[Characteristics and management of epileptic seizures in emergency department and diagnostic correlation at discharge]. / Características y manejo de las crisis epilépticas en urgencias y su correlación diagnóstica tras el ingreso.

BACKGROUND: Patients with seizures are common in the emergency department (ED), yet little is known regarding the management of these patients. This study was performed to define the demographic characteristics of patients with seizure disorders in the ED patient population and to determine final disposition, diagnostic and therapeutic activities, and to evaluate the concordance between provisional and definitive diagnosis. MATERIAL AND METHODS: We recorded prospectively all patients which were diagnosed of seizure in ED of Hospital Clínico of Zaragoza between November 1th and April 30th. Chart review was used to gather definitive diagnosis regarding these patients. RESULTS: Of the 54,022 patients who presented to the ED during the study period, 137 (0.36%) had complains related to seizures. Sixty one (44%) of these patients were admitted to the hospital. New-onset seizures were thought to be present in 60% of patients. Blood work was abnormal in 12% of patients and 48% of patients had pathological findings in neuroimaging study. False positive diagnosis was present in 33% of patients. The most important trigger of seizures in epileptic patients was tapped suddenly the antiepileptic drug treatment. CONCLUSIONS: We found a false positive diagnosis in 33% of patients, and the most important confounding pathology was sincope and stroke. High percentaje of pathological findings in neuroimaging studies were found. Electroencefalographic and toxicological studies were performed less than is recommended.

Dolor torácico y bloqueo de rama izquierda sin isquemia miocárdica / Chest pain and left bundle branch block without myocardial ischemia

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Características y manejo de las crisis epilépticas en urgencias y su correlación diagnóstica tras el ingreso / Characteristics and management of epileptic seizures in emergency department and diagnostic correlation at discharge

Introducción: las crisis convulsivas suponen un porcentaje elevado de las consultas en los servicios de urgencias, pero poco es conocido en relación al manejo y derivación de estos enfermos. El objetivo fue conocer el perfil de los pacientes que acuden a urgencias con crisis epilépticas, las medidas diagnósticas y terapéuticas, destino de los pacientes tras su valoración, así como la concordancia entre el diagnóstico inicial y definitivo de estos pacientes. Material y métodos: registramos prospectivamente todos los pacientes que acudieron al Servicio de Urgencias del Hospital Clínico de Zaragoza durante el periodo comprendido entre el 1 de noviembre del 2004 y 30 de abril del 2005 y que fueron diagnosticados de crisis comicial. Posteriormente se revisaron las historias clínicas de aquellos pacientes ingresados para determinar el diagnóstico definitivo. Resultados: de los 54.022 pacientes atendidos a urgencias, 137 (0,25%) fueron diagnosticados de crisis convulsiva, requiriendo ingreso hospitalario 61 (44%). Las crisis de novo representaron el 60% de los pacientes ingresados. Un 12% fueron secundarios a alteraciones analíticas y un 48% de los pacientes presentaron hallazgos patológicos en la neuroimagen; la falta de cumplimiento terapéutico con bajos niveles plasmáticos de fármacos fue el principal factor precipitante en los epilépticos conocidos. Los falsos positivos representaron el 33% de los diagnósticosde urgencias. Conclusiones: encontramos un tercio de errores respecto al diagnóstico de urgencias, siendo la causa más frecuente de error los síncopes y los ictus. Elevado porcentaje de diagnóstico etiológico por neuroimagen así como la escasez en la realización de electroencefalogramas y estudios toxicológicos

Background: Patients with seizures are common in the emergency department (ED), yet little is known regarding the management of these patients. This study was performed to define the demographic characteristics of patients with seizure disorders in the ED patient population and to determine final disposition, diagnostic and therapeutic activities, and to evaluate the concordance between provisional and definitive diagnosis. Material and methods: We recorded prospectively all patients which were diagnosed of seizure in ED of Hospital Clínico of Zaragoza between November 1th and April 30 th. Chart review was used to gather definitive diagnosis regarding these patients. Results: Of the 54,022 patients who presented to the ED during the study period, 137 (0.36%) had complains related to seizures. Sixty one(44%) of these patients were admitted to the hospital. New-onset seizures were thought to be present in 60% of patients. Blood work was abnormal in 12% of patients and 48% of patients had pathological findings in neuroimaging study. False positive diagnosis was present in 33% ofpatients. The most important trigger of seizures in epileptic patients was tapped suddenly the antiepileptic drug treatment. Conclusions: We found a false positive diagnosis in 33% of patients,and the most important confounding pathology was sincope and stroke.High percentaje of pathological findings in neuroimaging studies werefound. Electroencefalographic and toxicological studies were performed less than is recommended

Características del síndrome de Guillain-Barré en el área III de salud de la Comunidad Autónoma de Aragón / Characteristics of Guillain-Barré syndrome in the healthy area III of Aragon Country

Introducción: el síndrome de Guillain-Barré (SGB) es una polineuropatía inflamatoria autoinmune caracterizada por la presencia de parálisis fláccida con arreflexia, trastorno sensorial variable y disociación albúmino-citológica en el LCR.Pacientes y métodos: estudio retrospectivo de 30 pacientes diagnosticados de SGB entre 1999 y 2005 en el Hospital Clínico de Zaragoza. Se evaluó la incidencia anual, distribución estacional y regional, antecedentes de infección, características clínicas, neurofisiológicas y electrocardiográficas (ECG). Resultados: la incidencia fue de 1,56/100000 habitantes/año. Mayor frecuencia de eventos en invierno sin alcanzar significación estadística. Mayor frecuencia en sexo masculino (66,7%) e incremento de la incidencia con la edad en ambos sexos. La forma de presentación más frecuente fue la paraparesia de extremidades inferiores seguida de la afectación de pares craneales. El 62,5% recibió tratamiento inmunomodulador. La mortalidad fue del 10%. El 13% presentó alteraciones autonómicas. Alteraciones electrocardiográficas en el 37% de los pacientes. Conclusiones: la incidencia del SGB en Aragón es similar a la que se encontró en otras series. Observamos un aumento de la incidencia con la edad y predilección por los meses de invierno. Elevado porcentaje de pacientes con anomalías ECG mayoritariamente asintomáticas

Introduction: Guillain-Barré Syndrome is an acute immune-mediated inflammatory polyneuropathy characterized by flaccid paresia with a rreflexia, change able sensitive disorder and albumino cytologic dissociation in the cerebrospinal fluid (CSF). Patients and methods: We conducted a retrospective study of 30 GBS patients diagnosed in Hospital Clínico de Zaragoza between 1999 and 2005. Annual incidence, seasonal distribution, preceding acute infection; clinical, electrophysiological and electrocardiographic (ECG) data and evolution were all evaluated. Results: The incidence was 1.56/100000 inhabitants/year. We observed an upward tendency during winter months. The rates of incidence were higher in men (66.7%) and increased with age in both sexes. Main clinical presentation form was paraparesia of lower limbs followed on cranial nerve palsy. Immunoglobulin therapy was received by 62.5%of patients. The rate of death was 10%. Thirteen per cent of patients haddys autonomia. Electrocardiographic abnormalities were present in 37% of patients. Conclusions: GBS incidence in Aragon Country is similar to that found in other studies. An increase with age and an upward tendency during the winter months was observed. High percentage of abnormalities in ECG but the majority of patients was asymptomatic

Disfunción valvular protésica con síntomas atípicos. ¿Endocarditis o trombosis? / Prosthetic valve dysfunction with atypical symptoms. Endocarditis or trombosis?

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Diplejia facial: variante regional del síndrome de Guillian-Barré / Facial diplejia: a regional variant of Guillian-Barre syndrome

Diplejia facial es una manifestación clínica poco frecuente que puede presentarse como consecuencia de múltiples etiologías. Presentamos un paciente con una infección periodontal crónica que sufrió de forma brusca una parálisis facial inicialmente izquierda, que rápidamente se hizo bilateral. La aparición posterior de parestesias distales en extremidad superior derecha e hiporreflexia, junto con la disociación albúmino-citológica en el LCR, permitieron establecer el diagnóstico de variante regional del Síndrome de Guillian-Barré (SGB). La diplejia facial es idiopática en el 25% de casos, siendo la causa más frecuente. Sin embargo, existe un elevado porcentaje de casos secundarios a múltiples etiologías como el SGB donde es frecuente la afectación del nervio facial habitualmente asociado a otros trastornos motores siendo infrecuente la diplejia facial aislada. Concluimos la necesidad de sospecha clínica para realización de punción lumbar y RNM para descartar procesos neoplásicos y poder determinar la etiología responsable para establecer un adecuado abordaje terapéutico

Facial palsy is a uncommon clinical manifestation that it can be caused by different ethiologies. We show a patient with a chronic periodontal disease who presented a sudden facial palsy, initially in left-face but it becomes bilateral quickly. In few days he associated paresthesias in his right arm and hiporreflexia. These clinical findings with albumin-citological dissociation, they had allowed to establish the diagnosis of regional variant of Guillain-Barré Syndrome (SGB). Facial diplejia is an idiopathic manifestation in 25% of patients, and this is the most common cause. However, facial diplejia can be secondary to many ethiologies as SGB. The affectation of facial nerve associated to other motor symptoms in SGB is frequent, but it is not frequent the presentation as facial diplejia alone. In conclusion, it is necessary a high clinical suspicion to do a lumbar punction (PL) and MRI to reject neoplasic pathologies and to obtain a diagnosis and an adequatted treatment

Alteraciones de la migración neuronal: una causa de epilepsia farmacorresistente curable / Neuronal migration disorders: a cause of curable medication resistant epilepsy

Introducción. La displasia cortical focal es una alteraciónde la migración neuronal que se manifiesta con crisis epilépticashabitualmente farmacorresistentes. La mejoría en las técnicasde neuroimagen durante los últimos años ha permitido el diagnósticoy tratamiento quirúrgico de algunos pacientes tratados en politerapiadurante muchos años con mal control de las crisis. Caso clínico.Varón de 22 años con crisis epilépticas desde los 18 meses,refractario a múltiples combinaciones de fármacos antiepilépticos(FAE) orales con electroencefalogramas que mostraban descargasfrontales, punta-onda rápida, de mayor expresión izquierda y técnicasde neuroimagen repetidamente normales. Tras su último ingresopor reagudización de las crisis se repitió el estudio de neuroimageny se observó displasia cortical focal frontal izquierda, por loque se inició valoración neuroquirúrgica. En la actualidad, seis mesesdespués de la intervención, el paciente no ha presentado nuevascrisis epilépticas y se ha iniciado la reducción del tratamiento conFAE orales. Conclusión. Resulta necesario repetir estudios de neuroimagenen pacientes estudiados previamente ante la posibilidadde rescatar de la refractariedad a un grupo de pacientes condenadosa mal control de sus crisis junto con los efectos secundarios demuchos de los FAE

Introduction. Focal cortical dysplasia is a neuronal migration disorder that appears with bouts of epileptic seizuresthat are usually medication resistant. The improvements introduced into neuroimaging techniques in recent years have madeit possible to diagnose and offer surgical treatment to certain patients who have been under polytherapy for many years withpoor control over their seizures. Case report. We report the case of a 22-year-old male with epileptic fits since the age of 18months, who was refractory to multiple combinations of oral antiepileptic drugs (AEDs) with electroencephalograms thatdisplayed frontal, fast spike-wave discharges, with greater expression on the left side and findings from neuroimaging techniquesthat were repeatedly normal. After being readmitted to hospital because his seizures had got worse, the neuroimaging studywas repeated and left frontal focal cortical dysplasia was observed, which led us to start considering neurosurgery. At present,six months after the intervention, the patient has had no further convulsive fits and therapy with oral AEDs is being reduced.Conclusions. Neuroimaging studies must be repeated in patients that have already been examined because in this way it maybe possible to save a group of patients (who would otherwise have to resign to poor control over their seizures as well as theside effects of many AEDs) from becoming medication resistant

Estudio de los factores de riesgo en la amnesia global transitoria y su diferenciación del accidente isquémico transitorio / A study of the risk factors in transient global amnesia and its differentiation from a transient ischemic attack

Introduction. Transient global amnesia (TGA) is a clinical condition that has been described in many studies, but its pathophysiology is not fully understood. In recent years the theory of valvular insufficiency in the jugular vein has been added to the classical hypotheses that link it to migraine, to epilepsy and –the most widely accepted– to transient ischemic attacks (TIA), although the real origin of the condition has still not been determined. Patients and methods. In a retrospective study we compared 131 patients diagnosed with TGA between 1993 and 2004 with 262 patients who were diagnosed as having TIA over the same period. Results. Mean age was 65.94 years in TGA versus 71.11 years in the case of TIA. There was a higher rate of arterial hypertension among the patients with TGA and diabetes mellitus was more frequent among those with TIA (p < 0.05 in both cases). Emboligenic heart disease was scarce among patients with TGA. The number of patients with a history of ischaemic heart disease and a history and the development of cerebrovascular diseases was greater among those with TIA than in cases of TGA (p < 0.05). The TGA recurrence rate was 12%. The percentage of pathological findings in the CAT brain scan was higher in patients with TIA (p < 0.05). There are no significant differences between patients with TGA and TIAas far as treatment on hospital discharge is concerned. Conclusions. TGA does not seem to be a symptom of an arteriosclerotic pathology nor does it appear to offer a higher risk of heart or cerebrovascular disease and, therefore, antiaggregating therapy would not be indicated in such cases (AU)

Introducción. La amnesia global transitoria (AGT) es una manifestación clínica descrita en muchos estudios, pero cuya fisiopatología no está aclarada. A las hipótesis clásicas de asociación con migraña, epilepsia y la más aceptada de evento isquémico transitorio (AIT), se ha añadido en los últimos años la teoría de insuficiencia valvular yugular sin poder establecerse el origen real del cuadro. Pacientes y métodos. Estudio retrospectivo de 131 pacientes diagnosticados de AGT entre 1993 y 2004 comparados con 262 pacientes con AIT diagnosticados durante el mismo período. Resultados. Edad media de 65,94 años en AGT frente a 71,11 años en AIT. Mayor frecuencia de hipertensión arterial entre los pacientes con AGT y de diabetes mellitus en pacientes con AIT (p < 0,05 en ambos casos). Escasa cardiopatía embolígena en pacientes con AGT. Mayor frecuencia de antecedentes de cardiopatía isquémica y de antecedentes y desarrollo de enfermedad cerebrovascular en los pacientes con AIT respecto a la AGT (p < 0,05). Recurrencia de la AGT del 12%. Mayor porcentaje de hallazgos patológicos en la TC cerebral en pacientes con AIT (p < 0,05). No hay diferencias significativas en cuanto al tratamiento al alta entre los pacientes con AGT y AIT. Conclusión. La AGT no parece ser una manifestación de la patología arterioesclerótica ni presentar mayor riesgo de enfermedad cardio o cerebrovascular y, por lo tanto, no estaría indicado el tratamiento antiagregante (AU)