Consensus statement on the use of alemtuzumab in daily clinical practice in Spain.

INTRODUCTION: Alemtuzumab is a highly effective drug approved by the European Medicines Agency as a disease-modifying drug for the treatment of relapsing-remitting multiple sclerosis. OBJECTIVE: A consensus document was drafted on the management of alemtuzumab in routine clinical practice in Spain. DEVELOPMENT: A group of multiple sclerosis specialists reviewed articles addressing treatment with alemtuzumab in patients with multiple sclerosis and published before December 2017. The included studies assessed the drug's efficacy, effectiveness, and safety; screening for infections and vaccination; and administration and monitoring aspects. The initial proposed recommendations were developed by a coordinating group and based on the available evidence and their clinical experience. The consensus process was carried out in 2 stages, with the initial threshold percentage for group agreement established at 80%. The final document with all the recommendations agreed by the working group was submitted for external review and the comments received were considered by the coordinating group. CONCLUSION: The present document is intended to be used as a tool for optimising the management of alemtuzumab in routine clinical practice.

Consenso de expertos sobre el uso de alemtuzumab en la práctica clínica diaria en España / Consensus statement on the use of alemtuzumab in daily clinical practice in Spain

Introducción: Alemtuzumab es un fármaco de alta eficacia aprobado por la Agencia Europea de Medicamentos como tratamiento modificador de la enfermedad en pacientes con esclerosis múltiple remitente recurrente.ObjetivoElaborar un documento de consenso sobre el manejo de alemtuzumab en la práctica clínica habitual, que sea de aplicación en el ámbito español.DesarrolloUn grupo de expertos en esclerosis múltiple revisó las publicaciones disponibles hasta diciembre de 2017, de tratamiento con alemtuzumab y esclerosis múltiple. Se incluyeron trabajos sobre eficacia, efectividad y seguridad, despistaje de infecciones y vacunación, administración y monitorización. La propuesta inicial de recomendaciones fue desarrollada por un grupo coordinador con base en la evidencia disponible y en su experiencia clínica. El proceso de consenso se llevó a cabo en 2 etapas; se estableció como porcentaje inicial de acuerdo grupal el 80%. El documento final con todas las recomendaciones acordadas por el grupo de trabajo se sometió a revisión externa y los comentarios recibidos fueron considerados por el grupo coordinador.ConclusionesEl documento aportado pretende ser una herramienta útil para facilitar el manejo del fármaco en condiciones de práctica clínica habitual. (AU)

Introduction: Alemtuzumab is a highly effective drug approved by the European Medicines Agency as a disease-modifying drug for the treatment of relapsing-remitting multiple sclerosis.ObjectiveA consensus document was drafted on the management of alemtuzumab in routine clinical practice in Spain.DevelopmentA group of multiple sclerosis specialists reviewed articles addressing treatment with alemtuzumab in patients with multiple sclerosis and published before December 2017. The included studies assessed the drug's efficacy, effectiveness, and safety; screening for infections and vaccination; and administration and monitoring aspects. The initial proposed recommendations were developed by a coordinating group and based on the available evidence and their clinical experience. The consensus process was carried out in 2 stages, with the initial threshold percentage for group agreement established at 80%. The final document with all the recommendations agreed by the working group was submitted for external review and the comments received were considered by the coordinating group.ConclusionThe present document is intended to be used as a tool for optimising the management of alemtuzumab in routine clinical practice. (AU)

Consensus statement on the use of alemtuzumab in daily clinical practice in Spain. / Consenso de expertos sobre el uso de alemtuzumab en la práctica clínica diaria en España.

INTRODUCTION: Alemtuzumab is a highly effective drug approved by the European Medicines Agency as a disease-modifying drug for the treatment of relapsing-remitting multiple sclerosis. OBJECTIVE: A consensus document was drafted on the management of alemtuzumab in routine clinical practice in Spain. DEVELOPMENT: A group of multiple sclerosis specialists reviewed articles addressing treatment with alemtuzumab in patients with multiple sclerosis and published before December 2017. The included studies assessed the drug's efficacy, effectiveness, and safety; screening for infections and vaccination; and administration and monitoring aspects. The initial proposed recommendations were developed by a coordinating group and based on the available evidence and their clinical experience. The consensus process was carried out in 2 stages, with the initial threshold percentage for group agreement established at 80%. The final document with all the recommendations agreed by the working group was submitted for external review and the comments received were considered by the coordinating group. CONCLUSION: The present document is intended to be used as a tool for optimising the management of alemtuzumab in routine clinical practice.

Consenso para el tratamiento de la esclerosis múltiple 2016. Sociedad Española de Neurología / Consensus statement on the treatment of multiple sclerosis by the Spanish Society of Neurology in 2016

La incorporación de nuevos medicamentos para modificar el curso de la esclerosis múltiple y la complejidad de su uso plantea la conveniencia de utilizar consensos terapéuticos. El consenso actual ha sido elaborado por el grupo de enfermedades desmielinizantes de la Sociedad Española de Neurología y actualiza consensos previamente publicados. Se enumeran los medicamentos aprobados para la esclerosis múltiple con sus indicaciones oficiales. Se analizan aspectos relacionados con el tratamiento, como la presencia de actividad, la precocidad, el mantenimiento terapéutico, el seguimiento, el fallo terapéutico, los cambios de medicación y el tratamiento en situaciones especiales. Se elaboran indicaciones de tratamiento desde el síndrome desmielinizante aislado a las distintas formas de esclerosis múltiple detallando recomendaciones de tratamiento inicial, cambios de medicación, con consideraciones sobre terapia combinada e inducción y aspectos prácticos del uso de medicamentos

With the advent of new disease-modifying drugs, the treatment of multiple sclerosis is becoming increasingly complex. Using consensus statements is therefore advisable. The present consensus statement, which was drawn up by the Spanish Society of Neurology's study group for demyelinating diseases, updates previous consensus statements on the disease. The present study lists the medications currently approved for multiple sclerosis and their official indications, and analyses such treatment-related aspects as activity, early treatment, maintenance, follow-up, treatment failure, changes in medication, and special therapeutic situations. This consensus statement includes treatment recommendations for a wide range of demyelinating diseases, from isolated demyelinating syndromes to the different forms of multiple sclerosis, as well as recommendations for initial therapy and changes in drug medication, and additional comments on induction and combined therapy and practical aspects of the use of these drugs

Consensus statement on the treatment of multiple sclerosis by the Spanish Society of Neurology in 2016. / Consenso para el tratamiento de la esclerosis múltiple 2016. Sociedad Española de Neurología.

With the advent of new disease-modifying drugs, the treatment of multiple sclerosis is becoming increasingly complex. Using consensus statements is therefore advisable. The present consensus statement, which was drawn up by the Spanish Society of Neurology's study group for demyelinating diseases, updates previous consensus statements on the disease. The present study lists the medications currently approved for multiple sclerosis and their official indications, and analyses such treatment-related aspects as activity, early treatment, maintenance, follow-up, treatment failure, changes in medication, and special therapeutic situations. This consensus statement includes treatment recommendations for a wide range of demyelinating diseases, from isolated demyelinating syndromes to the different forms of multiple sclerosis, as well as recommendations for initial therapy and changes in drug medication, and additional comments on induction and combined therapy and practical aspects of the use of these drugs.

[A new assessment for episodic memory. Episodic memory test and caregiver's episodic memory test]. / Un nuevo test para la valoración de la memoria episódica. Test episódico y test episódico del cuidador.

INTRODUCTION AND OBJECTIVES: The purpose of the episodic memory test and the caregiver's episodic memory test is to evaluate episodic memory according to its definition in a way that is feasible for families and achieves high degrees of sensitivity and specificity. METHODS AND RESULTS: We administered a test consisting of 10 questions about episodic events to 332 subjects, of whom 65 had Alzheimer's disease (AD), 115 had amnestic MCI (aMCI) and 152 showed no cognitive impairment according to Reisberg's global deterioration scale (GDS). We calculated the test's sensitivity and specificity to distinguish AD from episodic aMCI and from normal ageing. The area under the ROC curve for the diagnosis of aMCI was 0.94 and the best cut-off value was 20; for that value, sensitivity was 89% and specificity was 82%. For a diagnosis of AD, the area under the ROC curve was 0.99 and the best cut-off point was 17, with a sensitivity of 98% and a specificity of 91%. A subsequent study using similar methodology yielded similar results when the test was administered directly by the caregiver. CONCLUSIONS: The episodic memory test and the caregiver's episodic memory test are useful as brief screening tools for identifying patients with early-stage AD. It is suitable for use by primary care medical staff and in the home, since it can be administered by a caregiver. The test's limitations are that it must be administered by a reliable caregiver and the fact that it measures episodic memory only.

[Normalisation and validation of the Brief Neuropsychological Battery as the reference neuropsychological test in multiple sclerosis]. / Normalizacion y validacion de la bateria neuropsicologica breve como test neuropsicologico de referencia en la esclerosis multiple.

INTRODUCTION. The current batteries such as the Brief Repeatable Battery of Neuropsychological Tests (BRB-N) for evaluating cognitive decline in patients with multiple sclerosis are complex and time-consuming. AIM. To obtain normative values and validate a new battery. SUBJECTS AND METHODS. Four neuropsychological tests were finally included (episodic memory, the Symbol-Digit Modalities Test, a category fluency test, and the Paced Auditory Serial Addition Test). Normative values (overall and by age group) were derived by administering the battery to healthy subjects (5th percentile was the limit of normal). External validity was explored by comparison with the BRB-N. The new battery was also administered to a subsample after 4 weeks to assess reproducibility. RESULTS. To provide normative data, 1036 healthy subjects were recruited. The mean completion time was 18.5 ± 5.2 minutes. For the 229 subjects who were administered the new battery and the BRB-N, no statistically significant differences were found except for mean completion time (19 ± 4 vs 25 ± 5 minutes). In the reproducibility study, there were no significant differences except in the memory tests. CONCLUSION. The scores on the new battery and the BRB-N were strongly correlated although the shorter completion time and ease of administration could make the new battery preferable in clinical practice.

Efectividad del acetato de glatiramero en la práctica clínica: un estudio observacional / The effectiveness of glatiramer acetate in clinical practice: an observational stud

Objetivos. Evaluar la efectividad clínica y la seguridad del acetato de glatiramero en las condiciones de la práctica diaria. Pacientes y métodos. Estudio retrospectivo, observacional, en pacientes con esclerosis múltiple tratados con acetato de glatiramero en las condiciones de la práctica clínica. El criterio principal de valoración fue la efectividad clínica del acetato de glatiramero. Resultados. En el estudio se incluyeron un total de 104 pacientes (mujeres: 59,6%; edad de inicio del acetato de glatiramero: 39,9 ± 10,9 años; tratamiento anterior para la esclerosis múltiple: 30,8%). Los pacientes recibieron acetato de glatiramero durante 3,6 ± 1,9 años. Durante el primer año de tratamiento con el acetato de glatiramero, la tasa de recidivas se redujo un 60%, en 47 pacientes (45,1%) se redujo el número de recidivas, 67 pacientes (68,4%) no sufrieron recidiva y 78 pacientes (75%) no mostraron progresión. Durante el segundo año de tratamiento con acetato de glatiramero, la tasa de recidivas había disminuido un 70%, en 43 pacientes (41,3%) se redujo el número de recidivas, 63 pacientes (75,9%) no sufrieron recidiva y 59 pacientes (56,7%) no mostraron progresión. No se notificaron recidivas ni progresión en 56 (53,8%) y 41 pacientes (39,4%) durante el primer y segundo año de tratamiento, respectivamente. La suspensión del acetato de glatiramero sólo fue necesaria en tres pacientes. Los acontecimientos adversos más frecuentes fueron cansancio (28,9%) y espasticidad (7,7%). Conclusión. La evaluación del acetato de glatiramero en las condiciones de la práctica clínica respalda el perfil de eficacia y seguridad observado en ensayos clínicos previamente publicados (AU)

Aim. To evaluate the clinical effectiveness and safety of glatiramer acetate for use in routine clinical practice. Patients and methods. A retrospective, observational study was conducted on patients with multiple sclerosis who were treated with glatiramer acetate in clinical practice. The primary outcome was the clinical effectiveness of glatiramer acetate treatment. Results. The study included a total of 104 patients (women, 59.6%; age at onset of glatiramer acetate treatment, 39.9 ± 10.9 years; prior treatment for multiple sclerosis, 30.8%). The patients had received glatiramer acetate treatment for an average of 3.6 ± 1.9 years. During the first year of glatiramer acetate treatment, the relapse rate decreased by 60%. At this time, the number of relapses had decreased for 47 patients (45.1%), 67 patients (68.4%) had not suffered a relapse and 78 patients (75.0%) showed no signs of progression. During the second year of glatiramer acetate treatment, the relapse rate decreased by 70%. At this time, the number of relapses had decreased for 43 patients (41.3%), 63 patients (75.9%) had not suffered a relapse and 59 patients (56.7%) showed no signs of progression. There were no reported relapses or progression in 56 patients (53.8%) and 41 patients (39.4%) during the first and second years of treatment, respectively. Discontinuation of glatiramer acetate was necessary in only three patients. The most common adverse effects included fatigue (28.9%) and spasticity (7.7%). Conclusion. This evaluation of glatiramer acetate use in clinical practice supports the effectiveness and the safety profile observed in previously published clinical trial studies (AU)

Guía de uso adecuado de modelos animales para el desarrollo de terapias en esclerosis múltiple / Guidelines on the appropriate use of animal models for developing therapies in multiple sclerosis

Introducción. La búsqueda de terapias efectivas para la esclerosis múltiple (EM) y la definición de ventanas terapéuticas apropiadas, así como el establecimiento de mejores biomarcadores diagnósticos y pronósticos, continúan siendo un reto para investigadores tanto básicos como clínicos. El desarrollo y el método de evaluación de los estudios preclínicos en modelos animales podrían subyacer al hecho de que terapias eficaces en modelos animales fracasen en su aplicación clínica. Objetivo. Unificar la metodología en la aplicación de los modelos experimentales para la EM mediante la elaboración, por parte de grupos españoles expertos pertenecientes a la Red Española de Esclerosis Múltiple, de una guía de recomendaciones para los estudios preclínicos. Desarrollo. Se ha realizado una valoración detallada de los modelos experimentales adecuados y su aplicación en función del objetivo perseguido, incorporando estándares y criterios de calidad imprescindibles en un estudio preclínico. Conclusiones. El éxito traslacional en el avance terapéutico de la EM conlleva la adquisición de compromisos metodológicos en los modelos experimentales, de manera que se optimice la bondad y adecuación del modelo al estudio perseguido. Las recomendaciones establecidas en esta guía podrían ayudar a generar datos preclínicos de utilidad en la práctica clínica (AU)

Introduction. The advance in the achievement of effective therapies for multiple sclerosis (MS), the definition of appropriate therapeutic windows and to establish better diagnostic and prognostic biomarkers have become a challenging task for both researchers and clinicians. Some pitfalls in clinical trials might be related to lack of adequacy of the preclinical studies in MS experimental animal models Aim. To standardize the methodological protocols of experimental models by developing a set of guidelines for preclinical studies by groups of experts from REEM (Spanish Network for MS). Development. A guide with recommendations for the application of MS models including a detailed assessment of appropriate experimental models taking into account the objective of the study that has been presented. Standards and quality criteria necessary in a preclinical study have been included. Conclusions. Standardized animal models of MS are essential to increase the success of the preclinical findings in order to transfer them to the clinical practice (AU)

[Review of the novelties presented at the 26th Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) (II)]. / Revision de las novedades presentadas en el XXVI Congreso del Comite Europeo para el Tratamiento e Investigacion en Esclerosis Multiple (ECTRIMS) (II).

The new insights presented at European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS), held in the city of Gothenburg, Sweden, in October 2010, have been summarized at the third edition of Post-ECTRIMS meeting held in Madrid in November 2010. Encouraging findings from the 5-years follow up extension from PreCISe study confirm the benefit of early treatment with glatiramer acetate in patients with clinically isolated syndromes (CIS) against the conversion to clinically definitive multiple sclerosis and cerebral atrophy with an adequate safety and tolerability. Regarding treatment decision with escalation or induction therapy, different strategies have been proposed depending on to the characteristics of the individual patient with CIS. Findings from several of the reported studies have revealed the favorable role of combined therapy on relapse rate but not on magnetic resonance parameters in patients with recurrent-remittent multiple sclerosis. Novel therapies such as alemtuzumab, daclizumab ofatutumab or ocrelizumab have shown promising findings regarding efficacy. Nevertheless, safety findings for these emerging therapies have detected some severe adverse events, the main ones being potentially fatal opportunistic infections such as progressive multifocal leukoencephalopathy (PML) caused by JC virus, mainly linked to natalizumab treatment. In this regard, clinicians will face the assessment of he benefit-risk ratio when deciding on the adequate treatment for each patient in the clinical setting. In this regard, determination of antibodies to JC virus by a novel two-step enzyme-linked immunosorbent assay (ELISA) could provide clinicians with a useful tool to stratify PML risk in patients. Regarding non pharmacologic therapies, behavioral intervention has emerged as an effective therapy in the treatment of depression in multiple sclerosis, showing additional benefits on fatigue, disability and adherence to treatment.

[Interferon-beta response in multiple sclerosis associated with pre-treatment disability]. / Respuesta al interferon beta en la esclerosis multiple asociada con la discapacidad previa al tratamiento.

AIM: To study pre-treatment clinical features and influence of neutralising antibodies (NABs) in clinical response to interferon-beta (IFNB). PATIENTS AND METHODS: We analysed clinical characteristics and NABs to IFNB in 96 multiple sclerosis patients treated with IFNB. Clinical response was established by clinical criteria: = 1 relapse or an increase = 0.5 or 1 point in the Expanded Disability Status Scale (EDSS) score after one year of treatment compared with the year prior to IFNB therapy. RESULTS: Baseline clinical characteristics were similar for responders and non-responders, except for a significantly higher baseline mean EDSS score in non-responders. Time-to-first-relapse was longer and the number of patients relapse-free was higher for NAB-negative patients, but we were unable to show an association with the disability status, probably due to sample size. CONCLUSIONS: Response to IFNB was significantly associated with pre-treatment disability measured by the EDSS. The presence of NABs to IFNB presented a delayed negative effect for relapses.

Respuesta al interferón beta en la esclerosis múltiple asociada con la discapacidad previa al tratamiento / Interferon-beta response in multiple sclerosis associated with pre-treatment disability

Objetivo. Estudiar las características clínicas y la influenciade los anticuerpos neutralizantes (NAB) en la respuestaclínica al interferón beta (IFNB). Pacientes y métodos. Analizamoslas características clínicas y los NAB frente al IFNB en 96 pacientescon esclerosis múltiple tratados con IFNB. La respuesta clínicase estableció mediante criterios clínicos: ≥ 1 brote o un incremento≥ 0,5 o 1 punto en la escala expandida del estado de discapacidad(EDSS, Expanded Disability Status Scale) tras un año de tratamientocomparado con el año previo al inicio del tratamiento con IFNB.Resultados. Las características clínicas basales fueron similarespara los pacientes respondedores y los no respondedores, exceptopor la EDSS media previa al tratamiento, que era significativamentemayor en los pacientes no respondedores. El tiempo hasta el primerbrote era mayor y el número de pacientes libres de brote eramayor entre los pacientes NAB-negativos, pero fuimos incapaces dedemostrar una asociación del estado de NAB y el estado de discapacidad,probablemente debido al tamaño muestral. Conclusiones.La respuesta al IFNB está significativamente asociada a la discapacidadprevia al tratamiento medida con la EDSS. La presencia deNAB frente al IFNB presentaba un efecto negativo retardado conrespecto a los brotes

Aim. To study pre-treatment clinical features and influence of neutralising antibodies (NABs) in clinical responseto interferon-beta (IFNB). Patients and methods.We analysed clinical characteristics and NABs to IFNB in 96 multiple sclerosispatients treated with IFNB. Clinical response was established by clinical criteria: ≥ 1 relapse or an increase ≥ 0.5 or 1 pointin the Expanded Disability Status Scale (EDSS) score after one year of treatment compared with the year prior to IFNBtherapy. Results. Baseline clinical characteristics were similar for responders and non-responders, except for a significantlyhigher baseline mean EDSS score in non-responders. Time-to-first-relapse was longer and the number of patients relapse-freewas higher for NAB-negative patients, but we were unable to show an association with the disability status, probably due tosample size. Conclusions. Response to IFNB was significantly associated with pre-treatment disability measured by the EDSS.The presence of NABs to IFNB presented a delayed negative effect for relapses

[Tolosa-Hunt syndrome and orbital pseudotumour. Overlapping conditions in a case with an unusual clinical profile]. / Síndrome de Tolosa-Hunt y pseudotumor orbitario. Entidades solapadas en un caso con perfil clínico no habitual.

INTRODUCTION: The origin of Tolosa-Hunt syndrome (THS) and orbital pseudotumour (OP) is not fully understood. It is acknowledged as having an unspecific granulomatous inflammatory nature in different locations. Although there are differences between the clinical features of the two conditions, they also share a number of physiopathogenetic, therapeutic and, in some cases, iconographic similarities. Possible clinical recurrences are common in the two conditions and a broad differential diagnosis is required in all cases. Yet, the association of both processes in the same patient, with radiological proof of the migration of the inflammatory injury, is not frequent. CASE REPORT: We report the case of a male patient with a long history of recurring unilateral painful ophthalmoplegia that was sensitive to steroids; criteria for THS were fulfilled and there was later development of homolateral OP, six years after the onset of his symptoms. The findings in serial studies conducted with magnetic resonance imaging must be highlighted. The patient was submitted to a surgical intervention to treat the orbital injury and a chronic inflammatory process was observed in the fibrotic phase. CONCLUSIONS: Inflammatory pseudotumour and THS perhaps have more points in common than has traditionally been accepted. To our knowledge few cases of the above-mentioned association have been reported in the same patient. When confronted by cases of painful ophthalmoplegia with excessive recurrences the physician must consider the possibility of other alternative diagnoses.

Síndrome de Tolosa-Hunt y pseudotumor orbitario. Entidades solapadas en un caso con perfil clínico no habitual / Tolosa-hunt syndrome and orbital pseudotumour. Overlapping conditions in a case with an unusual clinical profile

Introducción. El origen del síndrome de Tolosa-Hunt (STH) y del pseudotumor orbitario (PO) no es del todo conocido. Se admite su naturaleza inflamatoria granulomatosa localizaciones diferentes. Aunque existen divergencias clínicas entre ambos, también comparten similitudes fisiopatogénicas, terapéuticas y, en algunos casos, iconográficas. Las posibles recurrencias clínicas en ambas entidades son comunes y requieren en todo caso un amplio diagnóstico diferencial. Sin embargo, no es frecuente la asociación de ambos procesos en el mismo paciente, con documentación radiológica de la migración de la lesión inflamatoria. Caso clínico. Se presenta un paciente con oftalmoplejía dolorosa unilateral recurrente de larga evolución, sensible a esteroides, con criterios de STH y posterior desarrollo de PO homolateral, seis años tras el comienzo de sus síntomas. Destacamos los hallazgos de neuroimagen en resonancias magnéticas seriadas. Se interviene al paciente a causa de la lesión orbitaria, y se evidencia unproceso inflamatorio crónico en fase fibrótica. Conclusión. Quizás el pseudotumor inflamatorio y el STH compartan más aspectos comunes de lo tradicionalmente aceptado. En nuestro conocimiento existen pocos casos documentados de la citada asociación en elm ismo paciente. Los casos de oftalmoplejía dolorosa con excesivas recurrencias deben suscitar al clínico la posibilidad de otras alternativas diagnósticas (AU)

Introduction. The origin of Tolosa-Hunt syndrome (THS) and orbital pseudotumour (OP) is not fully understood. Itis acknowledged as having an unspecific granulomatous inflammatory nature in different locations. Although there are differences between the clinical features of the two conditions, they also share a number of physiopathogenetic, therapeutic and, in some cases, iconographic similarities. Possible clinical recurrences are common in the two conditions and a broad differential diagnosis is required in all cases. Yet, the association of both processes in the same patient, with radiological proof of the migration of the inflammatory injury, is not frequent. Case report. We report the case of a male patient with a long history of recurring unilateral painful ophthalmoplegia that was sensitive to steroids; criteria for THS were fulfilled and there was later development of homolateral OP, six years after the onset of his symptoms. The findings in serial studies conducted with magnetic resonance imaging must be highlighted. The patient was submitted to a surgical intervention to treat the orbital injury and a chronic inflammatory process was observed in the fibrotic phase. Conclusions. Inflammatory pseudotumour and THSperhaps have more points in common than has traditionally been accepted. To our knowledge few cases of the above-mentioned association have been reported in the same patient. When confronted by cases of painful ophthalmoplegia with excessive recurrences the physician must consider the possibility of other alternative diagnoses (AU)

[Clinical features of relapsing remitting-multiple sclerosis. Prognostic factors]. / Clínica de la esclerosis múltiple recidivante-remitente. Factores pronósticos.

Multiple sclerosis is the most frequent chronic neurological disease in young adults of the white population in developed countries. The diagnosis has been notably improved by the use of universal diagnostic criteria and by the extraordinary help of the paraclinical methods of laboratory studies, evocated potentials and particularly magnetic resonance imaging. Nowadays there are consensus criteria for the classification of the different clinical subtypes. Relapsing remitting multiple sclerosis is the most frequent subtype and eventually evolves to a secondary progressive form. Ultimately there have been notably advances in the knowledge of the natural history and of the pathogenetic mechanisms of the disease, which has permitted a more precocious therapeutic intervention, that ideally will provide a more benign prognosis for this disease.

Clínica de la esclerosis múltiple recidivante-remitente. Factores pronósticos / Clinical features of relapsing-remitting multiple sclerosis. Prognostic factors

Introducción. La esclerosis múltiple es la enfermedad neurológica crónica más frecuente de los adultos jóvenes de raza blanca en los países desarrollados. Desarrollo. El diagnóstico ha mejorado mucho al utilizarse unos criterios diagnósticos de forma universal y contarse con el apoyo de las técnicas paraclínicas de laboratorio, potenciales evocados y muy particularmente de la resonancia magnética. Existen criterios de consenso para la clasificación de las diferentes formas clínicas. La esclerosis múltiple recidivante-remitente es la forma más frecuente, eventualmente evoluciona a una forma progresiva secundaria. Conclusión. En los últimos años se ha avanzado notablemente en el conocimiento de la historia natural y de los mecanismos patogénicos, lo que está permitiendo la intervención terapéutica más temprana, que idealmente conducirá a conseguir un mejor pronóstico para esta enfermedad (AU)

Tratamiento del vértigo / Therapy of dizziness

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[Angiogram-negative subarachnoid hemorrhage. Should the procedure be repeated?]. / Hemorragia subaracnoidea con angiografía negativa. Debe repetirse el estudio?

Most cases of non-traumatic subarachnoid hemorrhage are caused by rupture of an arterial aneurysm or an arteriovenous malformation. The first angiogram performed is normal nearly 20% of the time. To review the need to repeat angiography if the first study is negative. Review of patients admitted to our hospital with subarachnoid hemorrhage in recent years. All had had high quality angiography performed, that was repeated if the first study was negative. We analyzed 112 cases of subarachnoid hemorrhage, of which 27 (24.1%) had angiographic studies of the four main cerebral vessels that failed to reveal the origin of the hemorrhage. An aneurysm that had not previously been seen was detected in 2 patients (7.4%), whether or not there had been vasospasm in the first study. Given our findings, the low incidence of complications in the first study and the seriousness of the pathology under consideration, we suggest that angiography should be repeated unless there are major contraindications.