Microvascular decompression for trigeminal neuralgia: A retrospective analysis of long-term outcomes and prognostic factors.

INTRODUCTION: Microvascular decompression is considered to be the most effective and only etiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascular compression found in up to 95% of cases. This study aims to report the long-term outcomes and to identify prognostic factors in a series of patients with trigeminal neuralgia treated by microvascular decompression. METHODS: A retrospective observational study of 152 consecutive patients operated by microvascular decompression with at least six months of follow-up. The surgical results, including pain relief according to the Barrow Neurological Institute pain scale, complications and the medical treatment during the follow-up period were reviewed. Binary regression analysis was performed to identify factors associated with a good long-term outcome. RESULTS: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 months were included. At the final follow-up visit, 83% of the patients had achieved significant relief of the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequent complications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age and having paroxysmal pain were associated with a long-term pain relief. CONCLUSIONS: Our results support the notion that microvascular decompression is an effective and safe therapy in patients with trigeminal neuralgia. A multidisciplinary approach with an early referral to a neurosurgical unit many be beneficial in patients who are refractory to pharmacological treatment.

Manejo y factores de riesgo de mortalidad del estatus epiléptico: estudio retrospectivo / Status epilepticus management and mortality risk factors: A retrospective study

Introducción: El estatus epiléptico (SE, por sus siglas en inglés) es una urgencia neurológica con altas tasas de mortalidad. En este estudio analizamos el manejo del SE e identificamos factores de riesgo de mortalidad en los que realizar intervenciones de mejora o modificaciones en los protocolos de actuación hospitalarios. Métodos: Retrospectivamente se analizaron los datos demográficos de tratamiento y pronóstico de 65 pacientes (59 [44,5-77] años, 53,8% mujeres) que ingresaron en un hospital terciario cumpliendo los criterios de SE de la ILAE 2015, durante un periodo de 18 meses. Resultados: Treinta (46,2%) pacientes tenían antecedentes de epilepsia. Las causas más frecuentes de SE fueron enfermedad cerebrovascular (27,7%) e infección sistémica (16,9%). Se registraron desviaciones respecto al tratamiento habitual: la administración de las benzodiazepinas como primer fármaco solo en 33 (50,8%) pacientes, la combinación de 2 benzodiazepinas en 7 (10,8%) pacientes y el uso off-label de lacosamida en 5 (7,7%) pacientes. El electroencefalograma (EEG) fue realizado únicamente en 26 (40%) pacientes y solo 5 EEG (7,7% de pacientes) en las primeras 12 h. La tasa de mortalidad fue del 21,5%. Ictus agudo y complicaciones cerebrovasculares se asociaron con mortalidad, mientras que epilepsia previa e ingreso en la unidad de cuidados intensivos (UCI) fueron factores de buen pronóstico (p < 0,05). Conclusiones: Para mejorar el manejo del SE y reducir la tasa de mortalidad, sería recomendable implementar actividades formativas dirigidas a los profesionales del departamento de urgencias, así como el ingreso electivo en la UCI para pacientes con factores de riesgo (primera crisis epiléptica, con ictus agudo o complicaciones cardiovasculares). (AU)

Introduction: Status epilepticus (SE) is a neurological emergency with relatively high mortality rates. In this study, we analysed the management of SE and identified mortality risk factors that may be addressed with educational interventions or modifications to hospital protocols. Methods: In this retrospective study, we analysed demographic, treatment, and outcome data from 65 patients (mean age, 59 years [range, 44.5-77]; 53.8% women) who were admitted to our tertiary hospital during an 18-month period and met the 2015 International League Against Epilepsy criteria for SE. Results: Thirty patients (46.2%) had history of epilepsy. The most frequent causes of SE were cerebrovascular disease (27.7%) and systemic infection (16.9%). The following deviations were observed in the administration of the antiepileptic drugs: benzodiazepines were used as first option in only 33 (50.8%) patients; the combination of 2 benzodiazepines was recorded in 7 cases (10.8%); and lacosamide was used as an off-label drug in 5 patients (7.7%). Electroencephalography studies were performed in only 26 patients (40%); and only 5 studies (7.7% of patients) were performed within 12 hours of seizure onset. The mortality rate was 21.5%. Acute stroke and cerebrovascular complications were associated with higher mortality rates, while previous history of epilepsy and admission to intensive care were related to better prognosis (P <.05). Conclusions: To improve SE management and reduce mortality rates, training activities targeting emergency department physicians should be implemented, together with elective intensive care admission for patients with multiple mortality risk factors (eg, absence of history of epilepsy, acute stroke, or cardiovascular complications). (AU)

Status epilepticus management and mortality risk factors: a retrospective study.

INTRODUCTION: Status epilepticus (SE) is a neurological emergency with relatively high mortality rates. In this study, we analysed the management of SE and identified mortality risk factors that may be addressed with educational interventions or modifications to hospital protocols. METHODS: In this retrospective study, we analysed demographic, treatment, and outcome data from 65 patients (mean age, 59 years [range, 44.5-77]; 53.8% women) who were admitted to our tertiary hospital during an 18-month period and met the 2015 International League Against Epilepsy criteria for SE. RESULTS: Thirty patients (46.2%) had history of epilepsy. The most frequent causes of SE were cerebrovascular disease (27.7%) and systemic infection (16.9%). The following deviations were observed in the administration of the antiepileptic drugs: benzodiazepines were used as first option in only 33 (50.8%) patients; the combination of 2 benzodiazepines was recorded in 7 cases (10.8%); and lacosamide was used as an off-label drug in 5 patients (7.7%). Electroencephalography studies were performed in only 26 patients (40%); and only 5 studies (7.7% of patients) were performed within 12 hours of seizure onset. The mortality rate was 21.5%. Acute stroke and cerebrovascular complications were associated with higher mortality rates, while previous history of epilepsy and admission to intensive care were related to better prognosis (P <  .05). CONCLUSIONS: To improve SE management and reduce mortality rates, training activities targeting emergency department physicians should be implemented, together with elective intensive care admission for patients with multiple mortality risk factors (eg, absence of history of epilepsy, acute stroke, or cardiovascular complications).

A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment.

INTRODUCTION: Recent analyses emphasise that The Benchmark Stroke Door-to-Needle Time (DNT) should be 30min. This study aimed to determine if a new in-hospital IVT protocol is effective in reducing door-to-needle time and correcting previously identified factors associated with delays. MATERIAL AND METHODS: In 2014, we gradually introduced a series of measures aimed to reduce door-to-needle time for patients receiving IVT, and compared it before (2009-2012) and after (2014-2017) the new protocol was introduced. RESULTS: The sample included 239 patients before and 222 after the introduction of the protocol. Median overall door-to-needle time was 27min after the protocol was fully implemented (a 48% reduction on previous door-to-needle time [52min], P<.001)]. Median door-to-needle time was lower when pre-hospital code stroke was activated (22min). We observed a 26-min reduction in the median time from onset to treatment (P<.001). After the protocol was implemented, the "3-hour-effect" did not affect door-to-needle time (P=.98). Computed tomography angiography studies performed before IVT were associated with increased door-to-needle time (P<.001); however, the test was performed after IVT was started in most cases. CONCLUSIONS: Hospital reorganisation and multidisciplinary collaboration brought median door-to-needle time below 30min and corrected previously identified delay factors. Furthermore, overall time from onset to treatment was also reduced and more stroke patients were treated within 90min of symptom onset.

Un nuevo protocolo intrahospitalario reduce el tiempo puerta-aguja en el ictus agudo tratado con trombolisis intravenosa a menos de 30 minutos / A new protocol reduces median door-to-needle time to the benchmark of 30 minutes in acute stroke treatment

Introducción: El objetivo del tiempo puerta-aguja en el ictus isquémico agudo tratado con trombólisis intravenosa (TIV) tiende a situarse actualmente en los 30 min. Determinamos si un nuevo protocolo de actuación intrahospitalario es eficaz para reducir el intervalo puerta-aguja y corregir los factores de demora previamente identificados.Material y métodosEn 2014 se implantaron gradualmente unas medidas diseñadas para acortar los tiempos de actuación intrahospitalarios en los pacientes tratados con TIV. Se compararon los tiempos de actuación antes (2009-2012) y después (febrero 2014-abril 2017) de la introducción del nuevo protocolo.ResultadosSe incluyeron 239 pacientes antes y 222 después. Cuando todas las medidas fueron introducidas, la mediana global de tiempo puerta-aguja fue de 27 min (previa 52 min, 48% menos, p < 0,001) y de 22 min cuando se activó el código ictus extrahospitalario. El tiempo global al tratamiento (inicio-aguja) se redujo en 26 min de mediana (p < 0,001). En el período postintervención ya no se objetivó el «efecto de fin de ventana» (p = 0,98). Aunque la angio-TC antes de la TIV continuó retrasando los tiempos de actuación (p < 0,001), tras el nuevo protocolo, esta prueba se realizó después del inicio del tratamiento en la mayoría de los casos.ConclusionesLa reorganización intrahospitalaria y la colaboración multidisciplinar han situado la mediana de tiempo puerta-aguja por debajo de los 30 min y han corregido los factores de demora identificados previamente. Además, se ha reducido el tiempo global al tratamiento y una mayor proporción de pacientes son tratados en los primeros 90 min desde el inicio de los síntomas. (AU)

Introduction: Recent analyses emphasize that The Benchmark Stroke Door-to-Needle Time (DNT) should be 30 min. This study aimed to determine if a new in-hospital IVT protocol is effective in reducing door-to-needle time and correcting previously identified factors associated with delays.Material and methodsIn 2014, we gradually introduced a series of measures aimed to reduce door-to-needle time for patients receiving IVT, and compared it before (2009-2012) and after (2014-2017) the new protocol was introduced.ResultsThe sample included 239 patients before and 222 after the introduction of the protocol. Median overall door-to-needle time was 27 min after the protocol was fully implemented (a 48% reduction on previous door-to-needle time [52 minutes], P<.001)]. Median door-to-needle time was lower when pre-hospital code stroke was activated (22 min). We observed a 26-min reduction in the median time from onset to treatment (P<.001). After the protocol was implemented, the «3-hour-effect» did not affect door-to-needle time time (P=.98). Computed tomography angiography studies performed before IVT were associated with increased door-to-needle time (P<.001); however, the test was performed after IVT was started in most cases.ConclusionsHospital reorganisation and multidisciplinary collaboration brought median door-to-needle time below 30 min and corrected previously identified delay factors. Furthermore, overall time from onset to treatment was also reduced and more stroke patients were treated within 90 min of symptom onset. (AU)

Combination of white matter hyperintensities and Aß burden is related to cognitive composites domain scores in subjective cognitive decline: the FACEHBI cohort.

BACKGROUND: To explore whether the combination of white matter hyperintensities (WMHs) and amyloid-beta (Aß) deposition is associated with worse cognitive performance on cognitive composites (CCs) domain scores in individuals with subjective cognitive decline (SCD). METHODS: Two hundred participants from the FACEHBI cohort underwent structural magnetic resonance imaging (MRI), 18F-florbetaben positron emission tomography (FBB-PET), and neuropsychological assessment. WMHs were addressed through the Fazekas scale, the Age-Related White Matter Changes (ARWMC) scale, and the FreeSurfer pipeline. Eight CCs domain scores were created using the principal component analysis (PCA). Age, sex, education, and apolipoprotein E (APOE) were used as adjusting variables. RESULTS: Adjusted multiple linear regression models showed that FreeSurfer (B - .245; 95% CI - .1.676, - .393, p = .016) and ß burden (SUVR) (B - .180; 95% CI - 2.140, - .292; p = .070) were associated with face-name associative memory CCs domain score, although the latest one was not statistically significant after correction for multiple testing (p = .070). There was non-significant interaction of these two factors on this same CCs domain score (p = .54). However, its cumulative effects on face-name associative performance indicated that those individuals with either higher WMH load or higher Aß burden showed the worst performance on the face-name associative memory CCs domain score. CONCLUSIONS: Our results suggest that increased WMH load and increased Aß are independently associated with poorer episodic memory performance in SCD individuals, indicating a cumulative effect of the combination of these two pathological conditions in promoting lower cognitive performance, an aspect that could help in terms of treatment and prevention.

Microvascular decompression for trigeminal neuralgia: A retrospective analysis of long-term outcomes and prognostic factors.

INTRODUCTION: Microvascular decompression is considered to be the most effective and only etiological surgical treatment for classical trigeminal neuralgia, relieving the neurovascular compression found in up to 95% of cases. This study aims to report the long-term outcomes and to identify prognostic factors in a series of patients with trigeminal neuralgia treated by microvascular decompression. METHODS: A retrospective observational study of 152 consecutive patients operated by microvascular decompression with at least six months of follow-up. The surgical results, including pain relief according to the Barrow Neurological Institute pain scale, complications and the medical treatment during the follow-up period were reviewed. Binary regression analysis was performed to identify factors associated with a good long-term outcome. RESULTS: A total of 152 patients with a mean age of 60 years and a mean follow-up of 43 months were included. At the final follow-up visit, 83% of the patients had achieved significant relief of the pain and 63% could reduce the absolute drug doses by 50% or more. The most frequent complications were wound infection (4.5%) and CSF fistula (7%). Being over 70 years of age and having paroxysmal pain were associated with a long-term pain relief. CONCLUSIONS: Our results support the notion that microvascular decompression is an effective and safe therapy in patients with trigeminal neuralgia. A multidisciplinary approach with an early referral to a neurosurgical unit many be beneficial in patients who are refractory to pharmacological treatment.

Status epiléptico refractario en enfermedad de Creutzfeldt-Jakob genética por mutación E200K / Refractory status epilepticus in genetic Creutzfeldt-Jakob disease with E200K mutation

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Status epilepticus management and mortality risk factors: A retrospective study. / Manejo y factores de riesgo de mortalidad del estatus epiléptico: estudio retrospectivo.

INTRODUCTION: Status epilepticus (SE) is a neurological emergency with relatively high mortality rates. In this study, we analysed the management of SE and identified mortality risk factors that may be addressed with educational interventions or modifications to hospital protocols. METHODS: In this retrospective study, we analysed demographic, treatment, and outcome data from 65 patients (mean age, 59 years [range, 44.5-77]; 53.8% women) who were admitted to our tertiary hospital during an 18-month period and met the 2015 International League Against Epilepsy criteria for SE. RESULTS: Thirty patients (46.2%) had history of epilepsy. The most frequent causes of SE were cerebrovascular disease (27.7%) and systemic infection (16.9%). The following deviations were observed in the administration of the antiepileptic drugs: benzodiazepines were used as first option in only 33 (50.8%) patients; the combination of 2 benzodiazepines was recorded in 7 cases (10.8%); and lacosamide was used as an off-label drug in 5 patients (7.7%). Electroencephalography studies were performed in only 26 patients (40%); and only 5 studies (7.7% of patients) were performed within 12 hours of seizure onset. The mortality rate was 21.5%. Acute stroke and cerebrovascular complications were associated with higher mortality rates, while previous history of epilepsy and admission to intensive care were related to better prognosis (P <.05). CONCLUSIONS: To improve SE management and reduce mortality rates, training activities targeting emergency department physicians should be implemented, together with elective intensive care admission for patients with multiple mortality risk factors (eg, absence of history of epilepsy, acute stroke, or cardiovascular complications).

[Cognitive impairment in very elderly patients: a retrospective study in a neurology service]. / Deterioro cognitivo en el paciente muy anciano: estudio retrospectivo en una consulta de neurologia.

INTRODUCTION: A considerable proportion of very elderly patients with cognitive impairment are attended in the general neurology offices. There are few studies about the clinical characteristics of these patients. AIM: To describe the background and clinical features of very elderly patients who come to the general neurology clinic due to cognitive complaints or suspected cognitive impairment. PATIENTS AND METHODS: We retrospectively studied 336 patients (296 patients < 85 years vs. 40 patients >= 85 years of age) who had been mostly referred by primary care physicians. Cognitive performance was measured by the Mini-Mental State Examination and the overall (i.e., cognitive and functional) clinical situation was measured by the Clinical Dementia Rating scale. RESULTS: Older patients had more frequently cognitive impairment (mild cognitive impairment or dementia), both at the first visit and at the one-year follow-up visit (p < 0.0005). No differences were found in symptom duration (2.0 ± 2.1 vs. 1.5 ± 1.4 years), type of symptoms, or comorbidity. Alzheimer's disease was the most frequent etiological diagnosis in both age groups (82.4% vs. 75.0%; p > 0.05). CONCLUSIONS: Very elderly patients studied in the neurology office have a higher risk of presenting cognitive impairment, despite being comparable in terms of symptoms and time of evolution. These results could be explained from the hypotheses of brain reserve and combined brain pathology.

TITLE: Deterioro cognitivo en el paciente muy anciano: estudio retrospectivo en una consulta de neurologia.Introduccion. Una considerable proporcion de pacientes muy ancianos con deterioro cognitivo son atendidos en las consultas generales de neurologia, pero existen pocos estudios acerca de las caracteristicas clinicas de estos pacientes. Objetivo. Describir los antecedentes y rasgos clinicos de los pacientes muy ancianos que acuden a consulta general de neurologia por quejas o sospecha de deterioro cognitivo. Pacientes y metodos. Se estudio retrospectivamente a 336 pacientes (296 pacientes < 85 años frente a 40 pacientes >= 85 años) que habian sido remitidos en su mayoria desde la atencion primaria. El rendimiento cognitivo se midio mediante el test minimental de Folstein, y la situacion clinica global (cognitiva y funcional), mediante la escala de estadificacion clinica de la demencia. Resultados. Los pacientes de mas edad presentaban con mayor frecuencia deterioro cognitivo (alteracion cognitiva leve o demencia), tanto en la primera visita como en la visita de seguimiento al cabo de un año (p < 0,0005). No se encontraron diferencias en el tiempo desde el inicio de los sintomas (2,0 ± 2,1 frente a 1,5 ± 1,4 años), el tipo de sintomas ni la comorbilidad. La enfermedad de Alzheimer fue el diagnostico etiologico final mas frecuente en los dos grupos de edad (82,4% frente a 75%; p > 0,05). Conclusiones. Los pacientes muy ancianos estudiados en la consulta de neurologia presentan con mayor frecuencia deterioro cognitivo, a pesar de tener un tiempo de evolucion y una sintomatologia similares. Estos resultados podrian explicarse desde la hipotesis de la reserva cerebral y de la patologia cerebral combinada.