Utility of 18F-FDG-PET/CT in patients suspected of paraneoplastic neurological syndrome: importance of risk classification

Purpose. To assess the diagnostic impact of 18F-FDG-PET/CT in patients suspected of paraneoplastic neurological syndrome (PNS) based on our own pre-test risk classification (PRC). Methods. A multicenter retrospective longitudinal study was conducted from 2006 to 2014. We designed a seven-point scoring system using the clinical syndrome characteristics [classical (CS) and non-classical syndromes (NCS)] and its location (central, peripheral, in the neuromuscular junction or combined), onconeural antibodies and tumor markers. Patients were classified as low (score 0-2), intermediate (3-4) and high (5-7) pre-test risk of PNS. FDG-PET/CT was classified as negative or positive. Final diagnosis according Graus’ criteria (definite, possible or no PNS) was established. Relations between clinical and metabolic variables with the final diagnosis were studied. Results. 73 patients were included, with a follow-up time of 33 months. Eleven (15 %) patients were finally diagnosed with neoplasm (8 invasive cancers). Ultimately, 13 (18 %) and 24 (33 %) subjects were diagnosed as definite or possible PNS. All the patients with final diagnosis of neoplasm had a CS (p = 0.005). PET/CT was helpful to diagnose 6/8 (75 %) invasive cancers. PET/CT findings were associated with the final diagnosis of neoplasm (p = 0.003) and the diagnosis of PNS attending to Graus’ criteria (p = 0.019). PRC showed significant association with the final diagnosis of neoplasm and PET/CT results. A majority of patients (10/11) diagnosed of neoplasm had intermediate/high-risk. Conclusions. Our PRC seems to be a valid tool to select candidates for PET/CT imaging in this setting. PET/CT detected malignancy in a significant proportion of patients with invasive cancer (AU)

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PET/TC con 18F-FDG en la valoración de pacientes con sospecha de síndrome paraneoplásico neurológico / 18F-FDG PET/CT in the evaluation of patients suspected of paraneoplastic neurological syndrome

Objetivo. Definir el impacto diagnóstico de la PET/TC con 18F-FDG en función de las características clínicas del síndrome paraneoplásico neurológico (SPN). Material y métodos. Estudio retrospectivo multicéntrico y longitudinal de pacientes con sospecha de SPN. El cuadro clínico se clasificó en síndrome clásico (SC) o no clásico (SNC). Tras el seguimiento se estableció el diagnóstico de SPN definitivo o posible. Los cuadros que no encajaron en ninguna de las categorías previas se catalogaron como no clasificables. Se analizó el estado de los anticuerpos onconeuronales. La PET/TC se clasificó en positiva o negativa para la detección de malignidad. Se determinó la relación entre los hallazgos PET/TC y el diagnóstico final. Se analizaron las diferencias entre variables (Chi cuadrado de Pearson) y la relación entre el resultado de la PET/TC y el diagnóstico definitivo. Resultados. Se analizaron 64 pacientes. El 30% de los cuadros clínicos se catalogaron como SC y el 42% como SNC. Tras el seguimiento el 20% se clasificó en SPN posible y el 16% en definitivo. El 13% de los pacientes tenía anticuerpos onconeuronales positivos. El hecho de poseer un SPN definitivo se relacionó con un resultado positivo de la PET/TC (p = 0,08). Se demostró relación significativa entre la positividad de los anticuerpos y el diagnóstico final de proceso neoplásico (p = 0,04). La PET/TC fue eficaz en la correcta localización tumoral en 5/7 casos con cáncer invasivo. Conclusiones. La PET-TC mostró un mayor porcentaje de resultados positivos en pacientes con diagnóstico de SPN definitivo. A pesar de la baja prevalencia de malignidad en nuestra serie, la PET/TC detectó malignidad en una significativa proporción de pacientes con cáncer invasivo (AU)

Objective. This study aimed to determine the diagnostic impact of 18F-FDG PET/CT based on the clinical features of paraneoplastic neurological syndrome (PNS). Material and methods. Multicenter retrospective and longitudinal study of patients with suspicion of PNS. The clinical picture was classified into classic (CS) and non-classic syndrome (NCS). After the follow-up, the definitive or possible diagnosis of PNS was established. The pictures that did not match any of the previous criteria were categorized as non-classifiable. The state of the onco-neural antibodies was studied. The PET/CT was classified as positive or negative for the detection of malignancy. The relationship between PET/CT findings and the final diagnosis was determined. The differences between variables (Pearson test X2) and the relationship between the results of the PET/CT and the final diagnosis were analyzed. Results. A total of 64 patients were analyzed, classifying 30% as CS and 42% as NCS. After the follow-up, 20% and 16% of subjects were diagnosed as possible and definitive PNS, respectively. Positive onco-neural antibodies were found in 13% of the patients. A definitive diagnosis of PNS was associated with a positive PET/CT (P = .08). A significant relation between antibodies expression and final diagnosis of neoplasia (P = .04) was demonstrated. The PET/CT correctly localized malignancy in 5/7 cases of invasive cancer. Conclusions. The PET/CT showed a higher percentage of positive results in patients with definitive diagnosis of PNS. Despite the low prevalence of malignancy in our series, the PET/CT detected malignancy in a significant proportion of patients with invasive cancer (AU)

Utilidad diagnóstica del Test de las Fotos (Fototest) en deterioro cognitivo y demencia / Diagnostic accuracy of the Phototest for cognitive impairment and dementia

Introducción. El Test de las Fotos (Fototest) es un testrecientemente descrito, fácil, simple y muy breve (<3 min),con ventajas teóricas sobre los tests de cribado de demenciadisponibles. Nuestro objetivo es evaluar su utilidad diagnósticaen condiciones de práctica clínica habitual. Material y métodos. Estudio transversal en fase II de validaciónde pruebas diagnósticas en una muestra de 308 pacientesatendidos en la consulta de neurología general enriquecidacon 70 sujetos sanos. Se evaluó la utilidad diagnóstica (UD)del Fototest y se comparó con la del Eurotest y un test defluencia verbal (TFV) frente al diagnóstico clínico de demencia(DEM) y deterioro cognitivo (DET) mediante el cálculodel área bajo la curva ROC (aROC) y la determinación de losvalores de sensibilidad (S), especificidad (E) y cocientes deprobabilidad (CP). Resultados. La muestra total estaba compuesta por225 sujetos sin deterioro cognitivo (NOR), 58 con DET sinDEM y 95 DEM; los resultados del Fototest en los sujetosNOR se distribuyen normalmente (33,4±3,9 [media±desviaciónestándar]) y no están influenciados por variables educativas.La UD del Fototest para DEM y DET (0,95±0,01 [aROC±ee]) es similar a la del Eurotest y ambas superiores a las delTFV. El punto de corte 25/26 para DEM (S=0,88 [0,80-0,94]y E=0,90 [0,86-0,93]) y 28/29 para DET (S=0,90 [0,84-0,94] yE=0,90 [0,83-0,93]) maximizan la suma de S y E. Conclusiones. El Fototest es un test muy breve, fácil,aplicable a analfabetos, no influenciado por variables educativasy útil para la identificación de DET y DEM en la prácticaclínica cotidiana

Introduction. The recently developed Phototest is asimple, easy and very brief (<3 minutes) test with theoreticaladvantages over available dementia screeningtests. Our objective was to evaluate its diagnostic accuracyunder routine clinical conditions. Material and methods. A phase II cross-sectionalvalidation study of diagnostic tests was performed in asample of 308 patients referred to a general neurologydepartment and in a group of 70 healthy individuals.The diagnostic accuracy (DA) of the Phototest was assessedand compared with that of the Eurotest and a verbalfluency test (VFT) in relation to the clinical diagnosis ofdementia (DEM) and cognitive impairment (CI) by calculatingthe area under the ROC curve (aROC) and determiningSensitivity (Se), Specificity (Sp) and likelihood ratios. Results. The total sample comprised 225 subjects withoutCI (NOR), 58 with CI and without DEM and 95 withDEM. Phototest results showed a normal distribution inNOR subjects (33.4 ± 3.9 [mean ± standard desviation])and were not influenced by educational variables. TheDA of the Phototest for DEM and CI (0.95 ± 0.01[aROC±Se]) was similar to that of the Eurotest and higherfor both tests than that of the VFT. The cutoff pointsof 25/26 for DEM (Se=0.88 [0.80-0.94], Sp=0.90 [0.86-0.93]) and 28/29 for CI (Se=0.90 [0.84-0.94], Sp=0.90[0.83-0.93]) maximised the sum of Se and Sp. Conclusions. The Phototest is a very short test ofeasy application that is applicable to illiterate subjects,uninfluenced by educational variables and useful toidentify CI and DEM in routine clinical practice

Impacto de las advertencias contra la procrastinación sobre las demoras en la trombólisis del ictus / Impact of warning against procrastination of thrombolysis in ischemic stroke

Introducción. La fibrinólisis del ictus isquémico debe llevarse a cabo cuanto antes; conocer las causas de retraso permite su eventual corrección. En los primeros 17 casos que tratamos comprobamos que tendía a agotarse el período de ventana terapéutica; evaluamos si las advertencias frente a ello, sin otras modificaciones logísticas u organizativas, han tenido impacto en las demoras. Pacientes y métodos. Se estimuló la celeridad en el tratamiento. Con 51 pacientes tratados, comparamos características y tiempos de demora en los primeros 17 casos (febrero de 2002 a junio de 2004) y en los 17 más recientes (octubre de 2005 a abril de 2006), utilizando tests no paramétricos (significación si p < 0,05). Resultados. Ambos grupos son similares demográfica y clínicamente. El tiempo inicio-puerta se alargó (46 min frente a 75 min; p = 0,01) y dispersó. El tiempo entre tomografía axial computarizada (TAC) y tratamiento se redujo a la mitad (57 min frente a 30 min; p = 0,001), con el consecuente acortamiento del período ‘puerta-aguja’ (121 min frente a 90 min; p = 0,002). El tiempo puerta-TAC se mantuvo constante (50 min frente a 53 min; p = 0,9), y la demora total desde el inicio tampoco se modificó significativamente (165 min frente a 170 min; p = 0,7); la correlación lineal inversa entre tiempo de inicio-TAC y tiempo TAC-tratamiento perdió intensidad. Conclusiones. Las advertencias contra la procrastinación parecen haber sido eficaces para abreviar la toma de decisión de tratar (TAC-tratamiento) y el tiempo ‘puerta-aguja’, mientras que el tiempo utilizado en la evaluación clinicorradiológica (puerta-TAC), sobre el que no había habido actuaciones, no se modificó. Ello ha permitido realizar fibrinólisis a pacientes que llegan más tarde; así, aunque el tiempo inicio-tratamiento aparentemente no cambió, se incrementó la tasa de fibrinólisis

Introduction. Fibrinolysis in stroke should be carried out as soon as possible, but delays occur for various reasons. In the first 17 ischemic infarcts treated in our center we confirmed a tendency to exhaust the therapeutic window. We look now at whether warnings against this tendency, without other logistical or organizational modifications, have had an impact on delays. Patients and methods. Neurologists were encouraged to avoid procrastination. When we reached 51 treated patients, we compared features and delay times between the first 17 (February, 2002 to June, 2004) and the 17 most recent cases (October, 2005 to April, 2006). Non-parametric tests were used (significant if p < 0.05). Results. Both groups were similar clinically and demographically. The onset-arrival time lengthened (46 min vs. 75 min; p = 0.01) and scattered. The CTtreatment time halved (57 min vs. 30 min; p = 0.001), with consequent shortening of the ‘door-to-needle’ period (121 min vs. 90 min; p = 0.002). The arrival-CT time had remained constant (50 min vs. 53 min; p = 0.9), thus the total delay from onset did not change significantly (165 min vs. 170 min; p = 0.7), and the inverse linear correlation between the onset-CT time and the CT-treatment time weakened. Conclusions. Warnings against procrastination appear to be important in terms of shortening the delays. The time used for clinical-radiologic evaluation (arrival through CT) –about which there had been no action taken– had not been modified, but the time employed in the decision to treat (CT-treatment) and the ‘door-to-needle’ time had decreased appreciably. This effective compensatory reduction permitted treatment of late-arriving patients, such that although the overall time from onset to treatment apparently was not modified, the actual treatment rate increased

Vasculitis aislada del sistema nervioso central que imita una encefalitis de Rasmussen / Isolated vasculitis of the central nervous system resembling Rasmussen´s encephalitis

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