Tratamiento endovascular de la estenosis carotídea: experiencia en el Hospital Universitario Central de Asturias / Endovascular treatment of carotid stenosis: an experience in the Hospital Universitario Central de Asturias

Introducción. La estenosis carotídea es responsable de aproximadamente el 25% de los eventos cerebrovasculares isquémicos. La angioplastia-stent carotídeo (ASC) constituye un procedimiento mínimamente invasivo utilizado como alternativa a la endarterectomía carotídea, especialmente en pacientes de alto riesgo quirúrgico. Objetivo. Analizar la eficacia y seguridad del tratamiento endovascular de la estenosis carotídea en el Hospital Universitario Central de Asturias. Pacientes y métodos. Análisis retrospectivo de las estenosis carotídeas tratadas mediante ASC entre febrero de 2005 y abril de 2010, con registro de datos demográficos, diagnóstico clínico, indicación de tratamiento, tiempo entre el inicio de los síntomas y la realización del tratamiento, resultados angiográficos, complicaciones y seguimiento a largo plazo (incluyendo la tasa de reestenosis). Resultados. Se trataron 121 pacientes (77,8% varones y 22,2% mujeres), con una edad media de 70,8 ± 10,7 años. Los principales factores de riesgo vascular fueron hipertensión arterial (65,3%), tabaquismo (61,2%) y dislipidemia (42,1%). En el 86% de los casos se trataba de estenosis sintomáticas y en el 14% de asintomáticas. En un 60,3% de los casos se trataba de estenosis > 70%; en un 30,6%, de estenosis preoclusivas, y en un 9,1%, de recanalizaciones de oclusiones carotídeas inestables. El tiempo medio de tratamiento fue de 17,0 ± 8,3 días tras el evento isquémico. La estenosis residual fue inferior al 30% en todos los casos. La tasa de morbimortalidad a 30 días fue del 4,1% y la tasa de reestenosis a lo largo de un seguimiento medio de 31,2 ± 10,8 meses fue del 2,4%. Conclusiones. La ASC en nuestro hospital se configura como una técnica eficaz y segura, con una tasa de complicaciones dentro de los parámetros que justifican su indicación (AU)

Introduction. Carotid stenosis accounts for about 25% of all ischaemic cerebrovascular events. Carotid angioplasty and stenting (CAS) is a minimally invasive procedure used as an alternative to carotid endarterectomy, especially in high surgical risk patients. Aim. To analyse the effectiveness and safety of the endovascular treatment of carotid stenosis in the Hospital Universitario Central de Asturias. Patients and methods. The study consisted in a retrospective analysis of the carotid stenoses treated by means of CAS between February 2005 and April 2010, and the following information was recorded: demographic data, clinical diagnosis, indication of treatment, time between the onset of symptoms and beginning of treatment, angiographic findings, complications and long-term follow-up (including the rate of restenosis). Results. Altogether 121 patients were treated (77.8% males and 22.2% females), with a mean age of 70.8 ± 10.7 years. The main vascular risk factors were arterial hypertension (65.3%), smoking (61.2%) and dyslipidaemia (42.1%). In 86% of cases the stenoses were symptomatic and in the remaining 14% they were asymptomatic. In 60.3% of cases they were stenoses > 70%, in 30.6% they were preocclusive stenoses and in 9.1% they were recanalisations of unstable carotid occlusions. The mean treatment time was 17.0 ± 8.3 days after the ischaemic event. The residual stenosis was less than 30% in all cases. The morbidity and mortality rate at 30 days was 4.1% and the rate of restenosis throughout a mean follow-up of 31.2 ± 10.8 months was 2.4%. Conclusions. In our hospital CAS is considered an effective and safe technique, with a rate of complications that is within the parameters that justify its indication (AU)

Neurogluten: patología neurológica por intolerancia al gluten / Neurological disorders associated with gluten sensitivity

Resumen. La intolerancia al gluten es un proceso sistémico de naturaleza autoinmune que se desarrolla, en sujetos con predisposición genética, al ingerir gluten. Aparece a cualquier edad y permanece a lo largo de toda la vida. Es más frecuente en mujeres, como ocurre con otras enfermedades autoinmunes. La enfermedad celíaca es la forma intestinal, así como la representación más importante del conjunto de patologías autoinmunes por gluten que involucran a diferentes sistemas. La afectación neurológica, con o sin enteropatía, es también frecuente y en su patogénesis intervienen el ataque inmunológico al tejido nervioso central y periférico y los cambios neurodegenerativos acompañantes. La expresión clínica es variada, pero los síndromes más comunes son la ataxia cerebelosa y la neuropatía periférica. Por último, la intolerancia al gluten se asocia, en variable proporción, a otras enfermedades complejas y podría influir en su evolución. La detección temprana de los casos de intolerancia al gluten con manifestaciones neurológicas podría proporcionar, con el tratamiento de la dieta sin gluten, un notable beneficio a los pacientes (AU)

Summary. Gluten sensitivity is a systemic autoimmune disease that occurs in genetically susceptible individuals on ingesting gluten. It can appear at any age, then becoming a permanent condition. It is more frequent in women, as happens with other autoimmune diseases. Celiac disease is the intestinal form and the most important manifestation among a set of gluten-induced autoimmune pathologies that affect different systems. Neurological manifestations of gluten sensitivity, with or without enteropathy, are also frequent, their pathogenesis including an immunological attack on the central and peripheral nervous tissue accompanied by neurodegenerative changes. The clinical manifestations are varied, but the most common syndromes are cerebellar ataxia and peripheral neuropathy. Finally, gluten sensitivity is associated to a varying degree, with other complex diseases and could influence their evolution. The early detection of cases of gluten sensitivity with neurological manifestations and subsequent treatment with the gluten-free diet could provide remarkable benefits to the patients (AU)

[Neurological disorders associated with gluten sensitivity]. / Neurogluten: patologia neurologica por intolerancia al gluten.

Gluten sensitivity is a systemic autoimmune disease that occurs in genetically susceptible individuals on ingesting gluten. It can appear at any age, then becoming a permanent condition. It is more frequent in women, as happens with other autoimmune diseases. Celiac disease is the intestinal form and the most important manifestation among a set of gluten-induced autoimmune pathologies that affect different systems. Neurological manifestations of gluten sensitivity, with or without enteropathy, are also frequent, their pathogenesis including an immunological attack on the central and peripheral nervous tissue accompanied by neurodegenerative changes. The clinical manifestations are varied, but the most common syndromes are cerebellar ataxia and peripheral neuropathy. Finally, gluten sensitivity is associated to a varying degree, with other complex diseases and could influence their evolution. The early detection of cases of gluten sensitivity with neurological manifestations and subsequent treatment with the gluten-free diet could provide remarkable benefits to the patients.

Adecuación de la profilaxis anticoagulante en pacientes con fibrilación auricular / Adequacy of anticoagulant prevention in patients with atrial fibrillation

Introducción. Las evidencias científicas demuestran que el tratamiento anticoagulante constituye la profilaxis más eficaz en pacientes con fibrilación auricular. Se presenta una cohorte de pacientes con ictus y fibrilación auricular conocida y se analiza la adecuación del tratamiento anticoagulante previo en función de sus características clínicas y demográficas. Pacientes y métodos. Estudio de observación prospectivo, que incluye pacientes ingresados durante un año en un Servicio de Neurología por ictus agudo y con antecedente de fibrilación auricular no valvular. Se comparó el perfil clínico y el pronóstico funcional de cada paciente con el tratamiento previo. Resultados. Se estudiaron 50 pacientes. El 32% recibían tratamiento con anticoagulantes orales (ACO), el 34% con antiagregantes plaquetarios y el 34% no recibía ningún tratamiento antitrombótico. Se demostraron diferencias estadísticamente significativas en los pacientes tratados con ACO en cuanto a los antecedentes de tratamiento con digoxina, isquemia cerebral, insuficiencia cardíaca y tipo de fibrilación. Los antecedentes de hipertensión arterial, diabetes mellitus y la edad no influyeron en su prescripción. Se encontró una tendencia estadísticamente no significativa a una clínica menos grave al ingreso y a un mejor estado funcional al alta, basado en las escalas NIHSS y Rankin modificada en los tratados con ACO. Conclusiones. Sólo el 32% de los pacientes recibían tratamiento previo con ACO, pese a que más del 90% tenían indicación para ello. Los resultados obtenidos sugieren una necesidad de optimizar las medidas de prevención primaria, máxime cuando se observa un mejor estado funcional final en pacientes tratados con ACO (AU)

Introduction. Although there is a consensus about the use of oral anticoagulants (OAC) to prevent stroke in patients with atrial fibrillation this treatment is underused in actual practice. Our aim was to determine the proportion of patients with previously known atrial fibrillation who were receiving OAC before stroke onset and their characteristics. Patients and methods. We recruited 50 patients who were admitted with acute stroke and previously known atrial fibrillation over a period of one year. Patients were classified according to the type of antithrombotic treatment they were on. The clinical picture was evaluated by the NIHSS. Functional prognosis was estimated by modified-Rankin score at discharge. Results. Of 50 patients, 16 (32%) were receiving OAC before stroke. Four variables were associated with prescription of OAC: treatment with digoxin, previous ischemic stroke or transient ischemic accident, congestive heart failure and the type of AF (chronic vs paroxysmal). Age and medical history of arterial hypertension, diabetes mellitus or ischemic cardiopathy did not influence the prescription. According to the NIHSS and modified-Rankin scales patients on OAC showed less serious strokes and presented a better functional situation at discharge than those who were not on that treatment. Conclusions. This study highlights the need to improve medical education about OAC in patients with atrial fibrillation because only 32% of patients received OAC before stroke although 90% of them should receive it according to current guidelines. Our results suggest that OAC treatment not only prevents stroke but may also contribute to the development of less serious strokes with a better functional prognosis (AU)

[Adequacy of anticoagulant prevention in patients with atrial fibrillation]. / Adecuación de la profilaxis anticoagulante en pacientes con fibrilación auricular.

INTRODUCTION: Although there is a consensus about the use of oral anticoagulants (OAC) to prevent stroke in patients with atrial fibrillation this treatment is underused in actual practice. Our aim was to determine the proportion of patients with previously known atrial fibrillation who were receiving OAC before stroke onset and their characteristics. PATIENTS AND METHODS: We recruited 50 patients who were admitted with acute stroke and previously known atrial fibrillation over a period of one year. Patients were classified according to the type of antithrombotic treatment they were on. The clinical picture was evaluated by the NIHSS. Functional prognosis was estimated by modified-Rankin score at discharge. RESULTS: Of 50 patients, 16 (32%) were receiving OAC before stroke. Four variables were associated with prescription of OAC: treatment with digoxin, previous ischemic stroke or transient ischemic accident, congestive heart failure and the type of AF (chronic vs paroxysmal). Age and medical history of arterial hypertension, diabetes mellitus or ischemic cardiopathy did not influence the prescription. According to the NIHSS and modified-Rankin scales patients on OAC showed less serious strokes and presented a better functional situation at discharge than those who were not on that treatment. CONCLUSIONS: This study highlights the need to improve medical education about OAC in patients with atrial fibrillation because only 32% of patients received OAC before stroke although 90% of them should receive it according to current guidelines. Our results suggest that OAC treatment not only prevents stroke but may also contribute to the development of less serious strokes with a better functional prognosis.

[Long lasting intracranial artery stenosis of embolic origin]. / Estenosis arterial intracraneal de origen embólico persistente en el tiempo.

INTRODUCTION: The term evanescent, or vanishing, has been used to describe those intracranial stenoses that are consecutive to the partial recanalization of an embolic occlusion. In general terms it has been admitted that those stenoses quickly disappear in parallel to the complete recanalization of the artery. This behaviour allows their differentiation from the atherosclerotic stenoses. CASE REPORT: We present here a 61-year-old male who suffered a middle cerebral artery territory stroke secondary to an atrial fibrillation. In the acute phase, a stenotic flow was found in the proximal portion of his left middle cerebral artery. Although it was an embolic occlusion, one year passed before the stenosis disappeared. DISCUSSION: Findings like this contradict the protocols in use (which consider a stenosis as atherosclerotic if it remains for more than three months), and stress the need for new studies which clarify the natural history of the intracranial arterial occlusions.

Inmunoglobulinas en el síndrome de Vogt-Koyanagi-Harada / Intravenous immunoglobulin therapy in Vogt-Koyanagi-Harada syndrome

El síndrome de Vogt-Koyanagi-Harada (VKH), o síndrome uveomeningítico, es una enfermedad sistémica que afecta a varios órganos: el ojo (panuveítis bilateral, desprendimientos serosos de retina), oído (tinnitus, pérdida auditiva), piel y pelo (vitíligo, alopecia, poliosis) y sistema nervioso (meningismo, cefalea, pleocitosis en líquido cefalorraquídeo). La etiología es desconocida, pero el mecanismo más probable es autoinmunitario en personas genéticamente susceptibles frente a antígenos de melanocitos. Presentamos el caso de un paciente de 25 años de edad con panuveítis que fue diagnosticado de síndrome de VKH. Se instauró tratamiento con esteroides intravenosos y ciclos de inmunoglobulinas con buena evolución. Concluimos que el tratamiento del síndrome de VKH debe ser precoz, pero de cualquier manera agresivo, con dosis altas de esteroides sistémicos e inmunoglobulinas intravenosos valorando el mantenimiento de estas últimas en forma de ciclos (AU)

[Intravenous immunoglobulin therapy in Vogt-Koyanagi-Harada syndrome]. / Inmunoglobulinas en el síndrome de Vogt-Koyanagi-Harada.

Vogt-Koyanagi-Harada (VKH) syndrome or uveomeningitic syndrome is a disease affecting several organs: eye (bilateral uveitis, exudative retinal detachments), ear (tinnitus, dysacousia), skin and hair (vitiligo, alopecia, poliosis) and the nervous system (meningism, headache, pleocytosis in cerebrospinal fluid). The etiology remains unknown but it is probably a cell-mediated autoimmune disorder in individuals genetically susceptible to antigenic components of melanocytes. We report a 25 year old patient with VKH syndrome treated with intravenous steroid therapy and cycles of intravenous immunoglobulin with good clinical response. We concluded that treatment of the VKH syndrome should be early but definitely aggressive with high doses of systemic corticosteroids and intravenous immunoglobulin, assessing the maintenance of the latter by cycles.

Cromosoma 20 en anillo: un síndrome identificable por las características electroclínicas / Ring chromosome 20: a distinctive electroclinical syndrome

El síndrome del cromosoma 20 en anillo se caracteriza por estados de mal no convulsivos refractarios a tratamiento y por ondas lentas generalizadas con punta/punta onda intercalada, de predominio frontotemporal. Presentamos el caso de una paciente de 18 años de edad con inicio de crisis a los 10 años que fueron refractarias a múltiples tratamientos. La exploración neurológica y el examen mediante resonancia magnética (RM) craneal fueron normales. En el electroencefalograma (EEG) intercrítico se registraron brotes subclínicos de 2-20 segundos de punta onda bilateral. En el electrocardiograma (EEG) crítico había una actividad paroxística continua con punta onda, onda lenta delta generalizada, coincidiendo con estado de mal no convulsivo. Tras la administración de 1 mg de clonazepam intravenoso se produjo una normalización clínica y electroencefalográfica. El estudio citogenético demostró cromosoma 20 en anillo en el 35 por ciento de las metafases. La epilepsia asociada con el cromosoma 20 en anillo constituye un síndrome con características electroclínicas propias (AU)