[Diagnostic value of cardiac 123I-metaiodobenzylguanidine (123I-MIBG) scintigraphy in Lewy body disorders]. / Valor diagnóstico de la gammagrafía cardíaca con 123I-metaiodobenzilguanidina en las enfermedades con cuerpos de Lewy.

INTRODUCTION: Lewy body disorders such as Parkinson's disease (PD) and Lewy body dementia (LBD) are associated with cardiac sympathetic denervation, which can be visualized on 123I-MIBG scintigraphy. Our objectives were to study the diagnostic value of this technique in Lewy body disorders and its relationship with PD clinical variables. PATIENTS AND METHODS: We studied 90 patients: 51 with PD, 19 with LBD, 9 with multiple system atrophy (MSA) and 11 controls. Scintigraphy images were qualitatively evaluated and early and delayed heart-to-mediastinum ratios (HMR) were calculated. The main confounding factors (ischemic heart disease, diabetes, hypertension and drugs) were controlled by multivariate linear regression analysis. We investigated correlations between scintigraphy variables and PD variables. RESULTS: The delayed HMR, which showed better discriminative ability was 2.03 +/- 0.32 in controls, 1.37 +/- 0.30 in PD (p<0.001 vs controls), 1.47+/-0.45 in LBD (p=0.001 vs controls) and 1.69+/-0.28 in MSA (p=0.02 vs controls; p=0.004 vs PD). This ratio was influenced by PD/LBD diagnosis (beta= -0.638; p<0.001) and to a lesser degree, by ischemic heart disease (beta= -0.244; p=0.028). Optimal cut-off value between PD/LBD and controls was 1.71 (83% sensitivity and 82% specificity). Within the PD group, those with a family history of PD/LB showed higher delayed HMR values (1.65+/-0.34 vs 1.30+/-0.24 without history; p<0.001) and proportion with normal scintigraphy (56% vs 5%; p=0.001). CONCLUSIONS: Cardiac 123I-MIBG scintigraphy is useful in the diagnosis of Lewy body disorders, although its value in PD is conditioned by having a family history of PD.

Valor diagnóstico de la gammagrafíacardíaca con 123I-metaiodobenzilguanidinaen las enfermedades con cuerpos de Lewy / Diagnostic value of cardiac 123I-metaiodobenzylguanidine (123I-MIBG) scintigraphy in Lewy body disorders

Introducción. Enfermedades con cuerpos de Lewy (ECL), como laenfermedad de Parkinson (EP) y la demencia con cuerpos de Lewy(DCL), asocian una denervación simpática cardíaca que puede evidenciarsemediante gammagrafía con 123I-metaiodobenzilguanidina(123I-MIBG). Nuestros objetivos fueron estudiar su valor diagnósticoen las ECL y su relación con variables clínicas de la EP.Pacientes y métodos. Estudiamos 90 pacientes: 51 con EP, 19 conDCL, 9 con atrofia multisistémica (AMS) y 11 controles. Se realizó valoracióncualitativa de la gammagrafía y se calcularon los índices corazón/mediastino (ICM) precoz y tardío. Los principales factores deconfusión (cardiopatía isquémica, diabetes, hipertensión y fármacos)se controlaron mediante regresión lineal multivariante. Efectuamoscorrelaciones entre las variables gammagráficas y del grupo con EP.Resultados. El ICM tardío, con mayor capacidad discriminativa,fue 2,03±0,32 en los controles, 1,37±0,30 en EP (p<0,001 vs controles),1,47±0,45 en DCL (p=0,001 vs controles) y 1,69±0,28 enAMS (p=0,02 vs controles; p=0,004 vs EP). En este índice influía eldiagnóstico de ECL (ß=–0,638; p<0,001) y en menor grado la cardiopatíaisquémica (ß=–0,244; p=0,028). Identificamos el valor 1,71como mejor punto de corte entre ECL y controles (sensibilidad 83%y especificidad 82%). Dentro del grupo con EP, aquellos con antecedentesfamiliares de EP mostraron mayores ICM tardío (1,65±0,34 vs1,30±0,24 sin antecedentes; p<0,001) y proporción de gammagrafíasnormales (56% vs 5%; p=0,001).Conclusiones. La gammagrafía cardíaca con 123I-MIBG es útilen el diagnóstico de ECL, si bien, en la EP su valor está condicionadopor el hecho de tener historia familiar de la enfermedad (AU)

Introduction. Lewy body disorders such as Parkinson’s disease(PD) and Lewy body dementia (LBD) are associated withcardiac sympathetic denervation, which can be visualized on123I-MIBG scintigraphy. Our objectives were to study the diagnosticvalue of this technique in Lewy body disorders and its relationshipwith PD clinical variables.Patients and methods. We studied 90 patients: 51 with PD,19 with LBD, 9 with multiple system atrophy (MSA) and 11 controls.Scintigraphy images were qualitatively evaluated and earlyand delayed heart-to-mediastinum ratios (HMR) were calculated.The main confounding factors (ischemic heart disease, diabetes,hypertension and drugs) were controlled by multivariate linearregression analysis. We investigated correlations between scintigraphyvariables and PD variables.Results. The delayed HMR, which showed better discriminativeability was 2.03 ± 0.32 in controls, 1.37 ± 0.30 in PD(p<0.001 vs controls), 1.47±0.45 in LBD (p=0.001 vs controls) and1.69±0.28 in MSA (p=0.02 vs controls; p=0.004 vs PD). This ratiowas influenced by PD/LBD diagnosis (ß=–0.638; p<0.001)and to a lesser degree, by ischemic heart disease (ß = –0.244;p=0.028). Optimal cut-off value between PD/LBD and controlswas 1.71 (83% sensitivity and 82% specificity). Within the PDgroup, those with a family history of PD/LB showed higher delayedHMR values (1.65±0.34 vs 1.30±0.24 without history; p<0.001)and proportion with normal scintigraphy (56% vs 5%; p=0.001).Conclusions. Cardiac 123I-MIBG scintigraphy is useful in thediagnosis of Lewy body disorders, although its value in PD isconditioned by having a family history of PD (AU)

[Impact of warning against procrastination of thrombolysis in ischemic stroke]. / Impacto de las advertencias contra la procrastinación sobre las demoras en la trombólisis del ictus.

INTRODUCTION: Fibrinolysis in stroke should be carried out as soon as possible, but delays occur for various reasons. In the first 17 ischemic infarcts treated in our center we confirmed a tendency to exhaust the therapeutic window. We look now at whether warnings against this tendency, without other logistical or organizational modifications, have had an impact on delays. PATIENTS AND METHODS: Neurologists were encouraged to avoid procrastination. When we reached 51 treated patients, we compared features and delay times between the first 17 (February, 2002 to June, 2004) and the 17 most recent cases (October, 2005 to April, 2006). Non-parametric tests were used (significant if p < 0.05). RESULTS: Both groups were similar clinically and demographically. The onset-arrival time lengthened (46 min vs. 75 min; p = 0.01) and scattered. The CT-treatment time halved (57 min vs. 30 min; p = 0.001), with consequent shortening of the 'door-to-needle' period (121 min vs. 90 min; p = 0.002). The arrival-CT time had remained constant (50 min vs. 53 min; p = 0.9), thus the total delay from onset did not change significantly (165 min vs. 170 min; p = 0.7), and the inverse linear correlation between the onset-CT time and the CT-treatment time weakened. CONCLUSIONS: Warnings against procrastination appear to be important in terms of shortening the delays. The time used for clinical-radiologic evaluation (arrival through CT)--about which there had been no action taken--had not been modified, but the time employed in the decision to treat (CT-treatment) and the 'door-to-needle' time had decreased appreciably. This effective compensatory reduction permitted treatment of late-arriving patients, such that although the overall time from onset to treatment apparently was not modified, the actual treatment rate increased.

Do alpha-synuclein aggregates in autonomic plexuses predate Lewy body disorders?: a cohort study.

OBJECTIVE: To determine the prevalence of alpha-synuclein (AS) aggregates in abdominopelvic autonomic plexuses in the general population and to evaluate the relationship between this finding and the subsequent development of neurologic dysfunction. METHODS: First, surgical specimens from 100 patients (ages 44 to 84) undergoing a wide resection of an abdominopelvic organ were examined by anti-AS immunostaining. Second, 16 patients (6 AS+ and 10 randomly selected AS-) participated in yearly double-blinded neurologic assessments. RESULTS: AS aggregates were found in autonomic plexuses in 9% of the whole sample (95% CI 3.4 to 14.6%) but were more common in vesicoprostatic (26%) than in digestive tract (4%) specimens. At 16 months after the biopsy, no prevalent cases of Parkinson disease, dementia, or autonomic failure were diagnosed among participants. One AS+ patient had previously been diagnosed with REM sleep behavior disorder. Seven of 10 control subjects but none of the 6 AS+ patients had a diagnosis of hypertension (p = 0.01). During phase IV of Valsalva maneuver, AS+ group exhibited a longer blood pressure recovery time (p = 0.03), with one patient showing absence of blood pressure overshoot. Cardiac [(123)I]metaiodobenzylguanidine uptake was reduced in the AS+ group (p = 0.03). Striatal [(123)I]ioflupane uptake was abnormally low in only one AS+ patient. At 30 months after the biopsy, lower cardiac and striatal uptake values tended to correlate with higher Unified Parkinson's Disease Rating Scale III scores (p = 0.07). CONCLUSION: The common presence of alpha-synuclein aggregates in peripheral autonomic neurons may represent an early presymptomatic phase in the development of Lewy body disorders.

Impacto de las advertencias contra la procrastinación sobre las demoras en la trombólisis del ictus / Impact of warning against procrastination of thrombolysis in ischemic stroke

Introducción. La fibrinólisis del ictus isquémico debe llevarse a cabo cuanto antes; conocer las causas de retraso permite su eventual corrección. En los primeros 17 casos que tratamos comprobamos que tendía a agotarse el período de ventana terapéutica; evaluamos si las advertencias frente a ello, sin otras modificaciones logísticas u organizativas, han tenido impacto en las demoras. Pacientes y métodos. Se estimuló la celeridad en el tratamiento. Con 51 pacientes tratados, comparamos características y tiempos de demora en los primeros 17 casos (febrero de 2002 a junio de 2004) y en los 17 más recientes (octubre de 2005 a abril de 2006), utilizando tests no paramétricos (significación si p < 0,05). Resultados. Ambos grupos son similares demográfica y clínicamente. El tiempo inicio-puerta se alargó (46 min frente a 75 min; p = 0,01) y dispersó. El tiempo entre tomografía axial computarizada (TAC) y tratamiento se redujo a la mitad (57 min frente a 30 min; p = 0,001), con el consecuente acortamiento del período ‘puerta-aguja’ (121 min frente a 90 min; p = 0,002). El tiempo puerta-TAC se mantuvo constante (50 min frente a 53 min; p = 0,9), y la demora total desde el inicio tampoco se modificó significativamente (165 min frente a 170 min; p = 0,7); la correlación lineal inversa entre tiempo de inicio-TAC y tiempo TAC-tratamiento perdió intensidad. Conclusiones. Las advertencias contra la procrastinación parecen haber sido eficaces para abreviar la toma de decisión de tratar (TAC-tratamiento) y el tiempo ‘puerta-aguja’, mientras que el tiempo utilizado en la evaluación clinicorradiológica (puerta-TAC), sobre el que no había habido actuaciones, no se modificó. Ello ha permitido realizar fibrinólisis a pacientes que llegan más tarde; así, aunque el tiempo inicio-tratamiento aparentemente no cambió, se incrementó la tasa de fibrinólisis

Introduction. Fibrinolysis in stroke should be carried out as soon as possible, but delays occur for various reasons. In the first 17 ischemic infarcts treated in our center we confirmed a tendency to exhaust the therapeutic window. We look now at whether warnings against this tendency, without other logistical or organizational modifications, have had an impact on delays. Patients and methods. Neurologists were encouraged to avoid procrastination. When we reached 51 treated patients, we compared features and delay times between the first 17 (February, 2002 to June, 2004) and the 17 most recent cases (October, 2005 to April, 2006). Non-parametric tests were used (significant if p < 0.05). Results. Both groups were similar clinically and demographically. The onset-arrival time lengthened (46 min vs. 75 min; p = 0.01) and scattered. The CTtreatment time halved (57 min vs. 30 min; p = 0.001), with consequent shortening of the ‘door-to-needle’ period (121 min vs. 90 min; p = 0.002). The arrival-CT time had remained constant (50 min vs. 53 min; p = 0.9), thus the total delay from onset did not change significantly (165 min vs. 170 min; p = 0.7), and the inverse linear correlation between the onset-CT time and the CT-treatment time weakened. Conclusions. Warnings against procrastination appear to be important in terms of shortening the delays. The time used for clinical-radiologic evaluation (arrival through CT) –about which there had been no action taken– had not been modified, but the time employed in the decision to treat (CT-treatment) and the ‘door-to-needle’ time had decreased appreciably. This effective compensatory reduction permitted treatment of late-arriving patients, such that although the overall time from onset to treatment apparently was not modified, the actual treatment rate increased

[Sign of hyperdense and hyperintense anterior cerebral artery]. / Signo de la arteria cerebral anterior hiperdensa e hiperintensa.

INTRODUCTION: The sign of a hyperdense middle cerebral artery (MCA) in computed tomography (CT) scan, or hyperintense MCA in magnetic resonance imaging (MRI) has been associated with recent acute occlusion of the vessel. Hyperdense or hyperintense signs in the basilar and cerebral posterior arteries in association with acute infarct have also been reported. These signs may help to clarify localization and provide prognostic information, especially when the clinical findings are not clear or conclusive. We hereby report on a case of acute infarct in the anterior cerebral artery (ACA) territory with hyperdensity and hyperintensity of the affected vessel. CASE REPORT: This is a case report of a 74 year old male patient with vascular risk factors who had the acute onset of speech impairment and left side hemiparesis, evolving over the next several hours to include depression of the level of consciousness, mutism, and right leg paresis. The A2 segment of the right ACA was found to be hyperdense in CT scan without contrast, and hyperintense in the FLAIR-MRI respectively. MR-angiography showed occlusion of the probably dominant right ACA at the A2 segment shortly after its onset. CONCLUSIONS: The finding of a hyperdense and hyperintense ACA may be useful for diagnosis of acute stroke in the ACA territory, particularly in clinically ambiguous cases. To our knowledge, this is the first reported case of hyperdense and hyperintense ACA as an early sign of acute stroke. Its prognostic value in the ACA is thus far unknown.

Vasculitis aislada del sistema nervioso central que imita una encefalitis de Rasmussen / Isolated vasculitis of the central nervous system resembling Rasmussen´s encephalitis

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[The value of the internal capsule signs in the stimulation of the subthalamic nucleus in Parkinson's disease]. / Valor de los signos de cápsula interna en la estimulación del núcleo subtalámico de la enfermedad de Parkinson.

INTRODUCTION: The effectiveness of stimulating the subthalamic nucleus (DBS-STN) in advanced Parkinson's disease (PD) largely depends on the correct placement of the electrodes. Since the sensory-motor region of the STN lies beside the internal capsule (IC), we believe that the motor effectiveness of DBS-STN could be related to the stimulation threshold in which IC signs appear (IC threshold). PATIENTS AND METHODS: An examination of 17 consecutive patients with advanced PD who had been submitted to bilateral DBS-STN (one case was unilateral) was carried out to determine the motor improvement on each side of the body (n = 33) and the energy consumption one year after surgery according to the IC threshold obtained during the programming. RESULTS: A 45% improvement was observed in the UPDRS III in off and there was a 24% reduction in the equivalent dose of levodopa with bilateral DBS-STN. When the electrodes were considered, there was a statistically significant improvement that depended on the IC threshold. Energy consumption differed significantly between electrodes with an IC threshold of 3-7 V (1.5 +/- 1.2 microW) and those with an IC threshold > 7 V (8.3 +/- 9.4 microW). CONCLUSIONS: During the stimulation phase and following the correct location of the STN, which was achieved by neurophysiological recording, the IC threshold has prognostic implications in medium-long term motor effectiveness and in the consumption of the battery in the generator.

Valor de los signos de cápsula interna en la estimulación del núcleo subtalámico de la enfermedad de Parkinson / The value of the internal capsule signs in the stimulation of the subthalamic nucleus in Parkinson’s disease

Introducción. La eficacia de la estimulación del núcleo subtalámico (ECP-NST) en la enfermedad de Parkinson (EP) avanzada depende en gran medida de la correcta implantación de los electrodos. Como la región sensitivomotora del NST está junto a la cápsula interna (CI), pensamos que la eficacia motora de ECP-NST podría relacionarse con el umbral de estimulación en el que aparecen signos de CI (umbral de CI). Pacientes y métodos. En 17 pacientes consecutivos con EP avanzada intervenidos mediante ECP-NST bilateral (uno unilateral) determinamos la mejoría motora en cada lado del cuerpo (n = 33) y el consumo de energía un año después de la cirugía en función del umbral de CI obtenido durante la programación. Resultados. Hubo una mejoría de un 45% en la UPDRS III en off y un 24% de descenso en la dosis equivalente de levodopa con la ECP-NST bilateral. Cuando consideramos los electrodos hubo una mejoría estadísticamente significativa que era dependiente del umbral de CI. El consumo energético difirió significativamente entre los electrodos con un umbral de CI 3-7 voltios (1,5 ± 1,2 mW) y aquéllos con un umbral de CI > 7 voltios (8,3 ± 9,4 mW). Conclusión. Durante la fase de estimulación y tras una correcta localización del NST, mediante registro neurofisiológico, el umbral de CI tiene implicaciones pronósticas en la eficacia motora a medio-largo plazo y en el consumo de la batería del generador (AU)

The effectiveness of stimulating the subthalamic nucleus (DBS-STN) in advanced Parkinson’s disease (PD) largely depends on the correct placement of the electrodes. Since the sensory-motor region of the STN lies beside the internal capsule (IC), we believe that the motor effectiveness of DBS-STN could be related to the stimulation threshold in which IC signs appear (IC threshold). Patients and methods. An examination of 17 consecutive patients with advanced PD who had been submitted to bilateral DBS-STN (one case was unilateral) was carried out to determine the motor improvement on each side of the body (n = 33) and the energy consumption one year after surgery according to the IC threshold obtained during the programming. Results. A 45% improvement was observed in the UPDRS III in off and there was a 24% reduction in the equivalent dose of levodopa with bilateral DBS-STN. When the electrodes were considered, there was a statistically significant improvement that depended on the IC threshold. Energy consumption differed significantly between electrodes with an IC threshold of 3-7 V (1.5 ± 1.2 μW) and those with an IC threshold > 7 V (8.3 ± 9.4 μW). Conclusions. During the stimulation phase and following the correct location of the STN, which was achieved by neurophysiological recording, the IC threshold has prognostic implications in mediumlong term motor effectiveness and in the consumption of the battery in the generator (AU)

Different patterns of medication change after subthalamic or pallidal stimulation for Parkinson's disease: target related effect or selection bias?

BACKGROUND: Bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) is favoured over bilateral globus pallidus internus (Gpi) DBS for symptomatic treatment of advanced Parkinson's disease (PD) due to the possibility of reducing medication, despite lack of definitive comparative evidence. OBJECTIVE: To analyse outcomes after one year of bilateral Gpi or STN DBS, with consideration of influence of selection bias on the pattern of postsurgical medication change. METHODS: The first patients to undergo bilateral Gpi (n = 10) or STN (n = 10) DBS at our centre were studied. They were assessed presurgically and one year after surgery (CAPIT protocol). RESULTS: Before surgery the Gpi DBS group had more dyskinesias and received lower doses of medication. At one year, mean reduction in UPDRS off medication score was 35% and 39% in the Gpi and STN groups, respectively (non-significant difference). Dyskinesias reduced in proportion to presurgical severity. The levodopa equivalent dose was significantly reduced only in the STN group (24%). This study high-lights the absence of significant differences between the groups in clinical scales and medication dose at one year. In the multivariate analysis of predictive factors for off-state motor improvement, the presurgical levodopa equivalent dose showed a direct relation in the STN and an inverse relation in the Gpi group. CONCLUSION: Differences in the patterns of medication change after Gpi and STN DBS may be partly due to a patient selection bias. Both procedures may be equally useful for different subgroups of patients with advanced PD, Gpi DBS especially for patients with lower threshold for dyskinesia.

[Clinical utility of deep brain stimulation in an advanced Parkinson's disease]. / Utilidad clínica de la estimulación cerebral profunda en la enfermedad de Parkinson avanzada.

INTRODUCTION: Bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN) or globus pallidus internus (GPi) have demonstrated efficacy in advanced Parkinson's disease (PD). We aimed to assess the clinical utility of these procedures in terms of the quality of life, and to determine the pre and postsurgical characteristics related to the outcome. METHOD: A prospective study was conducted on a cohort of 20 patients with advanced PD who underwent bilateral DBS: 14 in STN and 6 in GPi. They were assessed according to the CAPSIT-PD protocol before and after surgery, with a mean follow-up of 9 and 11 months, respectively. The main outcome variables were change in the UPDRS III score in off efficacy and the PDQ-39 quality of life questionnaire score (clinical utility). RESULTS: The STN group improved their UPDRS III in off by a mean of 35% (p = 0.001) and their PDQ-39 by 21% (p = 0.026). The GPi group improved their UPDRS III in off by 21% (p = 0.028) and their PDQ-39 by 37% (p = 0.116). The presurgical levodopa-equivalent dose was a positive predictor of the efficacy and clinical utility of STN DBS and a negative predictor of the efficacy of GPi DBS. In both groups, the clinical utility was determined by improvement in functional disability in off scales. CONCLUSIONS: Bilateral DBS demonstrated middle-term efficacy and clinical utility in the treatment of advanced PD. The presurgical levodopa-equivalent dose was a predictor of the efficacy and clinical utility of DBS.

[Patient autonomy]. / La autonomía del paciente.

Respecting the patient's autonomy is one of the fundamental principles on which biomedical ethics is based. The principle of autonomy considers the patient's freedom and responsibility, who decides what is good for himself/herself, although this is not shared by the physician. In the field of medical research, there are codes and guidelines that guarantee the protection of persons as research subjects. In Spain, recognition of the right of the patient's autonomy has been included in different legal and deontological guidelines. Law of Patient's Autonomy 41/2002 (LAP) is a response to the growing important in our society of the patients' rights as basic axis of the clinical-health care relationships. Different regional communities have also enacted legal guidelines that regulate the persons' autonomy to decide about that affecting his/her health, physical integrity, or life as well as the assumption by others of the decisions of representation or previous instructions. The basic paradigm of autonomy is the informed consent. The LAP establishes the obligation of obtaining the free and voluntary consent of the patient prior to any type of intervention, after offering him/her the adequate information. This basic guideline specifies the situations in which the informed consent is given in writing as well as the exceptions to this consent. Finally, the LAP details when the informed consent is advisable by representation, closely linked to the patient's capacity as well as the regulation of previous instructions.

[Clinical management. Clinical management units. Management agreements]. / Gestión clínica. Unidades de gestión clínica. Acuerdos de gestión.

Clinical management (CM) as a concept includes different innovating experiences in health care services management among developed countries, which were initiated during the late eighties and the first nineties. They were mostly due to the concern that political leaders had about their financial viability. CM, as far as it is understood in Spain, is an organizing model which considers the patient as the centre of the health system. It is guided towards disease, looking for continuous assistance and facilitates an autonomous management together with decentralization at the time of taking decisions. It involves professionals whose clinical practice, based on guides, medical records and care planning, incorporate the knowledge and methodology of "evidence based medicine". Clinical management units (CMU) are organizational types of CM, which implantation is spreading rapidly in the different national health care systems. They include a person who assumes responsibility for them, who act as the hospital directorship interlocutor and are autonomous at the time of managing the allocated resources related to their medical programmes and services. They have an information system adapted to their own needs and an outcome evaluation system which allows them "process" re-engineering. CMU's strengths and weaknesses are highly dependent on the professionals that integrate them. The CMU responsible carries out a management contract with the hospital directorship in which CMU competences, directorship's obligations, essential aspects to meet agreed goals, an outcome evaluation system and an incentives scheme are included.

[Activity and costs of diagnosis-related groups (DRG) of neurological services at the Virgen de las Nieves Hospital of Granada]. / Actividad y costes por GRD del Servicio de Neurología del Hospital Universitario Virgen de las Nieves de Granada.

INTRODUCTION: The influence on health costs of variations in the clinical practice of doctors makes it necessary for them to be involved in the administration of resources so as to increase the efficacy, effectiveness and efficiency of clinical units. OBJECTIVES: To analyze the activity of the Neurology Department of the Virgen de las Nieves Hospital of Granada and to determine its costs per GRD. PATIENTS AND METHODS: Activity during 1996 was compared with that of the previous year and with a standard using measurements of cases, efficiency in administration of beds, quality of data and quality of care. The GRD costs of the service were found. RESULTS: Ninety percent of the discharges were grouped in 20 GRD, and GRD 014 and 015 represented 44% of the productivity. Complexity of the cases was 5% more than in 1995, similar to that of Rule IV [20]. Extreme cases led to a third of all admissions. Mortality was less than expected (3.13%). Hospital stays made up 82% of the total cost. The cost of one stay in hospital was 463.686 pesetas. CONCLUSIONS: It is essential to improve the structure and procedures related to hospital care of patients with cerebral vacular pathology. Those with uncomplicated conditions should be attended as outpatients or in smaller hospitals. The GRD costs obtained are not comparable to those of other authors. Hospital activity should be measured homogeneously and use should be made of analytical accounting systems with common operators and standardized applications so as to obtain reliable, comparable data.