Systemic biomarker associated with poor outcome after futile reperfusion.

BACKGROUND: Successful recanalization does not lead to complete tissue reperfusion in a considerable percentage of ischemic stroke patients. This study aimed to identify biomarkers associated with futile recanalization. Leukoaraiosis predicts poor outcomes of this phenomenon. Soluble tumour necrosis factor-like weak inducer of apoptosis (sTWEAK), which is associated with leukoaraiosis degrees, could be a potential biomarker. METHODS: This study includes two cohorts of ischemic stroke patients in a multicentre retrospective observational study. Effective reperfusion, defined as a reduction of ≥8 points in the National Institutes of Health Stroke Scale (NIHSS) within the first 24 h, was used as a clinical marker of effective reperfusion. RESULTS: In the first cohort study, female sex, age, and high NIHSS at admission (44.7% vs. 81.1%, 71.3 ± 13.7 vs. 81.1 ± 6.7; 16 [13, 21] vs. 23 [17, 28] respectively; p < .0001) were confirmed as predictors of futile recanalization. ROC curve analysis showed that leukocyte levels (sensitivity of 99%, specificity of 55%) and sTWEAK level (sensitivity of 92%, specificity of 88%) can discriminate between poor and good outcomes. Both biomarkers simultaneously are higher associated with outcome after effective reperfusion (OR: 2.17; CI 95% 1.63-4.19; p < .0001) than individually (leukocytes OR: 1.38; CI 95% 1.00-1.64, p = .042; sTWEAK OR: 1.00; C I95% 1.00-1.01, p = .019). These results were validated using a second cohort, where leukocytes and sTWEAK showed a sensitivity of 100% and specificity of 66.7% and 75% respectively. CONCLUSIONS: Leukocyte and sTWEAK could be biomarkers of reperfusion failure and subsequent poor outcomes. Further studies will be necessary to explore its role in reperfusion processes.

Perfusion-weighted software written in Python for DSC-MRI analysis.

Introduction: Dynamic susceptibility-weighted contrast-enhanced (DSC) perfusion studies in magnetic resonance imaging (MRI) provide valuable data for studying vascular cerebral pathophysiology in different rodent models of brain diseases (stroke, tumor grading, and neurodegenerative models). The extraction of these hemodynamic parameters via DSC-MRI is based on tracer kinetic modeling, which can be solved using deconvolution-based methods, among others. Most of the post-processing software used in preclinical studies is home-built and custom-designed. Its use being, in most cases, limited to the institution responsible for the development. In this study, we designed a tool that performs the hemodynamic quantification process quickly and in a reliable way for research purposes. Methods: The DSC-MRI quantification tool, developed as a Python project, performs the basic mathematical steps to generate the parametric maps: cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), signal recovery (SR), and percentage signal recovery (PSR). For the validation process, a data set composed of MRI rat brain scans was evaluated: i) healthy animals, ii) temporal blood-brain barrier (BBB) dysfunction, iii) cerebral chronic hypoperfusion (CCH), iv) ischemic stroke, and v) glioblastoma multiforme (GBM) models. The resulting perfusion parameters were then compared with data retrieved from the literature. Results: A total of 30 animals were evaluated with our DSC-MRI quantification tool. In all the models, the hemodynamic parameters reported from the literature are reproduced and they are in the same range as our results. The Bland-Altman plot used to describe the agreement between our perfusion quantitative analyses and literature data regarding healthy rats, stroke, and GBM models, determined that the agreement for CBV and MTT is higher than for CBF. Conclusion: An open-source, Python-based DSC post-processing software package that performs key quantitative perfusion parameters has been developed. Regarding the different animal models used, the results obtained are consistent and in good agreement with the physiological patterns and values reported in the literature. Our development has been built in a modular framework to allow code customization or the addition of alternative algorithms not yet implemented.

Influence of Temperature Chronobiology on Stroke Outcome.

The circadian system regulates numerous physiological variables, including body temperature. Additionally, a circadian patter has been described in stroke onset. Considering this, we hypothesised that the chronobiology of temperature may have an impact on stroke onset and functional outcomes. We also studied the variation of blood biomarkers according to stroke onset time. This is a retrospective observational study. Of the patients included, 2763 had a stroke between midnight and 8:00 h; 1571 between 8:00-14:00 h; and 655 between 14:00 h and midnight. Axillary temperature was measured at admission. At this time, blood samples were collected for biomarker analysis (TNF-α, IL-1ß, IL-6, IL-10, and glutamate). Temperature was higher in patients admitted from 8:00 h to midnight (p < 0.0001). However, the percentage of poor outcome at 3 months was highest in patients from midnight to 8:00 h (57.7%, p < 0.001). The association between temperature and mortality was highest during night time (OR: 2.79; CI 95%: 2.36-3.28; p < 0.001). These patients exhibited high glutamate (220.2 ± 140.2 µM), IL-6 (32.8 ± 14.3 pg/mL) and low IL-10 (9.7 ± 14.3 pg/mL) levels. Therefore, temperature chronobiology could have a significant impact on stroke onset and functional outcome. Superficial body hyperthermia during sleep seems to be more dangerous than during wakefulness. Further studies will be necessary to confirm our data.

Thrombectomy aspiration post-market study in acute stroke with the Q aspiration catheter: the TAPAS study.

BACKGROUND: The Q Aspiration Catheter (MIVI Neuro) has demonstrated greater aspiration flow rates and ingestion forces compared with conventional catheters in vitro. The safety and performance of the Q Catheter was assessed using a direct aspiration first pass technique in patients with acute ischemic stroke at four neurointerventional centers in Spain. METHODS: We included adult patients who underwent mechanical thrombectomy between March 2019 and March 2020 using the Q Catheter as first-line therapy. Performance endpoints included final successful revascularization of the target vessel (defined as modified thrombolysis in cerebral infarction (mTICI) grade 2B/3), first pass revascularization, and overall Q Catheter revascularization. Safety endpoints were symptomatic intracranial hemorrhage (sICH), embolization to new territory (ENT), and procedural complications. Modified Rankin Scale (mRS) score and all-cause mortality were also assessed. RESULTS: Forty-five subjects were enrolled. The Q Catheter successfully navigated to the lesion in 95.5% (43/45) of patients. Final successful mTICI 2B/3 revascularization was achieved in 93.3% (42/45), first pass mTICI 2B/3 revascularization with the Q Catheter was 55.3% (21/38), and overall with Q Catheter mTICI 2B/3 revascularization was 65.8% (25/38). Favorable clinical outcome of mRS 0-2 was achieved in 55.6% (25/45). There were no cases of ENT. sICH and mortality rates were 2.2% (1/45) and 13.3% (6/45), respectively. CONCLUSION: In this multicenter, observational study, the Q Aspiration Catheter used as first-line therapy demonstrated a good and safe profile in terms of navigation, revascularization, and safety in patients with acute ischemic stroke.

Recommendations for the diagnosis and radiological follow-up of pituitary neuroendocrine tumours.

Pituitary neuroendocrine tumours (PitNETs) constitute a heterogeneous group of tumours with a gradually increasing incidence, partly accounted for by more sensitive imaging techniques and more extensive experience in neuroradiology in this regard. Although most PitNETs are indolent, some exhibit aggressive behaviour, and recurrence may be seen after surgical removal. The changes introduced in the WHO classification in 2017 and terminological debates in relation to neuroendocrine tumours warrant an update of the guidelines for the diagnosis, preoperative and postoperative management, and follow-up of response to treatment of PitNETs. This multidisciplinary document, an initiative of the Neuroendocrinology area of the Sociedad Española de Endocrinología y Nutrición [Spanish Society of Endocrinology and Nutrition] (SEEN), focuses on neuroimaging studies for the diagnosis, prognosis and follow-up of PitNETs. The basic requirements and elements that should be covered by magnetic resonance imaging are described, and a minimum radiology report to aid clinicians in treatment decision-making is proposed. This work supplements the consensus between the Neuroendocrinology area of the SEEN and the Sociedad Española de Anatomía Patológica [Spanish Society of Pathology] (SEAP) for the pathological study of PitNETs.

Carotid web: the challenging diagnosis of an under-recognized entity.

BACKGROUND: Determining the cause of acute ischemic stroke is crucial for patient management, particularly for preventing future stroke. In recent years, carotid web (CW), a non-atherosclerotic disorder of the carotid wall, has been found to be an underestimated source of cerebral emboli. OBJECTIVE: The present study aimed to analyze the clinical, radiological, and pathological findings, along with the treatments performed in patients with CW and ipsilateral ischemic events. METHODS: Patients with anterior circulation ischemic stroke or transient ischemic attack and ipsilateral CW were prospectively included from January 2019 to December 2021. RESULTS: Nine patients were enrolled. The median age was 55 (43-62) years, with a female-to-male ratio of 3.5:1. Of the total, seven patients (78%) consulted for recurrent ipsilateral ischemic events. Despite medical treatment, 44% of the patients experienced new episodes. Computed tomographic angiography was suggestive of CW in all cases in which it was performed. The interval between the first ischemic event and diagnosis of CW was of 13 (6-68) months. After ruling out any other possible etiology, every patient underwent carotid revascularization, one underwent stenting and eight underwent carotidectomy. No severe or long-term complications were noted. Histological studies confirmed the diagnosis of CW. There were no recurrences after carotid revascularization during a follow-up of 24 (13-35) months. CONCLUSION: Knowledge of CW and differentiating it from atheroma plaques is essential, as medical management seems to be insufficient in many cases. Revascularization, which has been shown to be safe and effective, might be the best treatment modality.

Antihyperthermic Treatment in the Management of Malignant Infarction of the Middle Cerebral Artery.

Malignant infarction of the middle cerebral artery (m-MCA) is a complication of ischemic stroke. Since hyperthermia is a predictor of poor outcome, and antihyperthermic treatment is well tolerated, our main aim was to analyze whether the systemic temperature decrease within the first 24 h was associated with a better outcome. Furthermore, we studied potential biochemical and neuroimaging biomarkers. This is a retrospective observational analysis that included 119 patients. The temperature variations within the first 24 h were recorded. Biochemical laboratory parameters and neuroimaging variables were also analyzed. The temperature increase at the first 24 h (OR: 158.97; CI 95%: 7.29−3465.61; p < 0.001) was independently associated with a higher mortality. Moreover, antihyperthermic treatment (OR: 0.08; CI 95%: 0.02−0.38; p = 0.002) was significantly associated with a good outcome at 3 months. Importantly, antihyperthermic treatment was associated with higher survival at 3 months (78% vs. 50%, p = 0.003). Significant independently associations between the development of m-MCA and both microalbuminuria (OR: 1.01; CI 95%: 1.00−1.02; p = 0.005) and leukoaraiosis (OR: 3.07; CI 1.84−5.13−1.02; p < 0.0001) were observed. Thus, antihyperthermic treatment within the first 24 h was associated with both a better outcome and higher survival. An increased risk of developing m-MCA was associated with leukoaraiosis and an elevated level of microalbuminuria.

Five-Years Angiographic Follow-Up of Wide-Neck Intracranial Aneurysms Treated With LEO Plus Stent.

Background: This study aimed to evaluate the angiographic and clinical outcome, with an emphasis on long-term follow-up, of the LEO Plus stent for wide-neck intracranial aneurysms treated in a single center. Methods: We retrospectively examined a prospectively maintained database of patients treated with LEO Plus devices between January 2004 and December 2016. Data regarding patient demographics, aneurysm characteristics, and technical procedures were analyzed. Angiographic and clinical findings were recorded during the procedure and followed up over a period of at least 5 years. Results: We identified 101 patients with 116 aneurysms. In 16 patients, the stent could not safely be placed. Thus, a total of 97 LEO Plus devices were implanted in 97 aneurysms of 85 patients. Adverse events (acute and delayed) were observed in 21.6% of cases (17/85), and most were resolved (70.6%; 12/17). Moreover, 5 years after the procedure, total morbidity and mortality were 2.3% (2/85) and 3.5% (3/85), respectively. Long-term imaging follow-up showed complete occlusions, neck remnants, and residual aneurysms in 73.1% (57/78), 14.1% (11/78), and 12.8% (10/78) of cases, respectively. Conclusions: Long-term results of treatment of brain aneurysms with LEO stent show high rates of adequate and stable occlusion over time, with acceptable morbidity and mortality.

Treatment of Intracranial Aneurysms Using the New Silk Vista Flow Diverter: Safety Outcomes at Short-Term Follow-Up.

Background: Flow diverters are widely used as the first endovascular treatment option for complex brain aneurysms due to their high percentage of occlusion and low morbi-mortality. The Silk Vista device is a new generation of flow diverters designed to facilitate full visibility, improve apposition to the vessel wall, and enhance navigability. Indeed, its greatest advantage is that it enables the easier navigation of stents between 3.5 and 4.75 mm through a 0.021 microcatheter. The objective of this study was to evaluate the safety and effectiveness of Silk Vista systems for treating cerebral aneurysms. Methods: This prospective observational study included 25 consecutive patients with 27 wide-necked unruptured aneurysms treated with SILK Vista who were retrospectively analyzed for safety and efficacy. Results: Endovascular treatment was successfully performed in all patients. The final morbidity and mortality rates were both 0.0%. Short-term (3-5 months) angiographic follow-up revealed 21 complete occlusions and 6 near-complete occlusions. No significant parent artery stenosis was observed. Conclusions: This report demonstrates the efficacy of Silk Vista in treating brain aneurysms, although longer experiences should be carried out to confirm our results.

Balloon guide catheter improvements in thrombectomy outcomes persist despite advances in intracranial aspiration technology.

BACKGROUND: First-pass effect (FPE) has been established as a key metric for technical success and strongly correlates with better clinical outcomes. Most data supporting improved outcomes with the use of a balloon guide catheter (BGC) predate the advent of last-generation large-bore intracranial aspiration catheters. We aim to evaluate the impact of BGC in FPE and clinical outcomes in a large cohort of patients treated with contemporary technology. METHODS: Patients were recruited from the prospectively ongoing ROSSETTI registry. This registry includes all consecutive patients with anterior circulation large-vessel occlusion (LVO) from 10 comprehensive stroke centers in Spain. Demographic, clinical, angiographic, and clinical outcome data were compared between BGC and non-BGC groups. FPE was defined as the achievement of mTICI2c-3 after a single device pass. RESULTS: 426 patients were included out of which 271 (63.62%) used BCG. BGC-treated patients had higher FPE rate (45.8% vs 27.7%; P<0.001), higher final mTICI ≥2 c recanalization rate (76.8% vs 50.3%, respectively; P<0.001), shorter procedural time [median (IQR), 30 (19-58) vs 43 (33-71) min; P<0.001], higher NIHSS difference from admission to 24 hours [median (IQR), 8 (2-12) vs 3 (0-10); P=0.001], and lower mortality rate (17.6% vs 29.8%, P=0.026) compared with non-BGC patients. BGC use was an independent predictor of FPE (OR 2.197, 95% CI 1.436 to 3.361; P<0.001), and excellent clinical outcome at 3 months (OR 0.34, 95% CI 0.17 to 0.68; P=0.002). CONCLUSIONS: Our results support the benefit of BGC use on angiographic and clinical outcomes in anterior circulation LVO ischemic stroke remain significant even when considering recent improvements in intracranial aspiration technology.

Results of a Single Center's Stenting Procedure for the Treatment of Carotid Stenosis.

BACKGROUND: Stenting may be a safer alternative to endarterectomy for treating carotid artery stenosis (CAS), but its long-term efficacy is uncertain. There is a lack of long-term and noncontrolled clinical trial data that reflects "real-world" CAS. This study aimed to analyze the long-term efficacy and safety of our center's CAS procedure. METHODS: We retrospectively analyzed our database of patients who underwent CAS. Patient demographic data, previous risk factors, diagnostic and procedural information, and clinical and image follow-up data were collected from up to 1 year after treatment. RESULTS: Overall, 187 patients were analyzed. Our patient population largely comprised higher-risk patients compared with the patient populations of randomized controlled trials. We had more symptomatic (n = 145, 77.5%) than asymptomatic patients (n = 42, 22.5%), and 49% of patients had >90% stenosis. By the 30-day follow-up, there were 10 major adverse events (5.3%) observed in 8 patients (4.2%), including 7 strokes (3 ischemic and 4 hemorrhagic) and 3 deaths. By the 1-year follow-up, 6 strokes and 5 deaths occurred in 9 patients (4.8%), and color Doppler control showed that 87.6% of patients had stenosis-free stents. CONCLUSIONS: Despite our high-risk population group, there were high rates of successful stent placement, low complication rates, good clinical outcomes, and low rates of stenting restenosis.

Radiologic Clues to Cerebral Venous Thrombosis.

Cerebral venous thrombosis (CVT) is uncommon, representing approximately 0.5% of all cases of cerebrovascular disease worldwide. Many factors, alone or combined, can cause CVT. Although CVT can occur at any age, it most commonly affects neonates and young adults. CVT is difficult to diagnose clinically because patients can present with a wide spectrum of nonspecific manifestations, the most common of which are headache in 89%-91%, focal deficits in 52%-68%, and seizures in 39%-44% of patients. Consequently, imaging is fundamental to its diagnosis. MRI is the most sensitive and specific technique for diagnosis of CVT. The different MRI sequences, with and without the use of contrast material, have variable strengths. Contrast material-enhanced MR venography has the highest accuracy compared with sequences without contrast enhancement.Online supplemental material is available for this article.©RSNA, 2019.

Spontaneous Subarachnoid Hemorrhage with Negative Angiography Managed in a Stroke Unit: Clinical and Prognostic Characteristics.

BACKGROUND: Perimesencephalic subarachnoid hemorrhage (p-SAH) is linked to a benign prognosis compared with aneurysmal SAH. However, the outcome in nonperimesencephalic angiographically negative SAH (np-SAH) is not well established. We reviewed our experience and evaluated the clinical and prognostic differences between patients with p-SAH and np-SAH. METHODS: Retrospective observational study based on data collected prospectively from all patients admitted to our hospital with SAH during the past 11 years. After selecting patients with normal angiography, we categorized them as either p-SAH or np-SAH according to the Rinkel criteria. Demographic, clinical, radiologic, and prognostic features were recorded. RESULTS: We collected a total of 41 (12.53%) angiographically negative SAH: 17 p-SAH (41.46%) and 24 np-SAH (58%-53%). The np-SAH group included the 6 patients with Glasgow Coma Scale (GCS) less than 15 (P = .083), and all 5 patients with Hunt & Hess (H&H) scores more than II (P = .045), being the GCS = 15 and H&H less than II in the rest of np-SAH and in all of the p-SAH patients. The average hospital stay in days was longer in the np-SAH group (24 ± 7.08) than in the p-SAH group (17 ± 5.11; P = .55). Hydrocephalus requiring external ventricular drainage (EVD) was only recorded in the np-SAH group (29.16%, P = .029). On discharge, all patients had H&H grade less than II and modified Rankin Scale measured 3 months later was less than 2 in both groups. CONCLUSIONS: Our results agree with other studies showing a low complication rate for SAH patients with a normal angiography, especially in the p-SAH group. The prognosis appears to be less favorable in terms of a more frequent need for EVD, so a more cautious approach is recommended in this subgroup.

In vivo gastric detection of α-synuclein inclusions in Parkinson's disease.

α-Synuclein inclusions have been identified in the brain and some parts of the enteric nervous system in Parkinson's disease cases. We aimed to assess these inclusions in gastric mucosa samples from patients with symptomatic Parkinson's disease. Random biopsies were performed by gastroscopy in 28 patients with Parkinson's disease and in 29 age- and sex-matched controls. Gastroscopy was performed to start enteral levodopa (L-dopa) therapy in cases and for diagnostic purposes in controls (gastroesophageal reflux, anemia, and abdominal pain were the main indications). The clinical definition of cases and controls was made a priori. Six controls had data suggestive of "mild presymptomatic parkinsonism". Biopsy specimens were immunostained for α-synuclein. The neuropathological diagnosis was established post hoc. No differences were found in the baseline characteristics of the groups. Positive fibers for the α-synuclein protein were observed in 17 of 28 (60.7%) Parkinson's disease patients, 1 of 23 controls (4.3%), and 1 of 6 (16.7%) cases of incident "mild presymptomatic parkinsonism." Neuropathological diagnosis based on α-synuclein immunostaining showed a sensitivity of 85% (95% confidence interval [CI] 62.1-96.8), specificity of 95% (95% CI 76.2-99.9) and area under the receiver operating characteristics curve (AUC) of 0.90 (95% CI 0.80-1.00). No adverse events occurred. Detection of α-synuclein inclusions in the gastric mucosa is a useful and safe tool providing in vivo evidence of the underlying neurodegenerative peripheral involvement linked to Parkinson's disease. Further studies are warranted to determine its pathophysiological implications.

[Rapid progressive dementia with criteria for Creutzfeldt-Jakob disease: a case of cerebral intravascular lymphoma]. / Demencia rápidamente progresiva con criterios de enfermedad de Creutzfeldt-Jakob: un caso de linfoma intravascular cerebral.

TITLE: Demencia rapidamente progresiva con criterios de enfermedad de Creutzfeldt-Jakob: un caso de linfoma intravascular cerebral.

Demencia rápidamente progresiva con criterios de enfermedad de Creutzfeldt-Jakob: un caso de linfoma intravascular cerebral / Rapidly progressive dementia resembling Creutzfeldt-Jakob disease: a case of cerebral intravascular lymphomatosis

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[CLIPPERS syndrome with atypical distribution of lesions in magnetic resonance imaging of the brain]. / Sindrome CLIPPERS con distribucion atipica de las lesiones en la resonancia magnetica cerebral.

INTRODUCTION: CLIPPERS syndrome (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is an inflammatory process of the central nervous system whose distinguishing features are the enhancing punctiform lesions in the brainstem that appear in the magnetic resonance images. Clinically, it is accompanied by dysarthria, ataxia and diplopia, and usually responds to treatment with corticoids. Pathologically, T lymphocytes appear infiltrated in the perivascular spaces of the brainstem. CASE REPORT: We report the case of a 40-year-old woman with an initial subacute clinical picture of binocular diplopia, ataxia and dysarthria. The magnetic resonance brain scan revealed T2 hyperintense punctiform lesions in the stem, cerebellum, diencephalons and cortico-subcortical areas of both hemispheres, which were enhanced with contrast. An aetiological study was performed to rule out any underlying infectious, neoplastic or inflammatory origin, the results being negative. The patient was treated on two occasions with methylprednisolone, with a gradual lowering of the dosage, the response being favourable. CONCLUSIONS: Diplopia and ataxia, as in our case, are practically always present. The MR findings consist of punctiform enhancing lesions located in the pons extending towards the cerebellum, basal ganglia and corpus callosum, the enhancement gradient becoming lower as the distance increases rostrally away from the cortex, and caudally towards the spinal cord. In the case of our patient, this gradient is not respected, and the density found was similar to that of lesions at the supratentorial level. The differential diagnosis is wide-ranging and justifies an extensive diagnostic study with, in certain cases, a biopsy study of brain tissue. The disease courses in a relapsing-remitting pattern and the earlier steroid therapy is established and the more prolonged it is, the better the prognosis will be.

TITLE: Sindrome CLIPPERS con distribucion atipica de las lesiones en la resonancia magnetica cerebral.Introduccion. El sindrome CLIPPERS (chronic lymphocytic in?ammation with pontine perivascular enhancement responsive to steroids) es un proceso inflamatorio del sistema nervioso central cuyo rasgo distintivo son las lesiones puntiformes en el troncoencefalo captantes en los estudios de resonancia magnetica. Clinicamente, cursa con disartria, ataxia y diplopia, y suele responder a corticoides. Anatomopatologicamente, aparecen infiltrados de linfocitos T en los espacios perivasculares troncoencefalicos. Caso clinico. Mujer de 40 años con cuadro de instauracion subaguda de diplopia binocular, ataxia y disartria. En la resonancia magnetica cerebral presento lesiones puntiformes hipertintensas en secuencia T2 en el tronco, cerebelo, diencefalo y areas cortico-subcorticales bihemisfericas, que realzaron con contraste. Se realizo un estudio etiologico para descartar un origen infeccioso, neoplasico o inflamatorio subyacente, que resulto negativo. La paciente recibio tratamiento en dos ocasiones con metilprednisolona, con descenso progresivo de la dosis, con buena respuesta. Conclusiones. La diplopia y la ataxia, como en nuestro caso, estan presentes practicamente siempre. Los hallazgos en la RM consisten en lesiones captantes puntiformes localizadas en la protuberancia con extension hacia el cerebelo, ganglios basales y cuerpo calloso, con gradiente de captacion menor conforme se alejan rostralmente hacia la corteza, y caudalmente hacia la medula. En el caso de nuestra paciente, este gradiente no se respeta, encontrandose una densidad similar de las lesiones a nivel supratentorial. El diagnostico diferencial es amplio y justifica un estudio diagnostico extenso, y en casos seleccionados la biopsia cerebral. El curso de la enfermedad es remitente-recurrente, y el pronostico mejora cuanto mas precoz y prolongado es el tiempo de corticoterapia.

Síndrome CLIPPERS con distribución atípica de las lesiones en la resonancia magnética cerebral / CLIPPERS syndrome with atypical distribution of lesions in magnetic resonance imaging of the brain

Introducción. El síndrome CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) es un proceso inflamatorio del sistema nervioso central cuyo rasgo distintivo son las lesiones puntiformes en el troncoencéfalo captantes en los estudios de resonancia magnética. Clínicamente, cursa con disartria, ataxia y diplopía, y suele responder a corticoides. Anatomopatológicamente, aparecen infiltrados de linfocitos T en los espacios perivasculares troncoencefálicos. Caso clínico. Mujer de 40 años con cuadro de instauración subaguda de diplopía binocular, ataxia y disartria. En la resonancia magnética cerebral presentó lesiones puntiformes hipertintensas en secuencia T2 en el tronco, cerebelo, diencéfalo y áreas córtico-subcorticales bihemisféricas, que realzaron con contraste. Se realizó un estudio etiológico para descartar un origen infeccioso, neoplásico o inflamatorio subyacente, que resultó negativo. La paciente recibió tratamiento en dos ocasiones con metilprednisolona, con descenso progresivo de la dosis, con buena respuesta. Conclusiones. La diplopía y la ataxia, como en nuestro caso, están presentes prácticamente siempre. Los hallazgos en la RM consisten en lesiones captantes puntiformes localizadas en la protuberancia con extensión hacia el cerebelo, ganglios basales y cuerpo calloso, con gradiente de captación menor conforme se alejan rostralmente hacia la corteza, y caudalmente hacia la médula. En el caso de nuestra paciente, este gradiente no se respeta, encontrándose una densidad similar de las lesiones a nivel supratentorial. El diagnóstico diferencial es amplio y justifica un estudio diagnóstico extenso, y en casos seleccionados la biopsia cerebral. El curso de la enfermedad es remitente-recurrente, y el pronóstico mejora cuanto más precoz y prolongado es el tiempo de corticoterapia (AU)

Introduction. CLIPPERS syndrome (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids) is an inflammatory process of the central nervous system whose distinguishing features are the enhancing punctiform lesions in the brainstem that appear in the magnetic resonance images. Clinically, it is accompanied by dysarthria, ataxia and diplopia, and usually responds to treatment with corticoids. Pathologically, T lymphocytes appear infiltrated in the perivascular spaces of the brainstem. Case report. We report the case of a 40-year-old woman with an initial subacute clinical picture of binocular diplopia, ataxia and dysarthria. The magnetic resonance brain scan revealed T2 hyperintense punctiform lesions in the stem, cerebellum, diencephalons and cortico-subcortical areas of both hemispheres, which were enhanced with contrast. An aetiological study was performed to rule out any underlying infectious, neoplastic or inflammatory origin, the results being negative. The patient was treated on two occasions with methylprednisolone, with a gradual lowering of the dosage, the response being favourable. Conclusions. Diplopia and ataxia, as in our case, are practically always present. The MR findings consist of punctiform enhancing lesions located in the pons extending towards the cerebellum, basal ganglia and corpus callosum, the enhancement gradient becoming lower as the distance increases rostrally away from the cortex, and caudally towards the spinal cord. In the case of our patient, this gradient is not respected, and the density found was similar to that of lesions at the supratentorial level. The differential diagnosis is wide-ranging and justifies an extensive diagnostic study with, in certain cases, a biopsy study of brain tissue. The disease courses in a relapsing-remitting pattern and the earlier steroid therapy is established and the more prolonged it is, the better the prognosis will be (AU)

[Vagus nerve stimulation in patients with migraine]. / Estimulacion del nervio vago en pacientes migrañosos.

INTRODUCTION: Vagus nerve stimulation (VNS) has been approved for the treatment of refractory epilepsy when resective surgery is not possible, and has proved to be highly effective. Series published in the literature suggest a beneficial effect of VNS in the treatment of migraine. AIMS: To determine the degree to which headaches improve in patients with migraine after the placement of VNS to treat refractory epilepsy, and to evaluate what variables are associated with an increased chance of success with this measure. PATIENTS AND METHODS: An observation-based retrospective study was conducted from 1st January 1999 until 31st December 2010. Patients with VNS for refractory epilepsy were contacted by telephone, after selecting those who fulfilled International Headache Society criteria for migraine. Data collected included age, gender, year of placement, age at onset of epilepsy and migraine, improvement of seizures and migraine, presence of migraine with aura and coexistence of anxious-depressive syndrome. Ninety-four patients with VNS were contacted and 13 patients with migraine were selected. RESULTS: Following placement of the VNS, the number of episodes of migraine was seen to decrease by at least 50% in nine patients (69%) (p = 0.004) and there was a drop in the number of episodes of migraine in those patients who had also reduced their epileptic seizures (p = 0.012). No statistically significant associations were observed as regards sex, age, length of disease history, existence of migraine with aura or coexistence of anxious-depressive syndrome. CONCLUSIONS: VNS could have beneficial effects for patients with migraine, especially in cases that are difficult to control. Due to the type of study, these conclusions must be taken with caution. Prospective clinical studies are needed before introducing the technique into daily clinical practice.

TITLE: Estimulacion del nervio vago en pacientes migrañosos.Introduccion. La estimulacion del nervio vago (ENV) esta aprobada para el tratamiento de la epilepsia refractaria cuando no es posible cirugia resectiva, con una eficacia bien establecida. Series publicadas sugieren un efecto beneficioso de la ENV en la migraña. Objetivos. Determinar el grado de mejoria de la cefalea en pacientes migrañosos a los que se les habia implantado una ENV para tratamiento de la epilepsia refractaria y evaluar que variables se asocian a mayor posibilidad de exito con esta medida. Pacientes y metodos. Estudio observacional y retrospectivo desde el 1 de enero de 1999 hasta el 31 de diciembre de 2010. Se contacto telefonicamente con los pacientes con ENV para epilepsia refractaria, seleccionando a aquellos que cumplian los criterios de la Sociedad Internacional de Cefaleas para la migraña. Se recogieron edad, genero, año de implantacion, edad de inicio de la epilepsia y la migraña, mejoria de crisis y de migraña, presencia de aura migrañosa y coexistencia de sindrome ansiosodepresivo. Se contacto con 94 pacientes con ENV y se selecciono a 13 pacientes migrañosos. Resultados. Tras la implantacion de la ENV, se observo una disminucion de al menos el 50% de los episodios de migraña en nueve pacientes (69%) (p = 0,004), asi como una disminucion del numero de episodios de migraña en aquellos pacientes que tambien habian reducido sus crisis epilepticas (p = 0,012). No se observaron asociaciones estadisticamente significativas en cuanto al sexo, edad, tiempo de evolucion, existencia de aura migrañosa o coexistencia de sindrome ansiosodepresivo. Conclusiones. La ENV podria resultar beneficiosa en pacientes con migraña, especialmente en casos de dificil control. Debido al tipo estudio, hay que tomar estas conclusiones con precaucion. Seran necesarios estudios clinicos prospectivos antes de llevarse a la practica clinica habitual.