EPICON consensus: recommendations for proper management of switching to eslicarbazepine acetate in epilepsy. / Consenso Delphi EPICON: recomendaciones sobre el manejo adecuado del cambio a acetato de eslicarbazepina en epilepsia.

INTRODUCTION: The objective of the EPICON Project is to develop a set of recommendations on how to adequately switch from carbamazepine (CBZ) and oxcarbazepine (OXC) to eslicarbazepine acetate (ESL) in some patients with epilepsy. METHODS: A steering committee drafted a questionnaire of 56 questions regarding the transition from CBZ or OXC to ESL in clinical practice (methodology and change situation). The questionnaire was then distributed to 54 epilepsy experts in 2 rounds using the Delphi method. An agreement/disagreement consensus was defined when a median ≥ 7 points or ≤ 3 was achieved, respectively, and a relative interquartile range ≤ 0.40. We analysed the results obtained to reach our conclusions. RESULTS: Our main recommendations were the following: switching from CBZ to ESL must be carried out over a period of 1 to 3 weeks with a CBZ:ESL dose ratio of 1:1.3 and is recommended for patients who frequently forget to take their medication, those who work rotating shifts, polymedicated patients, subjects with cognitive problems, severe osteoporosis-osteopaenia, dyslipidaemia, or liver disease other than acute liver failure, as well as for men with erectile dysfunction caused by CBZ. The transition from OXC to ESL can take place overnight with an OXC:ESL dose ratio of 1:1 and it is recommended for patients who frequently forget to take their medication, those who work rotating shifts, polymedicated patients, or those with cognitive problems. The transition was not recommended for patients with prior rash due to CBZ or OXC use. CONCLUSION: The EPICON Project offers a set of recommendations about the clinical management of switching from CBZ or OXC to ESL, using the Delphi method.

Efficacy and safety of eslicarbazepine-acetate in elderly patients with focal epilepsy: Case series.

PURPOSE: Eslicarbazepine-acetate (ESL) is a third generation antiepileptic drug licensed as adjunctive therapy in adults with focal seizures. Efficacy and safety of ESL have been established in real-life setting. However, data about outcomes in elderly patients are scarce. Primary endpoint was to evaluate outcomes of ESL in elderly patients. METHOD: This was a retrospective survey that included patients >65years with focal seizures who started ESL between January 2010 and July 2012 at 12 Spanish Hospitals. ESL was prescribed individually according to real-life practice. Efficacy and safety were evaluated over 1year. These patients were included within the bigger study ESLIBASE. RESULTS: We included 29 patients, most of them males (18). Mean age was 71.2 year-old and epilepsy evolution was 20 years. Eighteen were pharmacorresistant at baseline. At 12 months, the mean dose was 850mg/day, the retention rate 69%, the responder rate 62% and 24.1% were seizure-free. At 12 months, 16 patients (55.2%) had ≥1 adverse effect (AE), that led to discontinuation in 7 patients. Dizziness, nausea and ataxia were the most common AEs. The tolerability profile improved in 4/5 patients who switched from carbamazepine (CBZ) or oxcarbazepine (OXC) to ESL due to AEs. CONCLUSIONS: ESL was well-tolerated and effective in elderly patients in a real-life setting over 1year, with a dose around 800mg/day. AE effects improved in most of who switched from CBZ or OXC to ESL.

EARLY-ESLI study: Long-term experience with eslicarbazepine acetate after first monotherapy failure.

PURPOSE: Evaluate real-life experience with eslicarbazepine acetate (ESL) after first monotherapy failure in a large series of patients with focal epilepsy. METHOD: Multicentre, retrospective, 1-year, observational study in patients older than 18 years, with focal epilepsy, who had failed first antiepileptic drug monotherapy and who received ESL. Data from clinical records were analysed at baseline, 3, 6 and 12 months to assess effectiveness and tolerability. RESULTS: Eslicarbazepine acetate was initiated in 253 patients. The 1-year retention rate was 92.9%, and the final median dose of ESL was 800 mg. At 12 months, 62.3% of patients had been seizure free for 6 months; 37.3% had been seizure free for 1 year. During follow-up, 31.6% of the patients reported ESL-related adverse events (AEs), most commonly somnolence (8.7%) and dizziness (5.1%), and 3.6% discontinued due to AEs. Hyponatraemia was observed in seven patients (2.8%). After starting ESL, 137 patients (54.2%) withdrew the prior monotherapy and converted to ESL monotherapy; 75.9% were seizure free, 87.6% were responders, 4.4% worsened, and 23.4% reported ESL-related AEs. CONCLUSION: Use of ESL after first monotherapy failure was associated with an optimal seizure control and tolerability profile. Over half of patients were converted to ESL monotherapy during follow-up.

Safety, efficacy and outcome-related factors of perampanel over 12 months in a real-world setting: The FYDATA study.

BACKGROUND: Real-world data of current antiepileptic drugs (AEDs) used to treat focal seizures is of importance to understand the efficacy and safety outside of the clinical trial setting. Here we report real-world data from a large series of patients treated with perampanel for 1year. METHODS: FYDATA was a multicentre, retrospective, 1-year observational study assessing the efficacy and safety of adjuvant perampanel in patients ≥12 years of age with focal epilepsy in a real-world setting. At 12 months, the proportion of patients who were seizure free, median percentage seizure reduction, proportion of responders, retention rate and proportion of patients with adverse events (AEs) were assessed. Analyses were also performed to identify any patient-, medication- and disease-related factors associated with a large clinical response or carry a risk for AEs. RESULTS: A total of 464 patients were included in the study with a retention rate of 60.6% at 1year. The mean number of prior AEDs was 7.8. The median percentage reduction in overall seizures was 33.3% (75% for secondary generalised seizures) after 1year, with 7.2% of patients achieving seizure freedom. Furthermore, patients on non-enzyme-inducing AEDs were more likely to achieve seizure freedom, and logistic regression revealed that patients aged ≥65 years, those with epilepsy due to a vascular aetiology and those who had received fewer prior AEDs showed a better clinical response to perampanel. A total of 62.9% of the patients experienced AEs at 12 months; dizziness, somnolence and irritability were the most frequent AEs. Patients with prior psychiatric comorbidities (hyperactivity and personality disorder) were more likely to experience psychiatric AEs with perampanel, and slower titration schedules were associated with less AEs overall. CONCLUSION: Perampanel, for the treatment of focal epilepsy in a real-world setting in a refractory population, over 1year, demonstrates a similar efficacy and safety profile to that observed in clinical trials. Our results have implications for the optimisation of perampanel use in a clinical setting.

Long-term safety and efficacy of eslicarbazepine acetate in patients with focal seizures: results of the 1-year ESLIBASE retrospective study.

BACKGROUND: Eslicarbazepine acetate (ESL) is a new antiepileptic drug (AED) licensed as adjunctive therapy in adults with partial-onset or focal seizures. OBJECTIVE: To evaluate in a clinical practice setting the long-term efficacy and safety of ESL in patients with focal seizures. METHODS: ESLIBASE was a retrospective study that included all patients with focal seizures who started ESL between January 2010 and July 2012 at 12 hospitals. ESL was prescribed individually according to real-life practice. Efficacy and safety were evaluated over 1 year. Switching from carbamazepine (CBZ) and oxcarbazepine (OXC) was assessed. RESULTS: Three hundred and twenty-seven patients were included; 78% of patients were taking ≥2 other AEDs at baseline. Most (87%) began ESL because of poor seizure control and 13% because of adverse events (AEs) with CBZ or OXC. After 1 year, 237 patients (72.4%) remained on ESL. At 3, 6 and 12 months, the responder rate was 46.3%, 57.9%, and 52.5%, and 21.0%, 28.0%, and 25.3% of patients were seizure free. The responder rate significantly increased when ESL was combined with a non-sodium channel-targeting drug (non-SC drug) (66.7%) versus an SC drug (47.7%; p<0.001). At 12 months, 40.7% of patients had ≥1 AE; AEs led to treatment discontinuation in 16.2%. Dizziness, nausea, and somnolence were the most common AEs. The tolerability profile improved in >50% of the patients who switched from CBZ or OXC to ESL because of AEs. CONCLUSIONS: ESL was well tolerated and effective in a real-world setting over 1 year. Side-effect profile improved when OXC and CBZ recipients were switched to ESL.

[Apolipoprotein E4 in dementia with Lewy bodies]. / Apolipoproteína e4 en la demencia con cuerpos de Lewy.

INTRODUCTION: There is a strong association between the e4 allele of apolipoprotein E (APOE) and Alzheimer's disease (AD). This converts this allele into a risk factor for the development of AD. The association between APOE4 and dementia with Lewy bodies (DLB) is under discussion. In DLB, the presence of APOE4 has been related with a greater amount of senile plaques and neurofibrillary tangles. METHOD: This is a case-control study in which the APOE genotype was determined using the modified PCR technique of Wenham in 306 patients with diagnosis of probably AD, NINCDS-ADRDA criteria, 58 cases of probably DLB, McKeith et al. consensus criteria (1996), all of them with SPECT with pathological 123I-FP-CIT and 80 normal controls (NC) having similar age and gender distribution. RESULTS: The frequency of alleles was: DLB group epsilon4: 16%; epsilon3: 75%; epsilon2: 9%; AD: epsilon4: 32%; epsilon3: 67%; epsilon2: 1%; and in the normal control group: epsilon4: 12%; epsilon3: 83%; epsilon2: 5%. The percentage of alleles in both genders was similar in the three groups. CONCLUSIONS: APOE4 percentage in DLB group (16%) was lower than in AD group (32%), and similar to the control group (12%). Considering that the presence of morphopathological Alzheimer type alterations in DBL, essentially neurofibrillary tangles, is inversely correlated with the presence of Parkinsonian signs, this group may represent pure forms of the disease, although the lack of neuropathological demonstration does not make it possible to confirm this hypothesis.

[Noninvasive diagnosis of cerebral venous thrombosis]. / Diagnóstico de trombosis venosas cerebrales mediante técnicas no invasivas.

OBJECTIVES: Cerebral venous thrombosis (CVT) is an uncommon condition. Its variable, unspecific clinical presentation causes delays in diagnosis. We analyze the validity of different neuroimaging techniques, including CT, MRI, MR angiography, and conventional angiography in the diagnosis of CVT. MATERIAL AND METHODS: We review the imaging findings of 12 patients with the final diagnosis of CVT. All 12 patients underwent CT as the initial imaging test; all 12 underwent MRI; 11 underwent MR angiography; and 4 underwent conventional angiography. Visualization of the thrombus or filling defects in the affected vessel were considered direct signs of CVT, whereas findings compatible with venous infarction were considered indirect signs. RESULTS: Of the 12 CT examinations, 4 showed direct signs, 2 indirect signs, and 6 only normal findings. Indirect signs of CVT were seen on follow-up CT in three of the patients with normal initial CT examination. CT failed to show the real extent of the process except in one case in which a cortical vein was affected. MRI detected thrombi in the affected territory in 6 cases; the empty delta sign was seen in 2 and signs of venous infarction in 8. MRI failed to diagnose CVT in one case. MR angiography showed direct signs of CVT in all cases, even without intravenous contrast, and the results were similar to those seen at conventional angiography. More than two locations were affected in 11 patients. CONCLUSIONS: At CT, indirect signs of CVT are seen, although sometimes not immediately. Direct signs can be so subtle that they can only be interpreted with experience. Furthermore, CT does not show the real extent of the process. Nevertheless, given its availability, contrast-enhanced CT should be the primary imaging test, both to rule out other possibilities and to indicate other neuroimaging studies, in this case MRI and MR angiography. The results obtained when these two techniques are performed simultaneously, even without contrast administration, are sufficient for diagnosis and are comparable to those at conventional angiography, but without the risks entailed and without exposing the patient to ionizing radiation.

Diagnóstico de trombosis venosas cerebrales mediante técnicas no invasivas / Noninvasive diagnosis of cerebral venous thrombosis

Objetivos. La trombosis venosa cerebral (TVC) es una patología poco frecuente. Su presentación clínica es inespecífica y variable, lo que ocasiona retrasos en el diagnóstico. Analizamos la validez de las diferentes pruebas de neuroimagen, tomografía computarizada (TC), resonancia magnética (RM), angio-resonancia magnética (RMV) y angiografía, en el diagnóstico de TVC. Material y métodos. Estudio retrospectivo sobre 12 pacientes con diagnóstico final de TVC. Se realizó TC, que fue la prueba inicial, y RM a todos los pacientes, a 11 RMV y en 4 ocasiones se hizo angiografía. Se valoraron como signos directos la visualización del trombo o defectos de repleción en el vaso afecto y como signo indirecto la identificación de hallazgos compatibles con infarto venoso. Resultados. De las 12 TC, 4 mostraron signos directos, 2 indirectos y 6 fueron normales; de éstas, en 3 pacientes se objetivaron signos indirectos en TC evolutivos. No mostró la extensión real del proceso salvo en un caso de afectación localizada de una vena cortical. En la RM se objetivó ocupación de los vasos del territorio venosos afecto en 6 casos, en 2 se apreció el signo del delta vacío y en 8 signos de infarto venoso. En una ocasión no fue diagnóstica. En todas las RMV se visualizaron signos directos de TVC, incluso sin contraste intravenoso. Los resultados fueron similares a los de las angiografías. Once pacientes presentaban afectación de más de 2 localizaciones. Conclusiones. La TC pone de manifiesto signos indirectos, a veces de modo tardío, y signos directos tan sutiles que requieren experiencia para ser interpretados. Además no valora la extensión real del proceso. De todos modos debe utilizarse como técnica de primer nivel, con contraste intravenoso, dada su disponibilidad en la mayoría de los centros, para excluir otras causas y servir para la indicación de otras pruebas de neuroimagen, en este caso RM y RMV. Los resultados obtenidos con la realización simultánea de ambas son equiparables a los de la angiografía, evita los riesgos de esta técnica, no expone al paciente a radiaciones ionizantes y es diagnóstica incluso sin la administración de contraste

Objectives. Cerebral venous thrombosis (CVT) is an uncommon condition. Its variable, unspecific clinical presentation causes delays in diagnosis. We analyze the validity of different neuroimaging techniques, including CT, MRI, MR angiography, and conventional angiography in the diagnosis of CVT. Material and methods. We review the imaging findings of 12 patients with the final diagnosis of CVT. All 12 patients underwent CT as the initial imaging test; all 12 underwent MRI; 11 underwent MR angiography; and 4 underwent conventional angiography. Visualization of the thrombus or filling defects in the affected vessel were considered direct signs of CVT, whereas findings compatible with venous infarction were considered indirect signs. Results. Of the 12 CT examinations, 4 showed direct signs, 2 indirect signs, and 6 only normal findings. Indirect signs of CVT were seen on follow-up CT in three of the patients with normal initial CT examination. CT failed to show the real extent of the process except in one case in which a cortical vein was affected. MRI detected thrombi in the affected territory in 6 cases; the empty delta sign was seen in 2 and signs of venous infarction in 8. MRI failed to diagnose CVT in one case. MR angiography showed direct signs of CVT in all cases, even without intravenous contrast, and the results were similar to those seen at conventional angiography. More than two locations were affected in 11 patients. Conclusions. At CT, indirect signs of CVT are seen, although sometimes not immediately. Direct signs can be so subtle that they can only be interpreted with experience. Furthermore, CT does not show the real extent of the process. Nevertheless, given its availability, contrast-enhanced CT should be the primary imaging test, both to rule out other possibilities and to indicate other neuroimaging studies, in this case MRI and MR angiography. The results obtained when these two techniques are performed simultaneously, even without contrast administration, are sufficient for diagnosis and are comparable to those at conventional angiography, but without the risks entailed and without exposing the patient to ionizing radiation

[Infiltration of the meninges or brain by a non-Hodgkin's lymphoma, diagnosed by flow cytometry in cerebrospinal fluid]. / Infiltracion meningea y cerebral por un linfoma no Hodgkin, diagnosticada por citometria de flujo en liquido cefalorraquideo.

INTRODUCTION: Two forms of growth are reported in the neuroradiology of cerebral lymphomas: mass, single or multiple lesions, with homogeneous contrast enhancement, and diffuse infiltration. Flow cytometry enables us to diagnose non-Hodgkin's lymphoma, when clonality of B cells is detected. It is usually employed with peripheral blood or bone marrow samples but can be used with cerebrospinal fluid (CSF). CASE REPORT: We report the case of a 68-year-old female, who was admitted to hospital because of rapidly progressive onset of confusion and right-side hemiparesis that developed in a matter of days. Magnetic resonance imaging (MRI) of the head showed a diffuse infiltrative lesion, without contrast enhancement, which covered the left basal nuclei, the left frontal white matter, the genu of the corpus callosum and the right frontal white matter. The CSF showed slight pleocytosis (20 cells/mL) and a notable degree of hypoglycorrhachia (10 mg/dL). The cytological examination only revealed lymphocytes, with no data indicating atypicality. The flow cytometry assay detected large mononuclear B cells, with the CD19 + CD20 + CD10-lambda phenotype, which is characteristic of diffuse non-Hodgkin's lymphoma of large B cells. The clinical course ran quickly towards a fatal outcome; it progressed to left-side hemiplegia and coma, and the patient died two weeks after admission to hospital. CONCLUSIONS: In cases of cerebral lymphoma, especially when the neuroradiological pattern displays diffuse infiltration and there are anomalies involving CSF, the flow cytometry in CSF can be diagnostic, thus avoiding the need for other invasive brain procedures to deal with lesions that are usually located deep inside the brain at badly defined sites.

Infiltración meníngea y cerebral por un linfoma no Hodgkin diagnosticada por citometría de flujo en el líquido cefalorraquídeo / Infiltrationof the meninges or brain by a non-hodgkin lymphoma, diagnosed by flow cytometry in cerebrospinal fluid

Introduction. Two forms of growth are reported in the neuroradiology of cerebral lymphomas: mass, single or multiple lesions, with homogeneous contrast enhancement, and diffuse infiltration. Flow cytometry enables us to diagnose non-Hodgkin’s lymphoma, when clonality of B cells is detected. It is usually employed with peripheral blood or bone marrow samples but can be used with cerebrospinal fluid (CSF). Case report. We report the case of a 68-year-old female, who was admitted to hospital because of rapidly progressive onset of confusion and right-side hemiparesis that developed in a matter of days. Magnetic resonance imaging (MRI) of the head showed a diffuse infiltrative lesion, without contrast enhancement, which covered the left basal nuclei, the left frontal white matter, the genu of the corpus callosum and the right frontal white matter. The CSF showed slight pleocytosis (20 cells/dL) and a notable degree of hypoglycorrhachia (10 mg/dL). The cytological examination only revealed lymphocytes, with no data indicating atypicality. The flow cytometry assay detected large mononuclear B cells, with the CD19 + CD20 + CD10-lambda phenotype, which is characteristic of diffuse non-Hodgkin’s lymphoma of large B cells. The clinical course ran quickly towards a fatal outcome; it progressed to left-side hemiplegia and coma, and the patient died two weeks after admission to hospital. Conclusions. In cases of cerebral lymphoma, especially when the euroradiological pattern displays diffuse infiltration and there are anomalies involving CSF, the flow cytometry in CSF can be diagnostic, thus avoiding the need for other invasive brain procedures to deal with lesions that are usually located deep inside the brain at badly defined sites (AU)

Introducción. En la neurorradiología de los linfomas cerebrales se describen dos formas de crecimiento: lesión en masa, única o múltiple, con captación homogénea de contraste, e infiltración difusa. La citometría de flujo permite diagnosticar un linfoma no Hodgkin B cuando se detecta clonalidad B; habitualmente, esta técnica se utiliza sobre muestras de sangre periférica o de médula ósea, pero puede usarse en el líquido cefalorraquídeo (LCR). Caso clínico. Mujer de 68 años que ingresó por confusión y hemiparesia derecha de instauración rápidamente progresiva en días. La resonancia magnética (RM) de cráneo mostró una lesión infiltrativa difusa, sin captación de contraste, que abarcaba los núcleos basales izquierdos, la sustancia blanca frontal izquierda, la rodilla del cuerpo calloso y la sustancia blanca frontal derecha. El LCR mostró una ligera pleocitosis (20 células/L) y una marcada hipoglucorraquia (10 mg/dL). La citología sólo objetivó linfocitos, sin datos de atipicidad. La citometría de flujo detectó células grandes mononucleares B, con fenotipo CD19 CD20 CD10-, propio de un linfoma no Hodgkin difuso de células grandes B. El curso clínico fue rápidamente fatal; progresó a hemiplejía izquierda y coma, y la paciente falleció a las dos semanas del ingreso. Conclusiones. En casos de linfoma cerebral, particular-mente cuando el patrón neurorradiológico es de infiltración difusa y existen anomalías licuorales, la citometría de flujo en el LCR puede ser diagnóstica y evitar otros procedimientos invasivos cerebrales sobre lesiones que habitualmente tienen una localización profunda y mal definida (AU)

[Sequential changes in magnetic resonance in a limbic status epilepticus]. / Cambios secuenciales en la resonancia magnética en estado epiléptico límbico.

INTRODUCTION: Transient alterations have been described in neuroimaging (MRI) studies of the non-convulsive focal status (NCFS). We report a case of NCFS together with the MRI findings. CASE REPORT: We describe the case of a 63-year-old female who had a sister and two female cousins with epilepsy; the patient was admitted to hospital after being in state of confusion for 72 hours. Two similar bouts of delirium were reported as having occurred in the 2 preceding years, both of which lasted only a few minutes, and at that time a cardiology study, EEG and MRI scans of the head were performed with normal results. The EEG was compatible with left temporal status and MRI, and presented hyperintensity in the left temporal lobe in T2 and Flair, with no mass effect, with gadolinium uptake in leptomeninges and cortex. CSF was acellular and there were high protein levels in cerebrospinal fluid with a value of 1 g/dL. The patient's situation continued for 10 days, and did not respond initially to antiepileptic treatment. Temporal NCFS was diagnosed, with a cryptogenic rather than idiopathic aetiology. A preliminary MRI scan was normal and another scan performed 10 days after resolution showed a clear regression of the lesion. We related these findings to vasogenic and cytotoxic oedema secondary to the status. An MRI scan carried out at 3 months was normal. CONCLUSIONS: This case lends support to reports, in relation to the appearance of NCFS, of MR images compatible with oedema secondary to rupture of the blood-brain barrier. We base it on sequential MRI studies and on high protein levels in CSF.

Cambios secuenciales en la resonancia magnética en estado epiléptico límbico / Sequential changes in magnetic resonance in a limbic status epilepticus

Introducción. En el estado no convulsivo focal (SNCF) se han descrito alteraciones transitorias en estudios de neuroimagen (RM). Presentamos un caso de SNCF y los hallazgos en RM. Caso clínico. Se trata de una mujer de 63 años con antecedentes de una hermana y dos primas con epilepsia que ingresa por presentar, desde 72 horas antes, un cuadro confusional. Se referían desde dos años antes dos episodios similares, de pocos minutos de duración por los que se realizó un estudio cardiológico, así como EEG y RM de cráneo, que fueron normales. El EEG fue compatible con estado temporal izquierdo y en la RM presentó en T 2 y FLAIR una hiperintensidad en el lóbulo temporal izquierdo, sin efecto de masa, con captación de gadolinio en las leptomeninges y el córtex. El LCR fue acelular, con hiperproteinorraquia de 1 g/dL. En su evolución persistió la situación durante 10 días, y no respondió inicialmente al tratamiento antiepiléptico. Se diagnosticó de SNCF temporal, de etiología criptogénica frente a idiopática. Los hallazgos en la RM, con una previa normal y otra diez días después de la resolución, con clara regresión de la lesión, los relacionamos con edema vasogénico y citotóxico secundario al estado. Una RM a los tres meses fue normal. Conclusión. Este caso apoya lo descrito con relación a la aparición en el SNCF, de imágenes en RM compatibles con edema secundario a rotura de barrera hematoencefálica Lo funda-mentamos en estudios RM secuenciales y en la hiperproteinorraquia en LCR

Introduction. Transient alterations have been described in neuroimaging (MRI) studies of the non-convulsive focal status (NCFS). We report a case of NCFS together with the MRI findings. Case report. We describe the case of a 63-year-old female who had a sister and two female cousins with epilepsy; the patient was admitted to hospital after being in state of confusion for 72 hours. Two similar bouts of delirium were reported as having occurred in the 2 preceding years, both of which lasted only a few minutes, and at that time a cardiology study, EEG and MRI scans of the head were performed with normal results. The EEG was compatible with left temporal status and MRI, and presented hyperintensity in the left temporal lobe in T 2 and FLAIR, with no mass effect, with gadolinium uptake in leptomeninges and cortex. CSF was acellular and there were high protein levels in cerebrospinal fluid with a value of 1 g/dL. The patient’s situation continued for 10 days, and did not respond initially to antiepileptic treatment. Temporal NCFS was diagnosed, with a cryptogenic rather than idiopathic aetiology. A preliminary MRI scan was normal and another scan performed 10 days after resolution showed a clear regression of the lesion. We related these findings to vasogenic and cytotoxic oedema secondary to the status. An MRI scan carried out at 3 months was normal. Conclusions. This case lends support to reports, in relation to the appearance of NCFS, of MR images compatible with oedema secondary to rupture of the blood-brain barrier. We base it on sequential MRI studies and on high protein levels in CSF

[Neuropathy of common sciatic nerve secondary to compartment syndrome as a complication after bariatric surgery]. / Neuropatía de nervio ciático común secundaria a síndrome compartimental como complicación de cirugía bariátrica.

INTRODUCTION: With regards to the use of bariatric surgery on very obese patients and prolonged interventions, isolated cases of a compartment syndrome by compression and secondary rhabdomyolysis have been described. We describe a case which presented with a compartment syndrome, rhabdomyolysis and neuropathy of the common sciatic nerve. CLINICAL CASE: A 39 year old male with morbid obesity and high blood pressure, who after being subjected to 5 hours long bariatric surgical intervention, presented with intense pain, muscle binding and paresis in the musculature dependent on left common sciatic nerve. A creatinkinase (CK) level of 78,000 IU and volume increase of the left gluteal compartment were noted. On serial computarized tomography scans this increased leading to gluteal atrophy and ischiotibials. Evolution was negative without functional recovery and poor pain control. The patient presented with a compartment syndrome and secondary rhabdomyolysis triggered by the pressure on the gluteal zone on the operating table. The prolonged duration of the surgery, obesity and microvascular affectation due to hypertension, could be factors implicated in the development of the syndrome. The affectation of the sciatic nerve, not described as a complication of this type of surgery, is explained by pressure exercised on the compartment block on the sciatic nerve, with secondary ischaemia. CONCLUSIONS: Early determination of CK, carrying out postural changes during surgery and early post-operative neuromuscular examination, looking for signs of compartment syndrome, should be systematically carried out after bariatric surgery. The early carrying out of a decompressive fasciotomy considering a compartment syndrome could reduce or avoid the neurological complications.

Spanish family with myalgia and cramps syndrome.

A Spanish family is reported with dystrophinopathy of myalgia and cramps syndrome type. There were five affected males and three females, and also six asymptomatic carriers. Muscle biopsy showed a dystrophic pattern, but immunohistochemistry carried out with three anti-dystrophin antibodies was normal. Dystrophin analysis by western blot revealed a dystrophin of reduced quantity and molecular weight. DNA analysis showed a deletion of the dystrophin gene involving exons 45-52. The natural history of this disorder and the large intrafamilial clinical variability are discussed.

[Multiple sclerosis and neurocysticercosis: a diagnostic dilemma]. / Esclerosis múltiple y neurocisticercosis. dilema diagnóstico.

INTRODUCTION: Both Multiple Sclerosis (MS) and Neurocysticercosis (NC) are two entities in which clinical manifestations, neuroimaging findings and immunoserologic assays are neither pathognomonic nor specific requiring for their diagnosis an accurate examination of the clinical history of patients and an adequate follow up. CASE REPORTS: Two patients who consulted non neurologists about focal neurological symptoms. Neuroimaging findings revealed multiple lesions, some of them contrast enhanced. A diagnosis of neurocysticercosis was established, supported in one of the patients by positive serologic assays for cysticerci and antihelmintic therapy began to be administered. Observing the clinical evolution of the patients, monitoring their clinical history and considering the diagnostic criteria proposed by McDonald for MS and by Del Brutto for NC the patients were finally diagnosed of MS. CONCLUSION: The first step to reach a diagnosis of MS is to consider such a possibility. The diagnosis is mainly based on clinical grounds and it is necessary to prove that symptoms disseminate or that alterations occur in neuroimaging findings both in time and space. It is of the utmost importance to establish a differential diagnosis with other conditions presenting with similar clinical manifestations, neuroimaging findings and cerebrospinal fluid tests results. Even with the latest criteria proposed for the diagnosis of MS and NC we may have doubts making it fundamental to cautiously interpret the clinical manifestations and tests results.