Causas no inflamatorias de consulta urgente en esclerosis múltiple / Non-inflammatory causes of emergency consultation in patients with multiple sclerosis

Objetivos: Describir consultas urgentes de pacientes con esclerosis múltiple (EM) distintas a brotes: causas, dificultades diagnósticas, características clínicas y tratamientos empleados.Material y métodosEstudio retrospectivo de los pacientes que acudieron a un Hospital de Día de EM en 2 años por sospecha de brote y que recibieron un diagnóstico alternativo. Se evaluaron variables demográficas, características clínicas de los pacientes, diagnósticos finales y tratamientos. Los pacientes con diagnóstico final de brote e inicialmente diagnosticados de pseudobrote se evaluaron específicamente. Con una finalidad exploratoria se compararon las características de los pacientes que consultaban por causas no inflamatorias con una cohorte de pacientes aleatoriamente seleccionados que habían sufrido un brote en el mismo periodo de tiempo.ResultadosSe incluyeron un total de 50 pacientes inicialmente diagnosticados de pseudobrotes (33 mujeres, con edad media 41,4 ± 11,7 años). Cuatro pacientes (8% del total) fueron inicialmente diagnosticados de pseudobrote aunque posteriormente fueron diagnosticados de un verdadero brote. La fiebre y el vértigo fueron los principales factores de confusión. Las causas no inflamatorias de consulta urgente fueron: neurológicas: 43,5% (20); infecciosas: 15,2% (7); psiquiátricas: 10,9% (5); vértigo: 8,6% (4); traumatológicas: 10,9% (5), y otras: 10,9% (5).ConclusionesLa mayor parte de las consultas urgentes no inflamatorias fueron causadas por síntomas relacionados con la EM. El seguimiento estrecho de brotes y pseudobrotes es necesario para detectar diagnósticos incorrectos, evitar tratamientos innecesarios y aliviar los síntomas de los pacientes. (AU)

Objectives: To describe non-relapse-related emergency consultations of patients with multiple sclerosis (MS): causes, difficulties in the diagnosis, clinical characteristics, and treatments administered.MethodsWe performed a retrospective study of patients who attended a multiple sclerosis day hospital due to suspected relapse and received an alternative diagnosis, over a 2-year period. Demographic data, clinical characteristics, final diagnosis, and treatments administered were evaluated. Patients who were initially diagnosed with pseudo-relapse and ultimately diagnosed with true relapse were evaluated specifically. As an exploratory analysis, patients who consulted with non-inflammatory causes were compared with a randomly selected cohort of patients with true relapses who attended the centre in the same period.ResultsThe study included 50 patients (33 were women; mean age 41.4 ± 11.7 years). Four patients (8%) were initially diagnosed with pseudo-relapse and later diagnosed as having a true relapse. Fever and vertigo were the main confounding factors. The non-inflammatory causes of emergency consultation were: neurological, 43.5% (20 patients); infectious, 15.2% (7); psychiatric, 10.9% (5); vertigo, 8.6% (4); trauma, 10.9% (5); and miscellaneous, 10.9% (5).ConclusionsMS-related symptoms constituted the most frequent cause of non-inflammatory emergency consultations. Close follow-up of relapse and pseudo-relapse is necessary to detect incorrect initial diagnoses, avoid unnecessary treatments, and relieve patients’ symptoms. (AU)

Non-inflammatory causes of emergency consultation in patients with multiple sclerosis.

OBJECTIVES: To describe non-relapse-related emergency consultations of patients with multiple sclerosis (MS): causes, difficulties in the diagnosis, clinical characteristics, and treatments administered. METHODS: We performed a retrospective study of patients who attended a multiple sclerosis day hospital due to suspected relapse and received an alternative diagnosis, over a 2-year period. Demographic data, clinical characteristics, final diagnosis, and treatments administered were evaluated. Patients who were initially diagnosed with pseudo-relapse and ultimately diagnosed with true relapse were evaluated specifically. As an exploratory analysis, patients who consulted with non-inflammatory causes were compared with a randomly selected cohort of patients with true relapses who attended the centre in the same period. RESULTS: The study included 50 patients (33 were women; mean age 41.4 ±â€¯11.7 years). Four patients (8%) were initially diagnosed with pseudo-relapse and later diagnosed as having a true relapse. Fever and vertigo were the main confounding factors. The non-inflammatory causes of emergency consultation were: neurological, 43.5% (20 patients); infectious, 15.2% (7); psychiatric, 10.9% (5); vertigo, 8.6% (4); trauma, 10.9% (5); and miscellaneous, 10.9% (5). CONCLUSIONS: MS-related symptoms constituted the most frequent cause of non-inflammatory emergency consultations. Close follow-up of relapse and pseudo-relapse is necessary to detect incorrect initial diagnoses, avoid unnecessary treatments, and relieve patients' symptoms.

Off-hour effects on stroke care and outcome in stroke centres.

BACKGROUND AND PURPOSE: Poorer stroke care processes and outcomes have been reported for acute stroke patients arriving at centres during off hours and weekends. OBJECTIVE: To compare each step of the continuous specialized care that Stroke Centres (SC) provide according to time of admission and final outcome. METHODS: Observational study of consecutive stroke patients admitted to SC during 2008 and 2009. Patients were classified into two groups according to their arrival time: Work Hours (WH) and Off Hour (OH) (weekends and any time other than 8:00 am to 3:00 pm on weekdays). Differences in time to diagnostic procedures, tPA administration, stroke outcome [modified Rankin Scale, (mRS)] and in-hospital fatality rates were analysed. RESULTS: A total of 912 patients were admitted. Data from 674 patients fulfilling study criteria were analysed. A total of 434 (64.4%) patients arrived during OH. No differences in stroke severity were found when comparing OH and WH. Time to blood test results was higher for WH (median 67 min vs. 47 min; P < 0.01), but time to cranial CT scan was similar. Intravenous tPA was administered to 58 (16.4%) OH vs. 26 (13.1%) WH patients (P = 0.33). OH arrival was not associated with poorer outcome (mRS ≥ 3) at discharge (32.8% vs. 37%; P = 0.27), or at the 3-month follow-up (30.6% vs. 27.6%, P = 0.52). No differences were found for in-hospital fatality rates (5.8% vs. 5.4%, P = 1.00). CONCLUSIONS: The care provided by SC with neurologists on call 24/7 prevents differences in outcomes associated with time of admission and guarantees equal attention to stroke patients.

Miocardiopatía de Takotsubo como complicación de un estado epiléptico / Takotsubo cardiomyopathy as a complication of an epileptic status

Introducción. Las complicaciones cardiológicas son la causa más frecuente de mortalidad en el estado epiléptico. La miocardiopatía de Takotsubo es una entidad descrita recientemente, que puede aparecer en numerosas emergencias médicas, entre ellas el estado epiléptico. Caso clínico. Se presenta un caso de miocardiopatía de Takotsubo en el contexto de un estado epiléptico y se revisan casos similares descritos en la literatura científica, especialmente la semiología y etiología de las crisis epilépticas, los datos epidemiológicos de los enfermos, las alteraciones en el electrocardiograma y las complicaciones ocurridas. La paciente, una mujer de 43 años, se recuperó por completo tanto cardiológica como neurológicamente, y no tuvo recurrencias en un año de seguimiento. Conclusión. La miocardiopatía de Takotsubo es una complicación grave y tratable que puede ocurrir en el estado epiléptico

Introduction. Cardiological complications are the most frequent cause of mortality in the epileptic status. Takotsubo cardiomyopathy is a recently reported condition that can appear in a number of medical emergencies, including epileptic status. Case report. We present a case of Takotsubo cardiomyopathy within the context of an epileptic status and we also review similar cases reported in the literature. Special attention is given to the semiology and aetiology of the epileptic seizures, patients’ epidemiological data, the alterations noted in the electrocardiogram and the complications that occurred. The patient, a 43-year-old female, recovered completely both cardiologically and neurologically, and did not suffer any relapses during the one-year follow-up. Conclusion. Takotsubo cardiomyopathy is a severe, treatable complication that can occur in the epileptic status

Tratamiento previo con estatinas y riesgo de complicaciones infecciosas tras un infarto cerebral agudo / Previous statins treatment and risk of post-stroke infections

Introducción y objetivo: Diversos estudios clínicos y experimentales atribuyen un efecto inmunosupresor a las estatinas y la administración de simvastatina en la fase aguda del ictus se ha asociado a mayor frecuencia de infecciones durante el ingreso. Nuestro objetivo es comprobar si el consumo previo de estatinas influye en la aparición de complicaciones infecciosas intrahospitalarias tras un infarto cerebral (IC). Pacientes y métodos: Estudio observacional incluyendo pacientes con IC ingresados en la Unidad de Ictus. Se analizan: datos demográficos, factores de riesgo vascular, gravedad al ingreso, subtipo etiológico de infarto cerebral y consumo previo de estatinas. Se ha estudiado la aparición de las siguientes complicaciones infecciosas durante la hospitalización: neumonía, infección urinaria, colitis pseudomembranosa y sepsis de cualquier origen agrupando a los enfermos en dos grupos: pacientes que previamente tomaban o no estatinas. Resultados: Se incluyeron 2.045 pacientes (1.162 varones) con edad media de 69,05 años (DE 12,5). El 15% (306 pacientes) tomaba estatinas previamente al IC. Dichos pacientes presentaban con mayor frecuencia que los que no lo hacían (p<0,0001) antecedente de HTA, DM, arteriopatía periférica e hipercolesterolemia. La frecuencia de infección intrahospitalaria fue similar en ambos grupos, tanto evaluada de manera global (11,8% vs 13%, p=0,643) como al analizar cada una de las infecciones separadamente. En el subgrupo de IC aterotrombótico, las estatinas se asociaron con una menor frecuencia de sepsis (OR no ajustado 0,949, IC 95% [0,928 – 0,971]). Conclusiones: El tratamiento previo con estatinas parece no influir en la frecuencia de complicaciones infecciosas intrahospitalarias tras un IC agudo (AU)

Introduction: Clinical and laboratory studies have attributed an inmuno-supressor effect to the statins. Furthermore, the administration of simvastatin in the acute onset of stroke has been associated with an increased infection frequency. Our objective is to assess the influence of statins previous treatment on infection after ischemic stroke. Patients and methods: Observational study of patients with ischaemic stroke hospitalised in a Stroke Unit. Demographic data, vascular risk factors, stroke severity, stroke subtype and previous statins treatment were evaluated. The following infections were registered: pneumonia, urinary tract infection, pseudomembranous colitis and sepsis. The patients were classified into two groups, depending on previous statin treatment. Results: A total of 2045 patients were included (1165 were male, aged 69.05±12.5 years). Of these, 306 (15%) patients were receiving statins prior to stroke. These patients had more frequently arterial hypertension, DM, peripheral arterial disease and hypercholesterolaemia than the patients who were not treated with statins (P < 0001). There was no statistically significant difference between overall in-hospital infection frequency between patients treated with statins and those with no statins treatment, (11.8% vs. 13%), nor in individual infection type: pneumonia (7.8% vs. 10.2%), urinary tract infection (4.2% vs. 2.8%), pseudomembranous colitis (0.3% vs. 0.7%) and sepsis (2.6% vs. 4.4%). In the atherothrombotic stroke subtype, statins were associated with a lower frequency of sepsis (unadjusted OR, 0.949; 95% CI; 0.928-0.971). Conclusions: Previous treatment with statins does not appear to influence the frequency of in-hospital infections in patients with ischaemic stroke (AU)

Previous statins treatment and risk of post-stroke infections.

INTRODUCTION: Clinical and laboratory studies have attributed an inmuno-supressor effect to the statins. Furthermore, the administration of simvastatin in the acute onset of stroke has been associated with an increased infection frequency. Our objective is to assess the influence of statins previous treatment on infection after ischemic stroke. PATIENTS AND METHODS: Observational study of patients with ischaemic stroke hospitalised in a Stroke Unit. Demographic data, vascular risk factors, stroke severity, stroke subtype and previous statins treatment were evaluated. The following infections were registered: pneumonia, urinary tract infection, pseudomembranous colitis and sepsis. The patients were classified into two groups, depending on previous statin treatment. RESULTS: A total of 2045 patients were included (1165 were male, aged 69.05±12.5 years). Of these, 306 (15%) patients were receiving statins prior to stroke. These patients had more frequently arterial hypertension, DM, peripheral arterial disease and hypercholesterolaemia than the patients who were not treated with statins (P<0001). There was no statistically significant difference between overall in-hospital infection frequency between patients treated with statins and those with no statins treatment, (11.8% vs. 13%), nor in individual infection type: pneumonia (7.8% vs. 10.2%), urinary tract infection (4.2% vs. 2.8%), pseudomembranous colitis (0.3% vs. 0.7%) and sepsis (2.6% vs. 4.4%). In the atherothrombotic stroke subtype, statins were associated with a lower frequency of sepsis (unadjusted OR, 0.949; 95% CI; 0.928-0.971). CONCLUSIONS: Previous treatment with statins does not appear to influence the frequency of in-hospital infections in patients with ischaemic stroke.

Fístula de LCR en una mujer con antecedente de hipertensión intracraneal idiopática / CSF fistula in a woman with a history of idiopathic intracranial hypertension

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[Hypercoagulability and ischemic stroke in young patients]. / Estados de hipercoagulabilidad e ictus isquémico en pacientes jóvenes.

INTRODUCTION: Hypercoagulable states have been reported as an established risk factor for cerebral venous thrombosis, but they have also been proposed as a predisposing factor for cerebral ischemia of arterial origin, especially among young patients. This may have implications on therapeutic management and secondary prevention. We have studied the frequency of prothrombotic abnormalities in young patients with ischaemic stroke, as other classic risk factors are less common in this group. MATERIALS AND METHODS: Observational study with sequential inclusion of patients under 55 with stroke or transient ischaemic attack (TIA) admitted to the Stroke Unit from January 2005 through December 2007. We analysed demographic data, severity and subtype of stroke, risk factors, including the presence of hypercoagulable states, and outcome. RESULTS: We included 100 patients, of whom 65 were men. The mean age was 42.6 ± 8.9 years, 46% with a hypercoagulable state, and no sex differences. Acquired hyperhomocysteinemia was the most common abnormality (18%), followed by protein C or S deficiency (8%), factor V Leiden mutation (5%) and methyl-tetrahydro-folate-reductase (MTHFR) C677T mutation (5%). Other findings included anticardiolipin antibodies (3%), presence of lupus anticoagulant (2%), thrombocytosis (3%) and G20210A prothrombin gene mutation (3%). No association was found between these states and the presence of other vascular risk factors, or more severe stroke or worse outcomes. There was an increased presence of these abnormalities in patients who were classified as atherothrombotic stroke (p = 0.04). CONCLUSIONS: The hypercoagulable states are common in young patients with ischaemic stroke, being present in up to 46% of them.

Estados de hipercoagulabilidad e ictus isquémico en pacientes jóvenes / Hypercoagulability and ischemic stroke in young patients

Introducción: Los estados de hipercoagulabilidad se han estudiado como una de las posibles etiologías de la trombosis venosa cerebral y, desde hace unos años, también como factor predisponente de isquemia cerebral de origen arterial, especialmente en pacientes jóvenes. Esto podría tener implicaciones en el manejo terapéutico y la prevención secundaria, por lo que nos proponemos estudiar la frecuencia de anomalías protrombóticas en pacientes jóvenes con ictus isquémico, subgrupo en que otros factores de riesgo clásicos son menos habituales. Material y métodos: Estudio observacional con inclusión secuencial de los pacientes menores de 55 an ̃os con infarto cerebral o ataque isquémico transitorio ingresados en la unidad de ictus desde enero de 2005 hasta diciembre de 2007. Se analizaron datos demográficos, gravedad y subtipo de ictus, factores de riesgo, incluidos los estados de hipercoagulabilidad, y evolución. Resultados: Se incluyó a 100 pacientes, de los que 65 eran varones, con una media ± desviación estándar de edad de 42,6 ± 8,9 años. El 46% presentó estado de hipercoagulabilidad, sin diferencia por sexo. La hiperhomocisteinemia adquirida fue la alteración más frecuente (18%), seguida del déficit de proteína C o S (8%), la mutación para el factor V de Leiden (5%) y la mutación C677T del gen de la metiltetrahidrofolato reductasa (MTHFR) (5%). Otras alteraciones procoagulantes fueron síndrome antifosfolípido (3%), anticoagulante lúpico (2%), trombocitosis (3%) y mutación 20210A del gen de la protrombina (3%). No se encontró relación de estas alteraciones con otros factores de riesgo vascular, como tampoco se relacionó la hipercoagulabilidad con el ictus de mayor gravedad o peor evolución. Se observó una mayor presencia de estas alteraciones en los pacientes catalogados de ictus de origen aterotrombótico (p = 0,04). Conclusiones: Los estados de hipercoagulabilidad son frecuentes en los pacientes menores de 55 años con ictus isquémico, encontrándose hasta en el 46% de ellos (AU)

Introduction: Hypercoagulable states have been reported as an established risk factor for cerebral venous thrombosis, but they have also been proposed as a predisposing factor for cerebral ischemia of arterial origin, especially among young patients. This may have implications on therapeutic management and secondary prevention. We have studied the frequency of prothrombotic abnormalities in young patients with ischaemic stroke, as other classic risk factors are less common in this group. Materials and methods: Observational study with sequential inclusion of patients under 55 with stroke or transient ischaemic attack (TIA) admitted to the Stroke Unit from January 2005 through December 2007. We analysed demographic data, severity and subtype of stroke, risk factors, including the presence of hypercoagulable states, and outcome. Results: We included 100 patients, of whom 65 were men. The mean age was 42.6 ± 8.9 years, 46% with a hypercoagulable state, and no sex differences. Acquired hyperhomocysteinemia was the most common abnormality (18%), followed by protein C or S deficiency (8%), factor V Leiden mutation (5%) and methyl-tetrahydro-folate-reductase (MTHFR) C677T mutation (5%). Other findings included anticardiolipin antibodies (3%), presence of lupus anticoagulant (2%), thrombocytosis (3%) and G20210A prothrombin gene mutation (3%). No association was found between these states and the presence of other vascular risk factors, or more severe stroke or worse outcomes. There was an increased presence of these abnormalities in patients who were classified as atherothrombotic stroke (p = 0.04). Conclusions: The hypercoagulable states are common in young patients with ischaemic stroke, being present in up to 46% of them (AU)