[Treatment of relapsing-remitting multiple sclerosis with fingolimod in routine clinical practice]. / Tratamiento de la esclerosis multiple remitente recurrente con fingolimod en la practica clinica habitual.

INTRODUCTION: Fingolimod is a selective immunosuppressant that targets the S1P receptor, and is indicated in the treatment of aggressive relapsing-remitting multiple sclerosis (RRMS) and following treatment failure with first-order drugs. AIM: To investigate the safety and effectiveness of fingolimod under the conditions of routine clinical practice. PATIENTS AND METHODS: We conducted an observational study with prospective follow-up of patients with RRMS who received fingolimod from January 2011 until February 2014. Data assessed were the annualised relapse rate (ARR), disability measured by the Expanded Disability Status Scale (EDSS), magnetic resonance activity and the appearance of side effects. RESULTS: Our sample consisted of 122 patients, 79.5% of them females and with a mean age of 26.8 years. They were classified, according to the last treatment received, as being: naive (aggressive RRMS; n = 17), previous treatment failure (n = 67) and withdrawal of natalizumab due to risk of progressive multifocal leukoencephalopathy (n = 38). After a mean follow-up of 29.9 ± 15.9 months, the ARR and the appearance of new lesions with gadolinium enhancement were reduced in both the naive and the previous treatment failure groups. There were no differences between the various subgroups as regards the progression of EDSS or the time elapsed until the first attack or treatment failure. The risk of treatment failure is higher with a baseline EDSS > 3 (hazard ratio: 4.24; p = 0.001) and presence of IgM oligoclonal bands (hazard ratio: 2.45; p < 0.022). CONCLUSIONS: Fingolimod is an effective and well-tolerated drug under conditions of routine clinical practice. Having a baseline EDSS > 3 and IgM oligoclonal bands is predictive of a poor response to fingolimod.

TITLE: Tratamiento de la esclerosis multiple remitente recurrente con fingolimod en la practica clinica habitual.Introduccion. El fingolimod es un inmunosupresor selectivo dirigido contra el receptor SP-1, indicado en el tratamiento de la esclerosis multiple remitente recurrente (EMRR) agresiva y tras el fracaso del tratamiento con farmacos de primera linea. Objetivo. Investigar la seguridad y efectividad del fingolimod en condiciones de practica clinica habitual. Pacientes y metodos. Estudio observacional con seguimiento prospectivo de pacientes con EMRR que recibieron fingolimod desde enero de 2011 hasta febrero de 2014. Se evaluo la tasa anual de brotes (TAB), la discapacidad medida por la escala expandida del estado de discapacidad (EDSS), la actividad en la resonancia magnetica y la aparicion de efectos adversos. Resultados. Incluimos 122 pacientes, el 79,5% mujeres y con una edad media de 26,8 antilde;os. Se clasificaron segun el ultimo tratamiento recibido en: naive (EMRR agresiva; n = 17), fracaso a terapias previas (n = 67) y retirada de natalizumab por riesgo de leucoencefalopatia multifocal progresiva (n = 38). Tras un seguimiento medio de 29,9 ± 15,9 meses, se redujo de forma significativa la TAB y la aparicion de nuevas lesiones con realce de gadolinio en el grupo naive y el de fracaso a terapias previas. No ha habido diferencias en la evolucion de la EDSS ni en el tiempo hasta el primer brote o el fracaso terapeutico entre los diferentes subgrupos. El riesgo a fracaso terapeutico es mayor con la EDSS basal > 3 (hazard ratio: 4,24; p = 0,001) y presencia de bandas oligoclonales IgM (hazard ratio: 2,45; p < 0,022). Conclusiones. El fingolimod es un farmaco eficaz y seguro en la EMRR en condiciones de practica clinica habitual. Tener una EDSS basal > 3 y bandas oligoclonales IgM predice una mala respuesta al fingolimod.

Experiencia clínica con los cannabinoides en la terapia de la espasticidad en la esclerosis múltiple / Clinical experiences with cannabinoids in spasticity management in multiple sclerosis

Introducción: La espasticidad es un síntoma muy frecuente entre los pacientes con esclerosis múltiple (EM). El objetivo del presente estudio es evaluar la efectividad y la seguridad de la combinación de delta-9-tetrahidrocannabinol (THC) y cannabidiol (CBD) en la práctica clínica del tratamiento de la espasticidad en EM. Métodos: Estudio observacional retrospectivo con los pacientes tratados con THC/CBD inhalado de abril del 2008 a marzo del 2012. Se recogieron variables descriptivas de paciente y tratamiento. La respuesta se evaluó mediante impresión global de respuesta terapéutica analizada por el médico. Resultados: Cincuenta y seis pacientes iniciaron tratamiento, 6 fueron excluidos por falta de datos. Se evaluó a 50 pacientes (42% hombres), mediana de edad 47,8 años, el 38% de ellos diagnosticados de EM primaria progresiva, el 44% de EM secundaria progresiva y el 18% de EM remitente recurrente. El motivo de prescripción fue espasticidad (44%), dolor (10%) o ambos (46%). Se suspendió tratamiento en 16 pacientes por inefectividad (7 pacientes), abandono (4) y efectos adversos (5). La mediana de tiempo de exposición de los pacientes que suspendieron tratamiento fue 30 días y 174 días para los que continuaban tratamiento al final del estudio. THC/CBD fue efectivo en un 80% de pacientes, con dosis mediana de 5 (2-10) pulverizaciones/ día. El perfil de efectos adversos fue: mareo (11 pacientes), somnolencia (6), debilidad muscular (7), molestias bucales (2), diarrea (3), sequedad de boca (2), visión borrosa (2), agitación (1), náuseas (1), ideas paranoides (1). Conclusiones: THC/CBD se muestra como una buena alternativa al tratamiento habitual mejorando la espasticidad refractaria en la EM con perfil de toxicidad aceptable

Introduction: Spasticity is a common symptom among patients with multiple sclerosis (MS). This study aims to assess the effectiveness and safety of the combination of delta- 9-tetrahydrocannabinol (THC) and cannabidiol (CBD) in clinical practice for the treatment of spasticity in MS. Methods: Retrospective observational study with patients treated with inhaled THC/CBD between April 2008 and March 2012. Descriptive patient and treatment variables were collected. Therapeutic response was evaluated based on the doctor’s analysis and overall impression. Results: Of the 56 patients who started treatment with THC/CBD, 6 were excluded because of missing data.We evaluated 50 patients (42% male) with a median age 47.8 years (25.6-76.8); 38% were diagnosed with primary progressive MS, 44% with secondary progressive MS, and 18% with relapsing-remitting MS. The reason for prescribing the drug was spasticity (44%), pain (10%), or both (46%). Treatment was discontinued in 16 patients because of ineffectiveness (7 patients), withdrawal (4), and adverse effects (5). The median exposure time in patients whose treatment was discontinued was 30 days vs 174 days in those whose treatment continued at the end of thestudy. THC/CBD was effective in 80% of patients at a median dose of 5 (2-10) inhalations/day. The adverse event profile consisted of dizziness (11 patients), somnolence (6), muscle weakness (7), oral discomfort (2), diarrhoea (3), dry mouth (2), blurred vision (2), agitation (1), nausea (1), and paranoid ideation (1). Conclusions: THC/CBD appears to be a good alternative to standard treatment as it improves refractory spasticity in MS and has an acceptable toxicity profile

Clinical experiences with cannabinoids in spasticity management in multiple sclerosis.

INTRODUCTION: Spasticity is a common symptom among patients with multiple sclerosis (MS). This study aims to assess the effectiveness and safety of the combination of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) in clinical practice for the treatment of spasticity in MS. METHODS: Retrospective observational study with patients treated with inhaled THC/CBD between April 2008 and March 2012. Descriptive patient and treatment variables were collected. Therapeutic response was evaluated based on the doctor's analysis and overall impression. RESULTS: Of the 56 patients who started treatment with THC/CBD, 6 were excluded because of missing data. We evaluated 50 patients (42% male) with a median age 47.8 years (25.6-76.8); 38% were diagnosed with primary progressive MS, 44% with secondary progressive MS, and 18% with relapsing-remitting MS. The reason for prescribing the drug was spasticity (44%), pain (10%), or both (46%). Treatment was discontinued in 16 patients because of ineffectiveness (7 patients), withdrawal (4), and adverse effects (5). The median exposure time in patients whose treatment was discontinued was 30 days vs 174 days in those whose treatment continued at the end of the study. THC/CBD was effective in 80% of patients at a median dose of 5 (2-10) inhalations/day. The adverse event profile consisted of dizziness (11 patients), somnolence (6), muscle weakness (7), oral discomfort (2), diarrhoea (3), dry mouth (2), blurred vision (2), agitation (1), nausea (1), and paranoid ideation (1). CONCLUSIONS: THC/CBD appears to be a good alternative to standard treatment as it improves refractory spasticity in MS and has an acceptable toxicity profile.

Estudio de la relación entre lesiones de sustancia blanca en la resonancia magnética y foramen oval permeable en pacientes con migraña / Study of the relationship between white matter lesions in the magnetic resonance imaging and patent foramen ovale

Introducción. Diversos estudios han demostrado unamayor prevalencia de lesiones de sustancia blanca (LSB) enresonancia magnética (RM) cerebral de pacientes con migraña.También se ha comunicado mayor frecuencia deshunt derecha-izquierda (SDI) en pacientes con migrañacon aura (MCA) que en población general. El objetivo denuestro estudio es explorar una eventual asociación entre laexistencia de LSB y la presencia o no de SDI en pacientescon migraña.Métodos. Se revisaron los pacientes con MCA o migrañasin aura (MSA) con estudio de RM, a los que se había determinadopreviamente SDI mediante doppler transcraneal(DTC). Se determinaron LSB (alteraciones de señal de sustanciablanca hiperintensas en secuencias ponderadas en T2y FLAIR sin alteración de señal en T1). Se relaciona la presenciade LSB con el tipo de migraña y presencia o no de SDImediante estadística univariante.Resultados. Cuarenta y cuatro pacientes con migraña(31 mujeres y 13 hombres); edad media: 39 años (23-66).Doce pacientes con MSA y 32 con MCA. Catorce pacientesmostraron LSB (31,8 %). Veintinueve pacientes (65,9 %) presentaronSDI. Los pacientes con LSB presentaron SDI tan sóloen un 26,7% y los pacientes con SDI presentaron LSB enun 34,5 %. No se apreciaron diferencias estadísticamentesignificativas (p=0,738).Conclusiones. No hemos podido demostrar una relaciónentre el SDI y la aparición de LSB en la RM cerebral ennuestra serie. Desconocemos la naturaleza de la asociaciónentre LSB y migraña, pero estos hallazgos sugieren que elmecanismo no sería el embolismo paradójico (AU)

Introduction. Previous studies have described a higherprevalence of white matter lesions (WML) in thebrain magnetic tesonance imaging (MRI) in patients withmigraine. A higher frequency of right-to-left shunt (RLS)in patients with migraine with aura (MA) than in generalpopulation has been reported. This study has aimed toinvestigate a possible association between the existenceof WML and the presence or non-presence of RLS in patientswith migraine.Methods. We have reviewed migraine patients sufferingMA or migraine without aura (MWA) with an MRIstudied in whom left-right shunt had been determinedpreviously by transcranial doppler (TCD). The presenceof WML was determined (white matter hyperintensitiesin T2-weighted MR images (T2WI) and FLAIR, withoutsignal alteration in T1WI). The presence of WML was relatedwith the type of migraine and presence or non-presenceof RLS by univariate statistics.Results. Forty four patients with migraine, 13 maleand 31 female, mean age 39 years (23-66) were studied.Twelve patients had MA and 32 MWA. Fourteen patientshad WML (31.8%), 29 patients (65.9%) RLS; 26.7% ofthe patients with WML also had RLS, and 34.5% of thepatients with RLS had WML. Non-statistically significantdifferences were observed (p=0.738).Conclusions. We could not demonstrate a relationshipbetween RLS and WML in the brain MRI of ourpatients. We do not know the nature of the associationbetween is the association between WML and migraine,but these findings suggest that the link would not be byparadoxical embolism (AU)

Afectación de las funciones cognitivas en la esclerosis múltiple secundaria progresiva / Compromise of the cognitive functions in progressive secondary multiple sclerosis

Definir el patrón de afectación cognitiva en un grupo homogéneo de pacientes afectados de esclerosis múltiplesecundaria progresiva (EMSP). Pacientes y métodos. Se incluyó a 42 pacientes mayores de edad con el diagnóstico de EMSP y un grado similar de discapacidad, un tiempo de evolución superior a 24 meses y en tratamiento con interferón beta-1b un mínimo de tres meses. Se les administró una batería de 10 test neuropsicológicos, seleccionados para este estudio y repartidos en dos sesiones de una hora. Además, se evaluó el estado emocional con el inventario de depresión de Beck y la escala de ansiedadde Hamilton. Definimos ‘deterioro cognitivo’ como la alteración de dos o más test. Resultados. El 73,8% eran mujeres; edad media: 45 años (rango: 25-62); Expanded Disability Status Scale media: 5,4 (rango: 3,0-7,5); tiempo medio de evolución: 34,5 meses (rango: 24-80), y tiempo medio de tratamiento: 13,5 meses (rango: 3-38 ). El 78,5% padecía deterioro cognitivo. Lasfunciones más alteradas fueron: capacidad atencional, percepción visuoespacial, fluidez verbal, memoria lógica a largo y corto plazo y razonamiento abstracto. La presencia de deterioro cognitivo se relacionó con el tiempo de evolución de la enfermedad (r = 0,31; p < 0,05) pero no con la edad, el grado de discapacidad o con la duración del tratamiento. Conclusión. El deterioro cognitivo es frecuente en la EMSP; la velocidad para la adquisición y procesamiento de nueva información y las funciones ejecutivas fueron las áreas afectadas con mayor frecuencia y gravedad. La alteración de la información visuoespacial fue un hallazgodiferencial de nuestra serie que podría contribuir al diagnóstico clínico de la progresión

To define the patterns of cognitive impairment in a homogeneous group of secondary progressive multiplesclerosis (SPMS) patients. Patients and methods. Forty-two SPMS patients were included with a similar degree of disability; all had been treated with interferon beta-1b for a minimum of 3 months. They voluntarily complimented a battery of 10 neuropsychological tests selected for this study, distributed in two sessions of one hour. In addition, the emotional state was evaluatedwith the Beck Depression Inventory and the Hamilton Anxiety Scale. We considered cognitive impairment as more than two tests altered, according with previously reported studies. Results. 73.8% of patients were women; mean age was 45 years (range: 25-62); mean EDSS was 5.4 (range: 3.0-7.5); mean evolution time was 34.5 months (range: 24-80); mean treatment durationwas 13.5 months (range: 3-38). Cognitive impairment was present in 78.5% of patients. The most frequently impaired functions were: attentional capacity, visuospatial perception, verbal fluency, short-term and long-term logic memory and abstractreasoning. The presence of cognitive impairment was related to the time of evolution of the disease (r = 0.31; p < 0.05) but not with the age, the degree of disability or the treatment duration. Conclusion. Cognitive impairment in the SPMS patients is afrequent finding, being the alteration in the speed for the acquisition and processing of new information, and the abstract reasoning the most frequent and severe altered functions. The also frequent impairment of visuospatial information was a differential finding in our study that could contribute to diagnosis of clinical progression

[Compromise of the cognitive functions in progressive secondary multiple sclerosis]. / Afectación de las funciones cognitivas en la esclerosis múltiple secundaria progresiva.

AIM: To define the patterns of cognitive impairment in a homogeneous group of secondary progressive multiple sclerosis (SPMS) patients. PATIENTS AND METHODS: Forty-two SPMS patients were included with a similar degree of disability; all had been treated with interferon beta-1b for a minimum of 3 months. They voluntarily complimented a battery of 10 neuropsychological tests selected for this study, distributed in two sessions of one hour. In addition, the emotional state was evaluated with the Beck Depression Inventory and the Hamilton Anxiety Scale. We considered cognitive impairment as more than two tests altered, according with previously reported studies. RESULTS: 73.8% of patients were women; mean age was 45 years (range: 25-62); mean EDSS was 5.4 (range: 3.0-7.5); mean evolution time was 34.5 months (range: 24-80); mean treatment duration was 13.5 months (range: 3-38). Cognitive impairment was present in 78.5% of patients. The most frequently impaired functions were: attentional capacity, visuospatial perception, verbal fluency, short-term and long-term logic memory and abstract reasoning. The presence of cognitive impairment was related to the time of evolution of the disease (r = 0.31; p < 0.05) but not with the age, the degree of disability or the treatment duration. CONCLUSION: Cognitive impairment in the SPMS patients is a frequent finding, being the alteration in the speed for the acquisition and processing of new information, and the abstract reasoning the most frequent and severe altered functions. The also frequent impairment of visuospatial information was a differential finding in our study that could contribute to diagnosis of clinical progression.

[Total brain T2-hyperintense lesion-volume and the axonal damage in the normal-appearing white matter of brainstem in early lapsing-remitting multiple sclerosis]. / Relación entre el volumen lesional cerebral total en resonancia magnética secuencia T2 y el daño neuroaxonal en la sustancia blanca aparentemente normal del tronco del encéfalo en la esclerosis múltiple remitente-recurrente.

AIM: To evaluate the relationship between the total brain T2-hyperintense lesion volume (TBT2LV) and the axonal damage in the normal-appearing white matter of brainstem measured by 1H-MRS in a group of early relapsing-remitting multiple sclerosis patients. SUBJECTS AND METHODS: 40 relapsing-remitting multiple sclerosis patients and ten sex- and age-matched healthy subjects were prospectively studied for two years. T2-weighted MR and 1H-MRS imaging were acquired at time of recruitment and at year two. The TBT2LV was calculated with a semiautomatic program; N-acetylaspartate (NAA), creatine (Cr) and choline (Cho) resonances areas were integrated with jMRUI program and the ratios were calculated for four volume elements that represented the brainstem. RESULTS: At basal study we obtained an axonal loss (as a decrement of NAA/ Cho ratio) in the group of patients compared with controls (p = 0.017); this axonal loss increased at the second year of the follow-up for patients (NAA/Cho decrease, p = 0.004, and NAA/Cr decrease, p = 0.002) meanwhile control subjects had no significant metabolic changes. Higher lesion load was correlated with a poor clinical outcome, being the correlation between the basal TBT2LV and the Expanded Disability Status Scale at second year (r = 0.299; p = 0.05). Besides, axonal loss was not homogeneous for all multiple sclerosis patients, being stronger in the subgroup of patients with high basal TBT2LV (p = 0.043; ANOVA). CONCLUSION: Our data suggest that axonal damage is early in multiple sclerosis and higher in patients high basal TBT2LV, suggesting a possible relationship between these two phenomena.

Relación entre el volumen lesional cerebral total en resonancia magnética secuencia T2 y el daño neuroaxonal en la sustancia blanca aparentemente normal del tronco del encéfalo en la esclerosis múltiple remitente-recurrente

Analizar mediante espectroscopia de protón el daño neuroaxonal en la sustancia blanca aparentementenormal del tronco del encéfalo y su relación con el volumen lesional cerebral total en T2 (VLCT2) medido por resonancia magnética, en pacientes con esclerosis múltiple remitente-recurrente. Sujetos y métodos. Estudio longitudinal prospectivo comparativo a dos años de las variaciones en la concentración de N-acetilaspartato (NAA), creatina (Cr) y colina (Co), medidas por espectroscopia de protón, en 40 pacientes afectos de esclerosis múltiple remitente-recurrente y 10 personas sanas ajustadas por sexo y edad. Los metabolitos se calcularon mediante el programa jMRUI en cuatro volúmenes de interés representadosen el troncoencéfalo, y el VLCT2, con un programa semiautomático. Resultados. El estudio basal mostró daño neuroaxonal (expresado como un menor cociente NAA/Co, p = 0,017) en el grupo de pacientes frente a los controles. El daño axonal se incrementó significativamente a los dos años sólo en el grupo de pacientes (descenso del cociente NAA/Co, p =0,004, y NAA/Cr, p = 0,002). Un mayor volumen lesional basal se correlacionó con una peor evolución clínica, representada por la Expanded Disability Status Scale a los 2 años (r = 0,299; p = 0,05). La intensidad del daño neuroaxonal no fue homogénea en todos los pacientes, siendo mayor en el subgrupo de pacientes con VLCT2 basal superior (p = 0,043; ANOVA). Conclusión.Los resultados sugieren que el daño neuroaxonal aparece precozmente en la esclerosis múltiple, que es progresivo y que se relaciona al menos parcialmente con el volumen lesional cerebral

To evaluate the relationship between the total brain T2-hyperintense lesion volume (TBT2LV) and the axonaldamage in the normal-appearing white matter of brainstem measured by 1H-MRS in a group of early relapsing-remitting multiple sclerosis patients. Subjects and methods. 40 relapsing-remitting multiple sclerosis patients and ten sex- and agematchedhealthy subjects were prospectively studied for two years. T2-weighted MR and 1H-MRS imaging were acquired attime of recruitment and at year two. The TBT2LV was calculated with a semiautomatic program; N-acetylaspartate (NAA), creatine (Cr) and choline (Cho) resonances areas were integrated with jMRUI program and the ratios were calculated for four volume elements that represented the brainstem. Results. At basal study we obtained an axonal loss (as a decrement of NAA/Cho ratio) in the group of patients compared with controls (p = 0.017); this axonal loss increased at the second year of the follow-up for patients (NAA/Cho decrease, p = 0.004, and NAA/Cr decrease, p = 0.002) meanwhile control subjects had no significant metabolic changes. Higher lesion load was correlated with a poor clinical outcome, being the correlation betweenthe basal TBT2LV and the Expanded Disability Status Scale at second year (r = 0.299; p = 0.05). Besides, axonal loss was not homogeneous for all multiple sclerosis patients, being stronger in the subgroup of patients with high basal TBT2LV (p = 0.043; ANOVA). Conclusion. Our data suggest that axonal damage is early in multiple sclerosis and higher in patients highbasal TBT2LV, suggesting a possible relationship between these two phenomena

Migraña con aura, shunt derecha-izquierda y frecuencia de crisis / Migraine with aura right-to-left shunt and frequency of seizures

Introducción. La elevada prevalencia de foramen oval permeable en la migraña con aura (MCA) parece bien establecida; sin embargo, no lo está la posible relación entre la magnitud del shunt derecha-izquierda (SDI) y la MCA. Como hipótesis, si el SDI tuviese algún papel desencadenante, aquellos sujetos con mayor grado de shunt podrían experimentar un mayor número de crisis. Exploramos esta eventual relación entre la magnitud del shunt y la incidencia de crisis. Pacientes y métodos. Se obtuvo la frecuencia de crisis (dividiéndolas en tres grupos de frecuencias crecientes), antecedentes y desencadenantes en una serie de 72 pacientes con MCA. Posteriormente se determinó la presencia y magnitud del SDI mediante Doppler transcraneal, siguiendo un método ya validado. Mediante análisis univariante, se evaluó la eventual asociación de la magnitud del shunt con la frecuencia de las crisis. Resultados. La edad media fue 36 años. Apareció SDI en 44 pacientes (61,1%) y fue patrón ‘ducha/cortina’ en el 38%. Presentaron frecuencia baja de crisis 27%, media 45% y alta 27%. No se asoció la frecuencia con la magnitud del shunt, ni tan siquiera al considerar sólo los casos de elevada frecuencia. Sí que se asociaba la elevada frecuencia con determinados desencadenantes. Conclusiones. Nuestro trabajo confirma una alta prevalencia de SDI entre los pacientes MCA, pero no encuentra asociación entre magnitud del shunt y la frecuencia de las crisis. Según discutimos, estos hallazgos en parte están en contra de una asociación o mecanismo desencadenante de crisis tipo ‘umbral’

Introduction. The high prevalence of patent foramen ovale in migraine with aura (MWA) seems to be well established; yet, the possible relation between the magnitude of the right-to-left shunt (RLS) and MWA is not so clear. As a hypothesis, if the RLS played a precipitating role, subjects with a larger degree of shunt might experience a higher number of seizures. We examine this possible relationship between the magnitude of the shunt and the incidence of seizures. Patients and methods. We examined a series of 72 patients with MWA to obtain the frequencies of seizures (dividing them into three groups of increasing frequency), history and precipitating factors. The presence and magnitude of the RLS were later determined by means of transcranial Doppler ultrasonography, following a method that had previously been validated. Univariate analysis was then used to evaluate the possible association between the magnitude of the shunt and the frequency of seizures. Results. The mean age was 36 years. RLS appeared in 44 patients (61.1%) and followed a ‘shower/curtain’ pattern in 38% of cases. Frequency of seizures was low in 27%, medium in 45% and high in 27% of patients. Frequency was not associated with the magnitude of the shunt even when only high-frequency cases were considered. High frequency was associated, however, with certain precipitating factors. Conclusions. Our study confirms the existence of a high prevalence of RLS in patients with MWA, but no association was found between the magnitude of the shunt and the frequency of the seizures. As discussed here, these findings are partly at odds with a ‘threshold’ type of association or mechanism that precipitates seizures

[Migraine with aura, right-to-left shunt and frequency of seizures]. / Migraña con aura, shunt derecha-izquierda y frecuencia de crisis.

INTRODUCTION: The high prevalence of patent foramen ovale in migraine with aura (MWA) seems to be well established; yet, the possible relation between the magnitude of the right-to-left shunt (RLS) and MWA is not so clear. As a hypothesis, if the RLS played a precipitating role, subjects with a larger degree of shunt might experience a higher number of seizures. We examine this possible relationship between the magnitude of the shunt and the incidence of seizures. PATIENTS AND METHODS: We examined a series of 72 patients with MWA to obtain the frequencies of seizures (dividing them into three groups of increasing frequency), history and precipitating factors. The presence and magnitude of the RLS were later determined by means of transcranial Doppler ultrasonography, following a method that had previously been validated. Univariate analysis was then used to evaluate the possible association between the magnitude of the shunt and the frequency of seizures. RESULTS: The mean age was 36 years. RLS appeared in 44 patients (61.1%) and followed a 'shower/curtain' pattern in 38% of cases. Frequency of seizures was low in 27%, medium in 45% and high in 27% of patients. Frequency was not associated with the magnitude of the shunt even when only high-frequency cases were considered. High frequency was associated, however, with certain precipitating factors. CONCLUSIONS: Our study confirms the existence of a high prevalence of RLS in patients with MWA, but no association was found between the magnitude of the shunt and the frequency of the seizures. As discussed here, these findings are partly at odds with a 'threshold' type of association or mechanism that precipitates seizures.

[Quality control of Doppler diagnoses in vascular neurology]. / Control de calidad del diagnóstico mediante Doppler en neurología vascular.

INTRODUCTION: The use of ultrasonography in the study of extracranial pathologies is becoming widespread among the different neurology services in our community. Its main limitation is that it is a technique that depends on the explorer. AIMS: The purpose of this study is to determine the reliability of our Neurosonology laboratory by validating its results. PATIENTS AND METHODS: We conducted a retrospective study by selecting the first 100 consecutive patients (with ischemic stroke) who had been examined in the year 2001 in the Neurosonology laboratory in our hospital. These subjects had to fulfil the requirement of having been submitted to both a Doppler study (carotid and transcranial) and a vascular neuroimaging study using magnetic resonance angiography (MRA) or panarteriography of the supra-aortic trunks (SAT) and of the brain by means of femoral puncture. RESULTS: In the study of the SAT the Doppler detected stenosis or occlusion with a sensitivity of 91.4% and a specificity of 92.3% and, therefore, a positive predictive value (PPV) of 86.4%. 75% of the occlusions were diagnosed with three false positives (which were in fact critical stenoses above 95% instead of occlusion). As regards the evaluation of the transcranial Doppler (TCD), the sensitivity of the Doppler scan to detect stenoses above 50% is situated at 79%, with a PPV of 93%. For diffuse atheromatosis, however, sensitivity is 92.8%, and specificity is 93%. DISCUSSION: Findings agree with those offered by other studies conducted in our area using this technique, and show the reliability of this technique carried out in our Neurosonology laboratory. We therefore believe that Doppler echography of the SAT and TCD can be used for achieve an initial evaluation of cerebrovascular pathologies.

Control de calidad del diagnóstico mediante Doppler en neurología vascular / Quality control of doppler diagnoses in vascuslar neurology

Introducción. La ultrasonografía en el estudio de la patología extracraneal se está generalizando entre los diversos servicios de neurología de nuestro entorno. Su principal limitación es ser una técnica dependiente del explorador. Objetivo. Establecer la fiabilidad de nuestro laboratorio de Neurosonología mediante la validación de sus resultados. Pacientes y métodos. Se realizó un estudio retrospectivo seleccionando los 100 primeros pacientes consecutivos (con ictus isquémico) que se estudiaron en el año 2001 en el laboratorio de Neurosonología de nuestro hospital; debían cumplir el requisito de haberse sometido tanto a un estudio Doppler (carotídeo y transcraneal) como a un estudio de neuroimagen vascular mediante angiografía por resonancia magnética (ARM) o panarteriografía de troncos supraaórticos (TSA) y cerebrales mediante punción femoral. Resultados. En el estudio de los TSA, el Doppler detectó estenosis u oclusión con una sensibilidad del 91,4 por ciento y una especificidad del 92,3 por ciento y, por tanto, un valor predictivo positivo (VPP) del 86,4 por ciento. Se diagnosticaron el 75 por ciento de las oclusiones con tres falsos positivos (que correspondían a estenosis críticas de más del 95 por ciento en lugar de oclusión). En cuanto a la valoración del Doppler transcraneal (DTC), la sensibilidad del Doppler para detectar estenosis mayores del 50 por ciento se sitúa en el 79 por ciento, con un VPP del 93 por ciento, mientras que para la ateromatosis difusa la sensibilidad es del 92,8 por ciento, y la especificidad, del 93 por ciento. Discusión. Los datos encontrados concuerdan con los ofrecidos por otros estudios realizados en nuestro medio con esta técnica, y demuestran la fiabilidad de esta técnica realizada en nuestro laboratorio de Neurosonología. De este modo pensamos que podemos emplear la ecografía Doppler de TSA y DTC para la evaluación inicial de la patología cerebrovascular (AU)

Introduction. The use of ultrasonography in the study of extracranial pathologies is becoming widespread among the different neurology services in our community. Its main limitation is that it is a technique that depends on the explorer. Aims. The purpose of this study is to determine the reliability of our Neurosonology laboratory by validating its results. Patients and methods. We conducted a retrospective study by selecting the first 100 consecutive patients (with ischemic stroke) who had been examined in the year 2001 in the Neurosonology laboratory in our hospital. These subjects had to fulfil the requirement of having been submitted to both a Doppler study (carotid and transcranial) and a vascular neuroimaging study using magnetic resonance angiography (MRA) or panarteriography of the supra-aortic trunks (SAT) and of the brain by means of femoral puncture. Results. In the study of the SAT the Doppler detected stenosis or occlusion with a sensitivity of 91.4% and a specificity of 92.3% and, therefore, a positive predictive value (PPV) of 86.4%. 75% of the occlusions were diagnosed with three false positives (which were in fact critical stenoses above 95% instead of occlusion). As regards the evaluation of the transcranial Doppler (TCD), the sensitivity of the Doppler scan to detect stenoses above 50% is situated at 79%, with a PPV of 93%. For diffuse atheromatosis, however, sensitivity is 92.8%, and specificity is 93%. Discussion. Findings agree with those offered by other studies conducted in our area using this technique, and show the reliability of this technique carried out in our Neurosonology laboratory. We therefore believe that Doppler echography of the SAT and TCD can be used for achieve an initial evaluation of cerebrovascular pathologies (AU)