Prognostic factors and analysis of mortality due to brain haemorrhages associated with vitamin K antagonist oral anticoagulants. Results from the TAC registry. / Factores pronósticos y análisis de la mortalidad de las hemorragias cerebrales asociadas a anticoagulantes orales antagonistas de la vitamina K. Resultados del Estudio TAC Registry.

INTRODUCTION: Intracranial haemorrhages (ICH) represent a severe and frequently lethal complication in patients treated with vitamin K antagonists (VKA). The purpose of our study is to describe the factors and clinical features associated with mortality in these patients. METHODS: We conducted an observational, retrospective, multi-centre study based on prospective stroke registries in Spain. We included all patients admitted to neurology departments during a one-year period who met the following inclusion criteria: being 18 or older, having a diagnosis of ICH, and receiving VKA. Clinical and radiological parameters and 3-month outcomes were analysed. RESULTS: A total of 235 patients from 21 hospitals were included. Mortality rate at 90 days was 42.6%. Bivariate analysis showed a significant association between death and the following factors: median NIHSS score at admission (5 [IQR = 9] vs 17 [IQR = 14] points, P<.01) and presence of an extensive hemispheric haemorrhage (4.9% vs 35%, P < .01; χ2). Extensive hemispheric haemorrhages, in addition to being the most lethal type, were associated with a shorter time to death (mean of 16.5 days; 95% CI: 7.1-26). A logistic regression model showed that only baseline NIHSS scores independently predicted death (odds ratio=1.13 [95% CI: 1.08-1.17] for each point in the scale). CONCLUSION: ICH in patients treated with VKA is associated with high mortality rates; mortality in these patients is mainly and independently associated with the clinical situation at stroke onset.

Amaurosis y necrosis bilateral del putamen en la intoxicación por metanol. Probable disfunción mitocondrial de origen tóxico / Bilateral blindness and putamen necrosis in methanol poisoning. Probable toxic induced mitochondrial dysfunction

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How many migraine patients need prolonged (>1 year) preventive treatment? Experience with topiramate.

The usual recommended duration of preventive treatment for migraine is 3-6 months. Our aim was to explore how many patients attending a specialised clinic need prolonged preventive treatment for longer than one year. Eighty consecutive migraine patients who received preventive treatment with topiramate for 3 months with good response and tolerability were included in this observational study. All patients continued on topiramate until they had completed 6 months, when this drug was stopped. Topiramate was reintroduced if there was a worsening. Topiramate was kept for 6 more months and then discontinued again. Those patients whose headaches became worse after this second withdrawal received topiramate again and were followed-up for at least half a year. Headaches did not worsen after the first withdrawal at 6 months in 40 patients (50%), while they clearly worsened in the remaining 40 patients. At the end of the first year only two patients out of these 40 (5%) discontinued topiramate and did not notice an increase in headache frequency after two months. In conclusion, around half of the patients attending a specialised clinic due to frequent headache need preventive treatment for more than one year. Our data suggest that the current practice recommending periods of preventive treatment of 3-6 months should be reconsidered for many patients.

Neurological complications after autologous stem cell transplantation.

INTRODUCTION: Autologous bone marrow (BMT) or peripheral blood stem cell transplantation (PBSCT) are increasingly used to treat hematological malignancies and solid tumors. The reported incidence of neurological complications varies greatly among the different centers, ranging from 11 to 39%. PATIENTS AND METHODS: In order to gain insight into the real incidence of early neurological complications (first 6 weeks) after autologous transplantation, we analyzed a series of 254 patients who underwent BMT/PBSCT for hematological malignancies (212 cases) or solid tumors (42 cases). RESULTS: Seven patients died during the early posttransplant period (incidence: 2.4%), and one of these deaths was related to a neurological complication. Eight patients developed neurologic complications (incidence: 2.8%). None of the patients developed cerebral hemorrhage during the early posttransplant period, despite a rather restrictive platelet transfusion support. Two out of 13 patients diagnosed AML and 3 out of 36 patients diagnosed Hodgkin's disease developed early neurological complications. DISCUSSION AND CONCLUSIONS: The neurological morbidity related to autologous transplantation was very low in our series of patients as compared to that reported in previous studies. This difference could be explained, at least in part, by a more restrictive definition of early neurologic complications.

[Triple association of mesencephalic syndromes]. / Triple asociación de síndromes mesencefálicos.

INTRODUCTION: The mesencephalic alternating syndromes or syndromes of Weber, Benedikt and Claude are uncommon in clinical practice. They are caused by a lesion in the mesencephalus which affects the third cranial nerve bundle, together with the corticospinal pathway, subthalamic nucleus and the dentato-rubric path. CLINICAL CASE: We present the case of a normotensive patient who, as a consequence of a hematoma in the mesencephalic tegmentum, had the association of these three syndromes consecutively. The clinical course was favorable, so that after three months of follow-up only paralysis of the third cranial nerve bundle persisted. DISCUSSION: In the syndromes of Weber, Benedikt and Claude there is the association of ophthalmoplegia with hemiplegia, or a cerebellar hemisyndrome or contralateral abnormal movements compatible with hemiballismus, respectively. Amongst the commonest causes are expansive processes, tumors and arteriovenous malformations. More rarely they are due to cerebrovascular accidents, which are usually ischemic and occasionally hemorrhagic in aetiology. CONCLUSIONS: Spontaneous mesencephalic hematomas are infrequent. They make up approximately 1% of all intracranial hematomas. The commonest site is the tegmentum followed by the peduncle and tectum. They have better prognosis than other hematomas of the brainstem.

[Multiple cranial neuropathy: an atypical variant of the Guillain-Barre syndrome?]. / Neuropatía craneal múltiple: una variante atípica del síndrome de Guillain-Barré?

INTRODUCTION: Multiple cranial neuropathy or polineuritis cranealis is rarely seen in everyday clinical practice. It is considered to be a topographically circumscribed form of the Guillain-Barré syndrome. The cases described have a wide range of clinical and biological characteristics. Some of these may be due to infectious agents. CLINICAL CASE: We present the case of a 50 year old man with acute onset of diplopia, dysphagia, anarthria, cervical and right arm flexor-extensor muscle weakness due to involvement of many motor cranial nerves and superior cervical nerve roots. On neurological examination there was mixed involvement, mainly of the axons of the nerve trunks involved. Studies to determine aetiology did not show any demonstrable agent. DISCUSSION AND CONCLUSIONS: Different topographical varieties of the Guillain-Barré syndrome have been described, including: Fisher's syndrome, pharyngo-cervico-brachial paralysis, arreflexive paraparesia, bilateral facial paralysis with paraesthesias, hyporeflexia and bilateral lumbar polyradiculopathy. We compare the clinical characteristics of our patient with those described in the literature. We found a degree of heterogenicity in the clinical and biological characteristics of the cases described, which may mean that they had different aetiologies. Therefore, we consider that before labelling these conditions as atypical variants of the Guillain-Barré syndrome, a thorough search should be made for a precise aetiology.

[Paget's disease of bone and basilar impression associated with an Arnold-Chiari type-1 malformation]. / Enfermedad ósea de Paget e impresión basilar asociadas a malformación de Arnold-Chiari tipo I.

The patient, a 78-year-old female with history of headache and progressive gait disturbance for almost one year, was admitted to our department because of dysphagia and dysphonia since three months before. Neurological examination revealed nystagmus, cerebellar ataxia, deafness, and vesical incontinence. No cerebral injuries were detected by computed tomography (CT) scan, although Paget's. Disease of Bone (PDB) was suggested, confirmed by biochemical and scintigraphic studies. The plain skull X-ray showed platybasia. As all the disarrangements were not explained by PDB complications alone, nuclear magnetic resonance imaging (MRI) was performed which demonstrated an Arnold-Chiari malformation (ACM) type I, with mild tonsillar herniation and anterior compression of the brainstem due to basilar impression, without syringomyelia. The association of PDB and ACM is a peculiarity seldom reported. The surgical approach was rejected, but the severity of symptoms and osteitis deformans biochemical activity needed a treatment; it was orientated to modify bone turnover using etidronate, a bisphosphonate, which induced clinical improvement and a decrease in serum alkaline phosphatase as well as in other bone resorption markers, without side effects. The good status and biochemical remission have been maintained a year later.

[The 'clock drawing test' in healthy elderly people]. / El test del reloj en ancianos sanos.

INTRODUCTION AND OBJECTIVE: In this paper we aim to determine the normal values of the clock drawing test in a sample group of 58 healthy elderly persons as a neuropsychological parameter for the evaluation of certain cognitive functions. MATERIAL AND METHODS: For this we have used our own adaptation of the quantitative parameters of the clock drawing test in the evaluation 'on command' and 'on copying'. We have also evaluated the possible interaction of the test with the following sample parameters: sex, age, and educational level and we have calculated the inter-examiner reliability of the test. RESULTS: The average scores obtained were: 8.04 'on-command' (SD 1.60) and 9.20 (SD 0.93) 'on-copying'. CONCLUSIONS: On analysis of our results we have not observed interaction of the parameters used (age, sex and educational level) with the scores obtained in the test, while there was a high level of inter-examiner reliability.

[Analysis of the block design test in a geriatric sample group]. / Análisis del 'dibujo del cubo' en una muestra geriátrica.

We have carried out a study to determine the normal values of the 'block design test' in a sample group of 58 healthy elderly persons, a test which is usually used in the clinical evaluation of constructive apraxia. We therefore describe a grading scale which has not been previously published, in order to check the possible usefulness of this drawing as a rapid test of cognitive evaluation. A study was made of the possible interaction of the test with sample parameters, age, sex, educational level and also the inter-examiner reliability. We have observed a significant interaction between the variables of sex and educational level. Also the inter-examiner reliability is not very good. In view of our results, we consider that the 'block design test' is not very useful in the evaluation of constructive praxis in healthy elderly persons, and therefore it does not seem to us to be a good test for the rapid evaluation of cognitive function in this group.

Effect of renal impairment on distribution of ofloxacin.

A study was made of the plasma and distribution kinetics of ofloxacin administered at a dosage of 400 mg orally to a group of healthy volunteers and a group of patients with renal impairment. Blood and blister fluid samples were taken at programmed times from all individuals included in the study. The analytical techniques for the determination of ofloxacin in both fluids were a plate diffusion method and a high-performance liquid chromatographic technique. The fitting of the experimental data to the kinetic model used was done with the help of the AUTOAN 2 and NONLIN 84 computer programs. In the groups of healthy volunteers, the elimination half-life mean values were found to be 5.1 and 5.9 h in plasma and blister fluid, respectively. The maximum concentration reached in plasma (3.9 micrograms/ml) proved to be slightly higher than that in interstitial tissue fluid (2.8 micrograms/ml). In the patients with renal impairment, the maximum concentrations in both plasma and blister fluid were significantly increased, in the order of 5 to 8 micrograms/ml in the former and 3 to 4 micrograms/ml in interstitial tissue fluid. The parameters seen to undergo an increase as a result of the renal impairment were the area under the curve of the plasma-time levels, the area under the curve of the blister fluid-time levels, and the elimination half-life in plasma and blister fluid. The degree of absorption and the access capacity of the drug to interstitial tissue fluid remained constant.