Pauta de actuación médico-quirúrgica en la meralgia parestésica / Medico-surgical approach to meralgia paresthetica

La meralgia parestésica es una entidad nosológica caracterizada por la presencia de parestesias, hipoestesia y disestesias en la región ántero-lateral del muslo. Su origen es la compresión del nervio fémorocutáneo lateral, bien en su trayecto intrapelviano, a su paso a través del ligamento inguinal, o bien por causas extrínsecas. Aunque la sintomatología puede considerarse banal y la causa en muchas ocasiones idiopática, es preciso protocolizar su diagnóstico y terapéutica, no sólo para descartar afecciones más graves sino para lograr un tratamiento eficaz. Presentamos una serie de 25 casos de meralgia parestésica y exponemos el protocolo diagnóstico y terapéutico. El diagnóstico se basa en la exploración clínica, la ecografía abdómino-pélvica y el estudio electrofisiológico. Este último consta de electromiografía, electroneurografía y potenciales evocados somatosensoriales. Se exponen los límites de normalidad de estas pruebas. El tratamiento comienza con la instauración de medidas higiénico-dietéticas (evitar prendas compresivas, reeducación postural, pérdida de peso), lo que logró la desaparición de los síntomas en el 40% de los casos. Si estas medidas no son eficaces se instaura tratamiento farmacológico, primero con anticomiciales y posteriormente con ansiolíticos o antidepresivos, lo que logró la curación del 52% de los pacientes. El 8% restante fue sometido a descompresión quirúrgica del nervio fémorocutáneo lateral al nivel del ligamento inguinal, que resolvió el cuadro de alteración de la sensibilidad. Concluímos que, la meralgia parestésica debe ser diagnosticada por neurofisiología y tratada secuencialmente mediante medidas higiénico-dietéticas, farmacológicas y neurolisis quirúrgica (AU)

The meralgia paresthetica is an entity characterized by the presence of parestesias, hipoestesia and disestesias in the ántero-lateral region of the thigh. It is caused by the compression of the lateral femorocutaneous nerve, well in its intrapelvic course, its passing through the inguinal ligament, or for extrinsic causes. Although the sintomatology can be considered banal and the ethiology in many occasions idiopatic, is necessary to protocolize its diagnosis and therapeutic, not only to discard more serious affections but to achieve an effective treatment. A series of 25 cases of meralgia paresthetica is presented and the diagnostic and therapeutic protocol is exposed. The diagnosis is based on the clinical exploration, abdomino-pelvic ecography and electrophisiologic study. This last one consists of electromiography, electroneurography and somatosensorial evoked potentials. The limits of normality of these tests are exposed. The treatment begins with the setting-up of hygienic-dietary measures (evitación of compresive garments, postural reeducation, loss of weight), with what the disappearance of the symptoms was achieved in 40% of the cases. If these measures are not effective pharmacological treatment is established, first with anticonvulsivants and later on with ansiolytic or antidepressants, with what the cure of 52% of the patients was achieved. The remaining 8% was subjected to surgical decompression of the nerve at the level of the inguinal ligament, with what were solved the sensibility disturbances. It is concluded that the meralgia paresthetica should be diagnosed by neurophysiologic study and treated sequentially by means of hygienicdietary, pharmacological measures and surgical neurolisis (AU)

[Pareidolia in Beato de Liébana's illuminated Visigothic codes]. / Pareidolia en los códices visigóticos iluminados de Beato de Liébana.

The visual perception alterations constitute a characteristic etymological field in some neurological and psychiatric processes (such as hallucinations, hallucinosis, etc.) that can also appear in healthy people (metamorphosias, pareidolias). The pareidolia is a phenomenon characterized by the non auto-provoked visualization of a perception in which reality and daydream are combined. It constitutes a source of inspiration for different artistic manifestations, is the basis of some common psychological explorations (such as Rorcharch test) and it even can be the explication to some situations considered as paranormals, for example the vision of faces in the Moon or in Mars or the apparition of sacred figures either in spots or shades... Beato of Liébana was a cantabrian presbyter, author in the eight century of the Comments of the Apocalypse exegesis, copied and illuminated repeated times all through the following centuries. Given the marked revealing and eschatological component of the Apocalypse, starting from the Leon's School (known also as Mozarabic since the Ninth Century), the original was enriched adding another texts with their own illustrations. From them, the Comments to Daniel's Book, from Saint Jeronimus, stands out. The whole of the illuminated Hispanic manuscripts constitutes a "corpus" of amazing codices international known today as Beatos. We have demonstrated that the first History's graphic representation of a pareidolia phenomenon is found in the miniature Visigoth Hispanic manuscripts known as Beatos; we have arrived to this conclusion studying two facsimiles from the x Century (Beato of Valcavado and Beato of Gerona) specially the miniature called Baltasar's Feast; in both codices, is illustrated how this Babylon king perceives the way a phantasmagoric hand spurts up from a candlestick flame and writes in the adjacent wall three mysterious words: MANE, TECEL, FARES, which were only interpreted by Prophet Daniel, requested ad hoc. Baltasar mixed up unintentionally the perceived and the daydreamed starting from a visual field barely structured, we conclude that he suffered from a pareilolia phenomenon, graphically represented by the first time in History in the Beatos.

Pareidolia en los códices visigóticos iluminados de Beato de Liébana / Pareidolia in Beato de Liébana's illuminated Visigothic codes

Las alteraciones perceptivas visuales constituyen un peculiar campo semiológico en determinados procesos neurológicos y psiquiátricos (alucinaciones, alucinosis) que pueden aparecer asimismo en sujetos sanos (metamorfopsias, pareidolia).La pareidolia es un fenómeno caracterizado por la visualización no autoprovocada de una percepción combinada entre lo real y lo fantaseado. Constituye una fuente de inspiración para diversas manifestaciones artísticas, es la base de algunas exploraciones psicológicas (test de Rorcharch) e incluso supone la explicación de algunas situaciones supuestamente paranormales (visión de rostros en la Luna o Marte, caras y figuras sagradas en manchas o sombras, etc.).Beato de Liébana fue un presbítero cántabro, autor en el siglo VIII de los Comentarios al Apocalipsis, exégesis copiada e iluminada repetidas veces a lo largo de los siglos siguientes. Dado el marcado componente revelatorio y escatológico del Apocalipsis, a partir de los manuscritos de la escuela leonesa o mozárabe (desde el siglo IX) el original beatense fue enriquecido añadiendo otros textos con sus propias ilustraciones, entre los que destacan los Comentarios al Libro de Daniel de San Jerónimo. El conjunto de manuscritos iluminados constituye un corpus de extraordinarios códices hispanos hoy conocidos internacionalmente como Beatos. Hemos demostrado que la primera representación gráfica de la historia de un fenómeno de pareidolia se encuentra en los manuscritos visigóticos miniados hispanos denominados Beatos, estudiando dos facsímiles de códices mozárabes del siglo X (Beatos de Valcavado y de Gerona), concretamente la miniatura denominada El festín de Baltasar. En ambos códices se ilustra cómo este rey babilónico percibe una fantasmagórica mano que surge del fuego de un candelabro y escribe en la pared adyacente tres misteriosas palabras (MANE, TECEL, FARES), que únicamente fueron interpretadas por el profeta Daniel, requerido ad hoc. Dado que Baltasar mezcló involuntariamente lo percibido con lo fantaseado a partir de un campo visual escasamente estructurado, concluimos que sufrió un fenómeno de pareidolia, representado gráficamente por primera vez en la historia en los Beatos. (AU)

[Neuroscience in Al Andalus and its influence on medieval scholastic medicine]. / La neurociencia en Al Andalus y su influencia en la medicina escolástica medieval.

INTRODUCTION: Since the application of technical medicine by the Greeks, modern neurology has been based on a body of knowledge and cultural heritage from ancient times. In this paper we review the contribution made by Al Andalus to neuroscience during the Middle Ages and its repercussions on modern neurology. DEVELOPMENT: Following the death of Mohammed in the vii century AD, Islam enjoyed one of the most spectacular periods of expansion in the history of mankind. Occupation of the cities of Alexandria and Gundishapur put the Arabs into contact with original Greco Latin manuscripts, which were assimilated and divulged by Islamic scientists in the middle eastern caliphates of Damascus and Bagdad as well as the western caliphates of Al Andalus (Spain) and Kairwan (Tunis). This classical hippocratico galenico medicine was refashioned into the so called arabized galenism, which markedly influenced the Scholastics and the cultured world of the lower Middle Ages and became the basis of European medicine until well into the Renaissance period. There was a first Spanish cultural Renaissance in Al Andalus during the ix xii centuries, which led to a flowering unheard of in the Middle Ages before then. Andalusian doctors made major contributions to the body of knowledge about neuroscience and developed major philosophical concepts of human understanding. Thus, Abulcasis (936 1013), the father of modern surgery, developed material and technical designs which are still used in neurosurgery. Averroes suggested the existence of Parkinson s syndrome and attributed photoreceptor properties to the retina. Avenzoar described meningitis, intracranial thrombophlebitis, mediastinal tumours and made contributions to modern neuropharmacology. Maimonides wrote about neuropsychiatric disorders and described rabies and belladonna intoxication. CONCLUSION: Aside from the political, religious and cultural differences between Al Andalus and the Christian kingdoms of the Iberian peninsula, the historical Andalusian period (711 1492) forms one of the most brilliant periods of Spanish neuroscience.

[Antoniana Margarita: Gómez Pereira, Francisco Lobato and the antecedents of cerebral mechanicism during the Spanish renaissance]. / Antoniana Margarita: Gómez Pereira, Francisco Lobato y los antecedentes del mecanicismo cerebral en el Renacimiento español.

The year 2000 is the fifth century of the birth, in Medina del Campo (Vallodolid, Spain) of licenciado Perea (Gomez Perea or Pereira). A man of the Renaissance, he was an outstanding doctor, humanist, theologist, nominalist philosopher, naturalist and practical engineer. He developed the first modern theory of behavior, based purely on mechanicistic principles, describing his ideas in a text known by the curious title of Antoniana Margarita. The objective of this paper is to pay him homage on the fifth centenary of his birth, making a historiographic study of Gomez Perea and his works, with particular emphasis on the ideological basis and its relationship with Renaissance hydraulic engineering, collaborating with his colleague Francisco Lobato, author of one of the only two pretechnological codices of sixteenth century Spain. The book Antoniana Margarita is written in Renaissance Latin and was published in Medina del Campo in 1554. It represents the first truly modern approach to brain function which excludes the providencialist concepts of Galen involving the soul and the spirit, in vogue until then, transmitted through the Arab and Scholastic tradition. Analyzing his theory of the automatism of animals Perea made the first description ever of the reflex arc and the conditioned reflex. He also established a topographical model of the brain in which he sketched the functioning of the prefrontal cortex and neurophysiology of memory. Perea was the immediate forerunner of Neuropsychology and of the methodology and organicist thought which predominates in modern Neurobiology. He was also a visionary of the Evolution of Darwin and of modern aetiology.

Antoniana Margarita: Gómez Pereira, Francisco Lobato y los antecedentes del mecanicismo cerebralen el Renacimiento español / Antoniana margarita: Gómez Pereira, Francisco Lobato and the antecedents of cerebral mechanicism during the spanish Renaissance

En el año 2000 se ha cumplido el quinto centenario del nacimiento en Medina del Campo (Valladolid, España), del `licenciado Perea' (Gómez Perea o Pereira). Hombre del renacimiento, fue médico prestigioso, humanista, teólogo, filósofo nominalista, naturalista e ingeniero práctico. Desarrolló el primer modelo teórico moderno de la conducta sobre una base puramente mecanicista, plasmando sus ideas en un texto conocido con el curioso título de Antoniana Margarita. El objetivo del presente trabajo es rendir un homenaje en el quinto centenario de su nacimiento, realizando un estudio historiográfico de Gómez Perea y su obra, haciendo especial hincapié en los antecedentes ideológicos y su relación con la ingeniería hidráulica renacentista colaborando con su paisano Francisco Lobato, autor de uno de los dos únicos códices pretecnológicos españoles del XVI. El libro Antoniana Margarita está escrito en latín renacentista y fue publicado en Medina del Campo en 1554. Representa el primer enfoque auténticamente moderno del funcionamiento cerebral que excluye los providencialistas conceptos galénicos de alma y espíritu, vigentes hasta entonces por transmisión arábica y escolástica. Analizando su `teoría del automatismo de las bestias', Perea describe por primera vez en la Historia el arco reflejo, el reflejo condicionado y establece un modelo topográfico cerebral donde se bosqueja el funcionamiento del córtex prefrontal y la neurofisiología de la memoria. Perea resulta ser el predecesor inmediato de la Neuropsicología y de la metodología y pensamiento organicista predominante en la moderna Neurobiología, además de ser un genial visionario del Evolucionismo darwiniano y de la moderna Etología (AU)

[Cerebral ischemia in Rendu-Osler-Weber disease]. / Isquemia cerebral en la enfermedad de Rendu-Osler-Weber.

Neurologic manifestations occur in 8-12% of the patients with Rendu-Osler-Weber disease or hereditary hemorrhagic telangiectasia (HHT), principally infectious and hemorrhagic and, less frequently, ischemic ones. More than a half of these neurologic complications are associated with pulmonary arterio-venous malformations (PAVM). The diagnosis of HHT is based on the presence of telangiectases, hemorrhagic events and a family history with an autosomal dominant pattern. We report a case of a patient diagnosed as having HHT with transient ischemic attacks and a PAVM, which was occluded by the use of embolotherapy. Cerebral ischemia in HHT is related to the existence of a PAVM and results from three mechanisms: 1) secondary poliglobulia and hyperviscosity because of the hypoxemia due to a right-left shunt; 2) communication between the airway and the pulmonary circulation during cough access, which produces gas embolism and hemoptysis; 3) and, finally, paradoxical embolism trough the PAVM, the same mechanism proposed to the infectious neurologic manifestations of the disease. When the diagnosis of HHT is suspected, early search and treatment of PAVM, with embolotherapy or surgery, are necessary in order to avoid respiratory problems (hemoptysis, exertional dyspnea, cianosis, clubbing) and neurologic complications.

Isquemia cerebral en la enfermedad de Rendu-Osler-Weber / Cerebral ischemia in Rendu-Osler-Weber disease

Un 8-12 por ciento de los pacientes con enfermedad de Rendu-Osler-Weber o telangiectasia hemorrágica hereditaria presenta manifestaciones neurológicas, sobre todo, hemorrágicas e infecciosas y, de forma menos frecuente, isquémicas. De ellos, más de la mitad asocian la presencia de malformaciones arteriovenosas pulmonares. El diagnóstico de la enfermedad se basa en la existencia de telangiectasias, fenómenos hemorrágicos y un patrón hereditario autosómico dominante. Se describe el caso clínico de un paciente, diagnosticado previamente de telangiectasia hemorrágica hereditaria, con accidentes isquémicos transitorios y una malformación arteriovenosa pulmonar que fue tratada mediante embolización. La isquemia cerebral en la telangiectasia hemorrágica hereditaria está relacionada con la presencia de una malformación arteriovenosa pulmonar y puede deberse a tres mecanismos: a) hiperviscosidad por poliglobulia secundaria a la hipoxemia provocada por la formación de un cortocircuito derecha-izquierda; b) comunicación de la vía aérea y la circulación pulmonar durante accesos de tos, lo que ocasiona una embolia gaseosa habitualmente acompañada de hemoptisis, y, por último, c) embolia paradójica a través de la malformación arteriovenosa pulmonar, que es, asimismo, el origen de las complicaciones neurológicas infecciosas de la enfermedad. En los pacientes con telangiectasia hemorrágica hereditaria debe investigarse la presencia de malformaciones arteriovenosas pulmonares y llevar a cabo de forma precoz su tratamiento, ya sea intravascular o quirúrgico, con el fin de evitar tanto problemas respiratorios (hemoptisis, disnea de esfuerzo, cianosis o acropaquías) como las posibles manifestaciones neurológicas. (AU)

[Syndromes involving rostral occlusion of the basilar artery: a preliminary study and proposal for a new clinical and neuro- radiological classification]. / Síndromes por oclusión rostral de la arteria basilar: estudio preliminar y propuesta de una nueva clasificación cliniconeurorradiológica.

Occlusion of the top of the basilar artery causes infarctions in supra- and infra-tentorial regions (thalamus, occipito-temporal lobes, rostral trunk and cerebellum) with characteristic clinical and radiological manifestations. We studied 17 patients with this syndrome whose clinical data and neurological images led us to classify them into four groups: type I (2 patients, 12%), showing mainly alterations in consciousness and ocular motricity, and bilateral thalamic infarction; type II (6 patients, 35%), with campimetric manifestations and uni- or bilateral ischemia of the occipito-temporal lobes; type III (5 patients, 29%), with associated corticospinal deficits and lacunar images in the rostral brainstem; and type IV (4 patients, 24%) with symptoms of and neuro-images revealing lesions in the cerebellum. The proposed classification is an attempt to facilitate diagnosis by neuro-imaging and to group patients according to prognosis.