Contraindications to intravenous thrombolysis in prehospital triage of thrombectomy candidates.

BACKGROUND AND PURPOSE: The existence of contraindications to intravenous thrombolysis (IVT) is considered a criterion for direct transfer of patients with suspected acute stroke to thrombectomy-capable centers in the prehospital setting. Our aim was to assess the utility of this criterion in a setting where routing protocols are defined by the Madrid - Direct Referral to Endovascular Center (M-DIRECT) prehospital scale. METHODS: This was a post hoc analysis of the M-DIRECT study. Reported contraindications to IVT were retrospectively collected from emergency medical services reports and categorized into late window, anticoagulant treatment and other contraindications. Final diagnosis and treatment rates were compared between patients with and without reported IVT contraindications and according to anticoagulant treatment or late window categories. RESULTS: The M-DIRECT study included 541 patients. Reported IVT contraindications were present in 227 (42.0%) patients. Regarding final diagnosis no significant differences were found between patients with or without reported IVT contraindications: ischaemic stroke (any) 65.6% vs. 62.1%, ischaemic stroke with large vessel occlusion (LVO) 32.2% vs. 28.3%, hemorrhagic stroke 15.4% vs. 15.6%, stroke mimic 18.9% vs. 22.3% respectively. Amongst patients with LVO, endovascular thrombectomy (EVT) was performed less often in the presence of IVT contraindications (56.2% vs. 74.2%). M-DIRECT-positive patients had higher rates of LVO and EVT compared with M-DIRECT-negative patients independent of reported IVT contraindications. CONCLUSIONS: Reported IVT contraindications alone do not increase EVT likelihood and should not be considered to determine routing in urban stroke networks.

The Direct Referral to Endovascular Center criteria: a proposal for pre-hospital evaluation of acute stroke in the Madrid Stroke Network.

BACKGROUND AND PURPOSE: For patients with acute ischaemic stroke due to large-vessel occlusion, it has recently been shown that mechanical thrombectomy (MT) with stent retrievers is better than medical treatment alone. However, few hospitals can provide MT 24 h/day 365 days/year, and it remains unclear whether selected patients with acute stroke should be directly transferred to the nearest MT-providing hospital to prevent treatment delays. Clinical scales such as Rapid Arterial Occlusion Evaluation (RACE) have been developed to predict large-vessel occlusion at a pre-hospital level, but their predictive value for MT is low. We propose new criteria to identify patients eligible for MT, with higher accuracy. METHODS: The Direct Referral to Endovascular Center criteria were defined based on a retrospective cohort of 317 patients admitted to a stroke center. The association of age, sex, RACE scale score and blood pressure with the likelihood of receiving MT were analyzed. Cut-off points with the highest association were thereafter evaluated in a prospective cohort of 153 patients from nine stroke units comprising the Madrid Stroke Network. RESULTS: Patients with a RACE scale score ≥ 5, systolic blood pressure <190 mmHg and age <81 years showed a significantly higher probability of undergoing MT (odds ratio, 33.38; 95% confidence interval, 12-92.9). This outcome was confirmed in the prospective cohort, with 68% sensitivity, 84% specificity, 42% positive and 94% negative predictive values for MT, ruling out 83% of hemorrhagic strokes. CONCLUSIONS: The Direct Referral to Endovascular Center criteria could be useful for identifying patients suitable for MT.

High frequency of endoluminal thrombus in patients with ischaemic stroke following AARS-CoV-2 infection.

BACKGROUND: Ischaemic stroke may be a major complication of SARS-CoV-2 infection. Studying and characterising the different aetiological subtypes, clinical characteristics, and functional outcomes may be valuable in guiding patient selection for optimal management and treatment. METHODS: Data were collected retrospectively on consecutive patients with COVID-19 who developed acute focal brain ischaemia (between 1 March and 19 April 2020) at a tertiary university hospital in Madrid (Spain). RESULTS: During the study period, 1594 patients were diagnosed with COVID-19. We found 22 patients with ischaemic stroke (1.38%), 6 of whom did not meet the inclusion criteria. The remaining 16 patients were included in the study (15 cases of ischaemic stroke and one case of transient ischaemic attack). Median baseline National Institutes of Health Stroke Scale score was 9 (interquartile range: 16), and mean (standard deviation) age was 73 years (12.8). Twelve patients (75%) were men. Mean time from COVID-19 symptom onset to stroke onset was 13 days. Large vessel occlusion was identified in 12 patients (75%). We detected elevated levels of D-dimer in 87.5% of patients and C-reactive protein in 81.2%. The main aetiology was atherothrombotic stroke (9 patients, 56.3%), with the predominant subtype being endoluminal thrombus (5 patients, 31.2%), involving the internal carotid artery in 4 cases and the aortic arch in one. The mortality rate in our series was 44% (7 of 16 patients). CONCLUSIONS: In patients with COVID-19, the most frequent stroke aetiology was atherothrombosis, with a high proportion of endoluminal thrombus (31.2% of patients). Our clinical and laboratory data support COVID-19-associated coagulopathy as a relevant pathophysiological mechanism for ischaemic stroke in these patients.

Levetiracetam efficacy in patients with Lennox-Gastaut syndrome. Presentation of a case.

INTRODUCTION: The Lennox-Gastaut syndrome (LGS) is one of the most severe epileptic encephalopathies of childhood, characterized by electro-clinical triad of generalized spike-wave activity, slow (POL) in the electroencephalogram (EEG), multiple types of seizures and development delay. This paper intends to describe the syndrome in a patient with a history of hypoxic-ischaemic encephalopathy and Lennox-Gastaut syndrome, and a good response to treatment with levetiracetam (LEV). METHOD: Descriptive study on the development of a 3 year old child with intrauterine asphyxia, multiorgan failure, metabolic acidosis, hypovolemic shock, and seizures with cerebral oedema, who developed a West syndrome, resistant to drug treatment. The semiology of seizures progressively changed to generalized episodes of hypertonia and myoclonus, with slow spike-wave electroencephalographic activity. RESULTS: With the diagnosis of Lennox-Gastaut syndrome the patient was treated with levetiracetam, showing a substantial improvement in the cognitive sphere, in the control of seizures, and electroencephalographic findings. CONCLUSIONS: Lennox-Gastaut syndrome is one of the most severe epileptic syndromes in paediatric patients. Levetiracetam can help cognitive improvement, and contribute to seizure control in these patients.

High frequency of endoluminal thrombus in patients with ischaemic stroke following SARS-CoV-2 infection. / Alta frecuencia de trombo endoluminal en pacientes con ictus isquémico tras la infección por coronavirus 2019.

BACKGROUND: Ischaemic stroke may be a major complication of SARS-CoV-2 infection. Studying and characterising the different aetiological subtypes, clinical characteristics, and functional outcomes may be valuable in guiding patient selection for optimal management and treatment. METHODS: Data were collected retrospectively on consecutive patients with SARS-CoV-2 infection who developed acute focal brain ischaemia (between 1 March and 19 April 2020) at a tertiary university hospital in Madrid (Spain). RESULTS: During the study period, 1594 patients were diagnosed with COVID-19. We found 22 patients with ischaemic stroke (1.38%), 6 of whom did not meet the inclusion criteria. The remaining 16 patients were included in the study (15 cases of ischaemic stroke and one case of transient ischaemic attack). Median baseline National Institutes of Health Stroke Scale score was 9 (interquartile range: 16), and mean (standard deviation) age was 73 years (12.8). Twelve patients (75%) were men. Mean time from COVID-19 symptom onset to stroke onset was 13 days. Large vessel occlusion was identified in 12 patients (75%). We detected elevated levels of D-dimer in 87.5% of patients and C-reactive protein in 81.2%. The main aetiology was atherothrombotic stroke (9 patients, 56.3%), with the predominant subtype being endoluminal thrombus (5 patients, 31.2%), involving the internal carotid artery in 4 cases and the aortic arch in one. The mortality rate in our series was 44% (7 of 16 patients). CONCLUSIONS: In patients with COVID-19, the most frequent stroke aetiology was atherothrombosis, with a high proportion of endoluminal thrombus (31.2% of patients). Our clinical and laboratory data support COVID-19-associated coagulopathy as a relevant pathophysiological mechanism for ischaemic stroke in these patients.

Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan. / Impacto de la pandemia de COVID-19 en la organización asistencial del ictus. Plan Ictus Madrid.

INTRODUCTION: The overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. METHODS: We conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). RESULTS: The survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. CONCLUSIONS: The organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up.

Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations. / Atención al ictus agudo durante la pandemia por COVID-19. Recomendaciones Plan Ictus Madrid.

INTRODUCTION: The COVID-19 pandemic has resulted in complete saturation of healthcare capacities, making it necessary to reorganise healthcare systems. In this context, we must guarantee the provision of acute stroke care and optimise code stroke protocols to reduce the risk of SARS-CoV-2 infection and rationalise the use of hospital resources. The Madrid Stroke multidisciplinary group presents a series of recommendations to achieve these goals. METHODS: We conducted a non-systematic literature search using the keywords "stroke" and "COVID-19" or "coronavirus" or "SARS-CoV-2." Our literature review also included other relevant studies known to the authors. Based on this literature review, a series of consensus recommendations were established by the Madrid Stroke multidisciplinary group and its neurology committee. RESULTS: These recommendations address 5 main objectives: 1) coordination of action protocols to ensure access to hospital care for stroke patients; 2) recognition of potentially COVID-19-positive stroke patients; 3) organisation of patient management to prevent SARS-CoV-2 infection among healthcare professionals; 4) avoidance of unnecessary neuroimaging studies and other procedures that may increase the risk of infection; and 5) safe, early discharge and follow-up to ensure bed availability. This management protocol has been called CORONA (Coordinate, Recognise, Organise, Neuroimaging, At home). CONCLUSIONS: The recommendations presented here may assist in the organisation of acute stroke care and the optimisation of healthcare resources, while ensuring the safety of healthcare professionals.

[Alteplase treatment for acute stroke 2007: an effective therapeutic option at our disposal]. / Tratamiento con alteplasa en el infarto cerebral agudo 2007: una opción terapéutica efectiva a nuestro alcance.

INTRODUCTION: The greatest progress has been made in the research field based on the early arterial recanalization strategy in cerebral ischemia. AIM: To carry out a revision of stroke treatment with intravenous thrombolysis during the therapeutic window period covering the first three hours of evolution. The revision focuses on information provided by clinical trials, meta-analysis and open-label reports studies. DEVELOPMENT: Clinical trials that study the use of alteplase in the acute stroke treatment, especially the two phase III clinical trials carried out by the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, are described. A great deal of useful information has been provided through systematic revisions that analyze data on these treatment clinical trials jointly. Meta-analysis studies are described: the Pooled Analysis of ATLANTIS, ECASS and NINDS t-PA Stroke Trials, Cochrane Meta-analysis: Thrombolysis for Acute Ischemic Stroke. Community based studies, especially the SITS-MOST study, were revised, and their findings were compared with other open-label t-PA studies. CONCLUSIONS: t-PA is effective when administered in the first three hours of evolution of stroke in selected patients and under ideal conditions, and it may be beneficial, using the same selection criteria, in a therapeutic window of four and a half hours. The treatment is effective when applied as part of the daily clinical practice in our environment. This effectiveness does not disappear when extending its use to a large number of qualified hospitals.

[Preadmission statins treatment in stroke patients: opportunity to treat high vascular risk patients]. / Antecedente del uso de estatinas en el ictus: oportunidad de mejora en el paciente con alto riesgo vascular por aterotrombosis.

AIM: To describe the use of preadmission statins in patients with cerebrovascular accident and the possible predictive factors. PATIENTS AND METHODS: Cross-sectional observational study of 795 consecutive patients with acute cerebrovascular accident. We assessed the differences among patients who were on preadmission statins (161) and those who were not (634), regarding vascular risk factors and clinical and neurosonological atherothrombotic disease markers. For univariate analysis, we used squared chi test, and for multivariate analysis, logistic regression analysis. RESULTS: Preadmission statins were 20.3%. In high vascular risk patients defined based on National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III), this reached 28% and it might be 72%. Predictive factors for preadmission statins use were, in a positive sense, the antecedent of hypercholesterolemia diagnosis (OR = 189; 95% CI = 58-615; p < or = 0.001) and stroke (OR = 2.1; 95% CI = 1.2-3.6; p < or = 0.01), and in a negative sense, smoking (OR = 0.38; 95% CI = 0.18-0.81; p = 0.012). CONCLUSIONS: In our population of patients with stroke, the predictive factors of preadmission statins did not adjust to the current therapeutic NCEP-ATP III recommendations; treatment with statins in high vascular risk population was way below the indications, it was 28% and it might be 72%.

[Familial microepidemic of food-borne botulism in the Region of Madrid]. / Microepidemia familiar de botulismo alimentario en la Comunidad de Madrid.

INTRODUCTION: Botulism is a syndrome caused by the toxin of the bacillus Clostridium botulinum. The toxin acts by blocking the presynaptic cholinergic endings of the neuromuscular junction and of the parasympathetic nervous system, and gives rise to a flaccid paralysis and parasympathetic failure. The most common way to catch the disease is by ingestion of the preformed toxin present in badly sterilised home-made preserves, although other mechanisms are also possible. Its incidence in Spain today is very low. CASE REPORTS: We report the case of three members of a family living together who presented a clinical picture of food-borne botulism. The initial clinical symptoms showed a predilection for ocular paresis and for dysautonomic symptoms of little specificity, and the familial aggregation was the fundamental evidence that suggested the diagnosis. Later, the patients' state got worse and two of them presented involvement of the respiratory function and required a lengthy stay in the intensive care unit. After a period of convalescence the three patients recovered without any sequelae. Botulinum toxin was detected by bioassay in some food samples, which allowed the diagnosis to be categorised as confirmed. CONCLUSIONS: The familial microepidemic reported here is a case of predominantly ocular and dysautonomic involvement. Likewise, it illustrates several aspects that are typical of the disease: the suspected diagnosis in cohabiting patients who visit at the same time for a similar clinical picture, the characteristic complications of the process and its treatment, the laboratory diagnosis and its natural history towards resolution.

TITLE: Microepidemia familiar de botulismo alimentario en la Comunidad de Madrid.Introduccion. El botulismo es un sindrome causado por la toxina del bacilo Clostridium botulinum. La toxina actua bloqueando las terminaciones colinergicas presinapticas de la placa motora y del sistema nervioso parasimpatico, y ocasiona una paralisis flacida y un fallo parasimpatico. El modo mas habitual de adquisicion de la enfermedad es por ingesta de toxina preformada presente en las conservas caseras mal esterilizadas, aunque otros mecanismos son posibles. Su incidencia actual en Espana es muy baja. Casos clinicos. Se describen tres miembros convivientes de una familia que presentaron un cuadro de botulismo alimentario. Las manifestaciones clinicas iniciales mostraron predileccion por la paresia ocular y por sintomatologia disautonomica de escasa especificidad, y la agregacion familiar fue el indicio fundamental que sugirio el diagnostico. Posteriormente, los pacientes empeoraron y dos de ellos presentaron afectacion de la funcion respiratoria y precisaron ingreso prolongado en la unidad de cuidados intensivos. Los tres pacientes convalecieron y se recuperaron sin secuelas. Se consiguio detectar la toxina botulinica por bioensayo en los restos de alimentos, lo que confiere al caso la categoria diagnostica de confirmado. Conclusiones. La microepidemia familiar presentada constituye un caso de afectacion inicial predominantemente ocular y disautonomica. Asimismo, ilustra varios aspectos tipicos de la enfermedad: la sospecha diagnostica ante pacientes convivientes que acuden simultaneamente por clinica similar, las complicaciones caracteristicas del proceso y su tratamiento, el diagnostico de laboratorio y su historia natural hacia la resolucion.

[Neuropathic pain as the reason for visiting Neurology: an analysis of its frequency]. / El dolor neuropático como motivo de consulta en Neurología: análisis de su frecuencia.

INTRODUCTION: Neuropathic pain (NP) is defined as pain that begins with or is caused by a primary injury or by a dysfunction in the nervous system. AIMS: Our aim was to evaluate how often patients visit Neurology as outpatients with NP as the main reason for referral. PATIENTS AND METHODS: A descriptive, cross sectional study was carried out on the use of the health care services; patients attended for the first time in a Neurology Screening visit were included consecutively. The variables studied were the following: the number of first visits and the total number of patients attended per visiting session, rate of patients with NP per visiting day, the topography and probable causation of the NP, and the rate of patients referred to the monographic NP clinic; the different quantitative variables are expressed in terms of their mean and standard deviation (SD), whereas the qualitative variables are given as their absolute value and the percentage. A total of 1,972 patients were attended, of whom 1,422 (72.1%) were first visits, with an average of 17.5 (SD: 2.5) new patients per visiting session. RESULTS: In all 113 patients clinically diagnosed with NP were identified, which represents a rate of 7.95% of the first visits. CONCLUSIONS: NP may be among the most frequent causes of the demand for neurological ambulatory care. The most common causes of NP were found to be trigeminal neuralgia, post-herpes neuralgia and diabetic polyneuropathy.

[Delays before and after arrival at the hospital in the treatment of strokes]. / Retraso extrahospitalario e intrahospitalario en el tratamiento del ictus.

INTRODUCTION: Only a minority of patients with acute stroke are eligible for fibrinolysis, and the main reason for this is that time runs out and goes beyond the therapeutic window. The chief delay occurs prior to arrival at the hospital, but there is also a nosocomial delay, which has received far less attention. AIMS: The purpose of our study was to describe the data on delays occurring before and after arrival at the hospital in a sample of patients with acute stroke, and to analyse possible associated factors, including the overload on health care services in the Emergency department, an aspect that has not previously been evaluated. PATIENTS AND METHODS: Epidemiological data, times of delays before and after entering the hospital, means of transport used and the health care workload in the Emergency department of the day of admission were collected for all the stroke patients admitted to the Stroke Unit of the Hospital General Universitario de Alicante throughout the period under study. RESULTS: From an initial sample of 460 patients, 423 were finally included in the study, with a mean delay before and after admission to hospital of 3.99 and 2.36 hours, respectively. Use of an ambulance and the haemorrhagic and transient ischemic attack subtypes were linked to a shorter delay before reaching the hospital, and arrival during the night shift was the only factor associated to a longer delay once inside the hospital. CONCLUSIONS: In our environment, there is a need to establish strategies aimed at shortening the times stroke patients take to reach the hospital and the time that elapses before they are attended.

[Prevalence of neurosonographic disturbances in chronic instability]. / Prevalencia de alteraciones neurosonológicas en la inestabilidad crónica.

INTRODUCTION: Dizziness is a common symptom at the outpatient clinic of family doctors. Its origin is usually multifactorial and its outcome is often benign. However, exists a tendency to relate the dizziness with a cerebrovascular disturbance. AIM. To determine if there are cerebrovascular disorders in patients with chronic dizziness using a non invasive technique. PATIENTS AND METHODS: A prospective study was conducted. It included 404 patients without limit of age. The patients were evaluated in a Neurology Outpatient Clinic, to select those patients with chronic instability. A neurosonographic exam was performed to all those selected patients. This exam included colour duplex of the cervical arteries and transcranial Doppler. RESULTS: Up to 54 % of the patients who were included in the study had a normal carotid study. For the rest of the patients, the thickness intima-media was the most prevalent finding. At the vertebrobasilar system the study of the vertebral arteries was completely normal in 81.7% followed by the presence of microangiopathy in 12.1%. The basilar system was also normal in a high figure (78%) followed by the microangiopathy (17.1%). CONCLUSIONS: The vascular disturbances in the vertebrobasilar system are an exceptional finding in patients with chronic instability.

Impacto de la pandemia de COVID-19 en la organización asistencial del ictus. Plan Ictus Madrid Pandemia COVID-19. Impacto en la asistencia del ictus. Plan Ictus Madrid / Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan

INTRODUCCIÓN: La sobrecarga asistencial y los cambios organizativos frente a la pandemia de COVID-19 podrían estar repercutiendo en la atención al ictus agudo en la Comunidad de Madrid. MÉTODOS: Encuesta estructurada en bloques: características del hospital, cambios en infraestructura y recursos, circuitos de código ictus, pruebas diagnósticas, rehabilitación y atención ambulatoria. Análisis descriptivo según el nivel de complejidad en la atención del ictus (disponibilidad o no de unidad de ictus y de trombectomía mecánica). RESULTADOS: De los 26 hospitales del SERMAS que atienden urgencias en adultos, 22 cumplimentaron la encuesta entre el 16 y 27 de abril. El 95% han cedido neurólogos para atender a pacientes afectados por la COVID-19. Se han reducido camas de neurología en el 89,4%, modificado los circuitos en urgencias para ictus en el 81%, con circuitos específicos para sospecha de infección por SARS-CoV2 en el 50%, y en el 42% de los hospitales los pacientes con ictus agudo positivos para SARS-CoV2 no ingresan en camas de neurología. Ha mejorado el acceso al tratamiento, con trombectomía mecánica las 24 h en el propio hospital en 10 hospitales, y se han reducido los traslados interhospitalarios secundarios. Se ha evitado el ingreso de pacientes con ataque isquémico transitorio o ictus leve (45%) y se han incorporado consultas telefónicas para seguimiento en el 100%. CONCLUSIONES: Los cambios organizativos de los hospitales de la Comunidad de Madrid frente a la pandemia por SARS-Co2 han modificado la dedicación de recursos humanos e infraestructuras de las unidades de neurología y los circuitos de atención del ictus, realización de pruebas diagnósticas, ingreso de los pacientes y seguimiento

INTRODUCTION: The overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. METHODS: We conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). RESULTS: The survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. CONCLUSIONS: The organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up

[Binocular diplopy as the presentation of a haematoma in the rectus inferior]. / Diplopía binocular como presentación de un hematoma del recto inferior.

INTRODUCTION: The presence of quick onset binocular diplopy makes it essential to carry out a comprehensive differential diagnosis. The most frequent causes in adults include vascular, post-traumatic, tumorous and myopathic pathologies. Yet, to perform a differential diagnosis we also have to take into account less common aetiologies such as demyelinating disease, carotid-cavernous fistulas and Tolosa Hunt syndrome, among others. We report the case of a patient who was admitted to our hospital because she presented an acute onset diplopy secondary to a spontaneous haematoma of the left rectus inferior. CASE REPORT: We describe the case of a 54-year-old female with a history of hypercholesterolemia, who was a smoker and allergic to iodine contrasts and who visited because of an acute onset diplopy accompanied by instability and pain in the left eye. The neurological examination revealed paresis of the extraocular muscles dependent on the left oculomotor nerve with left palpebral ptosis, paresis of the rectus inferior, with no involvement of the pupils. Other results of the exploration were within normal limits. A computerised axial tomography scan of the head showed a haemorrhage in the rectus inferior. Magnetic resonance images of the head revealed an increase in the volume of the left-side rectus inferior with signs of bleeding, and the rest of the complementary explorations were normal. The patient progressed favourably and the diplopy gradually disappeared. CONCLUSIONS: Spontaneous bleeding of the extraocular muscles, although infrequent, must be taken into account in the differential diagnosis of painful ophthalmoplegia with diplopy in patients with no underlying pathology, especially in the absence of other neurological disorders.

[Neurosonological findings in the carotid artery in a sample of patients with lacunar infarction]. / Hallazgos neurosonológicos carotídeos en una muestra de pacientes con infarto lacunar.

INTRODUCTION: Carotid stenosis has been reported as being associated to lacunar infarcts (LI) with variable frequency, but the aetiopathogenic relation between them is still subject to some controversy. AIMS: Our aim was to describe the prevalence of carotid disorders in a neurosonological study of a sample of patients with LI. PATIENTS AND METHODS: We analysed the results of the neurosonological study conducted on patients with clinical-radiological criteria of LI who were admitted to our Stroke Unit during the period of study. RESULTS: We studied 140 patients, and results were normal in only 42% of the cases. Stenosis > 50% was found in 10% of the cases and plaque without stenosis in 40.3% of the patients. In patients without plaque there was an increase in the tunica intima-media thickness in 7.2% of the cases. CONCLUSION: In most of the patients with LI there were anomalies in the study of the carotid performed using ultrasound scanning.

[Evaluation of hemodynamic parameters by transcranial Doppler in patients with leukoaraiosis]. / Estudio de los parámetros hemodinámicos en pacientes con leucoaraiosis mediante Doppler transcraneal.

INTRODUCTION: Leukoaraiosis is commonly found in neuroimaging in ancient people. The pathogenic theory that most suitably explains its origin is the vascular one, mainly linked to cerebral hemodynamic abnormalities. The techniques most frequently used in cerebral hemodynamic evaluation (PET and SPECT) are expensive and not widespread. Transcranial Doppler instead is cheaper and much more widespread. OBJECTIVE: Our aim has been to show whether transcranial Doppler is a useful tool for cerebral hemodynamic evaluation in leukoaraiosis. PATIENTS AND METHODS: We have prospectively included 116 patients aged 60-90 who came to the Neurology department with unspecific complaints such as dizziness or mild headache. Patients with recent history of stroke or moderate to severe cognitive impairment were excluded. RESULTS: Mean age was 74.4 +/- 6.3 years old. The prevalence of leukoaraiosis was 68.7%. Leukoaraiosis was significantly correlated with older age, lacunar infarctions, past history of stroke, cognitive impairment and to lower systolic and diastolic velocities in middle cerebral artery (MCA) and higher pulsatility index. Multivariate analysis only retained the lower diastolic velocity in MCA in the model. CONCLUSIONS: Transcranial Doppler can detect hemodynamic abnormalities in patients with leukoaraiosis and is therefore a very useful technique for the evaluation of this entity.

[Stroke and intracranial stenosis: clinical profile in a series of 134 patients in Spain]. / Ictus y estenosis intracraneal: perfil clínico de una serie española de 134 pacientes.

INTRODUCTION: Intracranial stenoses (IS) are known to be a manifestation of atherosclerosis and a cause of cerebral ischemia, although very few clinical reports have appeared describing such patients in our milieu. OBJECTIVE: The aim of this study was to describe the vascular risk factors, clinical presentation, radiological characteristics, aetiological role played in strokes and the vessels affected in a series of Spanish patients suffering from stroke and IS. PATIENTS AND METHODS: We conducted a retrospective descriptive study of patients admitted to the Cerebrovascular Pathology Unit with strokes and IS between 1990 and 2001. Data collected included: age, sex, arterial hypertension (AHT), diabetes (Db), hypercholesterolemia (HC), smoking (Sm), ischemic or emboligenic heart disease, intermittent claudication, carotid atheromatosis, clinical presentation of stroke and earlier lesions in computerised axial tomography (CAT) scans of the brain. RESULTS: 132 patients; 187 stenotic vessels: 65.7% males, mean age 68.3 years. AHT 65%, Db 39%, HC 40%, Sm 43%, ischemic heart disease 22%, emboligenic heart disease 17%, intermittent claudication 13%. CLINICAL PRESENTATION: TIA 16%, LACI 33%; PACI 25%, TACI 4%, POCI 19%. Significant carotid atheromatosis 26.5%. Symptomatic IS 50%: mean age 63.3 years, 64% females. Arteries affected: vertebral (VA) 28%; middle cerebral (MCA) 27%; carotid siphon 21%; basilar (BA) 10% (65% symptomatic); anterior cerebral (ACA) 5% and posterior cerebral (CPA) 4%. Normal cranial CAT scan 24%, lacunar infarcts 42%, territorial 32%; leukoaraiosis 17%. CONCLUSIONS: Patients with stroke and IS display different clinical profiles according to their sex (males: a higher number of vascular risk factors and clinical involvement of other territories; females are more symptomatic, AHT and HC); they usually present clinically as lacunar syndromes, with a scarce amount of significant atheromatous carotid involvement, except IS of the VA, and IS of the BA are the most symptomatic.

[Neurosonological studies in patients over 80 years old]. / Estudio neuroecográfico en mayores de 80 años.

INTRODUCTION: The link between cardiovascular risk factors and carotid atheromatosis has been shown to be more important in middle aged subjects than in the elderly. AIMS: Our aim was to study the frequency of carotid and intracranial atheromatosis in a population over the age of 80 and to compare the presence of neurosonological anomalies depending on whether the patients have suffered a stroke or not. We also wished to compare the findings according to the sex of the patient. PATIENTS AND METHODS: Patients over the age of 80 were studied at our Neurosonology laboratory using carotid and transcranial Doppler ultrasonography. The patients were analysed according to whether they had suffered an ischemic stroke or not. With regard to the carotid, a distinction was made between normal, non-significant atheromatosis and significant atheromatosis (stenosis > 50%). Intracranially, both the middle cerebral artery (normal, stenosis, microangiopathy and post-stenosis) and the basilar artery (normal, stenosis, microangiopathy and hyperdynamics) were studied. RESULTS: We recorded data concerning 832 patients: 342 males (44.1%), mean age 83.63 +/- 3.25 years, and 527 (63.3%) with stroke. The carotid study was pathological, with a higher frequency in stroke patients (32.1% compared with 41.9%; p = 0.002). The presence of atheromatosis was significantly linked to a higher risk of suffering a stroke and more intensely to its being more severe. Carotid studies were pathological with a higher frequency among males (28.7% compared with 40%; p < 0.001). No significant differences were found intracranially in any of the parameters analysed. CONCLUSIONS: There is a high frequency of carotid atheromatosis in patients over 80 years of age. Regardless of the age, carotid atheromatosis appears even more frequently in patients who have suffered a stroke and in males, and is significantly associated to the risk of suffering a stroke. Intracranially, no differences were found.

[Modification of clinical profile of stroke in atrial fibrillation patients. Effect of antithrombotic treatment]. / Modificacion del perfil clinico de los ictus en enfermos con fibrilacion auricular. Efecto del tratamiento antitrombotico.

BACKGROUND: Atrial fibrillation is present in 24% of the population over 60 and it increases the risk of stroke by 2,4% 3%/year. Antithrombotic treatment is considered as the treatment of choice for cardioembolic stroke prevention in this patients. As far as we know there are not relevant data about the influence of these treatments on the type of stroke that may develop in these patients. AIM: Analyze whether there are differences in the clinical profile and functional prognosis after stroke in patients with atrial fibrillation depending on the type of treatment they were on at the time of occurrence of the event. PATIENTS AND METHODS: We identified 67 patients who were admitted consecutively to our stroke unit with a stroke and atrial fibrillation over a period of 2 years. Patients were classified according to the type of antithrombotic treatment they were on. Functional prognosis was estimated by Rankin score at discharge. RESULTS: Treated patient showed a non significant tendency to suffer less severe strokes and present a better functional situation at discharge than those who were not on prophylactic treatment. Treated patients had a significant higher prevalence of previous TIA (44,2% vs 9,1%; p= 0,0042) and HBP (81,4% vs 52%; p= 0,041) than non treated patients. Embolic strokes were more frequent in non treated patients. CONCLUSION: Antithrombotic treatment not only prevents strokes but may also contribute to the development of less severe strokes with a better functional prognosis in patients with AF and does not contribute to increase complications in these group of patients.