disorders, which were associated two years later to generalised slowness with Hoehn and Yahr stage II akinetic-rigid symptoms; another two years later, he developed a dystonic attitude and melokinetic apraxia in the left upper limb. Conclusions. The two cases, which were initially compatible with progressive anarthria, progressed clinically towards frontotemporal dementia and corticobasal degeneration, which are entities that are included in ‘Pick complex’. This is a concept that we believe to be useful from a clinical point of view, given the variability that exists in the histology of the entities that have been proposed as members of this syndrome group, together with the progression of the cases described in the literature and the ones we have reported in this work (AU)

[Clinicopathological study of a case of oculopharyngeal muscular dystrophy]. / Estudio clinicopatológico de un caso de distrofia muscular oculofaríngea (DMOF).

One case of oculopharyngeal muscular dystrophy is reported, in a 75 year old white male with manifest family history of palpebral ptosis. He displayed bilateral ptosis and dysphagia. Diagnosis was carried out after clinical, electrical and bioptic procedures. Data obtained have been discussed with previous reports in the literature. It was necessary to perform a cricopharyngeal myotomy to overcome the malnutrition secondary to his swallowing problem.

[Syndrome of rostral occlusion of the basilar artery]. / Síndrome de oclusión rostral de la arteria basilar.

Upper occlusion of the basilar artery ("top of the basilar" syndrome) causes ischemics lesions in brainstem, thalamus and occipital and temporal lobes, producing visual, oculomotor and behavioral disorders, with slight motor affectation concomitant. We expose a case with a typical clinical setting and infarctions in thalamus and both occipital lobes with an unusual symmetric distribution.