[Eslicarbazepine in patients with hipercholesterolemia associated to carbamazepine and oxcarbacepine]. / Eslicarbacepina en pacientes con hipercolesterolemia asociada a carbamacepina y oxcarbacepina.

TITLE: Eslicarbacepina en pacientes con hipercolesterolemia asociada a carbamacepina y oxcarbacepina.

Neuroanatomy of financial decisions.

INTRODUCTION: Neuroeconomics is a new science that studies the brain processes involved in taking decisions, particularly related to economy and it has experienced an important advance in the recent years due to the development of the new neuroimaging techniques, basically functional magnetic resonance imaging. The aim of this paper it to carry out a review of the literature on the different neurological mechanisms involved in taking financial decisions, the concerned brain structures and the diseases that can affect them. SOURCES: We made a non systematic review of the literature in primary (PubMed) and secondary (Tripdatabase and Cochrane Library) bibliographic databases. We also used bibliography given by the Asociación Española de Neuroeconomía. DEVELOPMENT: Brain reward and loss aversion systems suppose a balance that makes us take one or another decision. Dopamine plays an important role on it and several brain structures have been involved in this balance such as the amygdale, the insula, the medial prefrontal cortex, the anterior and posterior cingulated cortex, the accumbens nucleus and the ventral tegmental area. The alteration of this balance may produce inappropriate financial behaviors what may occur in common diseases including depression, mania, alcoholism, gambling and several impulse control disorders. CONCLUSIONS: Neurologists should define our role in this interdisciplinary field due to the privileged position of our specialty to study how the brain works and due to the potential growing of this science in the near future.

Relación entre el sistema fibrinolítico y las enfermedades neurológicas / Relationship between fibrinolytic system and neurological diseases

Introducción. El sistema fibrinolítico, o sistema del plasminógeno, se compone de una serie de moléculas que convierten el plasminógeno en su forma activa plasmina, la cual es capaz de participar en múltiples procesos fisiopatológicos. Objetivo. Realizar una revisión de la bibliografía y analizar la relación entre el sistema fibrinolítico y las enfermedades neurológicas y sus posibles implicaciones terapéuticas al respecto. Desarrollo. El sistema fibrinolítico se ha involucrado en muy diversas patologías. Aunque tradicionalmente se pensaba que su relación con las enfermedades neurológicas era escasa, en los últimos años se han establecido importantes nexos de unión. De esta forma, el sistema fibrinolítico parece estar involucrado no solamente en enfermedades cerebrovasculares, sino también en la epilepsia, enfermedades neurodegenerativas, como la enfermedad de Alzheimer, enfermedades de perfil inflamatorio, como la esclerosis múltiple, alteraciones del sistema dopaminérgico, trastornos del aprendizaje o enfermedades del sistema nervioso periférico. Diferentes genotipos de los componentes de este sistema se han mostrado como factores protectores o de riesgo para el desarrollo de estas enfermedades, y la información acumulada a este respecto está aumentando sustancialmente. Conclusiones. Un mayor conocimiento de las relaciones entre el sistema fibrinolítico con las enfermedades neurológicas podría aclarar ciertos puntos sobre su fisiopatología y también suponer futuras líneas de prevención y tratamiento (AU)

Introduction. The fibrinolytic system, also named plasminogen system is formed by a group of molecules that transforms plasminogen in its active form plasmine, which is able to participate in a number of pathophysiological processes. Aim. To carry out a review of the literature and an analysis of the relationship between fibrinolytic system and neurological diseases and its potential therapeutic implications.Development. The fibrinolytic system has been involved in many different pathologies. Although its role in neurological diseases has always been thought to be scarce, many relations have been recently established. This way, fibrinolytic system seems to be involved not only in cerebrovascular diseases but also in epilepsy, inflammatory diseases such as multiple sclerosis, alterations of the dopaminergic system, learning disorders and several lesions of the peripheral nervous system. Different genotypes of several components of this system have been related as risk or protector factors to the development of these neurological diseases and information to this respect is rapidly increasing. Conclusions. A better knowledge about the relations between the fibrinolytic system and neurological diseases could clarify several aspects about their pathophysiology and it could suppose future prevention and treatment lines (AU)

[Relationship between fibrinolytic system and neurological diseases]. / Relacion entre el sistema fibrinolitico y las enfermedades neurologicas.

INTRODUCTION: The fibrinolytic system, also named plasminogen system is formed by a group of molecules that transforms plasminogen in its active form plasmine, which is able to participate in a number of pathophysiological processes. AIM: To carry out a review of the literature and an analysis of the relationship between fibrinolytic system and neurological diseases and its potential therapeutic implications. DEVELOPMENT: The fibrinolytic system has been involved in many different pathologies. Although its role in neurological diseases has always been thought to be scarce, many relations have been recently established. This way, fibrinolytic system seems to be involved not only in cerebrovascular diseases but also in epilepsy, inflammatory diseases such as multiple sclerosis, alterations of the dopaminergic system, learning disorders and several lesions of the peripheral nervous system. Different genotypes of several components of this system have been related as risk or protector factors to the development of these neurological diseases and information to this respect is rapidly increasing. CONCLUSIONS: A better knowledge about the relations between the fibrinolytic system and neurological diseases could clarify several aspects about their pathophysiology and it could suppose future prevention and treatment lines.

El dolor en la esclerosis múltiple: prevalencia, mecanismos, tipos y tratamiento / Pain in multiple sclerosis: prevalence, mechanisms, types and treatment

Introducción. El dolor es un síntoma frecuente en la esclerosis múltiple (EM), aunque su prevalencia y su importancia varían de unos estudios a otros. Objetivo. Analizar la prevalencia, tipos, mecanismos y tratamientos de los diferentes síndromes dolorosos que afectan a los pacientes con EM. Desarrollo. Se realiza una revisión no sistemática de la bibliografía sobre los aspectos anteriormente expuestos en los pacientes con EM. La prevalencia del dolor en esta enfermedad es superior a lo que se supuso inicialmente y existen series que lo sitúan hasta en un 86%. Afecta de modo importante a la calidad de vida, limitando tanto las actividades cotidianas como la vida laboral. Se asocia a edad avanzada, duración de la enfermedad, grado de discapacidad, fatiga y depresión. Existen diferentes tipos de dolor en los pacientes con EM y se han propuesto varias clasificaciones. Entre ellos se encuentran las disestesias en las extremidades, el dolor regional complejo, el signo de L’hermitte, la neuralgia del trigémino, el dolor asociado a neuritis óptica, los espasmos tónicos dolorosos, la lumbalgia y la cefalea. Respecto a los tratamientos, se utilizan los mismos que para los pacientes que no sufren EM, ya que los estudios realizados en pacientes con esta enfermedad son muy escasos. Conclusiones. El dolor afecta a un alto porcentaje de los pacientes con EM, su fisiopatología se desconoce y no existen tratamientos específicos, por lo que consideramos conveniente aumentar los estudios sobre el dolor en los pacientes con EM (AU)

Introduction. Pain is a frequent symptom in multiple sclerosis (MS), although its prevalence and its importance vary from one study to another. Aim. To analyse the prevalence, types, mechanisms and treatments of the different painful syndromes that affect patients with MS. Development. The work includes a non-systematic review of the literature on the above-mentioned aspects in patients with MS. The prevalence of pain in this disease is higher than what was initially supposed and some series estimate it to be up to 86%. It has important effects on patients’ quality of life, limiting both their daily activities and their working life. It is associated with advanced age, duration of the disease, degree of disability, fatigue and depression. There are different types of pain in patients with MS and several different classifications have been proposed. Examples of such systems of classification include dysesthesias in the extremities, complex regional pain, L’Hermitte’s sign, trigeminal neuralgia, pain associated to optic neuritis, painful tonic spasms, low back pain and headache. Treatments used are the same as those employed with patients who do not have MS, since few studies have been conducted in patients with this disease. Conclusions. Pain affects a high percentage of patients with MS, its pathophysiology is unknown and there are no specific treatments. We therefore recommend that further studies should be carried out to investigate the pain experienced by patients with MS (AU)

Acquired chronic hepatocerebral degeneration due to cirrhosis from non-alcoholic steatohepatitis.

INTRODUCTION AND OBJECTIVE: Acquired chronic hepatocerebral degeneration, acquired hepatolenticular degeneration or pseudo-Wilson is an infrequent disorder with a hepatic origin. Cases in the literature are scarce and it is frequently confused with hepatic encephalopathy and Wilson s disease. The aim of this essay is to report a patient suffering from this disorder due to cirrhosis from non-alcoholic steatohepatitis. CASE REPORT: We present a 54-year-old man diagnosed from cirrhosis grade B9 of the Child Pugh classification. He progressively developed a picture with bradylalia, mild postural and action tremor and spatial and temporal disorientation. Further studies demonstrated an increase of the values of hepatic transaminases and a hyperintensity in the basal nuclei in the cerebral magnetic resonance imaging. Clinical and radiological data established the diagnosis of hepatocerebral degeneration. CONCLUSIONS: Acquired chronic hepatocerebral degeneration is a disorder rarely reported in the literature that it is usually confused with other diseases. We alert about the need of having this diagnosis into account with patients developing neurological symptoms after hepatic disease.

[Glatiramer acetate in interferon beta non respondent relapsing-remitting multiple sclerosis]. / Acetato de glatiramero en pacientes con esclerosis múltiple remitente-recurrente no respondedores al interferón beta.

INTRODUCTION AND OBJECTIVE: There are 4 immunomodulator treatments approved as first line therapy for patients with re-lapsing-remitting multiple sclerosis (RRMS). The objective of this study is to assess if glatiramer acetate (GA) is useful or not in patients who have discontinued interferon beta due to a suboptimal response or adverse events. METHODS: This is an observational and retrospective study in RRMS patients who discontinued IFN-beta therapy (2.9+/-2.4 years of treatment) and switched to GA (1.9+/-1.4 years). They were classified in 2 groups depending on the reason for discontinuation: suboptimal response or side effects. In both treatments we analysed number of relapses, treatment duration and causes of discontinuation. RESULTS: We included 58 patients of which 20 discontinued IFN-beta for lack of effectiveness whereas 38 were due to adverse events. Patients who discontinued for suboptimal response changed from 1.38 +/- 0.95 relapses per year with IFN-beta to 0.52+/-0.86 with GA. Patients who discontinued for adverse events changed from 0.33 +/- 0.64 relapses per year with IFN-beta to 0.37+/-0.79 with GA. CONCLUSIONS: GA can be considered a good alternative treatment for MS patients with a suboptimal response or adverse events with IFN-beta which confirms the existence of different mechanisms of action in both drugs.

Síndrome hepatocerebral crónico secundario a cirrosis por esteatohepatitis no alcohólica / Acquired chronic hepatocerebral degeneration due to cirrhosis from non-alcoholic steatohepatitis

Fundamento y objetivo: el síndrome hepatocerebral crónico,también denominado degeneración hepatolenticular crónicaadquirida (DHCA) o pseudo-Wilson, es un trastorno poco frecuentede origen hepático. Los casos recogidos en la literatura son escasosy frecuentemente es confundido con la encefalopatía hepáticay con la enfermedad de Wilson. El objetivo de este artículo espresentar un paciente que sufre este trastorno de forma secundariaa una cirrosis por esteatohepatitis no alcohólica.Caso clínico: se trata de un varón de 54 años diagnosticadode cirrosis en grado funcional de Child-Pugh B9 que presentó uncuadro progresivo de bradilalia, temblor postural y de acción levey, en ocasiones, desorientación temporoespacial. Los estudioscomplementarios evidenciaron una elevación de las transaminasashepáticas y una hiperintensidad de los núcleos basales en la resonanciamagnética cerebral estableciéndose el diagnóstico deDHCA.Conclusiones: la DHCA es un trastorno poco descrito en laliteratura que en ocasiones es confundido con otras entidades. Esnecesario descartar la presencia de esta patología en los pacientescirróticos con alteraciones neurológicas tras una enfermedad hepática(AU)

Introduction and objective: acquired chronic hepatocerebraldegeneration, acquired hepatolenticular degeneration orpseudo-Wilson is an infrequent disorder with a hepatic origin.Cases in the literature are scarce and it is frequently confused withhepatic encephalopathy and Wilson’s disease. The aim of this essayis to report a patient suffering from this disorder due to cirrhosisfrom non-alcoholic steatohepatitis.Case report: we present a 54-year-old man diagnosed fromcirrhosis grade B9 of the Child Pugh classification. He progressivelydeveloped a picture with bradylalia, mild postural and actiontremor and spatial and temporal disorientation. Further studiesdemonstrated an increase of the values of hepatic transaminasesand a hiperintensity in the basal nuclei in the cerebral magneticresonance imaging. Clinical and radiological data established thediagnosis of hepatocerebral degeneration.Conclusions: acquired chronic hepatocerebral degenerationis a disorder rarely reported in the literature that it is usually confusedwith other diseases. We alert about the need of having thisdiagnosis into account with patients developing neurologicalsymptoms after hepatic disease(AU)

Neuromodulators and therapeutic targets in neuropathic pain: from molecules to man.

Neuropathic pain is a phenomenon characterized by a high population prevalence by possessing several etiologies. In contrast to nociceptive pain, painful signals in neuropathic pain are originated in the nervous system, present poor responses to conventional treatments and may worsen the quality of life. Antiepileptic drugs are increasingly used for different purposes including migraine, neuropathic pain, tremor or psychiatric disorders and they have started to be called neuromodulators. These drugs may act on very different targets such as sodium, potassium or calcium channels, purinergic, GABAergic, glutamatergic or vanilloid receptors and different cytokines including IL-6 or TNF, each if which may be important in managing some aspects of neuropathic pain. Antiepileptic drugs have demonstrated effectiveness in the treatment of this pathology, and owing to the important development of these drugs in the last years, they may become a very effective tool. On the other hand, the increasing knowledge of the pathophysiology of nociception is leading to new channels and receptors as potential targets for treatment. In this paper we try to review the different potential therapeutic targets and role of antiepileptic drugs in the treatment of this pathology.

[Worsening of migraine symptoms due to giant pineal cyst apoplexy]. / Agravamiento de un cuadro migrañoso por apoplejía de un quiste pineal gigante.

INTRODUCTION: Although the association between headaches and pineal gland cysts has been suggested on a number of occasions, no precise evidence of exactly what this relation involves has been produced to date. It is known, however, that a cyst in the pineal gland can bring on or worsen headaches, especially if it is large or there has been bleeding, due to obstructive compromise in the third ventricle and the resulting hydrocephalus that is produced. CASE REPORT: A 15 years-old male who had suffered from migraine from the age of 6 years and who suddenly experienced a worsening of his headaches, both as regards their frequency and their intensity, over the previous days; no known precipitating factor appeared to be involved. Magnetic resonance imaging of the brain revealed the presence of a giant cyst in the pineal gland, with a notable amount of blood inside it, which was producing an obstructive hydrocephalus. The decision was made to resort to surgical treatment, with resection of the cyst and placement of a shunt valve. As a result the patient's headaches improved greatly and this improvement continued throughout a six-month follow-up. CONCLUSIONS: Worsening of a headache, in this case migraine, for no apparent cause must make us consider secondary processes, although they may be as rare as the one described here.

Agravamiento de un cuadro migrañoso por apoplejía de un quiste pineal gigante / Worsening of migraine symptoms due to giant pineal cyst apoplexy

Introducción. Aunque la asociación entre cefalea y quistes de la glándula pineal se ha postulado en repetidas ocasiones, no se ha podido demostrar de forma precisa en qué consiste dicha relación. Sí es conocido el inicio o empeoramiento de las cefaleas por un quiste de la glándula pineal, sobre todo si éste es de gran tamaño, o ha sangrado, debido a la afectaciónobstructiva en el tercer ventrículo, y la hidrocefalia secundaria producida. Caso clínico. Varón de 15 años, migrañoso desde los 6 años, que en los últimos días sufrió un empeoramiento brusco de sus cefaleas, tanto en frecuencia como en intensidad, sin un desencadenante conocido. Se le realizó una resonancia magnética cerebral, que mostró un quiste gigante de laglándula pineal, con importante contenido hemático en su interior, el cual producía una hidrocefalia obstructiva. Se decidió intervenir quirúrgicamente, con resección del quiste y la colocación de una válvula de derivación. Como resultado, se produjo una importante mejoría de sus cefaleas, que se mantuvo durante un período de seguimiento de seis meses. Conclusión. Anteun agravamiento de una cefalea, en este caso migrañosa, sin causa aparente, se debe pensar en procesos secundarios, aunquepueden ser tan infrecuentes como el presentado

Introduction. Although the association between headaches and pineal gland cysts has been suggested on a numberof occasions, no precise evidence of exactly what this relation involves has been produced to date. It is known, however, that a cyst in the pineal gland can bring on or worsen headaches, especially if it is large or there has been bleeding, due to obstructive compromise in the third ventricle and the resulting hydrocephalus that is produced. Case report. A 15 years-old male who had suffered from migraine from the age of 6 years and who suddenly experienced a worsening of his headaches, both as regards their frequency and their intensity, over the previous days; no known precipitating factor appeared to be involved. Magnetic resonance imaging of the brain revealed the presence of a giant cyst in the pineal gland, with a notableamount of blood inside it, which was producing an obstructive hydrocephalus. The decision was made to resort to surgical treatment, with resection of the cyst and placement of a shunt valve. As a result the patient's headaches improved greatly andthis improvement continued throughout a six-month follow-up. Conclusions. Worsening of a headache, in this case migraine, for no apparent cause must make us consider secondary processes, although they may be as rare as the one described here

[Sexual intercourse as a trigger of transient global amnesia]. / Actividad sexual como factor desencadenante de amnesia global transitoria.

INTRODUCTION: Transient global amnesia (TGA) is characterised by impairment of anterograde memory and, to a certain extent, retrograde memory, which is associated with mild temporal and spatial disorientation that is completely re-established after a few hours. There are different hypotheses about its pathogenesis, including theories about a possible epileptic, migrainous or ischaemic foundation or its being due to venous congestion in the hippocampuses, although the cause remains unknown. In the same way, many precipitating factors have been related to this disorder, including pain, anxiety, changes in temperature, exercise, Valsalva manoeuvres, diagnostic testing, interventionism and long-distance flights. Sexual intercourse has also been related to this condition, although how it can exert an influence is not known and few cases have been reported in the literature to date. CASE REPORTS: Six patients who suffered from signs and symptoms of TGA that were clearly related to a sexual relationship, in whom both the neurological examination and the complementary tests that were performed were completely normal. We also gather the evidence in favour and against the association between intercourse and this condition. CONCLUSIONS: Although the pathophysiological mechanisms that link sexual intercourse with TGA are unknown, the relation between them appears increasingly more often in the literature. We draw attention to the need to take sexual activity into account as a possible precipitating factor in patients suffering from this disorder.

Actividad sexual como factor desencadenante de amnesia global transitoria / Sexual intercourse as a trigger of transient global amnesia

Introducción. La amnesia global transitoria (AGT) es un trastorno caracterizado por una alteración de la memoriaanterógrada con cierto componente retrógrado, asociado a leve desorientación temporoespacial que se resuelve por completo en un período de unas horas. Existen distintas hipótesis sobre su patogenia, entre las que se incluyen teorías sobre una posible base epiléptica, migrañosa, isquémica o por congestión venosa de los hipocampos, aunque la causa todavía se desconoce. De la misma forma, son muchos los desencadenantes que se han relacionado con este trastorno, entre los que se incluyenel dolor, la ansiedad, los cambios de temperatura, el ejercicio, las maniobras de Valsalva, las pruebas diagnósticas, el intervencionismo y los vuelos transoceánicos. El coito se ha relacionado también con este cuadro clínico, aunque no se conoce cómo puede influir y los casos descritos son todavía escasos en la bibliografía. Casos clínicos. Seis pacientes que sufrieron uncuadro de AGT en clara relación con una relación sexual, en los cuales tanto la exploración neurológica como las pruebas complementarias realizadas fueron rigurosamente normales y recogemos la evidencia a favor y en contra de la asociación entre el coito y esta patología. Conclusiones. Aunque no se conocen los mecanismos fisiopatológicos que relacionan el coito y la AGT, estas dos entidades aparecen relacionadas cada vez con más frecuencia en la bibliografía. Alertamos de la necesidadde tener en cuenta la actividad sexual como un posible factor desencadenante en los pacientes que sufren este trastorno

Introduction. Transient global amnesia (TGA) is characterised by impairment of anterograde memory and, to a certain extent, retrograde memory, which is associated with mild temporal and spatial disorientation that is completely re-established after a few hours. There are different hypotheses about its pathogenesis, including theories about a possible epileptic,migrainous or ischaemic foundation or its being due to venous congestion in the hippocampuses, although the cause remains unknown. In the same way, many precipitating factors have been related to this disorder, including pain, anxiety, changes intemperature, exercise, Valsalva manoeuvres, diagnostic testing, interventionism and long-distance flights. Sexual intercourse has also been related to this condition, although how it can exert an influence is not known and few cases have been reported in the literature to date. Case reports. Six patients who suffered from signs and symptoms of TGA that were clearly related to asexual relationship, in whom both the neurological examination and the complementary tests that were performed were completely normal. We also gather the evidence in favour and against the association between intercourse and this condition.Conclusions. Although the pathophysiological mechanisms that link sexual intercourse with TGA are unknown, the relation between them appears increasingly more often in the literature. We draw attention to the need to take sexual activity into account as a possible precipitating factor in patients suffering from this disorder

[Botulinum toxin type A in the treatment of neuropathic pain in a case of postherpetic neuralgia]. / Toxina botulínica tipo A en el tratamiento del dolor neuropático en un caso de neuralgia postherpética.

INTRODUCTION: Botulinum toxin type A has been used in a wide range of neurological diseases such as migraine, cervical dystonia, spasticity or tics. However, the use of this drug in the treatment of neuropathic pain is still uncommon despite the fact that more and more cases supporting its role as an alternative treatment are emerging in the literature. CASE REPORT: Herein, we report a case of an 83 year old woman who suffered from severe pain with neuropathic characteristics due to postherpetic neuralgia which was refractory to different conventional therapies. The neuropathic pain was dramatically improved by multiple botulinum toxin type A injections and the analgesia lasted 2 months. Treatment was well tolerated and there were no side effects. CONCLUSIONS: Using botulinum toxin has been effective and well tolerated in the treatment of postherpetic neuralgia in our patient. Despite the fact that its action mechanisms is still unknown, we consider that botulinum neurotoxin may be an alternative treatment in relieving refractory neuropathic pain and that controlled studies are needed to study this possibility.

[Unusual complications of the lumboperitoneal shunt as treatment of benign intracranial hypertension]. / Complicaciones inusuales de la derivación lumboperitoneal como tratamiento de la hipertensión intracraneal benigna.

INTRODUCTION: Intracranial hypertension is a picture characterized by elevated cerebrospinal fluid pressure that may cause some different complications including optic disc edema and visual accuracy alterations. Although treatment is generally pharmacological, invasive therapeutical techniques such as optic nerve sheath fenestration and lumboperitoneal shunt are sometimes required. The latter one is a technique that usually provides good results with a low complication rate, including infections, mechanical failure and overdrainage. CASE REPORT: We report the case of a 40 year-old female patient with an idiopathic intracranial hypertension picture who required a lumboperitoneal shunt due to her progressive deterioration. After a few hours, the patient developed an intracerebral hematoma and subarachnoid hemorrhage, and some days later she developed a venous sinus thrombosis. These two complications, although described in the literature, are very unusual. CONCLUSIONS: Even though the lumboperitoneal shunt is a safe technique with good results, it is not exempt from complications. We alert about the need to take into account subarachnoid hemorrhage and venous sinus thrombosis as possible complications in the followup of these patients.