High frequency of endoluminal thrombus in patients with ischaemic stroke following AARS-CoV-2 infection.

BACKGROUND: Ischaemic stroke may be a major complication of SARS-CoV-2 infection. Studying and characterising the different aetiological subtypes, clinical characteristics, and functional outcomes may be valuable in guiding patient selection for optimal management and treatment. METHODS: Data were collected retrospectively on consecutive patients with COVID-19 who developed acute focal brain ischaemia (between 1 March and 19 April 2020) at a tertiary university hospital in Madrid (Spain). RESULTS: During the study period, 1594 patients were diagnosed with COVID-19. We found 22 patients with ischaemic stroke (1.38%), 6 of whom did not meet the inclusion criteria. The remaining 16 patients were included in the study (15 cases of ischaemic stroke and one case of transient ischaemic attack). Median baseline National Institutes of Health Stroke Scale score was 9 (interquartile range: 16), and mean (standard deviation) age was 73 years (12.8). Twelve patients (75%) were men. Mean time from COVID-19 symptom onset to stroke onset was 13 days. Large vessel occlusion was identified in 12 patients (75%). We detected elevated levels of D-dimer in 87.5% of patients and C-reactive protein in 81.2%. The main aetiology was atherothrombotic stroke (9 patients, 56.3%), with the predominant subtype being endoluminal thrombus (5 patients, 31.2%), involving the internal carotid artery in 4 cases and the aortic arch in one. The mortality rate in our series was 44% (7 of 16 patients). CONCLUSIONS: In patients with COVID-19, the most frequent stroke aetiology was atherothrombosis, with a high proportion of endoluminal thrombus (31.2% of patients). Our clinical and laboratory data support COVID-19-associated coagulopathy as a relevant pathophysiological mechanism for ischaemic stroke in these patients.

High frequency of endoluminal thrombus in patients with ischaemic stroke following SARS-CoV-2 infection. / Alta frecuencia de trombo endoluminal en pacientes con ictus isquémico tras la infección por coronavirus 2019.

BACKGROUND: Ischaemic stroke may be a major complication of SARS-CoV-2 infection. Studying and characterising the different aetiological subtypes, clinical characteristics, and functional outcomes may be valuable in guiding patient selection for optimal management and treatment. METHODS: Data were collected retrospectively on consecutive patients with SARS-CoV-2 infection who developed acute focal brain ischaemia (between 1 March and 19 April 2020) at a tertiary university hospital in Madrid (Spain). RESULTS: During the study period, 1594 patients were diagnosed with COVID-19. We found 22 patients with ischaemic stroke (1.38%), 6 of whom did not meet the inclusion criteria. The remaining 16 patients were included in the study (15 cases of ischaemic stroke and one case of transient ischaemic attack). Median baseline National Institutes of Health Stroke Scale score was 9 (interquartile range: 16), and mean (standard deviation) age was 73 years (12.8). Twelve patients (75%) were men. Mean time from COVID-19 symptom onset to stroke onset was 13 days. Large vessel occlusion was identified in 12 patients (75%). We detected elevated levels of D-dimer in 87.5% of patients and C-reactive protein in 81.2%. The main aetiology was atherothrombotic stroke (9 patients, 56.3%), with the predominant subtype being endoluminal thrombus (5 patients, 31.2%), involving the internal carotid artery in 4 cases and the aortic arch in one. The mortality rate in our series was 44% (7 of 16 patients). CONCLUSIONS: In patients with COVID-19, the most frequent stroke aetiology was atherothrombosis, with a high proportion of endoluminal thrombus (31.2% of patients). Our clinical and laboratory data support COVID-19-associated coagulopathy as a relevant pathophysiological mechanism for ischaemic stroke in these patients.

Impacto de la pandemia de COVID-19 en la organización asistencial del ictus. Plan Ictus Madrid Pandemia COVID-19. Impacto en la asistencia del ictus. Plan Ictus Madrid / Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan

INTRODUCCIÓN: La sobrecarga asistencial y los cambios organizativos frente a la pandemia de COVID-19 podrían estar repercutiendo en la atención al ictus agudo en la Comunidad de Madrid. MÉTODOS: Encuesta estructurada en bloques: características del hospital, cambios en infraestructura y recursos, circuitos de código ictus, pruebas diagnósticas, rehabilitación y atención ambulatoria. Análisis descriptivo según el nivel de complejidad en la atención del ictus (disponibilidad o no de unidad de ictus y de trombectomía mecánica). RESULTADOS: De los 26 hospitales del SERMAS que atienden urgencias en adultos, 22 cumplimentaron la encuesta entre el 16 y 27 de abril. El 95% han cedido neurólogos para atender a pacientes afectados por la COVID-19. Se han reducido camas de neurología en el 89,4%, modificado los circuitos en urgencias para ictus en el 81%, con circuitos específicos para sospecha de infección por SARS-CoV2 en el 50%, y en el 42% de los hospitales los pacientes con ictus agudo positivos para SARS-CoV2 no ingresan en camas de neurología. Ha mejorado el acceso al tratamiento, con trombectomía mecánica las 24 h en el propio hospital en 10 hospitales, y se han reducido los traslados interhospitalarios secundarios. Se ha evitado el ingreso de pacientes con ataque isquémico transitorio o ictus leve (45%) y se han incorporado consultas telefónicas para seguimiento en el 100%. CONCLUSIONES: Los cambios organizativos de los hospitales de la Comunidad de Madrid frente a la pandemia por SARS-Co2 han modificado la dedicación de recursos humanos e infraestructuras de las unidades de neurología y los circuitos de atención del ictus, realización de pruebas diagnósticas, ingreso de los pacientes y seguimiento

INTRODUCTION: The overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. METHODS: We conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). RESULTS: The survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. CONCLUSIONS: The organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up

Contraindications to intravenous thrombolysis in prehospital triage of thrombectomy candidates.

BACKGROUND AND PURPOSE: The existence of contraindications to intravenous thrombolysis (IVT) is considered a criterion for direct transfer of patients with suspected acute stroke to thrombectomy-capable centers in the prehospital setting. Our aim was to assess the utility of this criterion in a setting where routing protocols are defined by the Madrid - Direct Referral to Endovascular Center (M-DIRECT) prehospital scale. METHODS: This was a post hoc analysis of the M-DIRECT study. Reported contraindications to IVT were retrospectively collected from emergency medical services reports and categorized into late window, anticoagulant treatment and other contraindications. Final diagnosis and treatment rates were compared between patients with and without reported IVT contraindications and according to anticoagulant treatment or late window categories. RESULTS: The M-DIRECT study included 541 patients. Reported IVT contraindications were present in 227 (42.0%) patients. Regarding final diagnosis no significant differences were found between patients with or without reported IVT contraindications: ischaemic stroke (any) 65.6% vs. 62.1%, ischaemic stroke with large vessel occlusion (LVO) 32.2% vs. 28.3%, hemorrhagic stroke 15.4% vs. 15.6%, stroke mimic 18.9% vs. 22.3% respectively. Amongst patients with LVO, endovascular thrombectomy (EVT) was performed less often in the presence of IVT contraindications (56.2% vs. 74.2%). M-DIRECT-positive patients had higher rates of LVO and EVT compared with M-DIRECT-negative patients independent of reported IVT contraindications. CONCLUSIONS: Reported IVT contraindications alone do not increase EVT likelihood and should not be considered to determine routing in urban stroke networks.

Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan. / Impacto de la pandemia de COVID-19 en la organización asistencial del ictus. Plan Ictus Madrid.

INTRODUCTION: The overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. METHODS: We conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). RESULTS: The survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. CONCLUSIONS: The organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up.

Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations. / Atención al ictus agudo durante la pandemia por COVID-19. Recomendaciones Plan Ictus Madrid.

INTRODUCTION: The COVID-19 pandemic has resulted in complete saturation of healthcare capacities, making it necessary to reorganise healthcare systems. In this context, we must guarantee the provision of acute stroke care and optimise code stroke protocols to reduce the risk of SARS-CoV-2 infection and rationalise the use of hospital resources. The Madrid Stroke multidisciplinary group presents a series of recommendations to achieve these goals. METHODS: We conducted a non-systematic literature search using the keywords "stroke" and "COVID-19" or "coronavirus" or "SARS-CoV-2." Our literature review also included other relevant studies known to the authors. Based on this literature review, a series of consensus recommendations were established by the Madrid Stroke multidisciplinary group and its neurology committee. RESULTS: These recommendations address 5 main objectives: 1) coordination of action protocols to ensure access to hospital care for stroke patients; 2) recognition of potentially COVID-19-positive stroke patients; 3) organisation of patient management to prevent SARS-CoV-2 infection among healthcare professionals; 4) avoidance of unnecessary neuroimaging studies and other procedures that may increase the risk of infection; and 5) safe, early discharge and follow-up to ensure bed availability. This management protocol has been called CORONA (Coordinate, Recognise, Organise, Neuroimaging, At home). CONCLUSIONS: The recommendations presented here may assist in the organisation of acute stroke care and the optimisation of healthcare resources, while ensuring the safety of healthcare professionals.

The Direct Referral to Endovascular Center criteria: a proposal for pre-hospital evaluation of acute stroke in the Madrid Stroke Network.

BACKGROUND AND PURPOSE: For patients with acute ischaemic stroke due to large-vessel occlusion, it has recently been shown that mechanical thrombectomy (MT) with stent retrievers is better than medical treatment alone. However, few hospitals can provide MT 24 h/day 365 days/year, and it remains unclear whether selected patients with acute stroke should be directly transferred to the nearest MT-providing hospital to prevent treatment delays. Clinical scales such as Rapid Arterial Occlusion Evaluation (RACE) have been developed to predict large-vessel occlusion at a pre-hospital level, but their predictive value for MT is low. We propose new criteria to identify patients eligible for MT, with higher accuracy. METHODS: The Direct Referral to Endovascular Center criteria were defined based on a retrospective cohort of 317 patients admitted to a stroke center. The association of age, sex, RACE scale score and blood pressure with the likelihood of receiving MT were analyzed. Cut-off points with the highest association were thereafter evaluated in a prospective cohort of 153 patients from nine stroke units comprising the Madrid Stroke Network. RESULTS: Patients with a RACE scale score ≥ 5, systolic blood pressure <190 mmHg and age <81 years showed a significantly higher probability of undergoing MT (odds ratio, 33.38; 95% confidence interval, 12-92.9). This outcome was confirmed in the prospective cohort, with 68% sensitivity, 84% specificity, 42% positive and 94% negative predictive values for MT, ruling out 83% of hemorrhagic strokes. CONCLUSIONS: The Direct Referral to Endovascular Center criteria could be useful for identifying patients suitable for MT.

[Familial microepidemic of food-borne botulism in the Region of Madrid]. / Microepidemia familiar de botulismo alimentario en la Comunidad de Madrid.

INTRODUCTION: Botulism is a syndrome caused by the toxin of the bacillus Clostridium botulinum. The toxin acts by blocking the presynaptic cholinergic endings of the neuromuscular junction and of the parasympathetic nervous system, and gives rise to a flaccid paralysis and parasympathetic failure. The most common way to catch the disease is by ingestion of the preformed toxin present in badly sterilised home-made preserves, although other mechanisms are also possible. Its incidence in Spain today is very low. CASE REPORTS: We report the case of three members of a family living together who presented a clinical picture of food-borne botulism. The initial clinical symptoms showed a predilection for ocular paresis and for dysautonomic symptoms of little specificity, and the familial aggregation was the fundamental evidence that suggested the diagnosis. Later, the patients' state got worse and two of them presented involvement of the respiratory function and required a lengthy stay in the intensive care unit. After a period of convalescence the three patients recovered without any sequelae. Botulinum toxin was detected by bioassay in some food samples, which allowed the diagnosis to be categorised as confirmed. CONCLUSIONS: The familial microepidemic reported here is a case of predominantly ocular and dysautonomic involvement. Likewise, it illustrates several aspects that are typical of the disease: the suspected diagnosis in cohabiting patients who visit at the same time for a similar clinical picture, the characteristic complications of the process and its treatment, the laboratory diagnosis and its natural history towards resolution.

TITLE: Microepidemia familiar de botulismo alimentario en la Comunidad de Madrid.Introduccion. El botulismo es un sindrome causado por la toxina del bacilo Clostridium botulinum. La toxina actua bloqueando las terminaciones colinergicas presinapticas de la placa motora y del sistema nervioso parasimpatico, y ocasiona una paralisis flacida y un fallo parasimpatico. El modo mas habitual de adquisicion de la enfermedad es por ingesta de toxina preformada presente en las conservas caseras mal esterilizadas, aunque otros mecanismos son posibles. Su incidencia actual en Espana es muy baja. Casos clinicos. Se describen tres miembros convivientes de una familia que presentaron un cuadro de botulismo alimentario. Las manifestaciones clinicas iniciales mostraron predileccion por la paresia ocular y por sintomatologia disautonomica de escasa especificidad, y la agregacion familiar fue el indicio fundamental que sugirio el diagnostico. Posteriormente, los pacientes empeoraron y dos de ellos presentaron afectacion de la funcion respiratoria y precisaron ingreso prolongado en la unidad de cuidados intensivos. Los tres pacientes convalecieron y se recuperaron sin secuelas. Se consiguio detectar la toxina botulinica por bioensayo en los restos de alimentos, lo que confiere al caso la categoria diagnostica de confirmado. Conclusiones. La microepidemia familiar presentada constituye un caso de afectacion inicial predominantemente ocular y disautonomica. Asimismo, ilustra varios aspectos tipicos de la enfermedad: la sospecha diagnostica ante pacientes convivientes que acuden simultaneamente por clinica similar, las complicaciones caracteristicas del proceso y su tratamiento, el diagnostico de laboratorio y su historia natural hacia la resolucion.

Eficacia del levetiracetam en pacientes con síndrome de Lennox-Gastaut. Presentación de un caso / Levetiracetam efficacy in patients with Lennox-Gastaut syndrome. Presentation of a case

Introducción: El síndrome de Lennox-Gastaut (SLG) es una de las encefalopatías epilépticas más severas de la infancia, caracterizada por la tríada electroclínica de actividad generalizada de punta onda lenta (POL) en el electroencefalograma (EEG), múltiples tipos de crisis epilépticas y retraso mental. Con este trabajo pretendemos describir el cuadro sindrómico en un paciente con antecedente de encefalopatía hipóxico-isquémica y SLG, y su respuesta al tratamiento con levetiracetam (LEV). Método: Estudio descriptivo evolutivo de un niño de 3 años con antecedentes obstétricos de asfixia intrauterina y repercusión multiorgánica, acidosis metabólica, shock hipovolémico y crisis convulsivas con edema cerebral que a los pocos meses de edad desarrolla un síndrome de West, resistente al tratamiento farmacológico. Progresivamente, la semiología de las crisis cambia a episodios de hipertonía generalizada y mioclonías, con actividad electroencefalográfica de punta-onda lenta. Resultados: Con el diagnóstico de SLG se inicia tratamiento con LEV, observándose una mejoría sustancial en la esfera cognitiva, en el control de las crisis, y en los hallazgos electroencefalográficos. Conclusiones: El SLG es uno de los síndromes epilépticos más graves en los pacientes pediátricos, tanto por su semiología como por su farmacorresistencia. El levetiracetam puede producir una mejoría cognitiva, además de contribuir al control de las crisis en estos pacientes (AU)

Introduction: The Lennox-Gastaut syndrome (LGS) is one of the most severe epileptic encephalopathies of childhood, characterized by electro-clinical triad of generalized spike-wave activity, slow (POL) in the electroencephalogram (EEG), multiple types of seizures and development delay. This paper intends to describe the syndrome in a patient with a history of hypoxic-ischaemic encephalopathy and Lennox-Gastaut syndrome, and a good response to treatment with levetiracetam (LEV). Method: Descriptive study on the development of a 3 year old child with intrauterine asphyxia, multiorgan failure, metabolic acidosis, hypovolemic shock, and seizures with cerebral oedema, who developed a West syndrome, resistant to drug treatment. The semiology of seizures progressively changed to generalized episodes of hypertonia and myoclonus, with slow spike-wave electroencephalographic activity. Results: With the diagnosis of Lennox-Gastaut syndrome the patient was treated with levetiracetam, showing a substantial improvement in the cognitive sphere, in the control of seizures, and electroencephalographic findings. Conclusions: Lennox-Gastaut syndrome is one of the most severe epileptic syndromes in paediatric patients. Levetiracetam can help cognitive improvement, and contribute to seizure control in these patients (AU)

Levetiracetam efficacy in patients with Lennox-Gastaut syndrome. Presentation of a case.

INTRODUCTION: The Lennox-Gastaut syndrome (LGS) is one of the most severe epileptic encephalopathies of childhood, characterized by electro-clinical triad of generalized spike-wave activity, slow (POL) in the electroencephalogram (EEG), multiple types of seizures and development delay. This paper intends to describe the syndrome in a patient with a history of hypoxic-ischaemic encephalopathy and Lennox-Gastaut syndrome, and a good response to treatment with levetiracetam (LEV). METHOD: Descriptive study on the development of a 3 year old child with intrauterine asphyxia, multiorgan failure, metabolic acidosis, hypovolemic shock, and seizures with cerebral oedema, who developed a West syndrome, resistant to drug treatment. The semiology of seizures progressively changed to generalized episodes of hypertonia and myoclonus, with slow spike-wave electroencephalographic activity. RESULTS: With the diagnosis of Lennox-Gastaut syndrome the patient was treated with levetiracetam, showing a substantial improvement in the cognitive sphere, in the control of seizures, and electroencephalographic findings. CONCLUSIONS: Lennox-Gastaut syndrome is one of the most severe epileptic syndromes in paediatric patients. Levetiracetam can help cognitive improvement, and contribute to seizure control in these patients.

Síndrome de Panayiotopoulos: a propósito de dos casos en hermanos gemelos / Panayiotopoulos syndrome: a report of two cases in twin brothers

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[Preadmission statins treatment in stroke patients: opportunity to treat high vascular risk patients]. / Antecedente del uso de estatinas en el ictus: oportunidad de mejora en el paciente con alto riesgo vascular por aterotrombosis.

AIM: To describe the use of preadmission statins in patients with cerebrovascular accident and the possible predictive factors. PATIENTS AND METHODS: Cross-sectional observational study of 795 consecutive patients with acute cerebrovascular accident. We assessed the differences among patients who were on preadmission statins (161) and those who were not (634), regarding vascular risk factors and clinical and neurosonological atherothrombotic disease markers. For univariate analysis, we used squared chi test, and for multivariate analysis, logistic regression analysis. RESULTS: Preadmission statins were 20.3%. In high vascular risk patients defined based on National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III), this reached 28% and it might be 72%. Predictive factors for preadmission statins use were, in a positive sense, the antecedent of hypercholesterolemia diagnosis (OR = 189; 95% CI = 58-615; p < or = 0.001) and stroke (OR = 2.1; 95% CI = 1.2-3.6; p < or = 0.01), and in a negative sense, smoking (OR = 0.38; 95% CI = 0.18-0.81; p = 0.012). CONCLUSIONS: In our population of patients with stroke, the predictive factors of preadmission statins did not adjust to the current therapeutic NCEP-ATP III recommendations; treatment with statins in high vascular risk population was way below the indications, it was 28% and it might be 72%.

[Alteplase treatment for acute stroke 2007: an effective therapeutic option at our disposal]. / Tratamiento con alteplasa en el infarto cerebral agudo 2007: una opción terapéutica efectiva a nuestro alcance.

INTRODUCTION: The greatest progress has been made in the research field based on the early arterial recanalization strategy in cerebral ischemia. AIM: To carry out a revision of stroke treatment with intravenous thrombolysis during the therapeutic window period covering the first three hours of evolution. The revision focuses on information provided by clinical trials, meta-analysis and open-label reports studies. DEVELOPMENT: Clinical trials that study the use of alteplase in the acute stroke treatment, especially the two phase III clinical trials carried out by the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, are described. A great deal of useful information has been provided through systematic revisions that analyze data on these treatment clinical trials jointly. Meta-analysis studies are described: the Pooled Analysis of ATLANTIS, ECASS and NINDS t-PA Stroke Trials, Cochrane Meta-analysis: Thrombolysis for Acute Ischemic Stroke. Community based studies, especially the SITS-MOST study, were revised, and their findings were compared with other open-label t-PA studies. CONCLUSIONS: t-PA is effective when administered in the first three hours of evolution of stroke in selected patients and under ideal conditions, and it may be beneficial, using the same selection criteria, in a therapeutic window of four and a half hours. The treatment is effective when applied as part of the daily clinical practice in our environment. This effectiveness does not disappear when extending its use to a large number of qualified hospitals.

Tratamiento con alteplasa en el infarto cerebral agudo 2007: una opción terapéutica efectiva a nuestro alcance / Alteplase treatment for acute stroke 2007: an effective therapeutic option at our disposal

Introducción. El campo de investigación basado en la estrategia de la recanalización arterial temprana en la isquemia cerebral es en el que más se ha avanzado. Objetivo. Realizar una revisión sobre el tratamiento del infarto cerebral con trombólisis intravenosa en el período de ventana terapéutica de las tres primeras horas de evolución. Centrada en la información generada por los ensayos clínicos, los metaanálisis y los estudios poblacionales. desarrollo. Describimos los ensayos clínicos que estudian el empleo de alteplasa en el tratamiento del infarto cerebral agudo, en especial los ensayos clínicos en fase III del National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Se ha generado mucha información útil a través de revisiones sistemáticas que analizan de forma conjunta los datos de los ensayos clínicos sobre este tratamiento. Describimos los estudios de metaanálisis: el Pooled Analysis of ATLANTIS, ECASS and NINDS t-PA Stroke Trials, y el Cochrane Meta-Analysis: Thrombolysis for Acute Ischemic Stroke. Revisamos también los estudios poblacionales, en especial el estudio SITS-MOST, y comparamos sus hallazgos con los de estudios poblacionales previos. Conclusiones. El t-PA es eficaz administrado en las tres primeras horas de evolución del infarto cerebral en pacientes seleccionados y en condiciones idóneas, y pudiera ser beneficioso, utilizando los mismos criterios de selección, en una ventana terapéutica de cuatro horas y media. Es un tratamiento efectivo cuando se aplica como parte de la práctica clínica diaria en nuestro medio. Esta efectividad no se pierde al extender su uso a un número mayor de hospitales debidamente cualificados (AU)

Introduction. The greatest progress has been made in the research field based on the early arterial recanalization strategy in cerebral ischemia. Aim. To carry out a revision of stroke treatment with intravenous thrombolysis during the therapeutic window period covering the first three hours of evolution. The revision focuses on information provided by clinical trials, meta-analysis and open-label reports studies. Development. Clinical trials that study the use of alteplase in the acute stroke treatment, especially the two phase III clinical trials carried out by the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, are described. A great deal of useful information has been provided through systematic revisions that analyze data on these treatment clinical trials jointly. Meta-analysis studies are described: the Pooled Analysis of ATLANTIS, ECASS and NINDS t-PA Stroke Trials, Cochrane Meta-analysis: Thrombolysis for Acute Ischemic Stroke. Community based studies, especially the SITS-MOST study, were revised, and their findings were compared with other open-label t-PA studies. Conclusions. t-PA is effective when administered in the first three hours of evolution of stroke in selected patients and under ideal conditions, and it may be beneficial, using the same selection criteria, in a therapeutic window of four and a half hours. The treatment is effective when applied as part of the daily clinical practice in our environment. This effectiveness does not disappear when extending its use to a large number of qualified hospitals (AU)

Deterioro neurológico brusco 12 horas después de un traumatismo severo / Sudden neurological deterioration twelve hours after a severe trauma

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[Neuropathic pain as the reason for visiting Neurology: an analysis of its frequency]. / El dolor neuropático como motivo de consulta en Neurología: análisis de su frecuencia.

INTRODUCTION: Neuropathic pain (NP) is defined as pain that begins with or is caused by a primary injury or by a dysfunction in the nervous system. AIMS: Our aim was to evaluate how often patients visit Neurology as outpatients with NP as the main reason for referral. PATIENTS AND METHODS: A descriptive, cross sectional study was carried out on the use of the health care services; patients attended for the first time in a Neurology Screening visit were included consecutively. The variables studied were the following: the number of first visits and the total number of patients attended per visiting session, rate of patients with NP per visiting day, the topography and probable causation of the NP, and the rate of patients referred to the monographic NP clinic; the different quantitative variables are expressed in terms of their mean and standard deviation (SD), whereas the qualitative variables are given as their absolute value and the percentage. A total of 1,972 patients were attended, of whom 1,422 (72.1%) were first visits, with an average of 17.5 (SD: 2.5) new patients per visiting session. RESULTS: In all 113 patients clinically diagnosed with NP were identified, which represents a rate of 7.95% of the first visits. CONCLUSIONS: NP may be among the most frequent causes of the demand for neurological ambulatory care. The most common causes of NP were found to be trigeminal neuralgia, post-herpes neuralgia and diabetic polyneuropathy.

El dolor neuropático como motivo de consulta en Neurología: análisis de su frecuencia / Neuropathic pain as the reason for visiting neurology: an analysis of its frequency

Introducción. El dolor neuropático (DN) se define como aquel dolor iniciado o causado por una lesión primaria o por una disfunción en el sistema nervioso. Objetivo. Evaluar la frecuencia con la que los pacientes con DN como motivo principal de derivación se remiten a una consulta ambulatoria de Neurología. Pacientes y métodos. Se trata de un estudio descriptivo, transversal sobreutilización de los servicios sanitarios; se incluyeron consecutivamente los pacientes atendidos por primera vez en una consulta de Neurología de selección; variables estudiadas: número de primeras visitas y número total de pacientes atendidos por sesión de consulta, tasa de pacientes con DN por día de consulta, la topografía y probable etiología del DN, y la tasa de pacientes remitidos a la consulta monográfica de DN; las diferentes variables cuantitativas se expresarán con su media y desviación estándar (DE), mientras que en las variables cualitativas esto se hará con su valor absoluto y el porcentaje. Se atendieron 1.972 pacientes, de los cuales 1.422(72,1%) fueron primeras visitas, con una media de 17,5 (DE: 2,5) pacientes nuevos por sesión de consulta. Resultados. Se identificaron113 pacientes con diagnóstico clínico de DN, lo que supone una tasa del 7,95% de las primeras visitas. Conclusiones. El DN puede estar entre las causas más frecuentes de demanda de asistencia neurológica ambulatoria. Las causas más frecuentes de DN fueron la neuralgia del trigémino, la neuralgia posherpética y la polineuropatía diabética (AU)

Introduction. Neuropathic pain (NP) is defined as pain that begins with or is caused by a primary injury or by a dysfunction in the nervous system. Aims. Our aim was to evaluate how often patients visit Neurology as outpatients with NPas the main reason for referral. Patients and methods. A descriptive, cross sectional study was carried out on the use of the health care services; patients attended for the first time in a Neurology Screening visit were included consecutively. The variables studied were the following: the number of first visits and the total number of patients attended per visiting session, rate of patients with NP per visiting day, the topography and probable causation of the NP, and the rate of patients referred to the monographic NP clinic; the different quantitative variables are expressed in terms of their mean and standard deviation (SD), whereas the qualitative variables are given as their absolute value and the percentage. A total of 1,972patients were attended, of whom 1,422 (72.1%) were first visits, with an average of 17.5 (SD: 2.5) new patients per visiting session. Results. In all 113 patients clinically diagnosed with NP were identified, which represents a rate of 7.95% of the first visits. Conclusions. NP may be among the most frequent causes of the demand for neurological ambulatory care. The most common causes of NP were found to be trigeminal neuralgia, post-herpes neuralgia and diabetic polyneuropathy (AU)