[Neuro-oncology: towards a cross-cutting and collaborative sub-specialty]. / Neurooncologia: por una subespecialidad transversal y colaborativa.

TITLE: Neurooncologia: por una subespecialidad transversal y colaborativa.

Herniación medular idiopática: una entidad poco frecuente / Idiopathic spinal cord herniation: a rare condition

La hernia medular idiopática es una entidad rara, causante de mielopatía progresiva. Es el resultado de una hernia de la médula espinal a través de un defecto de la duramadre, de etiología no conocida. La forma de presentación clínica más habitual es como un síndrome de Brown-Séquard. La importancia de un diagnóstico radiológico precoz radica en que es causa reversible de mielopatía, ya que el defecto dural es corregible quirúrgicamente con una alta tasa de recuperación funcional. La resonancia magnética es la técnica de imagen de elección para el diagnóstico. A continuación se presentan 2 casos de hernia medular idiopática donde se muestran los hallazgos radiológicos que nos permiten reconocer y diagnosticar esta entidad (AU)

Idiopathic spinal cord hernia, in which the reason that spinal cord protrudes through a defect in the dura mater is unknown, is a rare cause of progressive myelopathy. The most common clinical presentation is Brown-Séquard syndrome. Spinal cord herniation is a reversible cause of myelopathy: surgery to correct the defect in the dura mater has a high rate of functional recovery. Thus, early imaging detection is crucial. Magnetic resonance imaging is the technique of choice for the diagnosis. We present two cases of idiopathic spinal cord herniation and show the imaging findings that make it possible to recognize and diagnose this condition (AU)

[Idiopathic spinal cord herniation: a rare condition]. / Herniación medular idiopática: una entidad poco frecuente.

Idiopathic spinal cord hernia, in which the reason that spinal cord protrudes through a defect in the dura mater is unknown, is a rare cause of progressive myelopathy. The most common clinical presentation is Brown-Séquard syndrome. Spinal cord herniation is a reversible cause of myelopathy: surgery to correct the defect in the dura mater has a high rate of functional recovery. Thus, early imaging detection is crucial. Magnetic resonance imaging is the technique of choice for the diagnosis. We present two cases of idiopathic spinal cord herniation and show the imaging findings that make it possible to recognize and diagnose this condition.

[Management and improvement of the process of outpatient treatment of transient ischemic attacks in Neurology departments]. / Gestión y mejora del proceso de tratamiento ambulatorio del accidente isquémico transitorio en consultas de Neurología.

AIMS: To describe our experience in the ambulatory treatment of transient ischemic attacks (TIA) in a second-level hospital with the implementation of an example of process management within the different services involved in attending such conditions. PATIENTS AND METHODS: The following aspects of the process--mission, limits, flowchart, eligibility criteria and performance indicators (process, sentinel and effectiveness)--were defined by multidisciplinary consensus (Emergency, Vascular Surgery, Cardiology, Neurology and Radiology departments). This process was implemented from April 2002 to May 2004, and monthly assessments were carried out to check for problems and to introduce corrective measures. After ending the process, patients with TIA were admitted as inpatients for a hospital study. RESULTS: Definition of the process: medical care (diagnosis and treatment) of TIA patients who are eligible for a complete outpatient study within seven days. Patients evaluated: 254. Indicator 1 (percentage of suitable referrals): 2002: 53%, 2003: 75%, 2004: 73%. Indicator 2 (percentage of complete studies in less than one week): 2002: 35%, 2003: 57%, 2004: 50%; hospitalised: 90%. Indicator 3 (infarcts during the study): 2002: 4.3%, 2003: 0%, 2004: 0%; hospitalised: 0%. Indicator 4 (percentage of adjustments made to treatment): 2002: 39%, 2003: 31%, 2004: 62%; hospitalised: 72%. Mean delay before visit: in February 2002: 90 days, in April 2002: 7.67 days and in April 2003: 5.37. Problems detected: delays in referrals, failure to fit hospitalisation criteria, delays in carrying out examinations not included in the protocol, unsuitable indicator design. Steps taken: redefinition of indicators, modification of the referral system, adjustments made to the circuits involved in carrying out tests, review of hospitalisation criteria. CONCLUSIONS: Process management is an ideal tool for achieving ongoing improvements in clinical praxis. Early monitoring makes it possible to detect problems and to implement corrective measures. In our area, the study of TIA must be performed in a hospital inpatient regimen in order to comply with the guidelines for clinical practice.

Gestión y mejora del proceso de tratamiento ambulatorio del accidente isquémico transitorio en consultas de Neurología / Management and improvement of the process of outpatient treatment of transient ischemic attacks in neurology departments

Objetivo. Experiencia del tratamiento ambulatorio del accidente isquémico transitorio (AIT) en un hospital de segundo nivel con la puesta en marcha de un ejemplo de gestión por procesos entre todos los servicios implicados en su atención. Pacientes y métodos. Se definieron: misión, límites, diagrama de flujo, criterios de inclusión e indicadores de monitorización (de proceso, centinela y efectividad) del proceso por consenso multidisciplinar (Urgencias, Cirugía Vascular, Cardiología, Neurología y Radiología).Este proceso se implantó desde abril de 2002 hasta mayo de 2004,y se llevó a cabo una monitorización mensual para la detección de problemas y la introducción de medidas correctoras. Tras suspender el proceso, los pacientes con AIT ingresaron para un estudio hospitalario. Resultados. Definición del proceso: atención médica (diagnóstico y tratamiento) del paciente con AIT susceptible de realizar un estudio completo ambulatorio antes de siete días. Pacientes valorados: 254. Indicador 1 (porcentaje de remisiones apropiadas):2002: 53%, 2003: 75%, 2004: 73%. Indicador 2 (porcentaje de estudios completos en menos de una semana: 2002: 35%,2003: 57%, 2004: 50%; ingresados: 90%. Indicador 3 (infartos durante el estudio): 2002: 4,3%, 2003: 0%, 2004: 0%; ingresados:0%. Indicador 4 (porcentaje de ajustes del tratamiento): 2002:39%, 2003: 31%, 2004: 62%; ingresados: 72%. Demora media de cita: en febrero de 2002: 90 días, en abril de 2002: 7,67 días y en abril de 2003: 5,37. Problemas detectados: retraso en las citaciones, falta de ajuste a los criterios de ingreso, demora en exploraciones no incluidas en protocolo, diseño inadecuado de indicadores. Medidas adoptadas: redefinición de indicadores, modificación del sistema de citación, reajustes de los circuitos de realización de pruebas, revisión de los criterios de ingreso. Conclusiones. La gestión por procesos constituye la herramienta ideal para la mejora continua de la práctica clínica. La monitorización precoz permite detectar problemas e implantar medidas correctoras. En nuestro ámbito, el estudio del AIT debe realizarse en un régimen de ingreso hospitalario para ajustarnos a las recomendaciones de práctica clínica (AU)

Aims. To describe our experience in the ambulatory treatment of transient ischemic attacks (TIA) in a second-level hospital with the implementation of an example of process management within the different services involved in attending such conditions. Patients and methods. The following aspects of the process –mission, limits, flowchart, eligibility criteria and performance indicators (process, sentinel and effectiveness)– were defined by multidisciplinary consensus (Emergency, Vascular Surgery, Cardiology, Neurology and Radiology departments). This process was implemented from April 2002 to May 2004, and monthly assessments were carried out to check for problems and to introduce corrective measures. After ending the process, patients with TIA were admitted as inpatients for a hospital study. Results. Definition of the process: medical care (diagnosis and treatment) of TIA patients who are eligible for a complete outpatient study within seven days. Patients evaluated: 254.Indicator 1 (percentage of suitable referrals): 2002: 53%, 2003: 75%, 2004: 73%. Indicator 2 (percentage of complete studies inless than one week): 2002: 35%, 2003: 57%, 2004: 50%; hospitalised: 90%. Indicator 3 (infarcts during the study): 2002: 4.3%,2003: 0%, 2004: 0%; hospitalised: 0%. Indicator 4 (percentage of adjustments made to treatment): 2002: 39%, 2003: 31%,2004: 62%; hospitalised: 72%. Mean delay before visit: in February 2002: 90 days, in April 2002: 7.67 days and in April 2003:5.37. Problems detected: delays in referrals, failure to fit hospitalisation criteria, delays in carrying out examinations not included in the protocol, unsuitable indicator design. Steps taken: redefinition of indicators, modification of the referral system, adjustments made to the circuits involved in carrying out tests, review of hospitalisation criteria. Conclusions. Process management is an ideal tool for achieving ongoing improvements in clinical praxis. Early monitoring makes it possible to detect problems and to implement corrective measures. In our area, the study of TIA must be performed in a hospital inpatient regimen in order to comply with the guidelines for clinical practice (AU)

[Is progressive anarthria a clinical form of Pick complex?]. / Anartria progresiva: forma clínica del complejo Pick?

INTRODUCTION: Progressive anarthria is defined as a clinical entity with a degenerative origin consisting in progressive difficulty in articulating while grammatical, semantic and graphic aspects of language are preserved. It is included within the group of processes affecting restricted areas of the brain although its exact nosological location is not clear. We report two cases that progressed clinically towards frontotemporal dementia and corticobasal degeneration, respectively. CASE REPORTS: Case 1: a male who, at the age of 72, began with speech difficulties while comprehension and reading/writing skills were preserved. Three years later he developed apathy, bulimia, sexual indiscretions and aggressiveness, with preservation of visual memory, visual-constructional capacity and elementary writing skills. Case 2: a male who, at the age of 70, began with speech disorders, which were associated two years later to generalised slowness with Hoehn and Yahr stage II akinetic-rigid symptoms; another two years later, he developed a dystonic attitude and melokinetic apraxia in the left upper limb. CONCLUSIONS: The two cases, which were initially compatible with progressive anarthria, progressed clinically towards frontotemporal dementia and corticobasal degeneration, which are entities that are included in 'Pick complex'. This is a concept that we believe to be useful from a clinical point of view, given the variability that exists in the histology of the entities that have been proposed as members of this syndrome group, together with the progression of the cases described in the literature and the ones we have reported in this work.

Anartria progresiva: ¿forma clínica del complejo Pick? / Is progressive anarthria a clinical form of pick complex?

Introducción. La anartria progresiva se define como una entidad de origen degenerativo consistente en dificultad articulatoria progresiva con los aspectos gramaticales, semánticos y gráficos del lenguaje conservados. Enmarcada en los procesos que afectan a áreas cerebrales restringidas, su ubicación nosológica no está clara. Se comunican dos casos que evolucionaron clínicamente hacia demencia frontotemporal y degeneración corticobasal, respectivamente. Casos clínicos. Caso 1: varón, que debutó a los 72 años con dificultad en el habla, con comprensión y lectoescritura conservadas; tres años después desarrolló apatía, bulimia, indiscreciones sexuales y agresividad, con memoria visual, capacidad visuoconstructiva y escritura elemental conservadas. Caso 2: varón, que debuta a los 70 años con problemas en el habla, asociado dos años después a lentitud generalizada, con cuadro rígido acinético en II de Hoehn yYahr; dos años más tarde, desarrolló actitud distónica y apraxia melocinética en el miembro superior izquierdo. Conclusiones. Ambos casos, compatibles inicialmente con anartria progresiva, evolucionaron clínicamente hacia demencia frontotemporal y degeneración corticobasal, entidades incluidas en el 'complejo Pick', concepto que pensamos que es útil desde el punto de vista clínico, dada la variabilidad en la histología de las entidades que se proponen como integrantes de dicho grupo sindrómico, así como la evolución de los casos descritos en la literatura y los nuestros propios comunicados en este trabajo (AU)

Introduction. Progressive anarthria is defined as a clinical entity with a degenerative origin consisting in progressive difficulty in articulating while grammatical, semantic and graphic aspects of language are preserved. It is included within the group of processes affecting restricted areas of the brain although its exact nosological location is not clear. We report two cases that progressed clinically towards frontotemporal dementia and corticobasal degeneration, respectively. Case reports. Case 1: a male who, at the age of 72, began with speech difficulties while comprehension and reading/writing skills were preserved. Three years later he developed apathy, bulimia, sexual indiscretions and aggressiveness, with preservation of visual memory, visual-constructional capacity and elementary writing skills. Case 2: a male who, at the age of 70, began with speech disorders, which were associated two years later to generalised slowness with Hoehn and Yahr stage II akinetic-rigid symptoms; another two years later, he developed a dystonic attitude and melokinetic apraxia in the left upper limb. Conclusions. The two cases, which were initially compatible with progressive anarthria, progressed clinically towards frontotemporal dementia and corticobasal degeneration, which are entities that are included in ‘Pick complex’. This is a concept that we believe to be useful from a clinical point of view, given the variability that exists in the histology of the entities that have been proposed as members of this syndrome group, together with the progression of the cases described in the literature and the ones we have reported in this work (AU)

Coma secundario por intoxicación por atropina como intento autolítico / Secondary coma by atropine poisoning

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[Transient paradoxical embolism. Importance of early ultrasonography diagnosis]. / Embolia paradójica en tránsito. Importancia del diagnóstico ecocardiográfico precoz.

The paradoxical embolism or the crossing of an embolism through a permeable foramen ovale is considered to be a rare mechanism of cerebral embolism although its real frequency is unknown. Reports demonstrating the embolism during its crossing through cardiac cavities are scarce. Two cases of moving paradoxical embolism are presented. In the first, an infarction of the superior branch of the left middle cerebral artery was produced during the course of deep vein thrombosis and pulmonary thromboembolism with transesophageal echocardiography demonstrating the crossing of the embolism through the foramen ovale. Surgery performed 12 days later did not discover the auricular thrombus. In the second case, a mass was discovered in the right auricle with a permeable foramen ovale during the course of a left middle cerebral artery infarction and a large auricular thrombus was demonstrated in surgery. The diagnostic usefulness of early transsesophageal echocardiography in the diagnosis of moving paradoxal embolism is discussed.