Evolución a largo plazo de la hidrocefalia crónica del adulto idiopática tratada con válvula de derivación ventrículo-peritoneal / Long-term outcomes of adult chronic idiopathic hydrocephalus treated with a ventriculo-peritoneal shunt

Introducción. La hidrocefalia crónica del adulto idiopática (HCAI) es considerada una causa de demencia tratable mediante la implantación de una válvula de derivación ventrículo-peritoneal (VDVP). Nos planteamos estudiar la evolución clínica y funcional de la HCAI tratada con VDVP, así como los factores asociados con una mejor evolución a largo plazo. Sujetos y métodos. Estudio observacional de pacientes con diagnóstico de HCAI probable (según criterios de la Sociedad Japonesa de Neurocirugía) y tratados con VDVP entre 2008 y 2013 en un hospital de tercer nivel español. Se establecieron 4 grupos de respuesta clínica (normalización, mejoría parcial, mejoría dudosa y empeoramiento) y la situación funcional se evaluó mediante la escala de Rankin modificada (ERm). Resultados. Se incluyó a 29 pacientes con una edad media de 73,9 años. El 62,1% eran hombres y el 65,5% presentaban HTA. Se observó una respuesta clínica al menos parcial en el 58 y el 48% al año y al final del seguimiento (seguimiento medio de 37,8 meses), respectivamente. La edad, la frecuencia de HTA y las complicaciones quirúrgicas fueron superiores en el grupo con mala respuesta. Un paciente falleció, el 20,7% presentó complicaciones graves y el 69% era dependiente (ERm ≥ 3) al final del seguimiento. La edad se asoció de manera independiente a peor respuesta clínica al año y una mayor dependencia al final del seguimiento. Conclusión. El beneficio de la VDVP fue parcial y transitorio, con una alta frecuencia de complicaciones y dependencia funcional en el seguimiento a largo plazo, especialmente en los pacientes de mayor edad (AU)

Introduction. Adult chronic idiopathic hydrocephalus (ACIH) is a cause of dementia that can be treated by implanting a ventriculo-peritoneal shunt (VPS). We aim to study clinical and functional outcomes in patients with ACIH corrected with a VPS. Subjects and methods. Observational cohort study of patients diagnosed with probable ACIH (Japan Neurosurgical Society guidelines) and undergoing shunt placement between 2008 and 2013 in a centre of reference for neurosurgery in Spain. Clinical improvement was classified in 4 categories (resolution, partial improvement, equivocal improvement, and no improvement); functional outcome was assessed on the modified Rankin scale (mRS). Results. The study included 29 patients with a mean age of 73.9 years; 62.1% were male and 65.5% had hypertension. Clinical improvement (complete or partial) was observed in 58% after one year and in 48% by the end of the follow-up period (mean follow-up time was 37.8 months). Older age, presence of hypertension, and surgery-related complications were more prevalent in the group responding poorly to treatment. One patient died, 20.7% experienced severe complications, and 69% were dependent (mRS ≥ 3) by the end of the follow-up period. Age at diagnosis was independently associated with poorer clinical response at one year and a higher degree of dependency by the end of follow-up. Conclusion. Symptomatic benefits offered by VPS were partial and transient; treatment was associated with a high complication rate and poor functional outcomes in the long term, especially in the oldest patients (AU)

Long-term outcomes of adult chronic idiopathic hydrocephalus treated with a ventriculo-peritoneal shunt. / Evolución a largo plazo de la hidrocefalia crónica del adulto idiopática tratada con válvula de derivación ventrículo-peritoneal.

INTRODUCTION: Adult chronic idiopathic hydrocephalus (ACIH) is a cause of dementia that can be treated by implanting a ventriculo-peritoneal shunt (VPS). We aim to study clinical and functional outcomes in patients with ACIH corrected with a VPS. SUBJECTS AND METHODS: Observational cohort study of patients diagnosed with probable ACIH (Japan Neurosurgical Society guidelines) and undergoing shunt placement between 2008 and 2013 in a centre of reference for neurosurgery in Spain. Clinical improvement was classified in 4 categories (resolution, partial improvement, equivocal improvement, and no improvement); functional outcome was assessed on the modified Rankin scale (mRS). RESULTS: The study included 29 patients with a mean age of 73.9 years; 62.1% were male and 65.5% had hypertension. Clinical improvement (complete or partial) was observed in 58% after one year and in 48% by the end of the follow-up period (mean follow-up time was 37.8 months). Older age, presence of hypertension, and surgery-related complications were more prevalent in the group responding poorly to treatment. One patient died, 20.7% experienced severe complications, and 69% were dependent (mRS ≥ 3) by the end of the follow-up period. Age at diagnosis was independently associated with poorer clinical response at one year and a higher degree of dependency by the end of follow-up. CONCLUSION: Symptomatic benefits offered by VPS were partial and transient; treatment was associated with a high complication rate and poor functional outcomes in the long term, especially in the oldest patients.

Preventing diarrhoea in enteral nutrition: the impact of the delivery set hang time.

BACKGROUND: To meet the current recommendations for enteral tube feeding (ETF), we updated our previous practice in 2011 and began to use a 24-h delivery set hang time (DSHT). We evaluated the impact of this update on the risk of diarrhoea and in diarrhoea-free survival. METHODS: Observational, retrospective study with historical controls on ischaemic and haemorrhagic stroke patients undergoing ETF. Diarrhoea occurrence (≥ 3 liquid stools in 24 h) was compared between patients with a 24 h DSHT (2011-2014) and a 72/96 h DSHT (2010-2011). The analysis was conducted using Kaplan-Meier curves and a Cox regression model. RESULTS: A total of 175 patients were included [median age 81 years (IQR = 12), 46.9% males], 103 in the group with a 24 h DSHT and 72 in the group with a 72/96 h DSHT. The group with a 24 h DSHT had a lower diarrhoea frequency (13.6% vs. 34.7%, risk ratio: 0.39, 95% CI: 0.22-0.70, p = 0.001) and a lower diarrhoea incidence rate (0.87 vs. 2.32 cases of diarrhoea/100 patient*day, rate ratio: 0.37, 95% CI: 0.19-0.72, p = 0.004). The Kaplan-Meier curves showed a longer diarrhoea-free survival for this group (p = 0.003, log-rank test). A 24 h DSHT was associated with a lower risk of diarrhoea (HR = 0.27, 95% CI: 0.12-0.61, p = 0.002), adjusted by albumin, stroke severity, intravenous thrombolysis, the administration of clindamycin and cefotaxime, and the administration of an enteral formula for diabetic patients. CONCLUSIONS: The 24 h DSHT was independently associated with a lower risk of diarrhoea and longer diarrhoea-free survival in hospitalised patients with acute stroke under ETF, compared with a 72/96 h DSHT.

Enteral tube feeding of patients with acute stroke: when does the risk of diarrhoea increase?

BACKGROUND/AIM: We aimed to evaluate the relationship between the length of time acute stroke patients underwent enteral tube feeding (ETF) and episodes of diarrhoea, and to investigate the temporal cut-off point at which diarrhoea risk increases. METHODS: An observational, retrospective study was conducted on patients with acute stroke admitted to a Stroke Centre. Patients undergoing ETF (ETF group) and those not undergoing ETF (control group) were analysed and matched by age and stroke severity. Data regarding demographic and clinical variables were recorded. The analysis was conducted using a receiver operating characteristic (ROC) curve and multivariate analyses. RESULTS: A total of 130 inpatients was included (age 75.08 ± 11.53 years, 56.2% men). The ETF group had higher diarrhoea frequency (27.7% vs 6.2%, P = 0.001). The length of time on ETF was associated with diarrhoea development (odds ratio (OR), 1.12 increment per day; 95% confidence interval (CI) 1.05-1.18; P < 0.001), after adjusting for confounders. The ROC curve showed 7 days on ETF as a cut-off point for diarrhoea risk. Seven days or more on ETF was independently associated with diarrhoea (OR, 6.26; 95% CI 1.66-23.62; P = 0.007), whereas less than 7 days was not when compared with the control group (OR, 0.38; 95% CI 0.04-3.91; P = 0.413). CONCLUSIONS: The length of time on ETF is associated with diarrhoea development in patients with acute stroke, demonstrating a temporal cut-off point. Seven days or longer on ETF is related to the occurrence of diarrhoea, whereas less than 7 days on ETF does not show this effect.

Atrial fibrillation in young stroke patients: do we underestimate its prevalence?

BACKGROUND AND PURPOSE: The prevalence of atrial fibrillation (AF) in young stroke patients has rarely been reported and is considered an uncommon ischaemic stroke (IS) aetiology. Our objective was to analyse the prevalence of AF in IS patients up to 50 years of age and its relationship with stroke severity and outcomes. METHODS: This was an observational study of consecutive IS patients up to 50 years of age admitted to a stroke centre during a 5-year period (2007-2011). A complete cardiology study was performed with a daily electrocardiogram and cardiac monitoring for 72 h as well as echocardiography. In cases of stroke of unknown aetiology a 24-h Holter monitoring was performed. Baseline data, previously or newly diagnosed AF, structural heart disease (SHD) (valvulopathy/cardiomyopathy), stroke severity on admission as measured by the National Institutes of Health Stroke Scale (NIHSS) (moderate-severe stroke if NIHSS ≥ 8) and 3-month outcomes according to the modified Rankin Scale (mRS) (good outcome if mRS ≤ 2) were analysed. AF was classified as AF associated with SHD (AF-SHD) and AF not associated with SHD (AF-NSHD). RESULTS: One hundred and fifty-seven patients were included (mean age 43 years, 58.6% male). Fourteen subjects (8.9%) presented with AF, four with AF-NSHD and 10 with AF-SHD. AF was previously known in 10 patients (6.3%), two with AF-NSHD and eight with AF-SHD. A multivariate analysis showed an independent association between AF and moderate-severe IS (odds ratio 3.771, 95% CI 1.182-12.028), but AF was not an independent prognostic factor. CONCLUSION: AF may be more common than expected in young patients with IS and is associated with increased NIHSS scores.

Transient ischaemic attacks clinics provide equivalent and more efficient care than early in-hospital assessment.

BACKGROUND AND PURPOSE: Clinics for early management of transient ischaemic attacks (TIAs) have been developed in some stroke centres, resulting in reduced recurrence rates compared to appointment-based outpatient management, thus saving on hospitalization. We analysed the care process, recurrence rates and economic impact of the first year of work in our early-management TIA clinic and compared these with our previous in-hospital study protocols for low- and moderate-risk TIA patients. METHODS: This was a prospective evaluation of the management of low- to moderate-risk TIA patients, comparing a new TIA clinic model (2010) with a previous hospitalization model (2009). Demographic data, vascular risk factor profiles, diagnostic test performance, secondary prevention measures, final aetiological diagnoses and cerebrovascular recurrences at 7 and 90 days were compared between in-hospital and TIA clinic assessed patients. We also carried out an economic comparison of the costs of each model's process. RESULTS: Two hundred and eleven low- to moderate-risk TIA patients were included, of whom 40.8% were hospitalized. There were no differences between the TIA clinic assessed and in-hospital assessed patients in terms of risk factor diagnosis and secondary prevention measures. The stroke recurrence rate (2.4% vs. 1.2%; P = 0.65) was low and similar for both groups (CI 95%, 0.214-20.436; P = 0.52). Cost per patient was €393.28 for clinic versus €1931.18 for in-hospital management. Outpatient management resulted in a 77.8% reduction in hospitalizations. CONCLUSION: Transient ischaemic attacks clinics are efficient for the early management of low- to moderate-risk TIA patients compared to in-hospital assessment, with no higher recurrence rates and at almost one-fifth the cost.

Efficacy of intravenous thrombolysis according to stroke subtypes: the Madrid Stroke Network data.

OBJECTIVES: To identify possible differences in the early response to intravenous thrombolysis (IVT) or in stroke outcome at 3 months, based on stroke subtype in patients with acute ischaemic stroke (IS). METHODS: Multicentre stroke registry data were used, with prospective inclusion of consecutive patients with acute IVT-treated IS in five acute stroke units. We compared clinical improvement (National Institutes of Health Stroke Scale, NIHSS) at 24 h and at day 7 as well as functional outcome at 3 months (Modified Rankin Scale, mRS) amongst the different stroke subtypes (ICD-10). RESULTS: In total, 1479 patients were included; 178 (12%) had large vessel disease (LVD) with carotid stenosis ≥ 50%, 175 (11.8%) had other LVD, 638 (43%) had cardioembolism, 60 (4.1%) had lacunar infarction, 72 (4.9%) were patients with IS of other/unusual cause and 356 (24.1%) had unknown/multiple causes. Patients with lacunar infarction had lower stroke severity (median NIHSS 6) whilst cardioembolic IS was the most severe (median NIHSS 14) (P < 0.001). No differences in NIHSS improvement were found at 24 h. LVD patients with carotid stenosis (odds ratio 0.544; 95% CI 0.383-0.772; P = 0.001) were less likely to improve at day 7 after adjustment for age, gender, vascular risk factors and stroke severity. However, adjusted multivariate analysis showed no influence of stroke subtype on stroke outcome (mRS) at 3 months. Age, systolic blood pressure on admission and stroke severity were independently associated with mRS > 2 at 3 months. CONCLUSION: Although LVD patients with arterial stenosis ≥ 50% improve less than the other aetiologies at day 7, stroke aetiological subtype does not determine differences in IS outcome at 3 months after IVT.

Off-hour effects on stroke care and outcome in stroke centres.

BACKGROUND AND PURPOSE: Poorer stroke care processes and outcomes have been reported for acute stroke patients arriving at centres during off hours and weekends. OBJECTIVE: To compare each step of the continuous specialized care that Stroke Centres (SC) provide according to time of admission and final outcome. METHODS: Observational study of consecutive stroke patients admitted to SC during 2008 and 2009. Patients were classified into two groups according to their arrival time: Work Hours (WH) and Off Hour (OH) (weekends and any time other than 8:00 am to 3:00 pm on weekdays). Differences in time to diagnostic procedures, tPA administration, stroke outcome [modified Rankin Scale, (mRS)] and in-hospital fatality rates were analysed. RESULTS: A total of 912 patients were admitted. Data from 674 patients fulfilling study criteria were analysed. A total of 434 (64.4%) patients arrived during OH. No differences in stroke severity were found when comparing OH and WH. Time to blood test results was higher for WH (median 67 min vs. 47 min; P < 0.01), but time to cranial CT scan was similar. Intravenous tPA was administered to 58 (16.4%) OH vs. 26 (13.1%) WH patients (P = 0.33). OH arrival was not associated with poorer outcome (mRS ≥ 3) at discharge (32.8% vs. 37%; P = 0.27), or at the 3-month follow-up (30.6% vs. 27.6%, P = 0.52). No differences were found for in-hospital fatality rates (5.8% vs. 5.4%, P = 1.00). CONCLUSIONS: The care provided by SC with neurologists on call 24/7 prevents differences in outcomes associated with time of admission and guarantees equal attention to stroke patients.

Bajo rendimiento del ecocardiograma, comparado con el Doppler transcraneal, en la detección de la comunicación derecha-izquierda / Low sensitivity of the echocardiograph compared with contrast transcranial doppler in right-to-left shunt

Introducción: El Doppler transcraneal con contraste (DTC-c) tiene una alta sensibilidad para la detección de comunicación derecha-izquierda (CDI), probablemente mayor que la del ecocardiograma transtorácico (ETT) y comparable con la del transesofágico (ETE). Objetivo: Evaluar la precisión del ecocardiograma (ETT y ETE) para detectar CDI, comparándolo con DTC-c. Material y métodos: Estudio observacional de pacientes <55 años con isquemia cerebral de origen indeterminado (2007-2009) a los que se les realizó una monitorización con DTC-c para detectar CDI, en reposo y tras maniobra de Valsalva (MV). El ETT y ETE se realizaron cuando estaba indicado según el protocolo de estudio cerebrovascular de nuestro centro. La precisión del ETT y ETE para detectar CDI fue calculada comparándolos con DTC-c. Resultados: Se incluyeron 115 pacientes a los que se les realizó monitorización con DTC-c. Edad media 43,3 (DE 10,3) años, 51,3% hombres. El ETT se realizó en 102 y el ETE en 81 pacientes. La detección de CDI fue mayor con DTC-c que con ETT (67,6 vs. 22,5%, p=0,001) o con ETE (77,8 vs. 53,1%, p=0,001). El ETT, comparado con DTC-c tras MV, mostró: sensibilidad 31,8%, especificidad 96,9%, valor predictivo positivo (VPP) 95,6%, valor predictivo negativo (VPN) 40,5% y precisión 52.9% para detectar CDI. El ETE, comparado con DTC-c tras MV, mostró: sensibilidad 63,4%, especificidad 83,3%, VPP 93%, VPN 39,4% y precisión 67,9%. La precisión del ETT y ETE se incrementó cuando se compararon con el DTC-c en reposo. Conclusiones: El ETT y ETE presentan un número elevado de falsos negativos para detección de CDI, cuando se comparan con el DTC-c. Los estudios clínicos deberían considerar al DTC-c como mejor técnica para diagnosticar CDI cuando se sospecha embolia paradójica (AU)

Background: Contrast transcranial Doppler (c-TCD) has a high sensitivity for detecting right-to-left shunt (RLS), and is probably higher than transthoracic echocardiography (TTE) and comparable with transesophageal echocardiography (TEE).Objective: To evaluate the accuracy of echocardiography (TTE and TEE) to detect RLS compared to c-TCD.Material and methods: Observational study of patients <55 years old with cerebral ischaemia of undetermined origin (2007-2009). All underwent c-TCD monitoring to detect RLS, at rest and after Valsalva manoeuvre (VM). The TTE and TEE were performed when indicated by our cerebrovascular protocol. The accuracy of TTE and TEE for detecting RLS was calculated by comparing them with c-TCD. Results: A total of 115 patients with c-TCD, mean age 43.3 (SD 10.3) years, 51.3% male. The TTE was performed in 102, and TEE in 81, patients. RLS detection was higher with c-TCD than with TTE (67.6% vs. 22.5%, P=.001) or TEE (77.8% vs. 53.1%, P=.001). The TTE, compared with c-TCD after MV showed: sensitivity 31.8%, specificity 96.9%, positive predictive value (PPV) 95.6%, negative predictive value (NPV) 40.5% and accuracy 52.9% to detect RLS. TEE, compared with c-TCD after MV showed: sensitivity 63.4%, specificity 83.3%, PPV 93%, NPV 39.4% and accuracy 67.9%. The accuracy of TTE and TEE improved when they were compared with c-TCD at rest. Conclusions: TTE and TEE show a considerable number of false negatives for RLS detection. Clinical studies should consider the c-TCD as the best technique to diagnose RLS when a paradoxical embolism is suspected (AU)

[Low sensitivity of the echocardiograph compared with contrast transcranial Doppler in right-to-left shunt]. / Bajo rendimiento del ecocardiograma, comparado con el Doppler transcraneal, en la detección de la comunicación derecha-izquierda.

BACKGROUND: Contrast transcranial Doppler (c-TCD) has a high sensitivity for detecting right-to-left shunt (RLS), and is probably higher than transthoracic echocardiography (TTE) and comparable with transesophageal echocardiography (TEE). OBJECTIVE: To evaluate the accuracy of echocardiography (TTE and TEE) to detect RLS compared to c-TCD. MATERIAL AND METHODS: Observational study of patients <55 years old with cerebral ischaemia of undetermined origin (2007-2009). All underwent c-TCD monitoring to detect RLS, at rest and after Valsalva manoeuvre (VM). The TTE and TEE were performed when indicated by our cerebrovascular protocol. The accuracy of TTE and TEE for detecting RLS was calculated by comparing them with c-TCD. RESULTS: A total of 115 patients with c-TCD, mean age 43.3 (SD 10.3) years, 51.3% male. The TTE was performed in 102, and TEE in 81, patients. RLS detection was higher with c-TCD than with TTE (67.6% vs. 22.5%, P=.001) or TEE (77.8% vs. 53.1%, P=.001). The TTE, compared with c-TCD after MV showed: sensitivity 31.8%, specificity 96.9%, positive predictive value (PPV) 95.6%, negative predictive value (NPV) 40.5% and accuracy 52.9% to detect RLS. TEE, compared with c-TCD after MV showed: sensitivity 63.4%, specificity 83.3%, PPV 93%, NPV 39.4% and accuracy 67.9%. The accuracy of TTE and TEE improved when they were compared with c-TCD at rest. CONCLUSIONS: TTE and TEE show a considerable number of false negatives for RLS detection. Clinical studies should consider the c-TCD as the best technique to diagnose RLS when a paradoxical embolism is suspected.

Utility of the assessment of echogenicity in the identification of symptomatic carotid artery atheroma plaques in ischemic stroke patients.

BACKGROUND AND PURPOSE: Echogenicity of atheroma carotid plaques is related to a higher risk of stroke. Clinical and subjective ultrasound criteria are used to identify symptomatic plaques, but the standardized grayscale median (GSM) value may be an objective tool for this diagnosis. Our aim was to analyze the utility of assessing the echogenicity of atheroma carotid plaques in the identification of symptomatic plaques. METHODS: Observational prospective study with inclusion of acute noncardioembolic anterior cerebral circulation ischemic stroke patients. Only patients with bilateral atheroma plaques were included. Echogenicity of plaques was measured by a digital and standardized grayscale system in carotid ultrasound B-mode (longitudinal projection) conducted within the first week after admission. RESULTS: Sixty-six patients were included and 132 plaques were examined. Symptomatic atheroma plaques were less echogenic than asymptomatic ones (GSM 20.0 vs. 29.0; p = 0.002). A ROC curve analysis showed the predictive value of GSM with an AUC of 0.707 (95% CI 0.592-0.823; p = 0.002) and pointed to a value of 24.4 as the optimal cut-off level to identify a plaque as symptomatic (74% sensitivity; 67% specificity). This GSM cut-off point remained significantly associated with a high probability of symptomatic plaque even after the inclusion of the degree of carotid stenosis (either >70% or >50%) in the multivariate logistic regression models. CONCLUSIONS: The assessment of echogenicity of atheroma carotid plaques by the GSM value combined with clinical characteristics and stenosis degree may be useful in the identification of symptomatic plaques.

[Unilateral papillitis as the presenting symptom of neurosarcoidosis]. / Papilitis unilateral como presentación de neurosarcoidosis.

INTRODUCTION: Sarcoidosis is a granulomatous, multisystemic disease, of unknown etiology. Its prevalence is low, 40 cases by 100,000 inhabitants in Northern European countries. Respiratory symptoms are the most common, however this disease can affect other vital systems. Neurooftalmological manifestations have been reported one out of five cases, such as uveitis, cranial nerves palsy, and choroiditis; papillitis is seldom described. When initial symptoms of sarcoidosis are neurological features (less than 5%), diagnosis is challenging. CASE REPORTS: We present two cases of neurosarcoidosis in our hospital, during the last two years, in patients without previous diagnosis, which came for loss of visual acuity. The diagnostic was achieved by magnetic resonanace white matter lesions hyperintenses in T2, computed tomography thoracic mediastinic adenopathy and elevated determinations of angiotensin-converting enzyme, according to diagnostic criteria of neurosarcoidosis published in 2004. CONCLUSIONS: We propose to include neurosarcoidosis among known etiologies of unilateral papilitis. Since that, determination of angiotensin-converting enzyme should be performed in those cases.

Papilitis unilateral como presentación de neurosarcoidosis / Unilateral papillitis as the presenting symptom of neurosarcoidosis

La sarcoidosis es una enfermedad multisistémica granulomatosa, más frecuente en mujeres, con unaprevalencia de 40 casos por 100.000 habitantes y una clínica preferentemente pulmonar. La afectación neurooftalmológica se da en el 15-25% de los pacientes y la clínica habitual es la parálisis de los pares craneales, la uveítis y la coroiditis. El iniciode esta enfermedad con clínica neurológica apenas se da en el 5% de los pacientes con sarcoidosis. Casos clínicos. Presentamos dos casos de neurosarcoidosis en nuestro centro en los últimos dos años, en pacientes sin diagnóstico sistémico previo, que consultaron por una disminución de la agudeza visual. En la resonancia magnética craneal se encontraron lesiones en lasustancia blanca, hiperintensas en la secuencia T2; la tomografía computarizada de tórax mostró adenopatías mediastínicas y las determinaciones de la enzima convertidora de angiotensina estuvieron por encima de la normalidad. Se diagnosticó a los pacientes mediante criterios clínicos publicados en 2004. Conclusiones. Destacamos la importancia de incluir la neurosarcoidosisen el diagnóstico diferencial de la papilitis unilateral, así como la determinación de la enzima convertidora de angiotensina como parte de su estudio

Sarcoidosis is a granulomatous, multisystemic disease, of unknown etiology. Its prevalence is low, 40cases by 100.000 inhabitants in Northern European countries. Respiratory symptoms are the most common, however this disease can affect other vital systems. Neurooftalmological manifestations have been reported one out of five cases, such as uveitis, cranial nerves palsy, and choroiditis; papillitis is seldom described. When initial symptoms of sarcoidosis areneurological features (less than 5%), diagnosis is challenging. Case reports. We present two cases of neurosarcoidosis in our hospital, during the last two years, in patients without previous diagnosis, which came for loss of visual acuity. The diagnosticwas achieved by magnetic resonanace white matter lesions hyperintenses in T2, computed tomography thoracic mediastinic adenopathy and elevated determinations of angiotensin-converting enzyme, according to diagnostic criteria of neurosarcoidosis published in 2004. Conclusions. We propose to include neurosarcoidosis among known etiologies of unilateral papilitis. Sincethat, determination of angiotensin-converting enzyme should be performed in those cases

Varón de 79 años con nódulos pulmonares bilaterales cavitados / 79 year old male with bilateral cavitary pulmonary nodules

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