Delayed Neurological Improvement After Full Endovascular Reperfusion in Acute Anterior Circulation Ischemic Stroke.

Background and Purpose: We aimed to determine the prevalence and predictors of delayed neurological improvement (DNI) after complete endovascular reperfusion in anterior circulation acute ischemic stroke (AIS). Methods: Retrospective analysis of an online multicenter prospective reperfusion registry of patients with consecutive anterior circulation AIS treated with endovascular thrombectomy (EVT) from January 2018 to June 2019 in tertiary stroke centers of the NORDICTUS (NORD-Spain Network for Research and Innovation in ICTUS) network. We included patients with AIS with a proximal occlusion in whom a modified Thrombolysis in Cerebral Infarction 3 reperfusion pattern was obtained. DNI was defined if, despite absence of early neurological improvement during the first 24 hours, patients achieved functional independence on day 90. Clinical and radiological variables obtained before EVT were analyzed as potential predictors of DNI. Results: Of 1565 patients with consecutive AIS treated with EVT, 1381 had proximal anterior circulation occlusions, 803 (58%) of whom achieved a modified Thrombolysis in Cerebral Infarction 3. Of these, 628 patients fulfilled all selection criteria and were included in the study. Mean age was 73.8 years, 323 (51.4%) were female, and median baseline National Institutes of Health Stroke Scale was 16. Absence of early neurological improvement was observed in 142 (22.6%) patients; 32 of these (22.5%) achieved good long-term outcome and constitute the DNI group. Predictors of DNI in multivariable-adjusted logistic regression were male sex (odds ratio, 6.4 [95% CI, 2.1­22.3] P=0.002), lower pre-EVT National Institutes of Health Stroke Scale score (odds ratio, 1.4 [95% CI, 1.2­1.5], P<0.001), and intravenous thrombolysis (odds ratio, 9.1 [95% CI, 2.7­30.90], P<0.001). Conclusions: One-quarter of patients with anterior circulation AIS who do not clinically improve within the first 24 hours after complete cerebral endovascular recanalization will achieve long-term functional independence, regardless of the poor early clinical course. Male sex, lower initial clinical severity, and use of intravenous thrombolysis before EVT predicted this clinical pattern.

Encefalitis Límbica Autoinmune Asociada A Anticuerpos LGI1: Presentación De Un Caso Y Revisión De La Bibliografía / Autoimmune Limbic Encephalitis Associated With LGI1 Antibodies: Case Report And Review Of The Literature

RESUMEN Introducción: La encefalitis asociada a anticuerpos dirigidos contra la proteína 1 inactivada del glioma rica en leucina (LGI1) es una entidad poco frecuente de inicio subagudo que se caracteriza clínicamente por la presencia de alteraciones cognitivas, alteraciones conductuales y crisis epilépticas. El pronóstico en la mayoría de los casos es favorable, aunque son frecuentes los déficits amnésicos residuales. Caso clínico: Mujer de 76 años que comenzó de manera súbita con una serie de crisis tónico - clónicas generalizadas y posterior alteración del nivel de consciencia. Se inició tratamiento anticonvulsivante con discreta mejoría clínica. En la resonancia magnética realizada durante el ingreso se observó hiperintensidad en hipocampo izquierdo en secuencias T2 y T2-FLAIR. Ante la sospecha de encefalitis límbica autoinmune se inició tratamiento inmunomodulador con corticoesteriodes e inmunoglobulinas con mejoría clínica. Posteriormente se detectaron anticuerpos anti - LGI1 en líquido cefalorraquídeo. Conclusiones: La encefalitis autoinmune asociada a anticuerpos anti-LGI1 puede producir clínica neurológica variada y orden de instauración variable, incluso en ocasiones agudo. El tratamiento con inmunoterapia precoz es importante tanto para la mejoría clínica en la fase aguda como para el pronóstico a largo plazo.

Abstract Introduction: Leucine rich glioma inactivated protein 1 (LGI1) antibody encephalitis is a rare disease characterized by subacute memory impairment, behavioral disorders and epileptic seizures. Even most cases have a good outcome, residual cognitive deficits are common. Case report: 76-year-old woman who started with acute onset generalized tonic - clonic seizures and subsequent impaired level of consciousness. Antiepileptic treatment was started with slight clinical improvement. In magnetic resonance imaging performed during admission left hippocampal hyperintensity was seen in T2 and T2-FLAIR sequences. As autoimmune limbic encephalitis was suspected, immunomodulatory treatment with intravenous corticosteroids and immunoglobulins was started with clinical improvement. Afterwards, anti -LGI1 antibodies were positive in cerebrospinal fluid testing. Conclusions: anti - LGI1 antibody related encephalitis can produce different neurological manifestations and diverse onset, even acute. Early immunomodulatory treatment is important to improve both clinical manifestations and long - term outcome.

Carotid artery stenting in a single center, single operator, single type of device and 15 years of follow-up.

BACKGROUND: Revascularization with carotid stent (CAS) is considered the therapeutic alternative to endarterectomy (CEA). However, its role compared to CEA remains questioned, mainly due of the heterogeneity of long-term results. The objective of this study was to report the efficacy and durability of CAS in terms of stroke prevention in a "real world experience". METHOD: This was a single-center retrospective analysis of 344 patients treated with CAS between January 2001 and December 2015.The primary outcome of the trial was stroke, myocardial infarction, or death during a periprocedural period or any stroke event over a 15-year follow-up. The secondary aim was to identify risk factors for 30-day complications, long-term neurological complications, and intra-stent restenosis. RESULTS: The primary composite end point (any stroke, myocardial infarction, or death during the periprocedural period) was 2.3%. The use of an EPD was protective against major complications.Long-term follow-up was achieved in 294 patients (85,5%) with a median of 50 months (range 0-155 months). Fifty-six (16,3%) died within this period, most commonly of nonvascular causes (4 patients had stroke-related deaths). During the follow-up period, 8 strokes and 3 TIAs were diagnosed (3.2%).ISR determined by sequential ultrasound was assessed in 4.4% of the patients and remained asymptomatic in all but 2 patients (0.6%). All patients with restenosis underwent revascularization with balloon angioplasty. CONCLUSION: The long-term follow-up results of our study validate CAS as a safe and durable procedure with which to prevent ipsilateral stroke, with an acceptable rate of restenosis, recurrence and mortality.

Conocimiento de la enfermedad vascular cerebral en la población de Zaragoza / Knowledge of cerebrovascular disease in the population of Zaragoza

Introducción. El ictus es una de las principales causas de invalidez y mortalidad en nuestra sociedad, con importantes repercusiones socioeconómicas y sanitarias. La asistencia precoz puede mejorar el pronóstico de los pacientes. Actualmente, existen tratamientos en fase aguda, que consiguen reperfundir el tejido isquémico en riesgo y revertir la sintomatología, pero son pocos los pacientes que se benefician, por el retraso en su atención, debido a la falta de reconocimiento de los síntomas y la escasa percepción de gravedad. Objetivo. Analizar el conocimiento de la población de nuestra área de salud sobre el ictus. Sujetos y métodos. La muestra analizada ha sido la población del sector III de la provincia de Zaragoza, con selección aleatoria. La herramienta utilizada ha sido una encuesta telefónica estructurada (total de 583). Resultados. Un 63,5% de los encuestados desconoce los síntomas del ictus, y un 48%, los factores de riesgo vascular. Sólo un 9% reconoce al menos dos síntomas y dos factores de riesgo. En cuanto a la actitud, un 56% actuaría correctamente frente a un 44% que no. El análisis multivariante mostró que los factores más relacionados con el conocimiento fueron el nivel cultural y la edad joven. Vivir en un pueblo y sexo femenino se relacionaron con la mejor actitud. Conclusiones. El conocimiento del ictus es escaso, con una baja percepción de urgencia. Los factores que implican un mejor conocimiento son la edad joven y el nivel cultural alto (AU)

Introduction. Acute cerebrovascular disease is a major cause of disability and mortality, with important socio-economic and health impacts. Early stroke care can reduce mortality and improve prognosis. Right now, we can apply treatments in the acute phase, with capacity to reverse the symptoms, but few patients who benefit not reach the hospital soon. One reason for this delay is the lack of recognition of symptoms and poor perception of gravity. Aim. To find out the knowledge of the public about the stroke. Subjects and methods. The sample analyzed was the population of Sector III of Zaragoza, with random selection. The tool used was a telephone survey structured. We analyzed 583 surveys. Results. 63.5% of respondents did not know any symptoms of stroke. 48% do not know any vascular risk factor. Only 9% recognized at least two symptoms and two risk factors. Regarding the attitude, 56% act properly against 44% who do not. Multivariate analysis showed that the factors more related to knowledge are the cultural level and young age. Living in town, and female, they are associated with the best attitude. Conclusions. Knowledge about stroke is poor, with a low sense of urgency. The factors most associated with the best knowledge are young age and cultural level (AU)

Neuralgia occipital como primer síntoma de un hepatocarcinoma / Occipital neuralgia as the first symptom of a hepatocarcinoma

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Nighttime blood pressure in cluster headache.

BACKGROUND: It has been proposed that desaturation of oxygen during an apnea event is the trigger for cluster headache. Obstructive sleep apnea has been associated with a higher than normal cardiovascular morbidity and mortality. Some obstructive sleep apnea syndrome patients lack the sleep-related, nocturnal decrease, or "dip" in blood pressure, which is seen in normal individuals. OBJECTIVE: The aim of this study is to assess whether this non-dipper pattern is present in cluster headache patients. DESIGN AND METHODS: A total of 30 normotensive cluster headache patients underwent an ambulatory blood pressure monitoring. "Non dippers" were defined as patients with a nighttime mean blood pressure fall <10%. RESULTS: Fifteen cluster headache patients (50%) were non-dippers, a frequency higher than expected. The pattern of nocturnal non-dipping is associated with a higher body mass index. Non-dipper patients displayed higher mean nighttime systolic and diastolic blood pressure. No significant difference was observed in the mean 24-hour and daytime blood pressure. CONCLUSIONS: The high incidence (50%) of non-dipper pattern in both processes, cluster headache and obstructive sleep apnea syndrome, provides support for the hypothesis of a relationship between theses 2 disorders.

Orientación en el tiempo y deterioro cognitivo / Temporal orientation and cognitive impairment

Introducción. La orientación temporal forma parte de la mayoría de los tests de cribado para el diagnóstico de deterioro cognitivo. Una orientación temporal correcta implica activar tanto información semántica (conceptos de la fecha del calendario) como episódica (recuerdo de la fecha actual). Objetivo. Evaluación de la utilidad diagnóstica de una técnica de valoración de la orientación temporal, basada en una consigna abierta, y puntuación de la información semántica y episódica generadas (0-10 puntos). Sujetos y métodos. Se evaluó un total de 24 sujetos sin deterioro, 77 pacientes con deterioro cognitivo leve (DCL) y 62 pacientes con demencia, mediante test minimental/miniexamen cognitivo de 30 puntos, test de fluidez verbal semántica, escala de deterioro global, orientación temporal tipo minimental y orientación temporal tipo abierto. Se han analizado las áreas bajo la curva (aROC), sensibilidad y especificidad para la demencia y el deterioro cognitivo en cualquier grado (DCL y demencia). Resultados. La orientación temporal tipo abierto presentó la mayor área bajo la curva (aROC = 0,90) para la discriminación entre pacientes con demencia y sin demencia (DCL y sin deterioro) y un aROC = 0,83 para discriminar entre pacientes con DCL o demencia y sin deterioro. Para la demencia, con un punto de corte igual o inferior a 6, presentó una sensibilidad de 0,96 y una especificidad de 0,68, y para DCL y demencia, con un punto de corte igual o inferior a 7, una sensibilidad de 0,72 y una especificidad de 0,92. Conclusiones. Esta técnica es adecuada como instrumento de cribado en el deterioro cognitivo por su utilidad, brevedad y posición estratégica en la exploración del estado mental. Presenta alta sensibilidad con baja especificidad para la demencia y baja sensibilidad con alta especificidad para el deterioro en cualquier grado (AU)

Introduction. Temporal orientation is a component of most screening tests for diagnosing cognitive impairment. Correct temporal orientation involves activating both semantic information (concepts of the calendar date) and episodic information (remembering the current date). Aims. The aim of this study was to assess the diagnostic usefulness of a technique for evaluating temporal orientation, hich was open-ended, and scoring the semantic and episodic information thus generated (0-10 points). Subjects and methods. A total of 24 subjects without impairment, 77 patients with mild cognitive impairment (MCI) and 62 patients with dementia were evaluated by means of a 30-point mini-mental/mini-examination, semantic verbal fluency test, global deterioration scale, mini-mental-type temporal orientation and open-ended temporal orientation tests. The areas under the curve (aROC), sensitivity and specificity for dementia and cognitive impairment at any degree (MCI and dementia) were analysed. Results. Open-ended temporal orientation presented a greater area under the curve (aROC: 0.90) for discrimination between patients with dementia and without dementia (MCI and without impairment) and an aROC of 0.83 for discrimination between patients with MCI or dementia and without impairment. For dementia, with a cut-off point equal to or below 6, sensitivity was 0.96 and specificity was 0.68, and for MCI with dementia, with a cut-off point equal to or below 7, sensitivity was 0.72 and specificity was 0.92. Conclusions. The usefulness, conciseness and strategic position of this technique in examining mental status make it suitable as an instrument for screening for cognitive impairment. It has a high level of sensitivity with low specificity for dementia and low sensitivity with high specificity for any degree of impairment (AU)