Pseudoictus en el código ictus. Frecuencia, diagnóstico, tratamiento y destino / Stroke mimics in stroke code activations: frequency, diagnoses, treatment, and discharge destination

Objetivos: Conocer la frecuencia, diagnóstico, tratamiento trombolítico y destino de los pseudoictus (PI) atendidos como código ictus (CI), y valorar el impacto de incluir a mayores de 80 años. Método: Estudio prospectivo de una serie consecutiva de pacientes atendidos como CI, durante 50 meses, en los que se empleó tomografía computarizada craneal como prueba de neuroimagen. Se compara el primer periodo (2008-2010) en el que se siguieron los criterios SITS-MOST, con el segundo periodo (2010-2012) que se amplía la ventana temporal y se suprime el límite superior de edad. El diagnóstico se agrupa en 2 categorías: ictus (transitorio o establecido, que incluye infartos cerebrales, ataques isquémicos transitorios y hemorragias intracerebrales) y PI. Resultados: Se activaron 1.450 CI, de los que 288 se diagnosticaron como PI: 19,9% (IC 95%: 17,7-21,9%). Éstos presentaron menor edad y mayor frecuencia de mujeres. En el segundo periodo, aumentaron los mayores de 80 años (6,0% vs 22,6%, p < 0,001) y los PI disminuyeron del 23,8% al 16,2% (p 0,04). En mayores de 80 años, los PI son menos frecuentes (14,5% vs 20,4% p = 0,004). Los diagnósticos más frecuentes entre los PI son: crisis epiléptica 25,6% (IC 95%: 18,2-28,3%), síncope 16,8% (12,1-21,5%) y encefalopatía por enfermedad sistémica 16,4% (11,7-21,1%). Se trombolisaron 3 PI (1,0% IC95%: 0,2-3,0%) sin complicaciones hemorrágicas, que representan el 1,2% de los 257 trombolisados. El 46% (36,1-48,1%) de PI ingresaron en el hospital, y un 47,4% fue seguido por neurología. Conclusiones: El diagnóstico de PI es frecuente y básicamente clínico, donde una valoración neurológica experta es recomendable. La inclusión de mayores de 80 años se asoció a una reducción de PI (AU)

Objectives: To determine the frequency, of stroke mimics in stroke code activations, to analyze diagnoses, use of thrombolytic therapy and the discharge destinations of these patients; and to estimate the impact on these variables when patients over the age of 80 years are included. Methods: Prospective study of consecutive patients attended after stroke code activation; the study period was 50 months and the diagnostic image used was cranial computed tomography (CT). We compared the first period (2008-2010), in which we applied the SITS-MOST (Safe Implementation of Thrombolysis in Stroke Monitoring Study) criteria, to a second period (2010-2012), in which the time window for treatment was enlarged and there was no upper age limit for applying the criteria. Patients were grouped in 2 categories: stroke (transient or established, including cerebral infarction, transient ischemic attacks, and intracerebral hemorrhage) and pseudo-stroke (conditions mimicking stroke). Results: Stroke code was activated 1450 times; 288 cases were diagnosed as stroke mimics (19.9%; 95% CI, 17.7%-21.9%). This group was younger and included more women. In the second period, in which more patients over 80 years of age were attended (6.0% in the first period vs. 22.6% in the second, P<.001), the percentage of cases diagnosed as stroke mimics decreased (23.8% in the first period, 16.2% in the second; P<.001). Mimics were less frequent in patients over the age of 80 years (14.5% vs. 20.4% in younger patients, P=.004). The most frequent diagnoses in patients with conditions mimicking stroke were epileptic seizures (15.6%; 95% CI, 18.2%-28.3%), syncope (16.8%; 95% CI, 12.1%-21.5%), and encephalopathy due to systemic disease (16.4%; 95% CI, 11.7%-21.1%). Thrombolytic therapy was used in 3 patients with mimics (1%; 95% CI, 0.2%-3.0%) without hemorrhagic complications, which occurred in 1.2% of the 257 patients under this therapy. Forty-six percent of the patients with mimics were hospitalized (95% CI, 36.1%-48.1%); 47.4% were evaluated by a neurologist. Conclusions: Stroke mimics are common and diagnosis is essentially clinical; evaluation by a neurologist is advisable. The frequency of stroke mimics was lower when patients over the age of 80 years were considered (AU)

Evolución a largo plazo de la estenosis carotídea tratada endovascularmente: estudio prospectivo en una unidad neurovascular / Long-term development of carotid stenosis treated by endovascular means: a prospective study in a neurovascular unit

Objetivo. Aun hoy, a diferencia de la endarterectomía, la evolución a largo plazo en la angioplastia carotídea no está bien definida. El objetivo es describir la evolución a corto y largo plazo y la tasa de reestenosis de una serie consecutiva de pacientes con estenosis de carótida sometidos a tratamiento endovascular en el Hospital Universitario La Fe, diferenciando entre pacientes con y sin síntomas. Pacientes y métodos. Desde 1999 hasta 2010 se incluyeron 426 pacientes a los que se les realizó angioplastia carotídea (el 25,5% eran pacientes asintomáticos). Se llevó a cabo seguimiento clínico a 374 pacientes. Fueron visitados anualmente, y cada año se les realizó estudio neurosonológico. Se recogieron las complicaciones durante los 30 primeros días y las complicaciones a largo plazo; se recogió la tasa de reestenosis en el seguimiento y se valoraron las posibles diferencias entre pacientes con y sin síntomas. Resultados. La morbimortalidad en el primer mes fue del 4,2% (4,4% en pacientes sintomáticos y 3,8% en pacientes asintomáticos). El seguimiento medio fue de 55 meses: un 8% de pacientes presentó ictus, un 11% sufrió un infarto de miocardio y un 24,3% falleció, sin diferencias significativas entre los pacientes con y sin síntomas. La tasa de reestenosis fue del 17,3% a los cinco años, un 7,5% igual o superior al 50%, y de ellas, en el 1,1% fueron sintomáticas. Cinco pacientes con reestenosis significativa fueron tratados con éxito con técnicas endovasculares. Conclusiones. La angioplastia carotídea es una técnica efectiva y segura en manos experimentadas; nuestros resultados son buenos, tanto a corto como a largo plazo, con una baja tasa de reestenosis. En caso de producirse esta última, el intervencionismo vascular es seguro y eficaz (AU)

Aims. Even today, unlike endarterectomy, long-term development in carotid angioplasty has still not been well defined. The aim of this study is to describe both the short- and long-term development and the rate of restenosis in a consecutive series of patients with carotid stenosis who underwent endovascular treatment at the Hospital Universitario La Fe; a distinction is made between patients with and without symptoms. Patients and methods. From 1999 to 2010, 426 patients were submitted to a carotid angioplasty (25.5% were asymptomatic patients). Clinical follow-ups were conducted in the case of 374 patients. They had annual check-ups and every year a neurosonological study was performed. The aim was to determine what complications occurred during the first 30 days, as well as the long-term complications, to establish the rate of restenosis and to evaluate possible differences between patients with and without symptoms. Results. The morbidity and mortality rate in the first month was 4.2% (4.4% in symptomatic patients and 3.8% in asymptomatic patients). The mean follow-up time was 55 months: 8% of patients presented strokes, 11% suffered from myocardial infarct and 24.3% died, with no significant differences between patients with or without symptoms. The rate of restenosis was 17.3% at five years, 7.5% equal to or above 50% and, of those, 1.1% were symptomatic. Five patients with significant restenosis were successfully treated with endovascular techniques. Conclusions. Carotid angioplasty is an effective, safe technique in the hands of an experienced professional; our findings are good, both in the short and the long term, with a low rate of restenosis. If this latter condition occurs, vascular intervention techniques are safe and efficient (AU)

[Hemifacial spasm: over 10 years of treatment with botulinum toxin]. / Espasmo hemifacial: más de 10 años de tratamiento con toxina botulínica.

INTRODUCTION: The short-term beneficial and adverse effects of treatment with botulinum toxin (BT) in hemifacial spasm (HS) are well documented, but this is not the case with its long-term derivatives. AIMS. To describe the characteristics, the dose development, the side effects and the reason for giving up therapy in patients who have been on BT treatment for more than 10 years. We also sought to evaluate the effectiveness and safety of prolonged treatment in patients with HS. PATIENTS AND METHODS: We reviewed the demographic and clinical characteristics of patients who had had HS for more than 10 years since follow-up began. We analysed the mean dose development of BT per visit and year, the number of sessions per year, side effects and reasons for dropping out. We focused our attention on cases with more than 10 years' continuous treatment. RESULTS: The percentage of patients who had been on treatment for over ten years was 53.7%. The mean dose of BT per year rose progressively, and was significant (p < 0.05) during the first four years of treatment. There was no significant increase in the number of sessions. Altogether 46 side effects were observed, ptosis being the most frequent. These occurred during the first years of the early stages of the technique. The most common cause of dropout was loss to follow-up in 22 patients, followed by death in 11 cases. CONCLUSIONS: BT is a feasible, safe treatment option (with very few benign side effects) in the prolonged treatment of patients with HS.

Espasmo hemifacial: más de 10 años de tratamiento con toxina botulínica / Hemifacial spasm: over 10 years of treatment with botulinum toxin

Los efectos beneficiosos y secundarios a corto plazo del tratamiento con toxina botulínica (TB) enel espasmo hemifacial (EH) se conocen bien, pero no ocurre lo mismo con sus derivados a largo plazo. Objetivos. Describir las características, la evolución de la dosis, los efectos secundarios y la razón de abandono del tratamiento de pacientes conmás de 10 años de tratamiento con TB, y valorar la eficacia y la seguridad del tratamiento prolongado en pacientes con EH. Pacientes y métodos. Se revisaron las características demográficas y clínicas de los pacientes con EH de más 10 años desde el inicio del seguimiento. Analizamos la evolución de la dosis media de TB por visita por año, el número de sesiones por año,los efectos secundarios y las razones del abandono. Nos centramos en aquellos con más de 10 años de tratamiento continuado.Resultados. El porcentaje de pacientes con más de diez años de tratamiento era de 53,7%. La dosis media de TB por año incrementó progresivamente, siendo significativa (p < 0,05) los primeros cuatro años de tratamiento. No hubo un aumento significativo en el número de sesiones. Se recogieron un total de 46 efectos secundarios, siendo la ptosis el más frecuente. Éstos ocurrieron durante los primeros años del inicio de la técnica. La causa más frecuente de abandono fue la pérdida deseguimiento en 22 pacientes, seguida por fallecimiento en 11. Conclusión. La TB es una opción de tratamiento posible y segura (con mínimos efectos secundarios y benignos) en el tratamiento prolongado de los pacientes con EH

The short-term beneficial and adverse effects of treatment with botulinum toxin (BT) in hemifacialspasm (HS) are well documented, but this is not the case with its long-term derivatives. Aims. To describe the characteristics, the dose development, the side effects and the reason for giving up therapy in patients who have been on BT treatment for more than 10 years. We also sought to evaluate the effectiveness and safety of prolonged treatment in patients with HS. Patients andmethods. We reviewed the demographic and clinical characteristics of patients who had had HS for more than 10 years since follow-up began. We analysed the mean dose development of BT per visit and year, the number of sessions per year, side effects and reasons for dropping out. We focused our attention on cases with more than 10 years' continuous treatment. Results. The percentage of patients who had been on treatment for over ten years was 53.7%. The mean dose of BT per year rose progressively, and was significant (p < 0.05) during the first four years of treatment. There was no significant increase in the number of sessions. Altogether 46 side effects were observed, ptosis being the most frequent. These occurred during the first years of the early stages of the technique. The most common cause of dropout was loss to follow-up in 22 patients, followed bydeath in 11 cases. Conclusions. BT is a feasible, safe treatment option (with very few benign side effects) in the prolonged treatment of patients with HS

Abscesos amebianos hepáticos / Amebic liver abscesses

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