Oral anticoagulation and left atrial appendage closure: a new strategy for recurrent cardioembolic stroke.

BACKGROUND AND PURPOSE: There are no recommendations regarding how to treat cardioembolic recurrent strokes when patients are well anticoagulated. We evaluated the safety and efficacy of combining oral anticoagulation (OAC) with percutaneous left atrial appendage closure (LAAC) in patients with well-anticoagulated atrial fibrillation (AF) with recurrent strokes. METHODS: In an explorative, prospective, observational study, LAAC was performed in patients with AF with at least two ischaemic strokes in the previous year, despite good anticoagulation using the Amplatzer Cardiac Plug (St Jude Medical, St Paul, MN, USA) or Amulet Abbot device (Abbot Vascular, Santa Clara, CA, USA). We recorded age, type of AF, CHA2 DS2 -VASC and HAS-BLED scores, types of OAC and risk factors. After closure, treatment with aspirin (100 mg/day) was continued for 3 months in combination with indefinite OAC. Clinical status, recurrent embolisms and bleeding complications were recorded during follow-up. RESULTS: A total of 19 patients were included (mean age, 72.1 ± 9.6 years; mean CHA2 DS2 -VASC score, 5.3 ± 1.48; mean number of previous strokes, 2.78 ± 1.15). Thirteen had spontaneous echocardiographic contrast and all had dilatation of the left atrium. Eighteen patients had a multilobulated left atrial appendage, 17 with 'chicken-wing' morphology and one patient had a left atrial appendage thrombus. There were no complications during the procedure. Only one patient had a transient ischaemic attack and no major bleeding occurred during a mean follow-up of 17.4 ± 11.5 months. CONCLUSION: Combination therapy with indefinite OAC plus LAAC in patients with AF with recurrent strokes despite good anticoagulation should be considered in order to prevent a new stroke.

The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis mimicking an acute stroke.

BACKGROUND AND PURPOSE: The syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) can present as sudden onset of focal neurological deficits which are clinically and radiologically indistinguishable from an ischaemic stroke. Its diagnosis requires a lumbar puncture (LP), which contraindicates intravenous thrombolytic therapy (IV-tPA). METHODS: All patients referred to our stroke centre as a stroke code resulting in a final diagnosis of HaNDL syndrome from June 2005 to June 2015 were retrospectively analysed. RESULTS: Nine cases were identified: seven women and two men (mean age 27.6 years, range 15-51). Clinical onset consisted of isolated aphasia (two) and aphasia with right hemiparesis/hemiparaesthesia (seven). All patients had headache in the acute setting, lasting 2-12 h. Cranial computed tomography (CT) and CT angiography (CTA) were normal in all patients. Perfusion CT was performed in seven patients, showing left hemispheric focal hypoperfusion in five cases; the remaining two were normal. Five patients were initially diagnosed as stroke and treated uneventfully with IV-tPA. Cranial magnetic resonance imaging within 48 h was normal in all cases. LP performed in all patients showed pleocytosis (range 17-351 cells/mm(3) ), high protein levels (range 0.4-1.6 g/l) and normal glucose levels. All cases recovered within 12 h and suffered a second episode within 72 h. Patients were asymptomatic between episodes and after remission. CONCLUSIONS: The decision to thrombolyse or perform an LP in HaNDL patients mimicking a stroke is difficult in the acute setting. Perfusion CT can provide misleading results and CTA may be useful in ruling out occlusion of a cerebral vessel.

A collaborative system for endovascular treatment of acute ischaemic stroke: the Madrid Stroke Network experience.

BACKGROUND AND PURPOSE: The complexity and expense of endovascular treatment (EVT) for acute ischaemic stroke (AIS) can present difficulties in bringing this approach closer to the patients. A collaborative node was implemented involving three stroke centres (SCs) within the Madrid Stroke Network to provide round-the-clock access to EVT for AIS. METHODS: A weekly schedule was established to ensure that at least one SC was 'on-call' to provide EVT for all those with moderate to severe AIS due to large vessel occlusion, >4.5 h from symptom onset, or within this time-window but with contraindication to, or failure of, systemic thrombolysis. The time-window for treatment was 8 h for anterior circulation stroke and <24 h in posterior stroke. Outcomes measured were re-canalization rates, modified Rankin Scale (mRS) score at 3 months, mortality and symptomatic intra-cranial haemorrhage (SICH). RESULTS: Over a 2-year period (2012-2013), 303 candidate patients with AIS were considered for EVT as per protocol, and 196 (65%) received treatment. Reasons for non-treatment were significant improvement (14%), spontaneous re-canalization (26%), clinical worsening (9%) or radiological criteria of established infarction (31%). Re-canalization rate amongst treated patients was 80%. Median delay from symptom onset to re-canalization was 323 min (p25; p75 percentiles 255; 430). Mortality was 11%; independence (mRS 0-2) was 58%; SICH was 3%. CONCLUSIONS: Implementation of a collaborative network to provide EVT for AIS is feasible and effective. Results are good in terms of re-canalization rates and clinical outcomes.

Mechanical thrombectomy beyond 6 hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: experience at a tertiary hospital.

INTRODUCTION: Thrombectomy in the carotid artery territory was recently shown to be effective up to 24 hours after symptoms onset. METHODS: We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6 hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. RESULTS: Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting > 50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24 hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. CONCLUSION: In our experience, mechanical thrombectomy beyond 6 hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24 hours after onset merits study.

[Neurology in The Adventures of Tintin]. / La neurología en Las aventuras de Tintín.

INTRODUCTION: The presence of disease is a recurring theme in Herge's famous saga, The Adventures of Tintin, and has been reflected in a number of publications. However, the appearance of neurological disease in the work has received little attention from scholars. DEVELOPMENT: A review was conducted of the neurological symptoms that appear in the work published from 1930 to 1976 and their interpretation from a neurological point of view. The possible neurological symptoms in the main characters of the series have been analysed. Head trauma, the neurological sequelae of alcohol and dementia could explain some of the characters' behaviour. This study outlines these cases and their probable interpretation from a neurological perspective. CONCLUSION: Hardly any analyses and interpretations have been carried out on the presence of neurological disease in The Adventures of Tintin series. The work can be used as an informative example of neurological disease.

TITLE: La neurología en Las aventuras de Tintín.Introducción. La presencia de la enfermedad es un hecho recurrente en la famosa saga del autor Hergé, Las aventuras de Tintín, que se ha reflejado en algunos trabajos publicados. No obstante, la aparición de la enfermedad neurológica en la obra ha sido un hecho poco analizado. Desarrollo. Revisión de los síntomas neurológicos en los álbumes publicados desde 1930 a 1976 y su interpretación desde un punto de vista neurológico. Se han analizado los posibles síntomas neurológicos en los principales personajes de la serie. El trauma craneal, las secuelas neurológicas del alcohol y la demencia podrían explicar algunos comportamientos de los personajes. En este trabajo se exponen éstos y su probable interpretación desde un punto de vista neurológico. Conclusión. La presencia de la enfermedad neurológica en la serie Las aventuras de Tintín ha sido poco analizada e interpretada. La obra puede usarse como ejemplo divulgativo de la enfermedad neurológica.

Mechanical thrombectomy beyond 6hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: Experience at a tertiary hospital. / Trombectomía mecánica más allá de 6horas en ictus isquémico agudo con oclusión de gran vaso en territorio carotídeo: experiencia en un hospital terciario.

INTRODUCTION: Thrombectomy in the carotid artery territory was recently shown to be effective up to 24hours after symptoms onset. METHODS: We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. RESULTS: Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting>50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. CONCLUSION: In our experience, mechanical thrombectomy beyond 6hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24hours after onset merits study.

Intravenous thrombolysis for acute ischemic stroke in centenarians.

PURPOSE: The benefit of intravenous alteplase is well established for patients with disabling stroke symptoms regardless of age, although data on outcomes in centenarian patients are scarce. We present our experience in patients beyond 100 years. METHODS: Descriptive study including centenarians from our single-centre prospective registry who underwent intravenous thrombolysis with alteplase for acute ischemic stroke in our tertiary university hospital. Clinical variables and functional outcome at 3 months were collected. RESULTS: Four patients, all women, functionally independent (mRS ≤ 2) were included. Treatment with alteplase was applied within 4.5 h of stroke onset. One patient complicated with pneumonia and died. Two patients were functionally independent (mRS ≤ 2) at discharge, while the third was partially dependent (mRS of 3 at discharge), improving after 3 months, (mRS 2). No serious hemorrhagic or systemic adverse events were registered. CONCLUSION: In our experience, intravenous thrombolysis may be beneficial and should be considered in patients over 100 years old with no previous disability.

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 global amnesia as an exclusive presenting symptom of thalamic infarct: a diagnostic challenge]. / Amnesia global aguda como forma exclusiva de presentacion de infarto talamico: un reto diagnostico.

INTRODUCTION: Isolated acute amnesia is an exceptional presenting symptom of thalamic stroke. This study analyses the clinical profile, the diagnosis, the treatment and the prognosis of these patients. CASE REPORTS: We conducted a retrospective review of the cases of thalamic infarct that presented exclusively as acute amnesia in our university tertiary hospital (n = 3) and a review of similar cases in PubMed (n = 20). 48% presented at least one risk factor of stroke (arterial hypertension, dyslipidaemia, diabetes mellitus, atrial fibrillation or a previous stroke). Amnesia was anterograde in three cases (13%) and global in the remaining 20 (87%). The infarct was detected in neuroimaging studies carried out within the first 24 hours in one patient (4%) and later in all the others; the average time until a diagnosis was established was 11 days. The initial CT scan was normal in five patients (22%). Eight cases (35%) required magnetic resonance imaging to detect the infarct. Of these, four subjects were studied directly with MR imaging. Amnesia clearly improved in eight patients (35%), and three of them (13%) made a full recovery. Fifteen patients (65%) presented mnemonic sequelae that interfered with their functional capacity. The clinical picture lasted less than 24 hours in two patients (9%). None of the cases received revasculisation therapy in the acute phase. CONCLUSION: The diagnosis of thalamic infarcts that begin exclusively with amnesia is very difficult and this has negative repercussions on their treatment in the acute phase. These infarcts can produce a functionally disabling memory deficit in a high percentage of patients.

TITLE: Amnesia global aguda como forma exclusiva de presentacion de infarto talamico: un reto diagnostico.Introduccion. La amnesia aguda aislada es una forma excepcional de presentacion del ictus talamico. Se analizan el perfil clinico, el diagnostico, el tratamiento y el pronostico de estos pacientes. Casos clinicos. Revision retrospectiva de los casos de infarto talamico que se presentaron exclusivamente como amnesia aguda en nuestro hospital terciario universitario (n = 3) y revision de casos similares en PubMed (n = 20). El 48% presentaba al menos un factor de riesgo de ictus (hipertension arterial, dislipidemia, diabetes mellitus, fibrilacion auricular o ictus previo). La amnesia fue anterograda en tres casos (13%) y global en los otros 20 (87%). El infarto se detecto en estudio de neuroimagen en las primeras 24 horas en un paciente (4%) y posteriormente en los demas, y la media de dias hasta el diagnostico fue de 11. La tomografia computarizada inicial fue normal en cinco (22%) pacientes. Precisaron estudio por resonancia magnetica ocho (35%) casos para detectar el infarto. De estos, cuatro sujetos se estudiaron directamente con resonancia magnetica. La amnesia presento una mejoria clara en ocho (35%) pacientes, y la recuperacion fue completa en tres (13%). Las secuelas mnesicas que interferian la capacidad funcional se presentaron en 15 pacientes (65%). La clinica persistio menos de 24 horas en dos pacientes (9%). Ningun caso recibio tratamiento revascularizador en fase aguda. Conclusion. Los infartos talamicos que comienzan de forma exclusiva con amnesia presentan notables dificultades diagnosticas que repercuten negativamente en su tratamiento en la fase aguda. Estos infartos pueden producir un deficit mnesico funcionalmente discapacitante en un porcentaje elevado de pacientes.

Reperfusion therapy in patients with acute ischaemic stroke caused by cervical artery dissection. / Tratamientos de reperfusión en el infarto cerebral agudo por disección de arterias cervicales.

INTRODUCTION: Cervical artery dissection (CAD) is responsible for up to 20% of all ischaemic strokes in patients younger than 45. The benefits of acute-phase reperfusion therapy in these patients have yet to be confirmed. METHODS: We conducted a retrospective review of patients with CAD admitted to a comprehensive stroke centre between 2010 and 2015. We recorded baseline clinical characteristics, treatments, functional outcomes, and mortality. RESULTS: We identified 35 cases of CAD (23 carotid/12 vertebral); mean age was 43.5 ± 9.5 years and 67.7% were men. Ten patients (32.3%) had a history of trauma. The most frequent risk factors were arterial hypertension (29%) and smoking (35.5%). The most common clinical presentation was ischaemic stroke (29 patients, 93.5%). The median baseline National Institute of Health Stroke Scale score was 6 (range, 0-41). The most frequently used diagnostic method was CT angiography (74.2%), followed by MRI (64.5%) and digital subtraction angiography (45.6%). Seven patients (22.6%) were treated with intravenous fibrinolysis and 11 (35.5%) with endovascular treatment plus intravenous fibrinolysis; at 3 months, functional independence (modified Rankin Scale scores 0-2) was achieved by 57.1% and 63.6% of these cases, respectively. One patient died (3.2%). CONCLUSIONS: In our sample, the most common form of presentation of CAD was ischaemic stroke. Reperfusion therapy seems to be a safe and effective option for these patients, and outcomes resemble those of other patients with ischaemic stroke. Larger comparative studies are necessary to better assess response to reperfusion therapy in acute ischaemic stroke.

Trombectomía mecánica más allá de 6 horas en ictus isquémico agudo con oclusión de gran vaso en territorio carotídeo: experiencia en un hospital terciario / Mechanical thrombectomy beyond 6 hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: Experience at a tertiary hospital

Introducción: La eficacia de la trombectomía mecánica en territorio carotídeo en las primeras 24 horas se ha probado con trabajos publicados recientemente. Métodos: Revisión retrospectiva a partir de un registro prospectivo en nuestro centro de referencia de ictus para valorar la eficacia y seguridad del tratamiento endovascular realizado más allá de las 6 horas de evolución de los síntomas en pacientes con ictus isquémico agudo y oclusión de gran vaso en territorio carotídeo, entre noviembre de 2016 y abril de 2019. Resultados: Se recopilaron datos de 59 pacientes (55,9% mujeres, mediana de edad 71 años). Treinta y tres pacientes fueron detectados al despertar. El 57,6% de los casos fueron traslados secundarios. La mediana de NIHSS basal fue 16. La mediana del ASPECTS fue 8 y el 94,9% de los pacientes presentó > 50% de tejido salvable. El 88,1% de los pacientes logró una recanalización satisfactoria, en 5 pacientes después de 24 horas de evolución. El 67,8% de los casos logró la independencia funcional a los 90 días de seguimiento. Los pacientes que no lograron la independencia funcional presentaban mayor edad, mayor proporción de fibrilación auricular, mayor tiempo punción-recanalización y mayor puntuación NIHSS, tanto basal como al alta. Conclusión: En nuestra experiencia la trombectomía mecánica después de las 6 horas se asoció con buenos resultados de funcionalidad a los 90 días. La edad, la puntuación NIHSS, el tiempo punción-recanalización y la prevalencia de fibrilación auricular fueron factores determinantes en el pronóstico funcional. La eficacia de este tratamiento por encima de las 24 horas merece ser estudiada.(AU)

Introduction: Thrombectomy in the carotid artery territory was recently shown to be effective up to 24 hours after symptoms onset. Methods: We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6 hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. Results: Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting > 50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24 hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. Conclusion: In our experience, mechanical thrombectomy beyond 6 hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24 hours after onset merits study.(AU)

La neurología en Las aventuras de Tintín / Neurology in The Adventures of Tintin

Introducción: La presencia de la enfermedad es un hecho recurrente en la famosa saga del autor Hergé, Las aventuras de Tintín, que se ha reflejado en algunos trabajos publicados. No obstante, la aparición de la enfermedad neurológica en la obra ha sido un hecho poco analizado. Desarrollo:Revisión de los síntomas neurológicos en los álbumes publicados desde 1930 a 1976 y su interpretación desde un punto de vista neurológico. Se han analizado los posibles síntomas neurológicos en los principales personajes de la serie. El trauma craneal, las secuelas neurológicas del alcohol y la demencia podrían explicar algunos comportamientos de los personajes. En este trabajo se exponen éstos y su probable interpretación desde un punto de vista neurológico. Conclusión: La presencia de la enfermedad neurológica en la serie Las aventuras de Tintín ha sido poco analizada e interpretada. La obra puede usarse como ejemplo divulgativo de la enfermedad neurológica.(AU)

Introduction: The presence of disease is a recurring theme in Hergé’s famous saga, The Adventures of Tintin, and has been reflected in a number of publications. However, the appearance of neurological disease in the work has received little attention from scholars. Development: A review was conducted of the neurological symptoms that appear in the work published from 1930 to 1976 and their interpretation from a neurological point of view. The possible neurological symptoms in the main characters of the series have been analysed. Head trauma, the neurological sequelae of alcohol and dementia could explain some of the characters’ behaviour. This study outlines these cases and their probable interpretation from a neurological perspective. Conclusion: Hardly any analyses and interpretations have been carried out on the presence of neurological disease in The Adventures of Tintin series. The work can be used as an informative example of neurological disease.(AU)

Stroke in young adults: Incidence rate, risk factors, treatment and prognosis. / Ictus en adultos jóvenes: incidencia, factores de riesgo, tratamiento y pronóstico.

OBJECTIVES: To analyse the incidence, risk factors, aetiology, treatment and clinical evolution of young patients with stroke. PATIENTS AND METHODS: Retrospective registry of patients aged 55 years or younger hospitalised in a stroke unit during 2014. We recorded the incidence rate for all strokes and analysed demographic data, risk factors, degree of stress, stroke type and aetiology, reperfusion treatments and clinical evolution. RESULTS: The study included 110 patients, the majority of whom were men (60.9%, 1.6:1 ratio). The incidence rate was 13.3% (110 of 830 strokes). Most of the patients had cardiovascular risk factors. Smoking was the most common risk factor (56.4%), followed by arterial hypertension (50%), dyslipidaemia (42.7%), obesity (33%), diabetes (18.2%) and emboligenic heart disease (12.7%). Some 64.3% of the heart disease cases and 51.1% of the dyslipidaemia cases were discovered during hospitalisation. Some 57.2% of the patients experienced psychosocial stress in the stage prior to the stroke. Some 83.6% of the stroke cases were ischaemic, 12.7% were haemorrhagic and 3.6% were venous sinus thrombosis. Of the ischaemic stroke cases, 30.4% were cryptogenic, 23.9% were lacunar, 16.3% were from uncommon causes, 15.2% were atherothrombotic and 14.1% were cardioembolic. Some 78.6% of the cerebral haemorrhage cases were hypertensive. Some 23.3% of the ischaemic stroke cases underwent reperfusion treatments in the acute phase, achieving levels of functional independence at 3 months of 62.5%. CONCLUSIONS: The majority of stroke events in patients 55 years of age or younger appear to be related to a high prevalence of classical cardiovascular risk factors and possibly to psychosocial stress.

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

Tratamientos de reperfusión en el infarto cerebral agudo por disección de arterias cervicales / Reperfusion therapy in patients with acute ischaemic stroke caused by cervical artery dissection

Introducción: Las disecciones de arteriales cervicales (DAC) provocan hasta el 20% de los ictus isquémicos en menores de 45 años. El beneficio de los tratamientos de reperfusión en fase aguda no está plenamente clarificado. Métodos: Revisión retrospectiva de pacientes con DAC ingresados en un centro terciario de ictus desde 2010 hasta 2015. Recogemos las características basales, clínicas, los tratamientos, el pronóstico funcional y la mortalidad. Resultados: Se registraron 35 DAC (23 carotídeas/12 vertebrales). La edad media fue de 43,5 ± 9,5 años y el 67,7% fueron varones. En 10 casos (32,3%) hubo antecedente de un traumatismo. Los factores de riesgo más frecuentes fueron la hipertensión arterial (29%) y el tabaquismo (35,5%). La presentación clínica más frecuente fue el infarto cerebral en 29 pacientes (93,5%). La mediana de puntuación National Institute of Health Stroke Scale basal fue de 6 (0-41). El método diagnóstico más empleado fue la angio-TC (74,2%), seguido de resonancia magnética (64,5%) y arteriografía cerebral (45,6%). Siete pacientes (22,6%) fueron tratados con fibrinólisis intravenosa y 11 (35,5%) con tratamiento endovascular (TEV) ± fibrinólisis intravenosa. A los 3 meses, la independencia funcional (escala de Rankin 0-2) fue del 57,1% y del 63,6%, respectivamente. Falleció un paciente (3,2%). Conclusiones: La forma de presentación más frecuente de la DAC fue el infarto cerebral. Estos casos pueden beneficiarse de terapias de reperfusión, con un pronóstico similar al resto de enfermos con ictus isquémicos. Se requieren registros más extensos para conocer mejor la respuesta a los tratamientos de reperfusión en fase aguda en este grupo de pacientes

Introduction: Cervical artery dissection (CAD) is responsible for up to 20% of all ischaemic strokes in patients younger than 45. The benefits of acute-phase reperfusion therapy in these patients have yet to be confirmed. Methods: We conducted a retrospective review of patients with CAD admitted to a comprehensive stroke centre between 2010 and 2015. We recorded baseline clinical characteristics, treatments, functional outcomes, and mortality. Results: We identified 35 cases of CAD (23 carotid/12 vertebral); mean age was 43.5 ± 9.5 years and 67.7% were men. Ten patients (32.3%) had a history of trauma. The most frequent risk factors were arterial hypertension (29%) and smoking (35.5%). The most common clinical presentation was ischaemic stroke (29 patients, 93.5%). The median baseline National Institute of Health Stroke Scale score was 6 (range, 0-41). The most frequently used diagnostic method was CT angiography (74.2%), followed by MRI (64.5%) and digital subtraction angiography (45.6%). Seven patients (22.6%) were treated with intravenous fibrinolysis and 11 (35.5%) with endovascular treatment plus intravenous fibrinolysis; at 3 months, functional independence (modified Rankin Scale scores 0-2) was achieved by 57.1% and 63.6% of these cases, respectively. One patient died (3.2%). Conclusions: In our sample, the most common form of presentation of CAD was ischaemic stroke. Reperfusion therapy seems to be a safe and effective option for these patients, and outcomes resemble those of other patients with ischaemic stroke. Larger comparative studies are necessary to better assess response to reperfusion therapy in acute ischaemic stroke

Disección arterial vertebral bilateral como manifestación inicial del síndrome de Cushing / Bilateral vertebral artery dissection as the initial manifestation of Cushing síndrome

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[Neurovascular intervention in the acute phase of cerebral infarction]. / Intervencionismo neurovascular en la fase aguda del infarto cerebral.

BACKGROUND AND PURPOSE: Endovascular therapies in acute ischaemic stroke may offer benefits to patients that are not eligible for standard use of intravenous tissue activator plasminogen (iv t-PA) or when this is not effective. Our aim is to present the initial experience in with endovascular techniques in the Community of Madrid. METHODS: We present data from our registry of acute ischaemic strokes treated with endovascular re-perfusion therapies in five University Hospitals in Madrid (Spain) during the period 2005-2009. We recorded demographic data, vascular risk factors, risk severity with the NIHSS (National Institute of Health Stroke Scale), endovascular techniques, complications and mortality rates. Functional outcome and neurological disability at 90 days was defined by the modified Rankin scale (mRs). RESULTS: A total of 41 patients were treated with endovascular therapies. Mean age was 58.6 ± 19.9, and 56.1% were males. Of those 22 patients had an anterior circulation stroke and 19 had a posterior circulation stroke. Baseline NIHSS score was: median, 17 [range, 2-34]; 7 patients had previously received iv t-PA. The following endovascular techniques were performed: mechanical disruption (26 patients), intra-arterial infusion of t-PA (26 patients), angioplasty and stenting (5 patients), mechanical use of MERCI device (3 patients). Partial or total re-canalization was achieved in 32 patients (78%). Only one patient had a symptomatic cerebral haemorrhage. Three months after stroke, 53.6% of the patients were independent (mRs ≤ 2) and overall mortality rate was 19.5%. CONCLUSIONS: Acute ischaemic stroke is a potentially treatable medical emergency within the first hours after the onset of symptoms. Stroke endovascular procedures constitute an alternative for patients with iv t-PA exclusion criteria or when this is not effective.

[Influence of the experience and of out-of-hospital stroke code in thrombolytic treatment of acute stroke]. / Influencia de la curva de aprendizaje y del código ictus extrahospitalario en el tratamiento trombolítico del ictus agudo.

INTRODUCTION: We present the experience for thrombolytic treatment using recombinant tisular plasminogen activator (rt-PA) at a university hospital. We analyze the influence of individual and collective acquired experience and of the activation of an out-of-hospital stroke code (OSC) on the delays to onset of treatment, number of patients treated and outcome. METHOD: Prospective register of patients with ischemic stroke treated with rt-PA within the period 1/2004- 12/2006. Comparison of results between patients treated during the three years of study and based on the individual experience of the neurologist who applies the treatment and on the patients treated with or without activation of OSC. RESULTS: A total of 87 patients were treated (mean age: 66.6 +/- 13.7). Door-to-needle time was 79 +/- 21 min in 2004, 64 +/-22 in 2005 and 63 +/- 26 in 2006 (p=0.003). Experienced neurologists started thrombolysis sooner (door-to-needle time: 62 +/- 22 min vs 75 +/- 27, p=0.03). Activation of the ESC reduced door-to-needle time (53 +/ 17 min vs 65 +/- 21; p=0.032) and door-to-computed tomography scan time (21 +/- 10 min vs 29 +/-24; p=0.016). There were no differences in outcome in the different groups. CONCLUSIONS: Individual and collective acquired experience and the activation of an OSC can lower in-hospital delays. This contributes to increasing the number of patients eligible for thrombolysis. Thrombolytic therapy is safe and effective even when it is applied by inexperienced neurologists if strict guidelines are followed.

Ictus en adultos jóvenes: incidencia, factores de riesgo, tratamiento y pronóstico / Stroke in young adults: incidence rate, risk factors, treatment and prognosis

Objetivos. Analizar la incidencia, los factores de riesgo, la etiología, el tratamiento y la evolución clínica de pacientes jóvenes con ictus. Pacientes y métodos. Registro retrospectivo de pacientes ≤ 55 años ingresados en una Unidad de Ictus durante el año 2014. Se recogió la incidencia sobre el total de ictus y se analizaron datos demográficos, factores de riesgo, grado de estrés, tipo y etiología del ictus, tratamientos de reperfusión y evolución clínica. Resultados. Se incluyó a 110 pacientes, la mayoría hombres (60,9%, ratio 1,6:1). La incidencia fue del 13,3% (110 de 830 ictus). La mayoría de los pacientes tenía factores de riesgo vascular. El tabaquismo fue el más frecuente (56,4%), seguido de la hipertensión arterial (50%), dislipidemia (42,7%), obesidad (33%), diabetes (18,2%) y cardiopatías embolígenas (12,7%). El 64,3% de las cardiopatías y el 51,1% de las dislipidemias se descubrieron durante el ingreso. El 57,2% de los pacientes presentaban estrés psicosocial en la etapa previa al ictus. El 83,6% de los ictus fueron isquémicos, el 12,7% hemorrágicos y el 3,6% trombosis de senos venosos. De los ictus isquémicos, el 30,4% fueron criptogénicos, el 23,9% lacunares, el 16,3% por causas infrecuentes, el 15,2% aterotrombóticos y el 14,1% cardioembólicos. El 78,6% de las hemorragias cerebrales fueron hipertensivas. El 23,3% de los ictus isquémicos recibieron tratamientos de reperfusión en fase aguda y se consiguieron niveles de independencia funcional a los 3 meses del 62,5%. Conclusiones. La mayoría de los ictus en pacientes ≤ 55 años parecen relacionarse con una elevada prevalencia de factores de riesgo vascular clásicos y posiblemente de estrés psicosocial (AU)

Objectives. To analyse the incidence, risk factors, aetiology, treatment and clinical evolution of young patients with stroke. Patients and methods. Retrospective registry of patients aged 55 years or younger hospitalised in a stroke unit during 2014. We recorded the incidence rate for all strokes and analysed demographic data, risk factors, degree of stress, stroke type and aetiology, reperfusion treatments and clinical evolution. Results. The study included 110 patients, the majority of whom were men (60.9%, 1.6:1 ratio). The incidence rate was 13.3% (110 of 830 strokes). Most of the patients had cardiovascular risk factors. Smoking was the most common risk factor (56.4%), followed by arterial hypertension (50%), dyslipidaemia (42.7%), obesity (33%), diabetes (18.2%) and emboligenic heart disease (12.7%). Some 64.3% of the heart disease cases and 51.1% of the dyslipidaemia cases were discovered during hospitalisation. Some 57.2% of the patients experienced psychosocial stress in the stage prior to the stroke. Some 83.6% of the stroke cases were ischaemic, 12.7% were haemorrhagic and 3.6% were venous sinus thrombosis. Of the ischaemic stroke cases, 30.4% were cryptogenic, 23.9% were lacunar, 16.3% were from uncommon causes, 15.2% were atherothrombotic and 14.1% were cardioembolic. Some 78.6% of the cerebral haemorrhage cases were hypertensive. Some 23.3% of the ischaemic stroke cases underwent reperfusion treatments in the acute phase, achieving levels of functional independence at 3 months of 62.5%. Conclusions. The majority of stroke events in patients 55 years of age or younger appear to be related to a high prevalence of classical cardiovascular risk factors and possibly to psychosocial stress (AU)