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.

Study protocol for a randomized controlled trial of the NEIVATECH virtual reality system to improve visual function in children with anisometropic amblyopia.

BACKGROUND: Interest in developing alternative methods for the treatment of amblyopia has long been a topic of interest among clinicians and researchers, as prescribed occlusion and penalization therapies do not always provide an effective response and are associated with a high risk of recurrence and non-compliance. Here, we present the protocol of a small-scale RCT to evaluate the safety and clinical efficacy of a novel VR-based system designed to provide binocular vision training to children with anisometropic amblyopia. METHODS: We aim to recruit a total of 60 children with anisometropic amblyopia aged 5-17 years with no previous treatment for amblyopia other than refractive correction from the pediatric ophthalmology units of the University Clinical Hospital of Valladolid and the Vithas Medimar International Hospital of Alicante. Children who meet the eligibility criteria and consent to participate will be randomly assigned to a three-month intervention group of 18 half-hour in-office therapy sessions with the NEIVATECH system (group A) or to a parallel group receiving 2 hours of conventional patching per day at home for the same period of time (group B). Assessments of visual function will be carried out before the intervention and at 1, 2 and 3 months, with changes in distance BCVA being the primary outcome measure to be considered. Patient safety, compliance, satisfaction and acceptance to treatment will also be assessed after therapy as other valuable outcome measures. In addition, a rsfMRI scan will be performed on a subgroup of 5 patients from each group at the pre-intervention visit and at the post-intervention visit to test the effects of both therapies on neural plasticity in the visual cortex. DISCUSSION: The NEIVATECH system has been conceived as a serious game designed to provide binocular vision training to anisometropic amblyopic children by complementing the concepts of perceptual learning, dichoptic training and gamification in an immersive VR environment. We hope that this novel approach may lead to greater improvements in vision performance than those provided so far by conventional patching in anisometropic amblyopic children. TRIAL REGISTRATION: This protocol was registered with ClinicalTrials.gov ( NCT04819386 ) on 29 March 2021.

[Effect of treatment with benzodiazepines on the hospital prognosis of Coronavirus disease 2019]. / Efecto del tratamiento con benzodiacepinas en el pronóstico hospitalario de la enfermedad por coronavirus 2019.

INTRODUCTION: The consequences of the use of of benzodiazepines in coronavirus disease 2019 have not yet been studied. We compared the hospital prognosis of patients hospitalized for coronavirus disease 2019 in benzodiazepine users and non-users. PATIENTS AND METHODS: Observational study with a retrospective cohort design. All consecutive patients admitted with a confirmed diagnosis of coronavirus disease 2019 were included. The patients under chronic treatment with benzodiazepines at the time of admission were studied and compared with non-users. The primary objective was to analyze the mortality of patients who used chronic benzodiazepines at the time of admission and compare them with those who did not use them. The secondary objective was to analyze the risk of severe disease due to coronavirus 2019, acute respiratory distress syndrome and admission to the Intensive Care Unit in both groups of patients. RESULTS: We included 576 patients, 138 (24.0%) used benzodiazepines. After adjusting for sex, age, baseline situation and all the different variables between both groups, benzodiazepine users did not show a higher odds of mortality (OR: 1,1, IC 95%: 0,7-1,9, p = 0,682) or higher risk of severe disease due to coronavirus 2019 (OR: 1.2, 95% CI: 0.7-1.8, p = 0.523). They also did not have a higher risk of acute respiratory distress syndrome (OR: 1.2, IC 95%: 0.8-1.9, p = 0.315) or more admission to the Intensive Care Unit (OR: 0.8, 95% CI: 0.4-1.4, p = 0.433). CONCLUSION: In our sample, treatment with benzodiazepines at the time of admission was not associated with a worse hospital prognosis in patients with coronavirus disease 2019.

TITLE: Efecto del tratamiento con benzodiacepinas en el pronóstico hospitalario de la enfermedad por coronavirus 2019.Introducción. Las consecuencias del consumo de benzodiacepinas en el marco de la la enfermedad por coronavirus 2019 (COVID-19) no se habían estudiado hasta ahora. En el presente estudio se comparó el pronóstico hospitalario de pacientes ingresados por COVID-19 que tomaban benzodiacepinas con el de otros ingresados por idéntico motivo que no las tomaban. Pacientes y métodos. Estudio observacional de cohortes retrospectivo. En el estudio se admitió a todos los pacientes consecutivos ingresados con un diagnóstico confirmado de COVID-19. Se estudió a los pacientes que en el momento del ingreso estaban en tratamiento crónico con benzodiacepinas en comparación con otros que no las tomaban. El objetivo principal fue analizar la mortalidad de dichos pacientes con uso crónico de benzodiacepinas y compararla con la mortalidad de los que no tomaban. El objetivo secundario fue analizar en ambos grupos de pacientes el riesgo de padecer un cuadro grave por COVID-19, el síndrome de dificultad respiratoria aguda o el ingreso en la unidad de cuidados intensivos. Resultados. Se admitieron 576 pacientes, 138 (24,0%) de los cuales tomaban benzodiacepinas. Después del ajuste por sexo, edad, situación inicial y todas las variables diferentes entre ambos grupos, los pacientes que tomaban benzodiacepinas no mostraron una probabilidad mayor de muerte (odds ratio: 1,1; IC 95%: 0,7-1,9; p = 0,682) ni un riesgo más acusado de COVID-19 grave (odds ratio: 1,2; IC 95%: 0,7-1,8; p = 0,523). Tampoco presentaron un riesgo mayor de síndrome de dificultad respiratoria aguda (odds ratio: 1,2; IC 95%: 0,8-1,9; p = 0,315) ni de ingreso en la unidad de cuidados intensivos (odds ratio: 0,8; IC 95%: 0,4-1,4; p = 0,433). Conclusión. En esta muestra de pacientes con COVID-2019, el tratamiento con benzodiacepinas en el momento del ingreso no apareció asociado con un empeoramiento del pronóstico hospitalario.

Efecto del tratamiento con benzodiacepinas en el pronóstico hospitalario de la enfermedad por coronavirus 2019 / Effect of treatment with benzodiazepines on the hospital prognosis of Coronavirus disease 2019

Introducción: Las consecuencias del consumo de benzodiacepinas en el marco de la la enfermedad por coronavirus 2019 (COVID-19) no se habían estudiado hasta ahora. En el presente estudio se comparó el pronóstico hospitalario de pacientes ingresados por COVID-19 que tomaban benzodiacepinas con el de otros ingresados por idéntico motivo que no las tomaban. Pacientes y métodos: Estudio observacional de cohortes retrospectivo. En el estudio se admitió a todos los pacientes consecutivos ingresados con un diagnóstico confirmado de COVID-19. Se estudió a los pacientes que en el momento del ingreso estaban en tratamiento crónico con benzodiacepinas en comparación con otros que no las tomaban. El objetivo principal fue analizar la mortalidad de dichos pacientes con uso crónico de benzodiacepinas y compararla con la mortalidad de los que no tomaban. El objetivo secundario fue analizar en ambos grupos de pacientes el riesgo de padecer un cuadro grave por COVID-19, el síndrome de dificultad respiratoria aguda o el ingreso en la unidad de cuidados intensivos. Resultados: Se admitieron 576 pacientes, 138 (24,0%) de los cuales tomaban benzodiacepinas. Después del ajuste por sexo, edad, situación inicial y todas las variables diferentes entre ambos grupos, los pacientes que tomaban benzodiacepinas no mostraron una probabilidad mayor de muerte (odds ratio: 1,1; IC 95%: 0,7-1,9; p = 0,682) ni un riesgo más acusado de COVID-19 grave (odds ratio: 1,2; IC 95%: 0,7-1,8; p = 0,523). Tampoco presentaron un riesgo mayor de síndrome de dificultad respiratoria aguda (odds ratio: 1,2; IC 95%: 0,8-1,9; p = 0,315) ni de ingreso en la unidad de cuidados intensivos (odds ratio: 0,8; IC 95%: 0,4-1,4; p = 0,433). Conclusión: En esta muestra de pacientes con COVID-2019, el tratamiento con benzodiacepinas en el momento del ingreso no apareció asociado con un empeoramiento del pronóstico hospitalario.(AU)

Introduction: The consequences of the use of of benzodiazepines in coronavirus disease 2019 have not yet been studied. We compared the hospital prognosis of patients hospitalized for coronavirus disease 2019 in benzodiazepine users and non-users. Patients and methods: Observational study with a retrospective cohort design. All consecutive patients admitted with a confirmed diagnosis of coronavirus disease 2019 were included. The patients under chronic treatment with benzodiazepines at the time of admission were studied and compared with non-users. The primary objective was to analyze the mortality of patients who used chronic benzodiazepines at the time of admission and compare them with those who did not use them. The secondary objective was to analyze the risk of severe disease due to coronavirus 2019, acute respiratory distress syndrome and admission to the Intensive Care Unit in both groups of patients. Results: We included 576 patients, 138 (24.0%) used benzodiazepines. After adjusting for sex, age, baseline situation and all the different variables between both groups, benzodiazepine users did not show a higher odds of mortality (OR: 1,1, IC 95%: 0,7-1,9, p = 0,682) or higher risk of severe disease due to coronavirus 2019 (OR: 1.2, 95% CI: 0.7-1.8, p = 0.523). They also did not have a higher risk of acute respiratory distress syndrome (OR: 1.2, IC 95%: 0.8-1.9, p = 0.315) or more admission to the Intensive Care Unit (OR: 0.8, 95% CI: 0.4-1.4, p = 0.433). Conclusion: In our sample, treatment with benzodiazepines at the time of admission was not associated with a worse hospital prognosis in patients with coronavirus disease 2019.(AU)

Rehabilitación integral postictus: efectos a largo plazo y factores socioambientales condicionantes del acceso / Comprehensive post-stroke rehabilitation: its long-term effects and the socio-environmental factors conditioning access to it

Introducción: La recuperación de todas las funciones cerebrales afectadas tras un ictus es esencial para la calidad de vida del paciente y la rehabilitación integral resulta clave. Objetivos: Identificar los factores sociales y ambientales condicionantes del acceso a la rehabilitación integral postictus, y valorar los efectos a largo plazo de la rehabilitación integral en la funcionalidad del paciente. Pacientes y método. Se estudia a 171 pacientes consecutivos (84 mujeres y 87 hombres) hospitalizados en 2015 en el servicio de neurología con un primer ictus isquémico, sin dependencia funcional previa, candidatos a rehabilitación integral. Se analizan diversas variables socioambientales y clínicas potencialmente asociadas al acceso a ésta. Se estudia el impacto pronóstico a largo plazo (período medio de 54 meses) sobre la situación funcional mediante el índice de Barthel. Resultados: La edad media de los pacientes era de 69 años. Sólo el 53% pudo acceder a la rehabilitación integral recomendada. Resultaron variables predictoras del acceso: residencia en medio urbano –odds ratio (OR): 2,957; intervalo de confianza al 95% (IC 95%): 1,067-8,199; p = 0,037–, complemento con rehabilitación privada (OR: 2,89; IC 95%: 1,13-7,392; p = 0,027) y mejor Rankin en el momento del alta (OR: 22,437; IC 95%: 3,247-155,058; p = 0,014). Tras un seguimiento medio durante 54 meses de los 137 supervivientes, el acceso a rehabilitación integral postictus se asoció independientemente a mejor situación funcional a largo plazo (OR: 12,441; IC 95%: 4,7-32,5; p < 0,001). Conclusiones: La rehabilitación integral postictus está asociada a un mejor pronóstico a largo plazo, pero su acceso está condicionado por factores ambientales y sociales, como el lugar de residencia y la posibilidad de contratar servicios privados.(AU)

Introduction: Recovery of all brain functions affected after stroke is essential for the patient’s quality of life, with comprehensive rehabilitation key. Objectives: Identify social and environmental factors affecting access to comprehensive post-ictus rehabilitation, and assess long-term effects of comprehensive rehabilitation on patient functionality. Patients and method: 171 consecutive patients (84 women and 87 men) hospitalized in 2015 in Neurology Service with first ischemic stroke, without prior functional dependence, candidates for comprehensive rehabilitation are studied. Various socio-environmental and clinical variables potentially associated with access to it are analyzed. The long-term prognostic impact (average period of 54 months) on the functional situation is studied using the Barthel index. Results: The average age of patients is 69 years. Only 53% were able to access the recommended comprehensive rehabilitation. Predictor variables of access were resulted: residence in urban environment (OR: 2,957; 95% CI: 1,067-8,199; p = 0.037), complement with private rehabilitation (OR: 2,89; 95% CI: 1,130-7,392; p = 0.027), best Rankin to high (OR: 22,437; 95% CI: 3,247-155,058; p = 0.014). After average follow-up for 54 months, of the 137 survivors, access to comprehensive post-ictus rehabilitation was independently associated with better long-term functional situation (OR: 12,441; 95% CI: 4.7-32.5; p < 0.001). Conclusions: Comprehensive post-ictus rehabilitation is associated with better long-term prognosis, but access to it is conditioned by environmental and social factors such as the place of residence and the possibility of contracting private services.(AU)

[Comprehensive post-stroke rehabilitation: its long-term effects and the socio-environmental factors conditioning access to it]. / Rehabilitación integral postictus: efectos a largo plazo y factores socioambientales condicionantes del acceso.

INTRODUCTION: Recovery of all brain functions affected after stroke is essential for the patient's quality of life, with comprehensive rehabilitation key. OBJECTIVES: Identify social and environmental factors affecting access to comprehensive post-ictus rehabilitation, and assess long-term effects of comprehensive rehabilitation on patient functionality. PATIENTS AND METHOD: 171 consecutive patients (84 women and 87 men) hospitalized in 2015 in Neurology Service with first ischemic stroke, without prior functional dependence, candidates for comprehensive rehabilitation are studied. Various socio-environmental and clinical variables potentially associated with access to it are analyzed. The long-term prognostic impact (average period of 54 months) on the functional situation is studied using the Barthel index. RESULTS: The average age of patients is 69 years. Only 53% were able to access the recommended comprehensive rehabilitation. Predictor variables of access were resulted: residence in urban environment (OR: 2,957; 95% CI: 1,067-8,199; p = 0.037), complement with private rehabilitation (OR: 2,89; 95% CI: 1,130-7,392; p = 0.027), best Rankin to high (OR: 22,437; 95% CI: 3,247-155,058; p = 0.014). After average follow-up for 54 months, of the 137 survivors, access to comprehensive post-ictus rehabilitation was independently associated with better long-term functional situation (OR: 12,441; 95% CI: 4.7-32.5; p < 0.001). CONCLUSIONS: Comprehensive post-ictus rehabilitation is associated with better long-term prognosis, but access to it is conditioned by environmental and social factors such as the place of residence and the possibility of contracting private services.

TITLE: Rehabilitación integral postictus: efectos a largo plazo y factores socioambientales condicionantes del acceso.Introducción. La recuperación de todas las funciones cerebrales afectadas tras un ictus es esencial para la calidad de vida del paciente y la rehabilitación integral resulta clave. Objetivos. Identificar los factores sociales y ambientales condicionantes del acceso a la rehabilitación integral postictus, y valorar los efectos a largo plazo de la rehabilitación integral en la funcionalidad del paciente. Pacientes y método. Se estudia a 171 pacientes consecutivos (84 mujeres y 87 hombres) hospitalizados en 2015 en el servicio de neurología con un primer ictus isquémico, sin dependencia funcional previa, candidatos a rehabilitación integral. Se analizan diversas variables socioambientales y clínicas potencialmente asociadas al acceso a ésta. Se estudia el impacto pronóstico a largo plazo (período medio de 54 meses) sobre la situación funcional mediante el índice de Barthel. Resultados. La edad media de los pacientes era de 69 años. Sólo el 53% pudo acceder a la rehabilitación integral recomendada. Resultaron variables predictoras del acceso: residencia en medio urbano ­odds ratio (OR): 2,957; intervalo de confianza al 95% (IC 95%): 1,067-8,199; p = 0,037­, complemento con rehabilitación privada (OR: 2,89; IC 95%: 1,13-7,392; p = 0,027) y mejor Rankin en el momento del alta (OR: 22,437; IC 95%: 3,247-155,058; p = 0,014). Tras un seguimiento medio durante 54 meses de los 137 supervivientes, el acceso a rehabilitación integral postictus se asoció independientemente a mejor situación funcional a largo plazo (OR: 12,441; IC 95%: 4,7-32,5; p menor de 0,001). Conclusiones. La rehabilitación integral postictus está asociada a un mejor pronóstico a largo plazo, pero su acceso está condicionado por factores ambientales y sociales, como el lugar de residencia y la posibilidad de contratar servicios privados.

Análisis de recursos asistenciales para el ictus en España en 2012: ¿beneficios de la Estrategia del Ictus del Sistema Nacional de Salud? / Analysis of stroke care resources in Spain in 2012: Have we benefitted from the Spanish Health System’s stroke care strategy?

Introducción: La Estrategia del Ictus del Sistema Nacional de Salud (EISNS) fue un documento de consenso entre las distintas administraciones y sociedades científicas que se desarrolló con el objetivo de mejorar la calidad del proceso asistencial y garantizar la equidad territorial. Nuestro objetivo fue analizar los recursos asistenciales existentes y si se había cumplido el objetivo de la EISNS. Material y métodos: La encuesta sobre los recursos disponibles se realizó por un comité de neurólogos de cada una de las comunidades autónomas (CC.AA), los cuales también realizaron la encuesta de 2008. Los ítems incluidos fueron el número de Unidades de Ictus (UI), su dotación (monitorización, neurólogo 24 h/7 días, ratio enfermería, protocolos), ratio cama UI/100.000 habitantes, recursos diagnósticos (ecografía cardíaca y arterial cerebral, neuroimagen avanzada), realización de trombolisis intravenosa, intervencionismo neurovascular (INV), cirugía del infarto maligno de la arteria cerebral media (ACM) y disponibilidad de la telemedicina. Resultados: Se incluyeron datos de 136 hospitales. Existen 45 UI distribuidas de un modo desigual. La relación cama de UI por habitantes y comunidad autónoma osciló entre 1/74.000 a 1/1.037.000 habitantes, cumpliendo el objetivo solo Cantabria y Navarra. Se realizaron por neurólogos 3.237 trombolisis intravenosas en 83 hospitales, con un porcentaje respecto del total de ictus isquémico entre el 0,3 y el 33,7%. Los hospitales sin UI tenían una disponibilidad variable de recursos. Se realiza INV en todas las CC.AA salvo La Rioja, la disponibilidad del INV 24 h/7 días solo existe en 17 ciudades. Hay 46 centros con cirugía del infarto maligno de la ACM y 5 con telemedicina. Conclusión: La asistencia al ictus ha mejorado en cuanto al incremento de hospitales participantes, la mayor aplicación de trombolisis intravenosa y procedimientos endovasculares, también en la cirugía del infarto maligno de la ACM, pero con insuficiente implantación de UI y de la telemedicina. La disponibilidad de recursos diagnósticos es buena en la mayoría de las UI, e irregular en el resto de hospitales. Las distintas CC.AA deben avanzar para garantizar el mejor tratamiento y equidad territorial, y así conseguir el objetivo de la EISNS

Introduction: The Spanish Health System’s stroke care strategy (EISNS) is a consensus statement that was drawn up by various government bodies and scientific societies with the aim of improving quality throughout the care process and ensuring equality among regions. Our objective is to analyse existing healthcare resources and establish whether they have met EISNS targets. Material and methods: The survey on available resources was conducted by a committee of neurologists representing each of Spain’s regions; the same committee also conducted the survey of 2008. The items included were the number of stroke units (SU), their resources (monitoring, neurologists on call 24 h/7d, nurse ratio, protocols), SU bed ratio/100 000 inhabitants, diagnostic resources (cardiac and cerebral arterial ultrasound, advanced neuroimaging), performing iv thrombolysis, neurovascular interventional radiology (neuro VIR), surgery for malignant middle cerebral artery (MCA) infarctions and telemedicine availability. Results: We included data from 136 hospitals and found 45 Stroke Units distributed unequally among regions. The ratio of SU beds to residents ranged from 1/74,000 to 1/1,037,000 inhabitants; only the regions of Cantabria and Navarre met the target. Neurologists performed 3,237 intravenous thrombolysis procedures in 83 hospitals; thrombolysis procedures compared to the total of ischaemic strokes yielded percentages ranging from 0.3 to 33.7%. Hospitals without SUs showed varying levels of available resources. Neuro VIR is performed in every region except La Rioja, and VIR is only available on a 24 h/7 d basis in 17 cities. Surgery for malignant MCA infarction is performed in 46 hospitals, and 5 have telemedicine. Conclusion: Stroke care has improved in terms of numbers of participating hospitals, the increased use of intravenous thrombolysis and endovascular procedures, and surgery for malignant MCA infarction. Implementation of SUs and telemedicine remain insufficient. The availability of diagnostic resources is good in most SUs and irregular in other hospitals. Regional governments should strive to ensure better care and territorial equality, which would achieve the EISNS objectives

Analysis of stroke care resources in Spain in 2012: have we benefitted from the Spanish Health System's stroke care strategy?

INTRODUCTION: The Spanish Health System's stroke care strategy (EISNS) is a consensus statement that was drawn up by various government bodies and scientific societies with the aim of improving quality throughout the care process and ensuring equality among regions. Our objective is to analyse existing healthcare resources and establish whether they have met EISNS targets. MATERIAL AND METHODS: The survey on available resources was conducted by a committee of neurologists representing each of Spain's regions; the same committee also conducted the survey of 2008. The items included were the number of stroke units (SU), their resources (monitoring, neurologists on call 24h/7d, nurse ratio, protocols), SU bed ratio/100,000 inhabitants, diagnostic resources (cardiac and cerebral arterial ultrasound, advanced neuroimaging), performing iv thrombolysis, neurovascular interventional radiology (neuro VIR), surgery for malignant middle cerebral artery (MCA) infarctions and telemedicine availability. RESULTS: We included data from 136 hospitals and found 45 Stroke Units distributed unequally among regions. The ratio of SU beds to residents ranged from 1/74,000 to 1/1,037,000 inhabitants; only the regions of Cantabria and Navarre met the target. Neurologists performed 3,237 intravenous thrombolysis procedures in 83 hospitals; thrombolysis procedures compared to the total of ischaemic strokes yielded percentages ranging from 0.3 to 33.7%. Hospitals without SUs showed varying levels of available resources. Neuro VIR is performed in every region except La Rioja, and VIR is only available on a 24h/7 d basis in 17 cities. Surgery for malignant MCA infarction is performed in 46 hospitals, and 5 have telemedicine. CONCLUSION: Stroke care has improved in terms of numbers of participating hospitals, the increased use of intravenous thrombolysis and endovascular procedures, and surgery for malignant MCA infarction. Implementation of SUs and telemedicine remain insufficient. The availability of diagnostic resources is good in most SUs and irregular in other hospitals. Regional governments should strive to ensure better care and territorial equality, which would achieve the EISNS objectives.

[Perfusion computed tomography makes it possible to overcome important SITS-MOST exclusion criteria for the endovenous thrombolysis of cerebral infarction]. / La tomografia computarizada de perfusion permite superar importantes criterios de exclusion SITS-MOST para la trombolisis endovenosa del infarto cerebral.

AIM. To study the frequency, safety and efficacy of perfusion computed tomography (PCT), through identification of brain tissue-at-risk, to guide intravenous thrombolysis in stroke patients with regulatory exclusion criteria (SITS-MOST and ECASS-3). PATIENTS AND METHODS. We studied consecutive acute non-lacunar ischemic stroke patients. After conventional CT was considered eligible, PCT was performed in the following circumstances: 4.5 to 6 h window, wake-up stroke or unknown time of onset; extent early infarct signs on CT; minor or severe stroke; seizures or loss of consciousness. Intravenous 0.9 mg/kg alteplase was indicated if: cerebral blood volume lesion covered < 1/3 of middle cerebral artery territory; mismatch > 20% between mean transit time and cerebral blood volume maps existed; and informed consent. SITS-MOST safety-efficacy parameters were used as endpoint variables. RESULTS. Between May 2009-April 2010, 66 hyperacute ischemic stroke patients a priori not eligible for intravenous thrombolysis underwent PCT. Indications were: > 4.5 h in 18 patients, wake up stroke or unknown onset in 25, extent infarct signs in 6, seizures at onset in 11, and minor stroke (NIHSS < 4) in 6. Twenty-nine (44%) of them finally received intravenous thrombolysis. Symptomatic hemorrhagic transformation occurred in 2 (6.9%) patient and 18 (62.1%) achieved a modified Rankin scale score equal or less than 2 on day 90. CONCLUSION. A high proportion of acute stroke patients with SITS-MOST and ECASS-3 exclusion criteria can be safely and efficaciously treated with intravenous thrombolysis using a PCT selection protocol. However randomized control trials will be needed to confirm our results.

Recursos asistenciales en ictus en España 2010: análisis de una encuesta nacional del Grupo de Estudio de Enfermedades Cerebrovasculares / Health care resources for stroke patients in Spain, 2010: analysis of a national survey by the Cerebrovascular Diseases Study Group

Introduction: Stroke is currently a major social health problem. For this reason, the Spanish Ministry of Health approved the Stroke National Strategy (SNS) in 2008 to improve the prevention, treatment and rehabilitation of stroke patients. This plan intends to guarantee 24-hour, 365-days neurological assistance in the whole country by the end of 2010. Our aim was to analyse the situation of stroke assistance in Spain in 2009. Material and methods: A committee of neurologists practicing in the different autonomous communities (AC), and who had not participated in the preparation of the SNS, was created. A national survey was performed including the number of stroke units (SU) and their characteristics (monitoring, 24-h/7-day on-call neurology service, nursing staff ratio and the use of protocols), bed ratio of SU/100,000 people, availability of intravenous thrombolysis therapy, neurovascular intervention (NI) and telemedicine. Results: We included data from 145 hospitals. There are 39 SU in Spain, unevenly distributed. The ratio between SU bed/number of people/AC varied from 1/75,000 to 1/1,037,000 inhabitants; Navarra and Cantabria met the goal. Intravenous thrombolysis therapy is used in 80 hospitals; the number of treatments per AC was between 7 and 536 in 2008. NI was performed in the 63% of the AC, with a total of 28 qualified hospitals (although only 1 hospital performed it 24h, 7days a week in 2009). There were 3 hospitals offering clinical telemedicine services. Conclusions: Assistance for stroke patients has improved in Spain compared to previous years, but there are still some important differences between the AC that must be eliminated to achieve the objectives of the SNS (AU)

Introducción: El ictus constituye un importante problema sociosanitario. Por ese motivo, el Ministerio de Sanidad aprobó en 2008 la Estrategia Nacional en Ictus (ENI) con el objetivo de mejorar la prevención, tratamiento y rehabilitación del paciente con ictus. Se pretende garantizar una atención neurológica en todo el país y a cualquier hora del día para final del 2010. Nuestro objetivo fue analizar la situación de la atención al ictus en España en el año 2009. Material y métodos: Se constituyó un comité de neurólogos de las diferentes CC. AA. que no hubieran participado en la ENI. Se elaboró una encuesta nacional que recogió el número de unidades de ictus (UI) y la dotación (monitorización, guardia de neurología 24h/7 días, ratio de enfermería y existencia de protocolos), ratio cama UI/100.000 habitantes, presencia de trombólisis iv, intervencionismo neurovascular (INV) y telemedicina. Resultados: Se incluyeron datos de 145 hospitales. Existen 39 UI distribuidas de un modo desigual. La relación cama de UI/número de habitantes/comunidad autónoma osciló entre 1/75.000 a 1/1.037.000 habitantes, cumpliendo el objetivo Navarra y Cantabria. Se realiza trombólisis iv en 80 hospitales, el número osciló entre 7-536 tratamientos/CC. AA. durante el año 2008. Se realiza INV en el 63% de las CC. AA., teniendo 28 centros capacitados, aunque sólo 1 la realizaba en 2009 las 24h/7 día. Existen 3 centros con telemedicina. Conclusiones: La asistencia al ictus ha mejorado en España respecto a unos años atrás, pero todavía existen importantes desigualdades por CC. AA. que deberían superarse si se quiere cumplir el objetivo de la ENI (AU)

Health care resources for stroke patients in Spain, 2010: analysis of a national survey by the Cerebrovascular Diseases Study Group.

INTRODUCTION: Stroke is currently a major social health problem. For this reason, the Spanish Ministry of Health approved the Stroke National Strategy (SNS) in 2008 to improve the prevention, treatment and rehabilitation of stroke patients. This plan intends to guarantee 24-hour, 365-days neurological assistance in the whole country by the end of 2010. Our aim was to analyse the situation of stroke assistance in Spain in 2009. MATERIAL AND METHODS: A committee of neurologists practicing in the different autonomous communities (AC), and who had not participated in the preparation of the SNS, was created. A national survey was performed including the number of stroke units (SU) and their characteristics (monitoring, 24-h/7-day on-call neurology service, nursing staff ratio and the use of protocols), bed ratio of SU/100,000 people, availability of intravenous thrombolysis therapy, neurovascular intervention (NI) and telemedicine. RESULTS: We included data from 145 hospitals. There are 39 SU in Spain, unevenly distributed. The ratio between SU bed/number of people/AC varied from 1/75,000 to 1/1,037,000 inhabitants; Navarra and Cantabria met the goal. Intravenous thrombolysis therapy is used in 80 hospitals; the number of treatments per AC was between 7 and 536 in 2008. NI was performed in the 63% of the AC, with a total of 28 qualified hospitals (although only 1 hospital performed it 24h, 7 days a week in 2009). There were 3 hospitals offering clinical telemedicine services. CONCLUSIONS: Assistance for stroke patients has improved in Spain compared to previous years, but there are still some important differences between the AC that must be eliminated to achieve the objectives of the SNS.

[Acute basilar artery thrombosis]. / Trombosis aguda de la arteria basilar.

Acute basilar artery thrombosis (ABT) has been largely considered a neurological catastrophe. With conventional treatment, only around 20% of patients achieve functional independence. An early presumptive diagnosis is essential to avoid treatment delay. Either multiparametric magnetic resonance imaging or computed tomography angiography source images may represent valid non-invasive tools to confirm ABT and evaluate ischemic tissue viability. The main determinant of ABT outcome is early recanalization but the most effective therapeutic option remains to be clarified. The BASICS prospective registry showed no superiority of intra-arterial over intravenous thrombolysis. Therefore, in the absence of contraindications, intravenous thrombolysis should be started as soon as possible and can be used as the main therapy when interventional procedures are not available. However, recent case series have reported high rates of functional independence (50%) after staged escalation therapy (ultra-early intravenous thrombolysis followed by on-demand endovascular mechanical thrombectomy). These results represent a hope for patients and neurologists and reinforce the need for innovation and research in this field.

Trombosis aguda de la arteria basilar / Acute basilar artery thrombosis

La trombosis aguda de la arteria basilar (TAB) ha sido considerada una catástrofe neurológica. Únicamente alrededor de un 20% de los pacientes alcanza un buen pronóstico con tratamiento convencional. Es importante establecer una sospecha diagnóstica precoz para evitar un retraso en el inicio del tratamiento. La evaluación diagnóstica incluye confirmación de la oclusión basilar y estimación de la viabilidad del tejido isquémico, y puede realizarse con resonancia magnética multiparamétrica o con angiotomografía computarizada combinada con sus imágenes fuente. La recanalización arterial precoz determina la posibilidad de alcanzar un buen pronóstico; sin embargo, se desconoce cuál es el mejor tratamiento de la TAB. No se ha demostrado que la trombólisis intraarterial sea superior a la intravenosa, de modo que en ausencia de contraindicaciones debe iniciarse cuanto antes la trombólisis intravenosa, que puede ser el tratamiento principal si no se cuenta con acceso al neurointervencionismo. Recientemente se han notificado tasas excelentes de buen pronóstico (50% de independencia funcional) empleando estrategias escalonadas de combinación de varias modalidades terapéuticas (trombólisis intravenosa ultraprecoz seguida de trombectomía mecánica endovascular de rescate). Estos resultados representan una esperanza para pacientes y neurólogos y suponen un reclamo para continuar innovando e investigando en este campo (AU)

Acute basilar artery thrombosis (ABT) has been largely considered a neurological catastrophe. With conventional treatment, only around 20% of patients achieve functional independence. An early presumptive diagnosis is essential to avoid treatment delay. Either multiparametric magnetic resonance imaging or computed tomography angiography source images may represent valid non-invasive tools to confirm ABT and evaluate ischemic tissue viability. The main determinant of ABT outcome is early recanalization but the most effective therapeutic option remains to be clarified. The BASICS prospective registry showed no superiority of intra-arterial over intravenous thrombolysis. Therefore, in the absence of contraindications, intravenous thrombolysis should be started as soon as possible and can be used as the main therapy when interventional procedures are not available. However, recent case series have reported high rates of functional independence (50%) after staged escalation therapy (ultra-early intravenous thrombolysis followed by on-demand endovascular mechanical thrombectomy). These results represent a hope for patients and neurologists and reinforce the need for innovation and research in this field (AU)

Factores clínicos predictores de la aparición de episodios vasculares tras un ataque isquémico transitorio / Clinical factors predicting the appearance of vascular events following a transient ischemic attack

Introducción. Los pacientes que han sufrido un ataque isquémico transitorio (AIT) tienen un elevado riesgo de sufrir un episodio vascular grave. La mayoría de ellos no se atienden de forma precoz y no se pueden beneficiar de un diagnóstico y tratamiento adecuados. Objetivo. Identificar los factores clínicos que predicen la aparición de un nuevo episodio vascular en estos pacientes. Pacientes y métodos. Estudiamos de forma prospectiva 104 pacientes con un AIT, atendidos en las primeras 24 horas tras el inicio de los síntomas, durante una mediana de seguimiento de 12,6 meses. Resultados. La incidencia de ictus, cardiopatía isquémica, arteriopatía periférica y muerte fue del 13, el 6, el 3 y el 8 por ciento, respectivamente. El análisis multivariante identificó, como predictores independientes de nuevos ictus, la edad mayor de 73 años (odds ratio -OR-, 4,46; IC 95 por ciento, 1,15-17,38) y la etiología aterotrombótica (OR, 4,36; IC 95 por ciento, 1,4413,18); de episodios de cardiopatía isquémica, el antecedente de padecer dicha cardiopatía (OR, 30,65; IC 95 por ciento, 2,94-319,17) y la toma de antidiabéticos orales (OR, 31,23; IC 95 por ciento, 2,65-368,74). La leucocitosis (OR 11,21; IC 95 por ciento, 1,25-100,39) se relacionó con las muertes de causa vascular, mientras que, nuevamente, la etiología aterotrombótica (OR, 3,83; IC 95 por ciento, 1,31-11,20) y el sexo masculino (OR 3,44; IC 95 por ciento, 1,02-11,60) se mostraron como predictores de la aparición de cualquier episodio vascular. Conclusiones. Nuestros resultados demuestran que el riesgo de sufrir episodios vasculares graves tras un AIT es elevado. Existen variables clínicas útiles (edad mayor de 73 años, etiología aterotrombótica, sexo masculino, toma de antidiabéticos orales y leucocitosis) para identificar los pacientes de mayor riesgo (AU)

[Reversible segmental cerebral vasoconstriction: the value of duplex transcranial Doppler in its diagnosis and follow up]. / Vasoconstriccion segmentaria cerebral reversible: utilidad del duplex transcraneal en el diagnostico y seguimiento.

INTRODUCTION: Reversible segmental cerebral vasoconstriction, also known as Call Fleming syndrome, is a clinical entity that consists of segmental vasoconstriction of the arteries in the brain, which can course with focal neurological deficits and which is characteristically reversible. Diagnosis and follow up of reversible segmental cerebral vasoconstriction is performed using cerebral arteriography, but no previous evaluation has been conducted of the role that duplex transcranial Doppler can play in this syndrome. CASE REPORT: Here we describe the case of a 57 year old female patient who began suffering from sudden bouts of headaches with no other accompanying clinical features. After ruling out the possibility of a subarachnoid haemorrhage by means of a spinal tap, a suspicion diagnosis of reversible segmental cerebral vasoconstriction was made through duplex transcranial Doppler and this was later confirmed by arteriography, which revealed a segmental stenosis in the upper branch of the left middle cerebral artery. Following treatment with nimodipine, the patient presented a clear clinical improvement and the reversibility of the cerebral vasoconstriction was confirmed by duplex transcranial Doppler. CONCLUSION: Contrast enhanced duplex transcranial Doppler would enable us to obtain an early diagnostic approximation in patients in whom segmental vasoconstriction is suspected; it could also constitute the choice non invasive follow up method in these patients.

[Clinical factors predicting the appearance of vascular events following a transient ischemic attack]. / Factores clinicos predictores de la aparicion de episodios vasculares tras un ataque isquemico transitorio.

INTRODUCTION: Patients who have suffered a transient ischemic attack (TIA) have a high risk of undergoing a severe vascular event. Most of them do not receive early attention and cannot benefit from an adequate diagnosis and treatment. AIMS: The aim of this study is to identify the clinical factors that predict the appearance of a new vascular event in these patients. PATIENTS AND METHODS: We conducted a prospective study of 104 TIA patients, who had been given attention during the first 24 hours after the onset of symptoms, for a mean follow up time of 12.6 months. RESULTS: The incidence rates of strokes, ischemic heart disease, peripheral arteriopathy and death were 13, 6, 3 and 8%, respectively. Multivariate analysis identified the following aspects as independent predictors of new strokes: an age above 73 odds ratio (OR) 4.46 (CI 95%, 1.15 17.38) and an atherothrombotic aetiology OR 4.36 (CI 95%, 1.4413.18); and episodes of ischemic heart disease, a history of suffering from such heart disease OR 30.65 (CI 95%, 2.94319.17) and taking oral antidiabetic drugs OR 31.23 (CI 95%, 2.65368.74). Leukocytosis OR 11.21 (CI 95%, 1.25100.39) is linked to the deaths caused by vascular disorders, whereas an atherothrombotic aetiology OR 3.83 (CI 95%, 1.31 11.20) and being male OR 3.44 (CI 95%, 1.02 11.60) were seen to be predictors of the appearance of any vascular event. CONCLUSIONS: Our findings showed that the risk of suffering severe vascular events after a TIA becomes higher. There are a number of useful clinical variables (age above 73, atherothrombotic aetiology, being male, taking oral antidiabetic drugs and leukocytosis) for identifying the patients at the highest risk.

[Study of the hypoplasic internal carotid artery by use of multislice spiral computed tomography. Two case reports]. / Estudio de la arteria carótida interna hipoplásica mediante tomografía computarizada helicoidal multicorte. A propósito de dos casos.

INTRODUCTION: Hypoplastic internal carotid artery (HICA) is a rare benign congenital malformation. Its angiographic image string sign is shared by entities that may be either medically or surgically treated. We report two cases diagnosed by helical computerized tomography (HCT). CASE REPORTS: Case 1: woman diagnosed clinically and by magnetic resonance (MR) of Chiari I malformation with associated syringomyelia. An HCT of the craniocervical junction was done to rule out osseous malformations. An hypoplastic posterior fossa (PF) with small right carotid foramen was diagnosed. An arteriography with HCT was done that showed the carotid string sign. Case 2: a 82 years old hypertensive woman with left hemiparesia and homonymous hemianopsia was diagnosed of right temporooccipital infarct. An HCT arteriography disclosed occlusion of the right posterior cerebral artery, calcification of the left carotid siphon and stenosis of the right siphon. Bi and tridimensional reconstructions of the circle of Willis, cranial base and distal cervical carotid arteries showed an hypoplastic right carotid artery and foramen. CONCLUSIONS: Multislice HCT is a recently incorporated diagnostic tool that allows a volumetric study in a short period of time, seconds. An angiographic study can be done intravenously in cases of vascular anomaly suspiction, hypoplastic carotid artery in the reported cases. HCT is the only current imaging tool that can diagnose this anomaly without the aid of other imaging studies.

Estudio de la arteria carótida interna hipoplásica mediantetomografía computarizada helicoidal multicorte. A propósito de dos casos / Study of the hypoplasic internal carotid artery by use of multislice spiral computed tomography. Two case reports

Introducción. La hipoplasia de la arteria carótida interna es una malformación congénita de presentación infrecuente. Su presencia se sospecha generalmente en el curso de un estudio angiográfico. La confirmación de la anomalía se realiza demostrando la presencia de un canal carotídeo hipoplásico en la base del cráneo con una tomografía computarizada (TAC). Presentamos dos casos diagnosticados con una tomografía computarizada helicoidal multicorte (TCHM). Casos clínicos. Caso 1: mujer diagnosticada clínicamente y mediante una resonancia magnética (RM) de malformación de Chiari I con siringomielia asociada. Se realizó una TCHM de charnela cervicoccipital para descartar malformaciones óseas. Se diagnosticó como hipoplasia ósea de fosa posterior con canal carotídeo derecho de pequeño tamaño. Se practicó una arteriografía con TCHM que mostró la imagen de una hipoplasia carotídea. Caso 2: mujer hipertensa de 82 años con hemiparesia y hemianopsia homónima izquierdas. La TAC convencional mostró un infarto temporoccipital derecho. Una arteriografía con TCHM mostró una oclusión de la arteria cerebral posterior derecha, calcificación del sifón carotídeo izquierdo y estenosis del derecho. Se realizaron reconstrucciones bi y tridimensionales del polígono de Willis, base del cráneo y carótidas cervicales distales que demostraron una carótida derecha y un foramen carotídeo hipoplásicos. Conclusión. La TCHM es una técnica radiológica de incorporación reciente que permite un estudio volumétrico en un período corto, en segundos. En las situaciones en que se sospecha una anomalía vascular se pueden realizar estudios arteriográficos por vía venosa, y se pueden demostrar las anomalías óseas asociadas con una sola adquisición de datos (AU)