Pseudoictus en el código ictus. Frecuencia, diagnóstico, tratamiento y destino / Stroke mimics in stroke code activations: frequency, diagnoses, treatment, and discharge destination

Objetivos: Conocer la frecuencia, diagnóstico, tratamiento trombolítico y destino de los pseudoictus (PI) atendidos como código ictus (CI), y valorar el impacto de incluir a mayores de 80 años. Método: Estudio prospectivo de una serie consecutiva de pacientes atendidos como CI, durante 50 meses, en los que se empleó tomografía computarizada craneal como prueba de neuroimagen. Se compara el primer periodo (2008-2010) en el que se siguieron los criterios SITS-MOST, con el segundo periodo (2010-2012) que se amplía la ventana temporal y se suprime el límite superior de edad. El diagnóstico se agrupa en 2 categorías: ictus (transitorio o establecido, que incluye infartos cerebrales, ataques isquémicos transitorios y hemorragias intracerebrales) y PI. Resultados: Se activaron 1.450 CI, de los que 288 se diagnosticaron como PI: 19,9% (IC 95%: 17,7-21,9%). Éstos presentaron menor edad y mayor frecuencia de mujeres. En el segundo periodo, aumentaron los mayores de 80 años (6,0% vs 22,6%, p < 0,001) y los PI disminuyeron del 23,8% al 16,2% (p 0,04). En mayores de 80 años, los PI son menos frecuentes (14,5% vs 20,4% p = 0,004). Los diagnósticos más frecuentes entre los PI son: crisis epiléptica 25,6% (IC 95%: 18,2-28,3%), síncope 16,8% (12,1-21,5%) y encefalopatía por enfermedad sistémica 16,4% (11,7-21,1%). Se trombolisaron 3 PI (1,0% IC95%: 0,2-3,0%) sin complicaciones hemorrágicas, que representan el 1,2% de los 257 trombolisados. El 46% (36,1-48,1%) de PI ingresaron en el hospital, y un 47,4% fue seguido por neurología. Conclusiones: El diagnóstico de PI es frecuente y básicamente clínico, donde una valoración neurológica experta es recomendable. La inclusión de mayores de 80 años se asoció a una reducción de PI (AU)

Objectives: To determine the frequency, of stroke mimics in stroke code activations, to analyze diagnoses, use of thrombolytic therapy and the discharge destinations of these patients; and to estimate the impact on these variables when patients over the age of 80 years are included. Methods: Prospective study of consecutive patients attended after stroke code activation; the study period was 50 months and the diagnostic image used was cranial computed tomography (CT). We compared the first period (2008-2010), in which we applied the SITS-MOST (Safe Implementation of Thrombolysis in Stroke Monitoring Study) criteria, to a second period (2010-2012), in which the time window for treatment was enlarged and there was no upper age limit for applying the criteria. Patients were grouped in 2 categories: stroke (transient or established, including cerebral infarction, transient ischemic attacks, and intracerebral hemorrhage) and pseudo-stroke (conditions mimicking stroke). Results: Stroke code was activated 1450 times; 288 cases were diagnosed as stroke mimics (19.9%; 95% CI, 17.7%-21.9%). This group was younger and included more women. In the second period, in which more patients over 80 years of age were attended (6.0% in the first period vs. 22.6% in the second, P<.001), the percentage of cases diagnosed as stroke mimics decreased (23.8% in the first period, 16.2% in the second; P<.001). Mimics were less frequent in patients over the age of 80 years (14.5% vs. 20.4% in younger patients, P=.004). The most frequent diagnoses in patients with conditions mimicking stroke were epileptic seizures (15.6%; 95% CI, 18.2%-28.3%), syncope (16.8%; 95% CI, 12.1%-21.5%), and encephalopathy due to systemic disease (16.4%; 95% CI, 11.7%-21.1%). Thrombolytic therapy was used in 3 patients with mimics (1%; 95% CI, 0.2%-3.0%) without hemorrhagic complications, which occurred in 1.2% of the 257 patients under this therapy. Forty-six percent of the patients with mimics were hospitalized (95% CI, 36.1%-48.1%); 47.4% were evaluated by a neurologist. Conclusions: Stroke mimics are common and diagnosis is essentially clinical; evaluation by a neurologist is advisable. The frequency of stroke mimics was lower when patients over the age of 80 years were considered (AU)

[Visual episodes in non-ketonic hyperglycemia: contribution of 1 case with alteration in diffusion magnetic resonance imaging]. / Crisis visuales en hiperglucemia no cetónica: aportación de un caso con alteración en resonancia magnética de difusión.

INTRODUCTION: Non-ketonic hyperglycemia (NKH) is recognized both as a direct cause of a precipitating factor of many types of epileptic seizures-partial motor, including partial motor status, complex partial, as well as reflex motor seizures and hemichorea-hemibalism syndrome. Less known is its association with isolated visual alterations. We present a clinical case with visual episodes and diffusion restriction. MATERIAL AND METHODS: Clinical description together with the results of complementary tests: magnetic resonance imaging (MRI) brain sequences: T1W, T2W, FLAIR, DP, diffusion; and magnetic resonance angio-imaging, electroencephalogram (EEG), visual campimetry, carotid echodoppler. CLINICAL CASE: 51 year old male with visual complaints manifested as bright light in left lower quadrant with progressive increase in frequency until it becomes constant. Polyuria, polydipsia and weight loss are associated. No personal background of diabetes mellitus, epilepsy or migraine. Among the laboratory tests, non-ketonic hyperglycemia of 569 mg/dl stands out. The visual campimetry showed left lower quadrantanopsia, the intercritical EEG was reported as normal and the brain MRI showed alteration in right cortical-subcortical occipital diffusion sequence. Interpreted as simple partial seizure in the occipital region secondary to hyperglycemia, it was corrected, and the subject was asymptomatic at one month of discharge. DISCUSSION: We stress that isolated visual episodes may be the initial manifestation of NKH. The rareness of the alteration in the diffussion MRI (interpretable as artifact) orients to a possible mechanism of simple partial status. A high index of suspicion of this entity is important since adequate hypoglycemic treatment permits a perfect control of the seizure.

Crisis visuales en hiperglucemia no cetónica: aportación de un caso con alteración en resonancia magnética de difusión / Visual episodes in non-ketonic hyperglycemia: contribution of 1 case with alteration in diffusion magnetic resonance imaging

Introducción. La hiperglucemia no cetónica (HNC) se reconoce tanto como una causa directa como un factor desencadenante de numerosos tipos de crisis epilépticas: parciales motoras incluyendo estatus parcial motor, parciales complejas, así como de crisis motoras reflejas y del síndrome hemicorea-hemibalismo. Menos conocida es su asociación con alteraciones visuales aisladas. Presentamos un caso clínico con crisis visuales y restricción en la difusión. Material y métodos. Descripción clínica junto a los resultados de pruebas complementarias: resonancia magnética (RM) cerebral secuencias: T1W, T2W, FLAIR, DP, difusión; así como angiorresonancia magnética, electroencefalograma (EEG), campimetría visual y eco-doppler carotídeo. Caso clínico. Varón de 51 años con quejas visuales manifestadas como luz brillante en cuadrante inferior izquierdo, con aumento progresivo en frecuencia hasta que se hace constante. Se asocia a poliuria, polidipsia y pérdida de peso. Sin antecedentes personales de diabetes mellitus, epilepsia o migraña. Entre las pruebas de laboratorio destaca una hiperglucemia de 569 mg/dl, no cetónica. La campimetría visual demostró cuadrantanopsia inferior izquierda, el EEG intercrítico se informó como normal y la RM cerebral demostró alteración en secuencia de difusión corticosubcortical occipital derecha. Interpretado como crisis epiléptica parcial simple occipital secundaria a hiperglucemia, se corrigió ésta hallándose asintomático al mes del alta. Discusión. Destacamos que las crisis visuales aisladas pueden ser la manifestación inicial de una HNC. Lo excepcional de la alteración en RM difusión (no interpretable como artefacto) orienta a posible mecanismo de estatus parcial simple. Es importante un alto índice de sospecha de esta entidad ya que un tratamiento hipoglucemiante adecuado permite un perfecto control de las crisis

Introduction. Non-ketonic hyperglycemia (NKH) is recognized both as a direct cause of a precipitating factor of many types of epileptic seizures-partial motor, including partial motor status, complex partial, as well as reflex motor seizures and hemichorea-hemibalism syndrome. Less known is its association with isolated visual alterations. We present a clinical case with visual episodes and diffusion restriction. Material and methods. Clinical description together with the results of complementary tests: magnetic resonance imaging (MRI) brain sequences: T1W, T2W, FLAIR, DP, diffusion; and magnetic resonance angio-imaging, electroencephalogram (EEG), visual campimetry, carotid echodoppler. Clinical case. 51 year old male with visual complaints manifested as bright light in left lower quadrant with progressive increase in frequency until it becomes constant. Polyuria, polydipsia and weight loss are associated. No personal background of diabetes mellitus, epilepsy or migraine. Among the laboratory tests, non-ketonic hyperglycemia of 569 mg/dl stands out. The visual campimetry showed left lower quadrantanopsia, the intercritical EEG was reported as normal and the brain MRI showed alteration in right cortical-subcortical occipital diffusion sequence. Interpreted as simple partial seizure in the occipital region secondary to hyperglycemia, it was corrected, and the subject was asymptomatic at one month of discharge. Discussion. We stress that isolated visual episodes may be the initial manifestation of NKH. The rareness of the alteration in the diffussion MRI (interpretable as arti- 89 fact) orients to a possible mechanism of simple partial status. A high index of suspicion of this entity is important since adequate hypoglycemic treatment permits a perfect control of the seizure

Aspirin or anticoagulants in stenosis of the middle cerebral artery: A randomized trial.

BACKGROUND: We report the results of an open, randomized, multicenter trial that compared the efficacy of aspirin to oral anticoagulants (OA) for the prevention of vascular events in patients with symptomatic stenosis of the middle cerebral artery (MCA). METHODS: Participants were randomly assigned to receive 300 mg/day of aspirin or a dose of OA (target INR 2-3). The MCA stenosis was demonstrated by conventional angiography or by at least two noninvasive examinations. Patients had either transient ischemic attack or cerebral infarct (CI) attributable to the MCA stenosis within 90 days before inclusion. The primary endpoint was: nonfatal CI, nonfatal acute myocardial infarct, vascular death and major hemorrhage. The patients were followed-up for a minimum of 1 year and a maximum of 3 years. RESULTS: The study included 28 patients (14 in each treatment group); the average age was 67 +/- 9.9 years. Men constituted 68% of the patients. After a mean follow-up of 23.1 +/- 10.9 months, there were no recurrences of CI in both groups. No endpoint was reported in the aspirin group, but 2 patients in the OA group (14.3%) exhibited vascular events: 1 acute myocardial infarct and 1 intracerebral hemorrhage). However, this difference was not statistically significant (p = 0.48). CONCLUSIONS: Our study suggests that aspirin is the treatment of choice for the prevention of vascular events in patients with symptomatic MCA stenosis.

Sleep disorder in alien hand syndrome.

A 63-year-old right-handed woman developed an alien hand syndrome (AHS) after an acute infarction in the territory of the left anterior cerebral artery. The uncontrolled hand movements were present during the daytime and eventually disturbed sleep. Polysomnography revealed that these motor actions only appeared when the patient was awake. These awakenings emerged mostly from NREM sleep stage 2 during the first half of the night. There was no evidence of any epileptiform activity, dyssomnia or parasomnia. These movements were controlled making her wear an oven mitt during sleep. The temporal distribution of this motor activity seems to follow the progressive hyperpolarization of anterior horn neurons that occurs when sleep deepens. The accommodation of the grasp reflex in AHS probably helps control this unwanted motor activity.

Implicit word cues facilitate impaired naming performance: evidence from a case of anomia.

Word-finding difficulties observed in some patients with anomia have been attributed to an insufficient activation of phonology by semantics. There are, however, few direct tests of this hypothesis. This paper reports the case of FR, who presented with anomic aphasia following temporal lobe epilepsy and a cavernoma in the left superior temporal lobe. His anomic deficit was characterized by: (1) no apparent associated semantic impairment; (2) item consistency for accuracy and errors across different administrations; (3) accuracy strongly correlated with word frequency; and (4) a partial, albeit weak, knowledge of the gender of unnamed items. We conducted a naming experiment in which target pictures were implicitly primed by briefly presented masked words. Results showed that the prior presentation of the written target name improved accuracy. When compared with unprimed trials, the presence of the primes also increased phonological errors and decreased semantic errors. We argue that automatic phonological activation derived directly from the implicit written primes interacted with the remaining phonological input from the picture's semantic representation leading to increased accuracy and a change in the balance of error types.

[Lacunar infarct and deep cerebral hemorrhage: a comparison of the risk factors]. / Infarto lacunar y hemorragia cerebral profunda: comparación de factores de riesgo.

INTRODUCTION: Lacunar infarcts (LI) and deep cerebral hemorrhages (DCH) have the same localization and a vasculopathy which appears to be similar, at the level of the small perforating arteries, classically attributed to arterial hypertension (AHT). OBJECTIVES: To compare the vascular risk factors of patients with lacunar ictus (LIc) and those with DCH, to try to determine how these may affect the appearance of one type of stroke or another. PATIENTS AND METHODS: We analyzed a prospective consecutive series of patients with cerebral vascular accidents (CVA), selecting 1,540 patients in the first 1,155 with a first CVA. We recorded demographic data and the following risk factors: previous transient ischemic accident (TIA), AHT, diabetes mellitus (DM), hypercholesterolemia, ischemic cardiopathy, atrial fibrillation and the presence of silent infarcts on CT. RESULTS: Two hundred and four patients had LIc and 163 had DCH. There was a significant dissociation between LIc and a history of TIA, DM, hypercholesterolemia and the presence of silent lacunar-type infarcts on CT. However, after multivariant analysis, DM did not continue to be an independent variable. Arterial blood pressure was found to be greater in the DCH group. CONCLUSIONS: The presence of different risk factors for LIc and DCH may be the key to understanding the mechanism which leads to one type or other of CVA.

Circadian variation in acute ischemic stroke: a hospital-based study.

BACKGROUND AND PURPOSE: We investigated circadian rhythm in ischemic stroke onset and its subtypes, differentiating between first-ever stroke and recurrent stroke. METHODS: A consecutive series of 1223 patients with ischemic stroke was admitted at 2 reference hospitals; the time of onset of symptoms was obtained, differentiating between onset while asleep and awake. We compared circadian rhythm between stroke types and between first-ever and recurrent stroke. RESULTS: The onset time was known in 914 patients; 25.6% experienced onset on awakening [higher incidence in thrombotic and lacunar stroke (28.9% and 28.4%, respectively) than in embolic stroke (18.8%)]. For all stroke subtypes, there was a significant diurnal variation, with a morning peak between 6 AM and noon; after redistributing the hour of onset of patients awakening with stroke, the morning peak was minimal in all types of stroke. There were no differences in circadian rhythm between patients with first-ever and recurrent stroke. CONCLUSIONS: Only hospitalized patients were studied. There is a circadian rhythm in all types of stroke, with higher frequency during the day and lower frequency in the last hours in the evening. The highest incidence in the early hours of the morning can be overestimated, due to patients who awaken with stroke. There is no difference in circadian rhythm between first-ever stroke and recurrent stroke.

[Delayed hospitalization of the patient with acute stroke]. / Retraso en la hospitalización del paciente con ictus agudo.

INTRODUCTION AND OBJECTIVE: We analyze the main factors influencing the time delay between onset and admission to the hospital in acute stroke. PATIENTS AND METHODS: Consecutive series of 1,344 patients with acute stroke or transient ischemic attack admitted at two reference hospitals of Valencia and included at the same stroke register. Factors assessed were age, sex, vascular risk factors, stroke onset and arrival at hospital, stroke severity and stroke subtype. RESULTS: In 30% of patients the stroke onset time was unknown. 70.7% of patients with acute stroke, and known onset, arrived to the hospital in the first six hours. The median time from onset to admission was: TIA, 2 hours; cerebral infarct, 3 hours (lacunar infarcts 5 hours, non-lacunar infarcts 2 hours) and intracerebral hemorrhage, 2 hours. Patients with severe stroke arrive earlier at the hospital (p < 0.001). Neither sex, age, nor vascular risk factors influence the delay time. CONCLUSIONS: The arrival time varies with stroke subtype: patients with intracerebral hemorrhage or TIA arrive earlier than those with cerebral infarct, and non-lacunar infarcts earlier than lacunar ones. Furthermore, patients with severe stroke are admitted sooner at the hospital.

Evaluation of auditory discrimination in children with ADD and without ADD.

Auditory discrimination abilities of children with and without attention deficits were investigated to measure the variability due to different response modes (verbal [NU-6] and picture pointing [GFW]) and competing messages (GFW). Results showed no differences between response modes in quiet, but significant differences in noise between groups with children having ADD showing poorer speech discrimination. Additionally, differential effects between types of competing messages for the same task were not found in the ADD group. These results are discussed in relation to the clinical use of these tests, the relationships seen between results, and implications for educational management.

Perception of loudness in children with ADD and without ADD.

Twenty-eight children identified with attention deficits and a comparison group of children without ADD were asked to judge the loudness of speech as comfortable (MCL) or tolerable (TL). Results indicated that children with attention deficits required a softer level to make both of these loudness judgements. Children with ADD had statistically significant differences in their choices of comfort levels (MCL = 51 dBHL) and choices of tolerance levels (TL = 95 dBHL) from their peers without ADD (MCL = 59 dBHL, TL = 100 dBHL). These findings are viewed in relation to perceptual differences between children with and without ADD. Additionally, implications for classroom management are discussed.

[The management of acute cerebrovascular disorders at the Emergency Services at the Castellon General Hospital]. / Enfermedad vásculocerebral aguda atendida en el servicio de Urgencias del Hospital General de Castellón.

OBJECTIVE: To analyse the policy for hospital admission in the case of the patients who come to the Emergency Ward with acute cerebrovascular disorders. METHOD: The study was based on a retrospective analysis of the release reports from the Emergency Ward of Castellón General Hospital in the course of 1991, in which stroke, or transitory ischemic attack (TIA) were diagnosed. RESULTS: 514 patients were attended to who went to the Emergency Ward because of cerebrovascular disorder. Of these, 57.2% were referred to hospital, with 42% being sent home. It was observed that 10.65% (n = 23) they did not accomplish the criteria for stroke. There was an overwhelming number of cases of TIA diagnosed (50.2%) in patients who were not admitted, contrasting with only 7.5% being selected for admission. We considered possible explanations for this. CONCLUSIONS: We observed that as far as making the decision to admit a patient with acute cerebrovascular disorder, priority for admission was given in those cases which showed the worst neurological deficiencies, and had a worse prognosis as a consequence. Similarly, the older age (average 76.5 years old) was a prominent factor as far as those who were not admitted.

[A study of mortality in patients with acute cerebrovascular pathology in the Castellon General Hospital]. / Análisis de mortalidad en pacientes con patología cerebrovascular aguda en el Hospital General de Castellón.

OBJECTIVE: To analyse the hospital death rate caused by acute cardiovascular disorder and their factors conducted. METHODS: We made a retrospective review of all patients suffering from this pathology who had gone into the Casualty Ward of the Castellón General Hospital in the course of 1991: we also looked for all patients with acute cardiovascular disorder who had died in the hospital. We studied the risk factors for the patients referred using a univariant analysis, comparing those still living with those who had died. RESULTS: We find 514 patients diagnosed as having acute cardiovascular disorder, with an stroke/TIA incidence rate of 188 cases per 100,000 inhabitants. The proportion of referred patients was 52%. Among these, the death rate was 27.8%. Factors affecting the death rate were the age of the patients, the reduction in the level of consciousness, and lateral gaze at the start of the stroke. CONCLUSIONS: We believe that the high death rate in our selection was due to the severity of the strokes and the advanced age of the patients, as was in accordance with the methodology used in the gathering of data, which made it possible to include patients who died early.