Repercusión de la introducción de neurología en un hospital comarcal de Andalucía / Impact of introducing neurology into a local hospital in Andalusia

Introducción: En Andalucía la mortalidad por ictus duplica la de otras autonomías lo que podría relacionarse con que, a diferencia del resto de CC. AA., sólo 3 de 17 hospitales comarcales cuentan con neurología. El objetivo de este estudio fue evaluar la repercusión de la introducción de un neurólogo en un hospital comarcal de Andalucía en la evaluación y evolución de pacientes con ictus.Métodos: Se realizó un estudio observacional de los ictus ingresados en el primer trimestre de 2006. Se analizaron indicadores de calidad, mortalidad y dependencia comparando los pacientes atendidos por neurología o medicina general. Resultados: En el primer trimestre de 2006 ingresaron 116 pacientes con ictus. Se detectaron diferencias significativas en la realización de las pruebas complementarias necesarias para el diagnóstico (Doppler, ecocardio). La estancia media fue significativamente menor en neurología. Se detectó una reducción absoluta de 39,1% de mortalidad y un incremento absoluto del 35,7% de pacientes independientes al final del seguimiento. Los únicos factores que reducen de forma independiente la estancia y la mortalidad son la atención por neurología durante el ingreso y una menor discapacidad al ingreso.Conclusión: La atención especializada por neurología es eficaz y coste-efectiva por la reducción en estancia hospitalaria, mortalidad y dependencia. La implantación de neurología en los hospitales comarcales de Andalucía es prioritaria para garantizar la equidad en el territorio nacional. Este objetivo debería incluirse en el Plan Andaluz de Atención al Ictus como paso previo para constituir una red de equipos/unidades de ictus (AU)

Introduction: The stroke mortality rate in Andalusia is twice that of other autonomous communities. This could be associated with the absence of neurologists in most local hospitals in this community, unlike in the rest of Spain. The objective of this study was to evaluate the impact of incorporating a neurologist to evaluate and monitor stroke patients in a local hospital in Andalusia. Methods: An observational study was conducted on stroke cases admitted in the first quarter of 2006. Quality indicators, mortality rates, and incapacity rates at follow-up were analysed, comparing groups with and without neurological care. Results: A total of 116 stroke patients were admitted. There were significant differences in tests performed to diagnose patients (Doppler and echocardiography). The mean hospital stay was significantly lower with neurology care. There was a 39.1% absolute decrease in mortality and a 35.7% absolute increase in capacity for daily life activities was also observed. Neurological care and a lower incapacity level at admission were the only two factors independently associated with a decrease in length of hospital stay and mortality.Conclusion: Specialised care by a neurologist is effective in reducing length of hospital stay, mortality and incapacity. The incorporation of neurologists in local hospitals in Andalusia should be a priority to guarantee equal care in all autonomous communities in Spain. This objective should be included in the Plan Andaluz de Atención al Ictus as a first step in forming a network of stroke units and teams (AU)

Fiabilidad del diagnóstico de ictus en urgencias / Reliability of stroke diagnosis in emergency departments

Introducción: Tanto en el Plan de atención sanitaria al ictus como en la Estrategia en ictus del Sistema Nacional de Salud se establece que solo se realizará fibrinólisis en los hospitales con unidad de ictus. Sin embargo, en Andalucía el Plan andaluz de atención al ictus incluye dentro de la cartera de servicios del equipo de ictus en los hospitales comarcales la realización de fibrinólisis prescindiendo de la figura del neurólogo en el tratamiento agudo del ictus. El objetivo de este estudio es evaluar si los médicos de urgencias realizan adecuadamente el diagnóstico de ictus. Métodos: Se recogieron los diagnósticos realizados en urgencias y al alta de hospitalización de todos los pacientes ingresados por motivos neurológicos en el hospital comarcal Infanta Elena durante el año 2006. Se analizó la validez del diagnóstico realizado en urgencias. Resultados: El número de ingresos por patología neurológica fue de 655 pacientes en 2006, representando el ictus un 76%. Aunque la sensibilidad del diagnóstico de ictus en urgencias resultó alta (95%), la especificidad del diagnóstico era muy baja (52%) y el valor predictivo positivo de un 75%. Conclusiones: Aplicar la fibrinólisis sobre la base del diagnóstico de ictus en urgencias implica someter a un riesgo no justificado de hemorragia cerebral a un número importante de pacientes diagnosticados erróneamente. Este riesgo hace cuestionable éticamente la administración de dicho tratamiento en los hospitales comarcales en las condiciones actuales. No solo es importante que el tratamiento fibrinolítico sea accesible a la población sino que dicho tratamiento se realice de forma segura por neurólogos en unidades de ictus (AU)

Introduction: According to the Spanish Stroke Health Care Plan and the Spanish Health National Service Stroke Strategy, thrombolysis should only be performed in hospitals with Stroke Units. However, the Andalusian Stroke Health Care Plan includes, within the list of services of the Stroke Team, the need to have a neurologist present for the performing of thrombolysis in local hospitals. The objective of this study is to evaluate whether emergency doctors are able to achieve a reliable diagnosis of stroke in order to safely perform thrombolysis. Methods: The diagnoses on hospital admission and discharge of all patients admitted for neurological reasons in 2006 in the community Hospital Infanta Elena (Huelva, Andalusia) were collected. The reliability of diagnosis performed by emergency doctors was analysed.Results: A total of 655 patients were admitted to the hospital for neurological reasons, and 76% of them were diagnosed as strokes. The sensitivity of stroke diagnosis made by emergency doctors was very high (97%), but specificity and positive predictive value of that diagnosis was low (52% and 75%, respectively). Conclusions: To apply thrombolysis based of the diagnosis of a stroke by emergency doctors may subject a significant number of erroneously diagnosed patients to an unnecessary risk of brain haemorrhage. This risk makes performing thrombolysis in community hospitals ethically questionable in these circumstances. Although it is important to have thrombolytic treatment available to everyone, this treatment must be performed safely by neurologists Stroke Units (AU)

Impact of introducing neurology into a local hospital in Andalusia.

INTRODUCTION: The stroke mortality rate in Andalusia is twice that of other autonomous communities. This could be associated with the absence of neurologists in most local hospitals in this community, unlike in the rest of Spain. The objective of this study was to evaluate the impact of incorporating a neurologist to evaluate and monitor stroke patients in a local hospital in Andalusia. METHODS: An observational study was conducted on stroke cases admitted in the first quarter of 2006. Quality indicators, mortality rates, and incapacity rates at follow-up were analysed, comparing groups with and without neurological care. RESULTS: A total of 116 stroke patients were admitted. There were significant differences in tests performed to diagnose patients (Doppler and echocardiography). The mean hospital stay was significantly lower with neurology care. There was a 39.1% absolute decrease in mortality and a 35.7% absolute increase in capacity for daily life activities was also observed. Neurological care and a lower incapacity level at admission were the only two factors independently associated with a decrease in length of hospital stay and mortality CONCLUSION: Specialised care by a neurologist is effective in reducing length of hospital stay, mortality and incapacity. The incorporation of neurologists in local hospitals in Andalusia should be a priority to guarantee equal care in all autonomous communities in Spain. This objective should be included in the Plan Andaluz de Atención al Ictus as a first step in forming a network of stroke units and teams.

[Reliability of stroke diagnosis in emergency departments]. / Fiabilidad del diagnóstico de ictus en urgencias.

INTRODUCTION: According to the Spanish Stroke Health Care Plan and the Spanish Health National Service Stroke Strategy, thrombolysis should only be performed in hospitals with Stroke Units. However, the Andalusian Stroke Health Care Plan includes, within the list of services of the Stroke Team, the need to have a neurologist present for the performing of thrombolysis in local hospitals. The objective of this study is to evaluate whether emergency doctors are able to achieve a reliable diagnosis of stroke in order to safely perform thrombolysis. METHODS: The diagnoses on hospital admission and discharge of all patients admitted for neurological reasons in 2006 in the community Hospital Infanta Elena (Huelva, Andalusia) were collected. The reliability of diagnosis performed by emergency doctors was analysed. RESULTS: A total of 655 patients were admitted to the hospital for neurological reasons, and 76% of them were diagnosed as strokes. The sensitivity of stroke diagnosis made by emergency doctors was very high (97%), but specificity and positive predictive value of that diagnosis was low (52% and 75%, respectively). CONCLUSIONS: To apply thrombolysis based of the diagnosis of a stroke by emergency doctors may subject a significant number of erroneously diagnosed patients to an unnecessary risk of brain haemorrhage. This risk makes performing thrombolysis in community hospitals ethically questionable in these circumstances. Although it is important to have thrombolytic treatment available to everyone, this treatment must be performed safely by neurologists Stroke Units.

[Frontal cortical infarction and contralateral postural and international tremor]. / Infarto cortical frontal y temblor postural e intencional contralateral.

INTRODUCTION: Movement disorders, when caused by ischemic stroke, may appear as initial manifestation or after a variable interval of time. Among postictal movement disorders tremor is an uncommon manifestation. Holmes' tremor, which is a mixed tremor, is the most frequent type of tremor after stroke. It is associated to infarcts of various localizations like mesencephalon, pons, cerebellum, and thalamus. Cortical infarct is exceptional as a cause of tremor. CASE REPORT: A sixty-three-year-old woman, with hypertension, who, 2 weeks after a cortical infarct located in the precentral circunvolution of the left frontal lobe, presented with a postural and intention tremor of low frequency (4 Hz) and high amplitude at the right arm. Tremor is still present 2 years after stroke and it has improved partially after treatment with clonazepam. DISCUSSION: Frontal cortical infarcts may cause a contralateral postural and intentional tremor. It usually appears after a time interval. Tremor physiopathology may be related, in these cases, to interruption of the inhibitory fronto-subcortical motor circuit.

Infarto cortical frontal y temblor postural e intencional contralateral / Frontal cortical infarction and contralateral postural and international tremor

Introducción. El ictus isquémico es una causa infrecuente de trastornos del movimiento que pueden formar parte de la clínica inicial o presentarse de forma diferida. Entre los movimientos involuntarios postictales el temblor es excepcional. El temblor más frecuente tras un ictus es un temblor mixto, de reposo, postural e intencional, denominado temblor de Holmes, que puede presentarse con infartos de topografía muy diversa (mesencéfalo, protuberancia, cerebelo y tálamo). La aparición de temblor tras infartos corticales es excepcional. Caso clínico. Mujer de 63 años, hipertensa, que 2 semanas después de un infarto cortical en la circunvolución precentral del lóbulo frontal izquierdo comenzó con un temblor postural e intencional, de gran amplitud y baja frecuencia (4 Hz) en el miembro superior derecho. El temblor persistía 2 años después del ictus y mejoró discretamente con clonazepam. Discusión. Los infartos corticales frontales son una causa infrecuente de temblor postural e intencional contralateral que suele presentarse de forma diferida. En estos casos la fisiopatología del temblor podría estar relacionada con la interrupción del circuito motor inhibidor frontosubcortical

Introduction. Movement disorders, when caused by ischemic stroke, may appear as initial manifestation or after a variable interval of time. Among postictal movement disorders tremor is an uncommon manifestation. Holmes’ tremor, which is a mixed tremor, is the most frequent type of tremor after stroke. It is associated to infarcts of various localizations like mesencephalon, pons, cerebellum, and thalamus. Cortical infarct is exceptional as a cause of tremor. Case report. A sixty-three-year-old woman, with hypertension, who, 2 weeks after a cortical infarct located in the precentral circunvolution of the left frontal lobe, presented with a postural and intention tremor of low frequency (4 Hz) and high amplitude at the right arm. Tremor is still present 2 years after stroke and it has improved partially after treatment with clonazepam. Discussion. Frontal cortical infarcts may cause a contralateral postural and intentional tremor. It usually appears after a time interval. Tremor physiopathology may be related, in these cases, to interruption of the inhibitory fronto-subcortical motor circuit

[A descriptive analysis of the demand for ambulatory neurological care in the health district of Huelva]. / Análisis descriptivo de la demanda de asistencia neurológica ambulatoria en un área sanitaria de Huelva.

INTRODUCTION: In recent years the demand for ambulatory neurological care has risen. Studying this situation can help to improve health care planning and the quality of the referrals from primary care. AIM: To analyse a number of variables involved in the first visits referred from primary care to neurology services. PATIENTS AND METHODS: We conducted a prospective, descriptive study in which data was consecutively collected about 500 new patients from primary care who had appointments for a visit to general neurology services in the health district of the province of Huelva. Demographic features, the reason for referral, initial diagnoses and the case resolution index were analysed. RESULTS: Mean age was 51 years old, and patients were predominantly female (63.4%). The most frequent diagnoses were headaches (42.8%) and cognitive impairment (12%). In 8.2% of cases the referred patients had no neurological pathology. Data showed that 40.2% were discharged after the first visit. CONCLUSIONS: The demographic characteristics and reasons for the visit were similar to those previously published on other regions in Spain. The high percentage of direct discharges translates into a poor selection of the patients referred from primary care. Improving the quality of referrals would make it possible to enhance the efficiency of ambulatory neurological care.

Análisis descriptivo de la demanda de asistencia neurológica ambulatoria en un área sanitaria de Huelva / A descriptive analysis of the demand for ambulatory neurological care in the health district of Huelva

Introducción. En los últimos años se ha incrementado la demanda de asistencia neurológica ambulatoria. Su estudio puede contribuir a mejorar la planificación sanitaria y la calidad de las derivaciones desde atención primaria. Objetivo. Analizar diversas variables de las primeras visitas remitidas desde atención primaria a las consultas de neurología. Pacientes y métodos. Estudio prospectivo descriptivo en el que se recogieron de forma consecutiva los datos de 500 pacientes nuevos procedentes de atención primaria citados en una consulta de neurología general en el área sanitaria de la provincia de Huelva. Se analizaron las características demográficas, el motivo de derivación, los diagnósticos iniciales y el índice de resolución de los casos. Resultados. La media de edad fue de 51 años, con un predominio femenino (63,4%). Los diagnósticos más frecuentes fueron las cefaleas (42,8%) y el deterioro cognitivo (12%). El 8,2% de los pacientes remitidos no tenía ninguna patología neurológica. El 40,2% fue dado de alta tras la primera visita. Conclusiones. Las características demográficas y los motivos de consulta son similares a los publicados previamente en otras comunidades españolas. El elevado porcentaje de altas directas traduce una escasa selección de los pacientes remitidos desde atención primaria. La mejora en la calidad de las derivaciones permitiría mejorar la eficiencia de la asistencia neurológica ambulatoria

Introduction. In recent years the demand for ambulatory neurological care has risen. Studying this situation can help to improve health care planning and the quality of the referrals from primary care. Aim.To analyse a number of variables involved in the first visits referred from primary care to neurology services. Patients and methods. We conducted a prospective, descriptive study in which data was consecutively collected about 500 new patients from primary care who had appointments for a visit to general neurology services in the health district of the province of Huelva. Demographic features, the reason for referral, initial diagnoses and the case resolution index were analysed. Results. Mean age was 51 years old, and patients were predominantly female (63.4%). The most frequent diagnoses were headaches (42.8%) and cognitive impairment (12%). In 8.2% of cases the referred patients had no neurological pathology. Data showed that 40.2% were discharged after the first visit. Conclusions. The demographic characteristics and reasons for the visit were similar to those previously published on other regions in Spain. The high percentage of direct discharges translates into a poor selection of the patients referred from primary care. Improving the quality of referrals would make it possible to enhance the efficiency of ambulatory neurological care

Cerebral hemodynamic changes after carotid angioplasty and stenting.

BACKGROUND AND PURPOSE: Carotid angioplasty stent placement (CAS) is an accepted alternative to endarterectomy. However, little is known about its effect on cerebral hemodynamics. We prospectively studied the early and delayed hemodynamic changes after CAS. MATERIALS AND METHODS: Sixty patients underwent CAS for >or=70% internal carotid artery stenosis. Transcranial Doppler (TCD) was done before, 6 hours, and 30 days after CAS. Cerebrovascular reserve to apnea (CVR) was measured. RESULTS: On the ipsilateral side, basal middle cerebral artery (MCA) middle flow velocity (MFV) and pulsatility index (PI) increased from 49.7 cm/s and 0.85, respectively, to 62.5 cm/s and 1.09 immediately after CAS (P < .05); anterior cerebral artery (ACA) MFV and PI increased from 50.7 cm/s and 0.90, to 58.9 cm/s and 1.08 (P < .05); and posterior cerebral artery (PCA) MFV decreased from 47.5 to 36.5 cm/s, with no change in PI (P < .05). On the contralateral side, nonsignificant changes were seen on MCA, immediately after CAS; ACA and PCA MFV decreased from 63.7 and 45.3 cm/s to 50.3 and 38.6 cm/s, respectively (P < .05); ACA and PCA PI increased from 0.96 and 1.00, respectively, to 1.04 and 1.04 (P < .05). At 30 days, ipsilateral MCA MFV and PI were 52.8 cm/s and 1.12, respectively (P < .05), and contralateral values were 49.6 cm/s (P < .05) and 1.02 (nonsignificant), respectively. Basal ipsilateral and contralateral CVR improved from 26.0% to 37.0% (P < .05), and from 30.1% to 33.5% (nonsignificant), respectively, at 30 days. CONCLUSIONS: CAS produces an early significant increase of MFV and PI in the ipsilateral anterior circulation. This effect is maintained, though minor, 30 days later. In addition, CAS results in an improvement of CVR at 30 days.

[Room tilt illusion: a rare symptom of migraine aura]. / Ilusión de inversión de la imagen visual: una manifestación excepcional de aura migrañosa.

INTRODUCTION: Room tilt illusion is a distorted perception of the spatial distribution of objects due to complex rotations in different planes. This distortion usually occurs in the vertical plane and is usually associated to vertebrobasilar ischemia. The etiology of the phenomenon varies greatly and only rarely corresponds to migraine aura. CASE REPORT: Since youth, a sixty-year-old woman had frequent episodes of room tilt illusion in the horizontal plane. These lasted from 30 minutes to 2 hours and were always followed by frontal headache fulfilling criteria for migraine (computerized tomography and magnetic resonance imaging) were normal. Visual symptoms and headache disappeared following treatment with flunarizine. DISCUSSION: Room tilt illusion might be a rare symptom of migraine aura. In this setting a functional depression of neurons from the posterior parietal cortex may occur, possibly mediated by chemical factors.

Ilusión de inversión de la imagen visual: una manifestación excepcional de aura migrañosa / Room tilt illusion: a rare symptom of migraine aura

Introducción. La ilusión de inversión de la imagen visual consiste en una percepción alterada de la situación de los objetos que se produce por rotaciones completas en los distintos planos del espacio. Esta alteración es más frecuente en el plano vertical y se asocia sobre todo a isquemia vertebrobasilar. La etiología del fenómeno es muy diversa y sólo excepcionalmente corresponde a un aura migrañosa. Caso clínico. Mujer de 60 años que desde su juventud presenta episodios de inversión visual en el plano horizontal, de 30 min a 2 h de duración, que siempre se siguen de una cefalea bifrontal con criterios de migraña. Los estudios de neuroimagen (tomografía computarizada y resonancia magnética craneal) fueron normales. Tanto los síntomas visuales como la cefalea desaparecieron al instaurar tratamiento con flunarizina. Discusión. La ilusión de inversión de la imagen visual puede ser una manifestación infrecuente de aura migrañosa. El mecanismo fisiopatológico consiste en una depresión funcional neuronal transitoria de la corteza parietal posterior, posiblemente mediada por factores químicos

Introduction. Room tilt illusion is a distorted perception of the spatial distribution of objects due to complex rotations in different planes. This distortion usually occurs in the vertical plane and is usually associated to vertebrobasilar ischemia. The etiology of the phenomenon varies greatly and only rarely corresponds to migraine aura. Case report. Since youth, a sixty-year-old woman had frequent episodes of room tilt illusion in the horizontal plane. These lasted from 30 minutes to 2 hours and were always followed by frontal headache fulfilling criteria for migraine (computerized tomography and magnetic resonance imaging) were normal. Visual symptoms and headache disappeared following treatment with flunarizine. Discussion. Room tilt illusion might be a rare symptom of migraine aura. In this setting a functional depression of neurons from the posterior parietal cortex may occur, possibly mediated by chemical factors

[Sequential changes in magnetic resonance in a limbic status epilepticus]. / Cambios secuenciales en la resonancia magnética en estado epiléptico límbico.

INTRODUCTION: Transient alterations have been described in neuroimaging (MRI) studies of the non-convulsive focal status (NCFS). We report a case of NCFS together with the MRI findings. CASE REPORT: We describe the case of a 63-year-old female who had a sister and two female cousins with epilepsy; the patient was admitted to hospital after being in state of confusion for 72 hours. Two similar bouts of delirium were reported as having occurred in the 2 preceding years, both of which lasted only a few minutes, and at that time a cardiology study, EEG and MRI scans of the head were performed with normal results. The EEG was compatible with left temporal status and MRI, and presented hyperintensity in the left temporal lobe in T2 and Flair, with no mass effect, with gadolinium uptake in leptomeninges and cortex. CSF was acellular and there were high protein levels in cerebrospinal fluid with a value of 1 g/dL. The patient's situation continued for 10 days, and did not respond initially to antiepileptic treatment. Temporal NCFS was diagnosed, with a cryptogenic rather than idiopathic aetiology. A preliminary MRI scan was normal and another scan performed 10 days after resolution showed a clear regression of the lesion. We related these findings to vasogenic and cytotoxic oedema secondary to the status. An MRI scan carried out at 3 months was normal. CONCLUSIONS: This case lends support to reports, in relation to the appearance of NCFS, of MR images compatible with oedema secondary to rupture of the blood-brain barrier. We base it on sequential MRI studies and on high protein levels in CSF.

Cambios secuenciales en la resonancia magnética en estado epiléptico límbico / Sequential changes in magnetic resonance in a limbic status epilepticus

Introducción. En el estado no convulsivo focal (SNCF) se han descrito alteraciones transitorias en estudios de neuroimagen (RM). Presentamos un caso de SNCF y los hallazgos en RM. Caso clínico. Se trata de una mujer de 63 años con antecedentes de una hermana y dos primas con epilepsia que ingresa por presentar, desde 72 horas antes, un cuadro confusional. Se referían desde dos años antes dos episodios similares, de pocos minutos de duración por los que se realizó un estudio cardiológico, así como EEG y RM de cráneo, que fueron normales. El EEG fue compatible con estado temporal izquierdo y en la RM presentó en T 2 y FLAIR una hiperintensidad en el lóbulo temporal izquierdo, sin efecto de masa, con captación de gadolinio en las leptomeninges y el córtex. El LCR fue acelular, con hiperproteinorraquia de 1 g/dL. En su evolución persistió la situación durante 10 días, y no respondió inicialmente al tratamiento antiepiléptico. Se diagnosticó de SNCF temporal, de etiología criptogénica frente a idiopática. Los hallazgos en la RM, con una previa normal y otra diez días después de la resolución, con clara regresión de la lesión, los relacionamos con edema vasogénico y citotóxico secundario al estado. Una RM a los tres meses fue normal. Conclusión. Este caso apoya lo descrito con relación a la aparición en el SNCF, de imágenes en RM compatibles con edema secundario a rotura de barrera hematoencefálica Lo funda-mentamos en estudios RM secuenciales y en la hiperproteinorraquia en LCR

Introduction. Transient alterations have been described in neuroimaging (MRI) studies of the non-convulsive focal status (NCFS). We report a case of NCFS together with the MRI findings. Case report. We describe the case of a 63-year-old female who had a sister and two female cousins with epilepsy; the patient was admitted to hospital after being in state of confusion for 72 hours. Two similar bouts of delirium were reported as having occurred in the 2 preceding years, both of which lasted only a few minutes, and at that time a cardiology study, EEG and MRI scans of the head were performed with normal results. The EEG was compatible with left temporal status and MRI, and presented hyperintensity in the left temporal lobe in T 2 and FLAIR, with no mass effect, with gadolinium uptake in leptomeninges and cortex. CSF was acellular and there were high protein levels in cerebrospinal fluid with a value of 1 g/dL. The patient’s situation continued for 10 days, and did not respond initially to antiepileptic treatment. Temporal NCFS was diagnosed, with a cryptogenic rather than idiopathic aetiology. A preliminary MRI scan was normal and another scan performed 10 days after resolution showed a clear regression of the lesion. We related these findings to vasogenic and cytotoxic oedema secondary to the status. An MRI scan carried out at 3 months was normal. Conclusions. This case lends support to reports, in relation to the appearance of NCFS, of MR images compatible with oedema secondary to rupture of the blood-brain barrier. We base it on sequential MRI studies and on high protein levels in CSF

Neurotoxicidad por aciclovir frente a encefalitis por varicela zoster en un paciente con insuficiencia renal crónica / Acyclovir neurotoxicity vs. encephalitis due to varicella zoster in a patient with chronic renal failure

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Análisis de 18 pacientes diagnosticados de distrofia muscular de tipo Becker / Analysis of 18 cases of Becker muscular dystrophy

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Infarto bulbar paramedial bilateral secundario a radioterapia / Bilateral paramedial bulbar infarction secondary to radiotherapy

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