[The impact of neurological and medical complications on the mortality and functional situation of acute stroke patients]. / Impacto de las complicaciones neurologicas y medicas sobre la mortalidad y situacion funcional de pacientes con ictus agudo.

INTRODUCTION: Stroke patients have a high risk of presenting complications, the appearance of which can condition the prognosis of the stroke. We studied the frequency and impact of the onset of several different complications on the early and mid-term prognosis of these patients. PATIENTS AND METHODS: We conducted an observation-based study of the patients admitted to a stroke unit. The complications that occurred while hospitalised were recorded, a distinction being drawn between neurological and medical complications. The study examined their influence, according to the subtype of stroke, on intra-hospital mortality and that at 90 days, as well as on the functional situation at 90 days, by analysing the clinical factors that are predictive for the appearance of complications. RESULTS: The sample consisted of 847 patients. Altogether, 29.5% of the patients presented complications, which were more frequent in haemorrhagic stroke (50.5% versus 26.6%; p < 0.0001). The most usual complications were of a neurological nature (21%). For both subtypes, the presence of complications was associated with a higher rate of mortality both in hospital (2.1% versus 12.6%; p < 0.0001) and at 90 days (5.7% versus 29.6%; p < 0.0001), and a lower probability of independence at 90 days (72.9% versus 30.4%; p < 0.0001). The severity of the stroke on admission revealed itself as the most powerful predictor of the onset of any type of complication. CONCLUSIONS: The appearance of complications during the acute phase of the stroke has an adverse influence on mortality and on the functional prognosis. The identification of predictive factors could reduce the impact upon the progress of acute stroke patients.

TITLE: Impacto de las complicaciones neurologicas y medicas sobre la mortalidad y situacion funcional de pacientes con ictus agudo.Introduccion. Los pacientes con ictus presentan un elevado riesgo de presentar complicaciones. Su aparicion puede condicionar el pronostico del ictus. Estudiamos la frecuencia y el impacto de la aparicion de diversas complicaciones en el pronostico precoz y a medio plazo en estos pacientes. Pacientes y metodos. Estudio observacional de los pacientes ingresados en una unidad de ictus. Se registraron las complicaciones durante su estancia, distinguiendose entre complicaciones neurologicas y medicas. Se estudio la influencia de estas segun subtipo de ictus en la mortalidad intrahospitalaria y a los 90 dias, y en la situacion funcional a los 90 dias, analizandose los factores clinicos predictores para la aparicion de complicaciones. Resultados. Muestra de 847 pacientes. Un 29,5% de los pacientes presento complicaciones, que fueron mas frecuentes en el ictus hemorragico (50,5% frente a 26,6%; p < 0,0001). Las complicaciones mas habituales fueron las neurologicas (21%). Para ambos subtipos, la presencia de complicaciones se asocio a mayor mortalidad intrahospitalaria (2,1% frente a 12,6%; p < 0,0001) y a 90 dias (5,7% frente a 29,6%; p < 0,0001), y menor probabilidad de independencia a 90 dias (72,9% frente a 30,4%; p < 0,0001). La gravedad del ictus al ingreso se mostro como el predictor mas potente en la aparicion de cualquier tipo de complicacion. Conclusiones. La aparicion de complicaciones durante la fase aguda del ictus influye de forma adversa en la mortalidad y en el pronostico funcional. La identificacion de factores predictores podria disminuir el impacto sobre la evolucion del paciente con un ictus agudo.

Situación funcional tras un ictus y experiencia acumulada de una unidad de ictus / Functional outcome of stroke and the cumulative experience of a stroke unit

Objetivo: Los pacientes con un ictus tienen más probabilidades de supervivencia e independencia si son atendidos en una unidad de ictus. La información disponible en nuestro entorno acerca de la influencia del aprendizaje sobre estos resultados es escasa. Analizamos la situación funcional y mortalidad en nuestros pacientes en función de la experiencia acumulada en una unidad de ictus. Pacientes y métodos: Estudio de cohortes retrospectivo de pacientes ingresados en una unidad de ictus. Diferenciamos 2 grupos según el año de ingreso: grupo A (julio 2007-diciembre 2009) y grupo B (enero 2010-diciembre 2011), analizando la evolución precoz en función de la puntuación en la escala de ictus del National Institute of Health y la mortalidad al alta y la situación funcional a medio plazo en función de la mortalidad y estado funcional según la escala Rankin a los 3 meses. Resultados: Se incluyó a 1.070 pacientes. No se obtuvo diferencias entre los grupos ni en la evolución favorable (68,3% vs. 63,9), ni en la mortalidad tanto hospitalaria (5,1% vs. 6,6%), como a los 90 días (12,8% vs. 13,1%), siendo mayor el porcentaje de independientes a los 90 días en el grupo B (56,3% vs. 65,5%: p = 0,03). El análisis multivariante ajustado por subtipo de ictus y tratamiento fibrinolítico mantuvo la asociación entre la independencia y el período de ingreso. Conclusiones: La probabilidad de independencia funcional de nuestros pacientes aumentó con la experiencia acumulada de nuestra Unidad de Ictus sin observarse diferencias en la mortalidad

Objective: Patients with acute stroke are more likely to survive and achieve independence if they are treated in a stroke unit. Available information in our setting is scarce. We analyse the outcomes of our patients on the basis of cumulative experience in a stroke unit. Patients and methods: A retrospective cohort study of patients admitted to a stroke unit. We differentiate between two groups according to the year of admission: group A (July 2007-December 2009) and group B (January 2010-December 2011), analysing early outcome based on the score on the National Institute of Health stroke salce and mortality at discharge, and medium-term outcome in terms of mortality and functional status according to the modified Rankin scale at three months. Results: A total 1070 patients were included. There were no differences between groups with respect to favourable outcome (68.3% vs 63.9), hospital mortality (5.1% vs 6.6%), or 90-day mortality (12.8% vs 13.1%). The percentage of patients who were independent at 90 days was greater in group B (56.3% vs 65.5%, P = .03). In the multivariate analysis adjusted for stroke subtype and fibrinolytic therapy, the association between patient independence and admission period remained present. Conclusions: The probability of functional independence in our patients increased alongside accumulated experience in our stroke unit with no differences in mortality

Functional outcome of stroke and the cumulative experience of a stroke unit.

OBJECTIVE: Patients with acute stroke are more likely to survive and achieve independence if they are treated in a stroke unit. Available information in our setting is scarce. We analyse the outcomes of our patients on the basis of cumulative experience in a stroke unit. PATIENTS AND METHODS: A retrospective cohort study of patients admitted to a stroke unit. We differentiate between two groups according to the year of admission: group A (July 2007-December 2009) and group B (January 2010-December 2011), analysing early outcome based on the score on the National Institute of Health stroke scale and mortality at discharge, and medium-term outcome in terms of mortality and functional status according to the modified Rankin scale at three months. RESULTS: A total 1070 patients were included. There were no differences between groups with respect to favourable outcome (68.3% vs 63.9), hospital mortality (5.1% vs 6.6%), or 90-day mortality (12.8% vs 13.1%). The percentage of patients who were independent at 90 days was greater in group B (56.3% vs 65.5%, P=.03). In the multivariate analysis adjusted for stroke subtype and fibrinolytic therapy, the association between patient independence and admission period remained present. CONCLUSIONS: The probability of functional independence in our patients increased alongside accumulated experience in our stroke unit with no differences in mortality.

Evolución y respuesta al tratamiento intravenoso con activador del plasminógeno tisular en relación con el hospital de derivación. Experiencia de una unidad de ictus de referencia / Development and response to intravenous treatment with tissue plasminogen activator with regard to referral hospitals. The experience of a stroke referral unit

Introducción. La administración del activador del plasminógeno tisular por vía intravenosa constituye un tratamiento seguro y eficaz en pacientes con un ictus isquémico agudo. El pronóstico depende de múltiples factores, siendo el intervalode tiempo desde el inicio del ictus hasta su administración uno de los de mayor impacto. Pacientes y métodos. Estudio prospectivo observacional de los pacientes que recibieron fibrinólisis intravenosa en nuestra unidad de ictus entre junio de 2007 y diciembre de 2010. Los pacientes se dividieron en dos grupos: los que acudieron directamente a urgencias de nuestro hospital y los que fueron derivados desde otros centros hospitalarios de Extremadura. Se compararon las características basales, la respuesta al tratamiento y la evolución entre ambos grupos. Resultados. Los pacientes que procedían de fuera de nuestra área de salud se caracterizaban por ser mayoritariamente varones, con ictus tipo TACI, y presentaban una mayor puntuación en la National Institutes of Health Stroke Scale (NIHSS).El tiempo hasta la administración de la fibrinólisis fue menor en los pacientes de nuestra área de salud. La NIHSS al alta fue mayor en pacientes que venían de otra área de salud, pero no hubo diferencias en la escala Rankin a los tres mesesni en la mortalidad. Conclusiones. Los pacientes sometidos a fibrinólisis que provienen de otro centro hospitalario obtienen al alta una puntuaciónen la NIHSS mayor. Esto probablemente se debe a un sesgo en la selección de los pacientes, derivando mayoritariamentevarones, con una peor situación clínica al ingreso y que reciben el tratamiento en un período significativamente mayor desde el inicio de los síntomas (AU)

Introduction. The intravenous administration of tissue plasminogen inhibitor is a safe and effective treatment for patients with an acute ischaemic stroke. The prognosis depends on a number of factors, the time that elapses between the onsetof the stroke and its administration being one of those with the greatest impact. Patients and methods. This is a prospective observational study of the patients who received intravenous fibrinolysis in our stroke unit between June 2007 and December 2010. The patients were divided into two groups, a distinction being made between those who went directly to A&E at our hospital and those who were referred from other hospitals in Extremadura. The baseline characteristics, response to treatment and development in each group were compared. Results. The patients who came from outside our health district were mainly males, with a TACI-type stroke and theypresented higher scores on the National Institutes of Health Stroke Scale (NIHSS). The time elapsed prior to administration of the fibrinolysis was shorter in the patients from our health district. The NIHSS score on discharge was higher in patientswho came from another health district, but there were no differences in the Rankin scale at three months or in themortality rate. Conclusions. Patients submitted to fibrinolysis who come from another hospital score higher on the NIHSS on discharge.This is probably due to a bias in the selection of the patients, since those referred are mainly males, who have a poorer clinical situation on admission and receive treatment in a significantly longer time interval following the onset of symptoms (AU)

[Validation of supra-aortic trunks ultrasound in the diagnosis of atherosclerotic disease of the internal carotid artery. Comparison of the results with angiography]. / Validación del estudio ultrasonológico de troncos supraaórticos en el diagnóstico de la enfermedad aterosclerótica de la arteria carótida interna. Comparación de los resultados con los de angiografía.

INTRODUCTION: Arteriosclerosis of the extra-cranial arteries is believed to be responsible for almost one-third of all ischaemic strokes. The sound diagnosis of the degree of stenosis is essential in deciding the best therapeutic strategy. Although cerebral angiography is considered the reference technique, ultrasound study (UST) is a more readily available, non-invasive and well-established procedure for quantifying carotid stenosis. However, on being a dependent exploratory technique, it is recommended that each laboratory validates its results against angiography. OBJECTIVES: To establish the validity of the neuro-ultrasound study in our laboratory for use in the diagnosis of extracranial atheromatous disease, and determine its capacity to quantify the degree of stenosis in the internal carotid artery. MATERIAL AND METHODS: A retrospective study of patients with extracranial carotid atheromatous disease, in whom the diagnostic process was carried out with carotid ultrasound as well as supra-aortic trunk digital-subtraction angiography. RESULTS: A total of 254 carotids were evaluated and the degree of stenosis being classified into > 50%, 70-99% and 100%. The UST for the first group had a sensitivity (Se) of 97%, a specificity (Sp) of 90%, a positive predictive value (PPV) of 94.6% and a negative predictive value (NPV) of 94.2%. The second group had an Se of 96.4%, Sp 93%; PPV 94.4% and NPV 95.4%. The respective values for carotid occlusion were, 85%, 96.8%, 80% and 97.8%. CONCLUSIONS: Our data validates the ability of UST performed in our Laboratory to diagnose the degree of carotid stenosis.

Validación del estudio ultrasonológico de troncos supraaórticos en el diagnóstico de la enfermedad aterosclerótica de la arteria carótida interna. Comparación de los resultados con los de angiografía / Validation of supra-aortic trunks ultrasound in the diagnosis of atherosclerotic disease of the internal carotid artery. Comparison of the results with angiography

Introducción: Se considera que la arteriosclerosis de las arterias extracraneales causa casi un tercio de los ictus isquémicos. El diagnóstico certero del grado de estenosis es fundamental para indicar la mejor estrategia terapéutica. Si bien la angiografía cerebral se considera la técnica de referencia, el estudio ultrasonográfico (EUS) es un procedimiento más disponible, no invasivo y bien establecido en la cuantificación de la estenosis carotídea. Sin embargo, al ser una técnica dependiente del explorador, se recomienda que cada laboratorio valide sus resultados frente a la angiografía. Objetivos: Establecer, en nuestro laboratorio, la validez del estudio neurosonológico en el diagnóstico de la enfermedad ateromatosa extracraneal y determinar su capacidad para cuantificar el grado de estenosis de la arteria carótida interna. Material y métodos: Estudio retrospectivo de los pacientes con enfermedad ateromatosa carotídea extracraneal en cuyo proceso diagnóstico se realizó tanto ultrasonografía carotídea como angiografía por sustracción digital de troncos supraaórticos. Resultados: Se evaluaron 254 carótidas clasificando el grado de estenosis en > 50%, 70-99% y 100%. Para el primer grupo el EUS obtuvo una sensibilidad del 97%, una especificidad del 90%, un valor predictivo positivo (VPP) del 94,6% y un VP negativo (VPN) del 94,2%. En el segundo grupo, se obtuvo: sensibilidad, 96,4%; especificidad, 93%; VPP, 94,4%, y VPN, 95,4%. Para la oclusión carotídea los valores respectivos fueron del 85, el 96,8, el 80 y el 97,8%. Conclusiones: Nuestros datos validan la capacidad del EUS realizado en nuestro laboratorio para el diagnóstico del grado de estenosis carotídea (AU)

Introduction: Arteriosclerosis of the extra-cranial arteries is believed to be responsible for almost one-third of all ischaemic strokes. The sound diagnosis of the degree of stenosis is essential in deciding the best therapeutic strategy. Although cerebral angiography is considered the reference technique, ultrasound study (UST) is a more readily available, non-invasive and well-established procedure for quantifying carotid stenosis. However, on being a dependent exploratory technique, it is recommended that each laboratory validates its results against angiography. Objetives: To establish the validity of the neuro-ultrasound study in our laboratory for use in the diagnosis of extracranial atheromatous disease, and determine its capacity to quantify the degree of stenosis in the internal carotid artery. Material and methods: A retrospective study of patients with extracranial carotid atheromatous disease, in whom the diagnostic process was carried out with carotid ultrasound as well as supra-aortic trunk digital-subtraction angiography. Results: A total of 254 carotids were evaluated and the degree of stenosis being classified into > 50%, 70-99% and 100%. The UST for the first group had a sensitivity (Se) of 97%, a specificity (Sp) of 90%, a positive predictive value (PPV) of 94.6% and a negative predictive value (NPV) of 94.2%. The second group had an Se of 96.4%, Sp 93%; PPV 94.4% and NPV 95.4%. The respective values for carotid occlusion were, 85%, 96.8%, 80% and 97.8%. Conclusions: Our data validates the ability of UST performed in our Laboratory to diagnose the degree of carotid stenosis (AU)

Angioplastia con prótesis endovascular en un caso de isquemia cerebral recurrente por estenosis de la arteria cerebral media / Angioplasty with stenting in a case of recurrent cerebral ischemia due to middle cerebral artery stenosis

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Réplica. Esclerosis múltiple y neurocisticercosis / Reply. Multiple sclerosis and neurocysticercosis

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[Cerebral haemorrhage in Sneddon's syndrome: case report and literature review]. / Hemorragia cerebral en el síndrome de Sneddon: caso clínico y revisión de la bibliografía.

INTRODUCTION: Sneddon's syndrome is the association between livedo reticularis and stroke. Hemorrhagic strokes in Sneddon's syndrome are exceptional. CASE REPORT: A 39-year-old woman who had had a livedo reticularis for about 14 years attended the Emergency Unit complaining of sudden, severe headache and numbness and weakness in her left extremities. Physical examination revealed left supranuclear facial palsy and left crural hemiparesis and hemihypoalgesia. Cranial CT showed a right parieto-occipital lobar haemorrhage. Immunological studies, including antiphospholipid antibodies, were negative. A cerebral angiography showed anomalies in most distal branches of intracranial arteries. Biopsies of the skin and digital arteries yielded non conclusive results. CONCLUSION: The association between livedo reticularis and stroke, together with the angiographic findings led us to the diagnosis of Sneddon's syndrome. When comparing our case with similar ones, we must point out to its onset with a hemorrhagic stroke and to the lobar location of the bleeding.

Hemorragia cerebral en el síndrome de Sneddon: caso clínico y revisión de la bibliografía / Cerebral haemorrhage in sneddon's syndrome: case report and literature review

Introducción. El síndrome de Sneddon es la asociación de livedo reticularis e ictus. Estos son casi siempre de naturaleza isquémica y, excepcionalmente, hemorrágicos. Caso clínico. Se trata de una mujer de 39 años de edad con dos abortos, hipertensión arterial mal controlada, tabaquismo y obesidad como antecedentes. Desde hacía unos 14 años presentaba una livedo reticularis y un fenómeno de Raynaud. Acudió a nuestro Servicio de Urgencias por un cuadro de cefalea intensa, de inicio brusco, junto a entumecimiento y debilidad de los miembros izquierdos. En la exploración física se objetivó una livedo reticularis generalizada y una focalidad neurológica consistente en parálisis facial supranuclear izquierda, hemiparesia izquierda de predominio crural y hemihipoalgesia y hemihipoestesia izquierdas. La tomografía axial computarizada craneal mostró un hematoma lobar parietooccipital derecho. La resonancia magnética craneal descartó otras lesiones. El estudio inmunológico, incluidos los anticuerpos antifosfolípido, resultó negativo. La arteriografía cerebral demostró la existencia de irregularidades en las ramas más distales de las arterias intracraneales. Las biopsias de piel y de arteria interdigital dieron resultados inespecíficos. Conclusión. La asociación en nuestra paciente de livedo reticularis e ictus, junto a los hallazgos angiográficos, justifican el diagnóstico de síndrome de Sneddon. Respecto a otros casos comunicados, destaca el inicio con un ictus hemorrágico y la localización lobar del sangrado (AU)

Introduction. Sneddon’s syndrome is the association between livedo reticularis and stroke. Hemorrhagic strokes in Sneddon’s syndrome are exceptional. Case report. A 39-year-old woman who had had a livedo reticularis for about 14 years attended the Emergency Unit complaining of sudden, severe headache and numbness and weakness in her left extremities. Physical examination revealed left supranuclear facial palsy and left crural hemiparesis and hemihypoalgesia. Cranial CT showed a right parieto-occipital lobar haemorrhage. Immunological studies, including antiphospholipid antibodies, were negative. A cerebral angiography showed anomalies in most distal branches of intracranial arteries. Biopsies of the skin and digital arteries yielded non conclusive results. Conclusion. The association between livedo reticularis and stroke, together with the angiographic findings led us to the diagnosis of Sneddon’s syndrome. When comparing our case with similar ones, we must point out to its onset with a hemorrhagic stroke and to the lobar location of the bleeding (AU)

[Multiple sclerosis and neurocysticercosis: a diagnostic dilemma]. / Esclerosis múltiple y neurocisticercosis. dilema diagnóstico.

INTRODUCTION: Both Multiple Sclerosis (MS) and Neurocysticercosis (NC) are two entities in which clinical manifestations, neuroimaging findings and immunoserologic assays are neither pathognomonic nor specific requiring for their diagnosis an accurate examination of the clinical history of patients and an adequate follow up. CASE REPORTS: Two patients who consulted non neurologists about focal neurological symptoms. Neuroimaging findings revealed multiple lesions, some of them contrast enhanced. A diagnosis of neurocysticercosis was established, supported in one of the patients by positive serologic assays for cysticerci and antihelmintic therapy began to be administered. Observing the clinical evolution of the patients, monitoring their clinical history and considering the diagnostic criteria proposed by McDonald for MS and by Del Brutto for NC the patients were finally diagnosed of MS. CONCLUSION: The first step to reach a diagnosis of MS is to consider such a possibility. The diagnosis is mainly based on clinical grounds and it is necessary to prove that symptoms disseminate or that alterations occur in neuroimaging findings both in time and space. It is of the utmost importance to establish a differential diagnosis with other conditions presenting with similar clinical manifestations, neuroimaging findings and cerebrospinal fluid tests results. Even with the latest criteria proposed for the diagnosis of MS and NC we may have doubts making it fundamental to cautiously interpret the clinical manifestations and tests results.

Esclerosis múltiple y neurocisticercosis. Dilema diagnóstico / Multiple sclerosis and neurocysticercosis: a diagnostic dilemma

Introducción. La esclerosis múltiple (EM) y la neurocisticercosis (NC) son dos entidades cuyas manifestaciones clínicas, hallazgos en neuroimagen y estudios inmunológicos y serológicos no son patognomónicos ni específicos, y una buena historia clínica y un buen seguimiento son fundamentales para el diagnóstico. Casos clínicos. Se trata de dos casos que consultaron por síntomas neurológicos focales, con el hallazgo en la neuroimagen de múltiples lesiones, algunas de ellas captadoras de contraste; se diagnosticó por ello, apoyado en uno de los casos por serología positi va para cisticerco, de NC, y se instauró un tratamiento antiparasitario. Con la evolución clínica, una historia clínica dirigida y sobre la base de los criterios diagnósticos propuestos por McDonald para la EM y por Del Brutto para la NC, se diagnosticaron de EM. Conclusiones. El primer escalón para llegar al diagnóstico de EM es plantearse esa posibilidad. El diagnóstico es todavía fundamentalmente clínico y precisa que se demuestre diseminación de síntomas, o cambios en la neuroimagen, tanto en el espacio como en el tiempo. Es preciso establecer el diagnóstico diferencial con otras entidades que comparten similitudes en la clínica, la neuroimagen y los hallazgos del LCR. Aun con los últimos criterios propuestos para el diagnóstico de EM y NC, pueden plantearse dudas que obligan a una interpretación cautelosa de la clínica y los resultados de los estudios (AU)

Introduction. Both multiple sclerosis (MS) and neurocysticercosis (NC) are two entities in which clinical manifestations, neuroimaging findings and immunoserologic assays are neither pathognomonic nor specific requiring for their diagnosis an accurate examination of the clinical history of patients and an adequate follow-up. Case reports. Two patients who consulted non neurologists about focal neurological symptoms. Neuroimaging findings revealed multiple lesions, some of them contrast-enhanced. A diagnosis of neurocysticercosis was established, supported in one of the patients by positive serologic assays for cysticerci and antihelmintic therapy began to be administered. Observing the clinical evolution of the patients, monitoring their clinical history and considering the diagnostic criteria proposed by McDonald for MS and by Del Brutto for NC the patients were finally diagnosed of MS. Conclusion. The first step to reach a diagnosis of MS is to consider such a possibility. The diagnosis is mainly based on clinical grounds and it is necessary to prove that symptoms disseminate or that alterations occur in neuroimaging findings both in time and space. It is of the utmost importance to establish a differential diagnosis with other conditions presenting with similar clinical manifestations, neuroimaging findings and cerebrospinal fluid tests results. Even with the latest criteria proposed for the diagnosis of MS and NC we may have doubts making it fundamental to cautiously interpret the clinical manifestations and tests results (AU)

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

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