Selection of patients for percutaneous closure in nonlacunar cryptogenic stroke associated with patent foramen ovale. Data from the NORDICTUS cooperative registry.

INTRODUCTION: There is an extending use of percutaneous closure of patent foramen ovale (PFO) as therapy for PFO-associated cryptogenic strokes. The aim of our study was to investigate the clinical practice of percutaneous closure of PFO and to analyse the variables for decision-making on the selection of patients for this procedure. METHOD: A prospective observational multicentric survey was conducted using all the cases of cryptogenic stroke/transient ischaemic attack associated with PFO recorded in the NORDICTUS hospital registry during the period 2018-2021. Clinical data, radiological patterns, echocardiogram data and factors related to PFO-associated stroke (thromboembolic disease and paradoxical embolism criteria) were recorded. The indication for closure was analysed according to age (≤/> 60 years) and the characteristics of the PFO. RESULTS: In the group ≤ 60 years (n = 488), 143 patients (29.3%) underwent PFO closure. The most influential variables for this therapy were detection of a high-risk PFO (OR 4.11; IC 2.6-6.5, P < .001), criteria for paradoxical embolism (OR 2.61; IC 1.28-5.28; P = .008) and previous use of antithrombotics (OR 2.67; IC 1.38-5.18; P = .009). In the > 60 years group (n = 124), 24 patients had PFO closure (19%). The variables related to this option were history of pulmonary thromboembolism, predisposition to thromboembolic disease, paradoxical embolism criteria, and high-risk PFO. CONCLUSIONS: The detection of a high-risk PFO (large shunt, shunt with associated aneurysm) is the main criterion for a percutaneous closure-based therapy. Other conditions to consider in the eligibility of patients are the history of thromboembolic disease, paradoxical embolism criteria or the previous use of antithrombotics.

Arritmias cardiacas en la unidad de ictus: análisis de los datos de la monitorización cardiaca / Cardiac arrhythmias in stroke unit patients. Evaluation of the cardiac monitoring data

Introducción: Las arritmias cardiacas son frecuentes en el ictus agudo. La monitorización cardiaca telemétrica es una técnica extendida en las unidades de ictus. La aparición de arritmias en el ictus agudo puede relacionarse con las interacciones cerebro-corazón o con la patología cardiaca. Se analiza las arritmias relevantes en pacientes ingresados en una unidad de ictus. Método: Estudio descriptivo observacional prospectivo de pacientes ingresados en una unidad de ictus con monitorización cardiaca. Se analizan las características de los pacientes y las arritmias registradas durante un año (2013). Se investigó el tiempo de aparición, su asociación con factores predisponentes y las consecuencias terapéuticas de la detección. Todos los pacientes al menos tuvieron 48 h de monitorización cardiaca. Resultados: Se analizó a 332 pacientes, de los cuales 98 (29,5%) presentaron algún tipo de arritmia relevante. Se registraron taquiarritmias (taquiarritmias ventriculares, taquiarritmias supraventriculares, actividad ectópica ventricular compleja) en 90 pacientes (27,1%), y bradiarritmias en 13 pacientes (3,91%). La aparición de arritmias se asoció a un mayor tamaño de la lesión y mayor edad de los pacientes. La detección de arritmias relevantes tuvo consecuencia terapéuticas en el 10% de todos los pacientes. La incidencia de arritmias fue mayor durante las primeras 48 h. Conclusiones: La evaluación sistemática de la monitorización cardiaca en pacientes con ictus agudo permite detectar arritmias cardiacas clínicamente relevantes. Su incidencia es mayor durante las primeras 48 h. La edad y el tamaño de la lesión cerebral se relacionan con su aparición. La detección de arritmias en una unidad de ictus tiene consecuencias terapéuticas fundamentales

Introduction: Cardiac arrhythmias are frequent in acute stroke. Stroke units are widely equipped with cardiac monitoring systems. Pre-existing heart diseases and heart-brain interactions may be implicated in causing cardiac arrhythmias in acute stroke. This article analyses cardiac arrhythmias detected in patients hospitalised in a stroke unit. Method: Prospective observational study of consecutive patients admitted to a stroke unit with cardiac monitoring. We collected clinical data from patients and the characteristics of their cardiac arrhythmias over a 1-year period (2013). Time of arrhythmia onset, associated predisposing factors, and the therapeutic decisions made after detection of arrhythmia were examined. All patients underwent continuous cardiac monitoring during no less than 48 hours. Results: Of a total of 332 patients admitted, significant cardiac arrhythmias occurred in 98 patients (29.5%) during their stay in the stroke unit. Tachyarrhythmia (ventricular tachyarrhythmias, supraventricular tachyarrhythmias, complex ventricular ectopy) was present in 90 patients (27.1%); bradyarrhythmia was present in 13 patients (3.91%). Arrhythmias were independently associated with larger size of brain lesion and older age. In 10% of the patient total, therapeutic actions were taken after detection of significant cardiac arrhythmias. Most events occurred within the first 48 hours after stroke unit admission. Conclusions: Systematic cardiac monitoring in patients with acute stroke is useful for detecting clinically relevant cardiac arrhythmias. Incidence of arrhythmia is higher in the first 48 hours after stroke unit admission. Age and lesion size were predicted appearance of arrhythmias. Detection of cardiac arrhythmias in a stroke unit has important implications for treatment

Cardiac arrhythmias in stroke unit patients. Evaluation of the cardiac monitoring data. / Arritmias cardiacas en la unidad de ictus: análisis de los datos de la monitorización cardiaca.

INTRODUCTION: Cardiac arrhythmias are frequent in acute stroke. Stroke units are widely equipped with cardiac monitoring systems. Pre-existing heart diseases and heart-brain interactions may be implicated in causing cardiac arrhythmias in acute stroke. This article analyses cardiac arrhythmias detected in patients hospitalised in a stroke unit. METHOD: Prospective observational study of consecutive patients admitted to a stroke unit with cardiac monitoring. We collected clinical data from patients and the characteristics of their cardiac arrhythmias over a 1-year period (2013). Time of arrhythmia onset, associated predisposing factors, and the therapeutic decisions made after detection of arrhythmia were examined. All patients underwent continuous cardiac monitoring during no less than 48hours. RESULTS: Of a total of 332 patients admitted, significant cardiac arrhythmias occurred in 98 patients (29.5%) during their stay in the stroke unit. Tachyarrhythmia (ventricular tachyarrhythmias, supraventricular tachyarrhythmias, complex ventricular ectopy) was present in 90 patients (27.1%); bradyarrhythmia was present in 13 patients (3.91%). Arrhythmias were independently associated with larger size of brain lesion and older age. In 10% of the patient total, therapeutic actions were taken after detection of significant cardiac arrhythmias. Most events occurred within the first 48hours after stroke unit admission. CONCLUSIONS: Systematic cardiac monitoring in patients with acute stroke is useful for detecting clinically relevant cardiac arrhythmias. Incidence of arrhythmia is higher in the first 48hours after stroke unit admission. Age and lesion size were predicted appearance of arrhythmias. Detection of cardiac arrhythmias in a stroke unit has important implications for treatment.

Multifocal-motor-neuropathy-like disease associated with Infliximab treatment in a patient with Crohn's disease.

Multifocal motor neuropathy is an immune-mediated disorder characterized by motor-conduction block in nerve-conduction studies. It is recognized that anti-TNF-α therapies are associated with immune-mediated conditions as adverse events. We report a case of multifocal-motor-neuropathy-like disease associated with the use of Infliximab in a patient with Crohn's disease. The diagnosis was based on neurophysiological evaluation and complete screening tests. Clinical and laboratory findings were not compatible with other potential causes. There was a mild response to the IVIg treatment, and once Infliximab treatment was withdrawn, the patient made slow but substantial progress in his motor function, with partial improvement of motor conduction blocks in the last neurophysiological evaluation. We believe there is a causal relationship between anti-TNF-α treatment and the disorder in this patient. There are few well-documented reports of this association. To our knowledge, our case is the first occurring in a patient with Crohn's disease.

Hemicorea de Sydenham como manifestación de fiebre reumática / Sydenham's hemichorea as a manifestation of rheumatic fever

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Emergencias en trastornos del movimiento hipercinéticos / Hyperkinetic movement disorder emergencies

Introducción. Una emergencia en trastornos del movimiento es cualquier trastorno neurológico, de instauración aguda o subaguda, en el cual la principal manifestación clínica es un trastorno del movimiento primario, que persiste durante horas o días, y en el que cualquier fallo en el diagnóstico preciso o en el manejo del paciente puede dar lugar a una importante morbilidad o incluso mortalidad. Aunque son muy infrecuentes, es importante reconocer estos cuadros clínicos porque la gravedad de los síntomas y signos lleva a los pacientes a solicitar atención médica urgente. Desarrollo. Diferenciamos dos escenarios diferentes: el debut abrupto de un trastorno del movimiento o la exacerbación de un trastorno del movimiento ya existente. Es esencial realizar un diagnóstico sindrómico y etiológico precoces para poder llevar a cabo un manejo urgente adecuado. El espectro de causas posibles es muy amplio, pero es esencial recordar que la etiología farmacológica es muy frecuente y común a todas ellas. Conclusiones. La actitud general a seguir en un paciente que acude a urgencias por un trastorno del movimiento es indagar sobre el consumo de fármacos o drogas, preguntar sobre enfermedades neurológicas y psiquiátricas previas e intentar categorizar el trastorno del movimiento entre las diferentes entidades nosológicas. De cara al manejo en la urgencia, existen tres pilares fundamentales: tratamiento de soporte, tratamiento sintomático y, si es posible, tratamiento específico en función de la etiología (AU)

Introduction. A movement disorder emergency is any neurological disorder, either acute or subacute, in which the main clinical manifestation is a primary movement disorder that lasts for hours or days, and in which any inaccuracy in the diagnosis or in the management of the patient may give rise to an important morbidity or even mortality. Although they are very infrequent, it is important to recognise these clinical pictures because the severity of the symptoms and signs leads patients to seek urgent medical attention. Development. TTwo different scenarios can be distinguished: the abrupt onset of a movement disorder or the exacerbation of an already-existing movement disorder. It is essential to perform an early diagnosis of the syndromes and aetiology so as to be able to carry out adequate urgent management. There is a very wide spectrum of possible causes, but it is essential to remember that pharmacological causation is very frequent and common in all of them. Conclusions. The general stance to be taken when a patient visits A&E due to a movement disorder is to enquire about the consumption of drugs of abuse or medication, to ask about previous neurological and psychiatric diseases and to try to categorise the movement disorder among the different nosological conditions. Management in the emergency situation rests upon three fundamental pillars, namely, support treatment, symptomatic treatment and, if possible, specific treatment depending on the aetiology (AU)

Neuroimagen funcional en el estudio de los parkinsonismos: PET y SPECT / Functional neuroimaging in the study of parkinsonisms: PET and SPECT

Introducción. Las técnicas de neuroimagen estructural convencional (TC, RM) tienen una utilidad limitada en el diagnóstico del paciente parkinsoniano. Por el contrario, las exploraciones de Medicina Nuclear (PET y SPECT) pueden ser herramientas útiles para la evaluación de estos pacientes, ya que permiten el estudio de aspectos neuroquímicos y funcionales. Objetivo. Revisar el papel de la neuroimagen funcional con PET Y SPECT en el estudio del sistema nigroestriatal y otras funciones cerebrales, con especial hincapié en el SPECT cerebral de transportadores de dopamina con I123-ioflupano, y su utilidad en el diagnóstico diferencial de la enfermedad de Parkinson y otros parkinsonismos. Conclusiones. El estudio de la función nigro-estriatal y de otros sistemas no dopaminérgicos es útil para el diagnóstico temprano de la enfermedad de Parkinson, incluso en fase promotora; para su diferenciación del temblor esencial, de otros parkinsonismos no degenerativos (psicógeno, farmacológico, vascular) y de parkinsonismos atípicos (atrofia multisistema, parálisis supranuclear progresiva, degeneración corticobasal); y para distinguir la enfermedad de Alzheimer de la demencia por cuerpos de Lewy. Otras pruebas y radiotrazadores, para diferentes moléculas-mecanismos que ocurren en la enfermedad de Parkinson y otros parkinsonismos, están en desarrollo y podrían servir tanto para afinar más en el diagnóstico como para comprender mejor los mecanismos moleculares subyacentes a estas enfermedades y desarrollar nuevas dianas terapéuticas (AU)

Introduction. Conventional structural neuroimaging techniques (CT, MRI) are of only limited use in the diagnosis of patients with parkinsonian disorders. In contrast, explorations using nuclear medicine tools (PET and SPECT) can be useful for appraising these patients, since they allow neurochemical and functional aspects to be studied. Aims. This work aims to review the role of functional neuroimaging with PET and SPECT in the study of the nigrostriatal system and other brain functions, with special emphasis on brain SPECT of dopamine transporters with i123-ioflupane and its usefulness in the differential diagnosis of Parkinson's disease and other parkinsonisms. Conclusions. The study of the nigrostriatal function and of other non-dopaminergic systems is useful for the early diagnosis of Parkinson's disease, even in the promoter stage; for differentiating it from essential tremor, from other non-degenerative parkinsonisms (psychogenic, pharmacological, vascular) and from atypical parkinsonisms (multiple system atrophy, progressive supranuclear palsy, corticobasal degeneration); and also for distinguishing Alzheimer's disease from dementia with Lewy bodies. Other tests and radiotracers, for different molecules-mechanisms that occur in Parkinson's disease and other parkinsonisms, are being developed and could be used both to fine-tune the diagnosis even more as well as to gain a better understanding of the molecular mechanisms underlying these diseases and develop new therapeutic targets (AU)

Epidemiología de la enfermedad vascular cerebral en los pacientes con diabetes / Epidemiology of stroke in patients with diabetes

Las relaciones epidemiológicas entre la diabetes y la enfermedad cerebrovasculartienen un notable interés clínico debido a la elevada prevalencia poblacionalde ambos procesos. La diabetes incrementa el riesgo de ictus en los pacientesadultos jóvenes y, principalmente, en la población femenina. La incidencia deictus en pacientes con diabetes tipo 2 es de dos a cuatro veces superior a la dela población general. El antecedente de diabetes se ha relacionado también conun peor pronóstico en los pacientes que sufren un ictus, y con un mayor riesgode recurrencia tras él. Y, fi nalmente, la enfermedad cerebrovascular subcortical(infarto lacunar, leucoencefalopatía) se asocia significativamente a la diabetes(AU)

The epidemiological relationship between diabetes and stroke has an evidentclinical interest due to the high prevalence of both diseases. Diabetes increasesthe risk of stroke in younger subjects, and this risk is most prominentin diabetic women. The incidence of stroke in type 2 diabetes mellitus is from2 to 4 times higher than in the general population. A previous history of diabetesis associated with worse prognosis and higher risk of recurrence in patientswith an acute cerebrovascular event. And finally, subcortical stroke (lacunarinfarction and ischaemic white matter disease) is significantly associated withdiabetes(AU)