Collateral circulation on perfusion-computed tomography-source images predicts the response to stroke intravenous thrombolysis.

BACKGROUND AND PURPOSE: Perfusion-computed tomography-source images (PCT-SI) may allow a dynamic assessment of leptomeningeal collateral arteries (LMC) filling and emptying in middle cerebral artery (MCA) ischaemic stroke. We described a regional LMC scale on PCT-SI and hypothesized that a higher collateral score would predict a better response to intravenous (iv) thrombolysis. METHODS: We studied consecutive ischaemic stroke patients with an acute MCA occlusion documented by transcranial Doppler/transcranial color-coded duplex, treated with iv thrombolysis who underwent PCT prior to treatment. Readers evaluated PCT-SI in a blinded fashion to assess LMC within the hypoperfused MCA territory. LMC scored as follows: 0, absence of vessels; 1, collateral supply filling ≤ 50%; 2, between> 50% and < 100%; 3, equal or more prominent when compared with the unaffected hemisphere. The scale was divided into good (scores 2-3) vs. poor (scores 0-1) collaterals. The predetermined primary end-point was a good 3-month functional outcome, while early neurological recovery, transcranial duplex-assessed 24-h MCA recanalization, 24-h hypodensity volume and hemorrhagic transformation were considered secondary end-points. RESULTS: Fifty-four patients were included (55.5% women, median NIHSS 10), and 4-13-23-14 patients had LMC score (LMCs) of 0-1-2-3, respectively. The probability of a good long-term outcome augmented gradually with increasing LMCs: (0) 0%; (1) 15.4%; (2) 65.2%; (3) 64.3%, P = 0.004. Good-LMCs was independently associated with a good outcome [OR 21.02 (95% CI 2.23-197.75), P = 0.008]. Patients with good LMCs had better early neurological recovery (P = 0.001), smaller hypodensity volumes (P < 0.001) and a clear trend towards a higher recanalization rate. CONCLUSIONS: A higher degree of LMC assessed by PCT-SI predicts good response to iv thrombolysis in MCA ischaemic stroke patients.

Cambio de tratamiento en pacientes con esclerosis múltiple y sus consecuencias en la práctica clínica / Change of treatment in patients with multiple sclerosis and its consequences in clinical practice

Introducción. El 30% de los pacientes con esclerosis múltiple (EM) presenta respuesta subóptima al tratamiento en los primeros años. El impacto real del cambio de tratamiento no está bien establecido. Objetivos. Describir nuestra práctica clínica sobre el cambio de tratamiento en los pacientes con EM con respuesta subóptima y analizar la evolución en función de nuestras decisiones terapéuticas. Pacientes y métodos. Estudio observacional y retrospectivo. Se incluyeron pacientes con EM remitente recurrente con al menos un brote después de instaurado el tratamiento inmunomodulador. Se tuvieron en cuenta la intención de cambio de tratamiento y los retrasos hasta el momento real del cambio. Las consecuencias teóricas de estas estrategias se midieron por los cambios en la curva esperada de la Multiple Sclerosis Severity Scale (MSSS). Resultados. Los pacientes que cambiaron de inmunomodulador mejoraron la curva esperada de la MSSS (p > 0,05) respecto a los que no (64,3% frente a 35,3%). Los pacientes que mejoraron esa curva habían cambiado de tratamiento antes que los que no mejoraron (1,9 meses frente a 6 meses), aunque las diferencias no fueron significativas. El tiempo transcurrido entre el planteamiento y el cambio real de tratamiento tuvo una media de 2,70 ± 3,55 meses. Conclusiones. A pesar de las limitaciones por el tamaño de la muestra, los pacientes con respuesta subóptima que cambian de tratamiento precozmente podrían beneficiarse de una mejoría en su evolución esperada por la MSSS (AU)

Introduction. Thirty per cent of patients with multiple sclerosis (MS) present a suboptimal response to treatment in the first few years. The real impact of the change of treatment has still not been well established. Aims. To describe our clinical practice with regard to the change of treatment in MS patients with a suboptimal response and to analyse their progress depending on our therapeutic decisions. Patients and methods. The study is observation-based and retrospective. The sample was made up of patients with relapsingremitting MS and at least one event after establishing immunomodulatory treatment. Both the intention to change treatment and the delays until the actual change took place were taken into account. The theoretical consequences of these strategies were measured by the changes in the expected curve of the Multiple Sclerosis Severity Scale (MSSS). Results. A comparison of those who changed immunomodulator with those that did not showed that 64.3% versus 35.3%, respectively, improved on the expected curve of the MSSS (p > 0.05). Patients who improved the expected curve of the MSSS had changed treatment before those who did not improve (1.9 months versus 6 months), although the differences were not significant. The mean time that elapsed between taking the decision to change and actually changing the treatment was 2.70 ± 3.55 months. Conclusions. Despite limitations due to the size of the sample, the patients with a suboptimal response who changed treatment early could benefit from an improvement in their expected progression on the MSSS (AU)

[Change of treatment in patients with multiple sclerosis and its consequences in clinical practice]. / Cambio de tratamiento en pacientes con esclerosis multiple y sus consecuencias en la practica clinica.

INTRODUCTION: Thirty per cent of patients with multiple sclerosis (MS) present a suboptimal response to treatment in the first few years. The real impact of the change of treatment has still not been well established. AIMS: To describe our clinical practice with regard to the change of treatment in MS patients with a suboptimal response and to analyse their progress depending on our therapeutic decisions. PATIENTS AND METHODS: The study is observation-based and retrospective. The sample was made up of patients with relapsing-remitting MS and at least one event after establishing immunomodulatory treatment. Both the intention to change treatment and the delays until the actual change took place were taken into account. The theoretical consequences of these strategies were measured by the changes in the expected curve of the Multiple Sclerosis Severity Scale (MSSS). RESULTS: A comparison of those who changed immunomodulator with those that did not showed that 64.3% versus 35.3%, respectively, improved on the expected curve of the MSSS (p > 0.05). Patients who improved the expected curve of the MSSS had changed treatment before those who did not improve (1.9 months versus 6 months), although the differences were not significant. The mean time that elapsed between taking the decision to change and actually changing the treatment was 2.70 ± 3.55 months. CONCLUSIONS: Despite limitations due to the size of the sample, the patients with a suboptimal response who changed treatment early could benefit from an improvement in their expected progression on the MSSS.

Prevalence of multiple sclerosis in Valladolid, northern Spain.

The aim of this study was to ascertain the prevalence of multiple sclerosis (MS) in a northern Spanish region and to compare it with that from the most recent epidemiological studies in the country. MS prevalence was studied for a period of 2 years using multiple sources of information in the province of Valladolid, with a sample comprising a total population of 92,632. Patients were classified according to the Poser criteria. The crude prevalence of definite and probable MS was 58.3 per 100,000 (95% confidence interval: 43.7-75.7). The same methods have been used in ascertaining similar prevalence rates in Vélez-Málaga, Osona, and Gijón and a slightly lower rate in Teruel. Our survey confirms Spain as a high-risk area for MS, with prevalence rates over 50 per 100,000.

[Impact of fatigue in multiple sclerosis: study of a population-based series in Valladolid]. / Impacto de la fatiga en la esclerosis múltiple: estudio de una serie de base poblacional en Valladolid.

INTRODUCTION: Fatigue is one of the commonest findings in multiple sclerosis (MS) although it has scarcely been investigated as an independent symptom. OBJECTIVE: To evaluate the effect of fatigue in a population based series of patients with MS and to analyze its relation to other clinical variables. METHODS: A descriptive, transverse study based on a geographically defined population. Fatigue was measured using the Krupp scale in 48 patients with definite clinical MS. We analyzed the relation between the degree of fatigue and sex, age of onset, age at the time of the study, type of evolution, index of progression of disability, duration of illness and degree of impairment according to the Expanded Disability Status Scale (EDSS) and neurological functional systems. RESULTS: 64.6% of the patients had a significant degree of fatigue. Of these, 90% considered fatigue to be one of the three most disabling symptoms of their illness. There was no difference between men and women in their perception of fatigue. The patients with progressive illness, of greater age and those with higher EDSS scores had more fatigue. This aspect was not affected by age of onset, duration of illness nor index of progression. CONCLUSIONS: Fatigue should be evaluated as an independent symptom of MS. Evaluation using specific scales may contribute to better understanding of the physiopathology and investigation of more effective treatment.

[Deficiency, disability and handicap in multiple sclerosis: a population-based study in Valladolid]. / Deficiencia, discapacidad y minusvalía en la esclerosis múltiple: un estudio de base poblacional en Valladolid.

INTRODUCTION: Apart from impairment there is hardly any other assessment of the repercussions of multiple sclerosis (MS) in population studies. OBJECTIVE: To analyze the functional state of en epidemiological series of patients in the Valladolid health district. MATERIAL AND METHODS: A descriptive transversal study of a geographically defined population base. During a period of three months and complementing a prevalence study, were assessed, by means of the Minimal Record of Disability, impairment, disability and handicap in a series of 51 patients (33 women and 18 men) with clinically defined MS, who lived in the area on 1 March 1997. RESULTS: There was a primarily progressive evolution in 21.6% of the patients, and secondarily progressive in 11.8%. Average follow-up time was 9.1 years (range 1-41) and average age of onset 27.8 years (range 14.7-51.0). The distribution of scores on the Expanded Disability Status Scale was bimodal (average and interquartile range: 3.0 (1.5-5.0). 80.4% of the patients continued to be ambulatory. 21.5% had frequent urinary incontinence or required a long-term urinary catheter. Less than 20% needed help with day to day activities. 78% of the patients complained of some degree of fatigue, and 51% had difficulties with social relationships. 59.4% of the patients had full-time jobs and 70.6% had no financial problems. CONCLUSIONS: The study shows that the functional state of persons with MS is better than was thought, and that assessment of the consequences of this illness should include disability and handicap profiles.