Stroke-related mortality in a tertiary care hospital in Andalusia: Analysis and reflections. / Mortalidad asociada al ictus en un hospital andaluz de tercer nivel. Análisis y reflexiones.

OBJECTIVES: Stroke is a very common cause of death, especially in southern Spain. The present study analyses in-hospital mortality associated with stroke in an Andalusian tertiary care hospital. METHODS: We gathered the files of all patients who had died at Hospital Universitario Virgen de las Nieves in Granada in 2013 and whose death certificates indicated stroke as the cause of death. We also gathered stroke patients discharge data and compared them to that of patients with acute coronary syndrome (ACS). RESULTS: A total of 825 patients had a diagnosis of stroke (96 deaths, 11.6%); of these, 562 had ischaemic stroke (44 deaths, 7.8%) and 263 haemorrhagic stroke (52 deaths, 19.7%). Patients with haemorrhagic stroke therefore showed greater mortality rate (OR=2.9). Patients in this group died after a shorter time in hospital (median, 4 vs 7 days; mean, 6 days). However, patients with ischaemic stroke were older and presented with more comorbidities. On the other hand, 617 patients had a diagnosis of ACS (36 deaths, 5.8%). The mortality odds ratio (MOR) was 2.1 (stroke/SCA). Around 23% of the patients who died from stroke were taking anticoagulants. 60% of the deceased patients with ischaemic stroke and 20% of those with haemorrhagic stroke had atrial fibrillation (AF); 35% of the patients with ischaemic stroke and AF were taking anticoagulants. CONCLUSIONS: Stroke is associated with higher admission and in-hospital mortality rates than SCA. Likewise, patients with haemorrhagic stroke showed higher mortality rates than those with ischaemic stroke. Patients with fatal stroke usually had a history of long-term treatment with anticoagulants; 2 thirds of the patients with fatal ischaemic stroke and atrial fibrillation were not receiving anticoagulants. According to our results, optimising prevention in patients with AF may have a positive impact on stroke-related in-hospital mortality.

[Impact of warning against procrastination of thrombolysis in ischemic stroke]. / Impacto de las advertencias contra la procrastinación sobre las demoras en la trombólisis del ictus.

INTRODUCTION: Fibrinolysis in stroke should be carried out as soon as possible, but delays occur for various reasons. In the first 17 ischemic infarcts treated in our center we confirmed a tendency to exhaust the therapeutic window. We look now at whether warnings against this tendency, without other logistical or organizational modifications, have had an impact on delays. PATIENTS AND METHODS: Neurologists were encouraged to avoid procrastination. When we reached 51 treated patients, we compared features and delay times between the first 17 (February, 2002 to June, 2004) and the 17 most recent cases (October, 2005 to April, 2006). Non-parametric tests were used (significant if p < 0.05). RESULTS: Both groups were similar clinically and demographically. The onset-arrival time lengthened (46 min vs. 75 min; p = 0.01) and scattered. The CT-treatment time halved (57 min vs. 30 min; p = 0.001), with consequent shortening of the 'door-to-needle' period (121 min vs. 90 min; p = 0.002). The arrival-CT time had remained constant (50 min vs. 53 min; p = 0.9), thus the total delay from onset did not change significantly (165 min vs. 170 min; p = 0.7), and the inverse linear correlation between the onset-CT time and the CT-treatment time weakened. CONCLUSIONS: Warnings against procrastination appear to be important in terms of shortening the delays. The time used for clinical-radiologic evaluation (arrival through CT)--about which there had been no action taken--had not been modified, but the time employed in the decision to treat (CT-treatment) and the 'door-to-needle' time had decreased appreciably. This effective compensatory reduction permitted treatment of late-arriving patients, such that although the overall time from onset to treatment apparently was not modified, the actual treatment rate increased.

El ictus en el hospital comarcal: por favor, llamen al neurólogo. Réplica / Strokes in the district hospital: please call the neurologist. Reply

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[Sign of hyperdense and hyperintense anterior cerebral artery]. / Signo de la arteria cerebral anterior hiperdensa e hiperintensa.

INTRODUCTION: The sign of a hyperdense middle cerebral artery (MCA) in computed tomography (CT) scan, or hyperintense MCA in magnetic resonance imaging (MRI) has been associated with recent acute occlusion of the vessel. Hyperdense or hyperintense signs in the basilar and cerebral posterior arteries in association with acute infarct have also been reported. These signs may help to clarify localization and provide prognostic information, especially when the clinical findings are not clear or conclusive. We hereby report on a case of acute infarct in the anterior cerebral artery (ACA) territory with hyperdensity and hyperintensity of the affected vessel. CASE REPORT: This is a case report of a 74 year old male patient with vascular risk factors who had the acute onset of speech impairment and left side hemiparesis, evolving over the next several hours to include depression of the level of consciousness, mutism, and right leg paresis. The A2 segment of the right ACA was found to be hyperdense in CT scan without contrast, and hyperintense in the FLAIR-MRI respectively. MR-angiography showed occlusion of the probably dominant right ACA at the A2 segment shortly after its onset. CONCLUSIONS: The finding of a hyperdense and hyperintense ACA may be useful for diagnosis of acute stroke in the ACA territory, particularly in clinically ambiguous cases. To our knowledge, this is the first reported case of hyperdense and hyperintense ACA as an early sign of acute stroke. Its prognostic value in the ACA is thus far unknown.

[Thrombolysis in stroke: inappropriate consideration of the 'window period' as the time available]. / Trombólisis en el ictus: consideración inapropiada del 'período de ventana' como tiempo disponible.

AIMS: The earlier r-TPA is administered in ischaemic strokes, the more effective it is. The aim of this study is to analyse the delay times in health care afforded in a consecutive series of cases that had received treatment, with a view to shortening them. PATIENTS AND METHODS: We analysed the medical records of the first patients to be treated in our centre. The paper describes several variables involving demographic and clinical factors, as well as the delay in entering the Emergency department, performing a CAT scan and especially the time elapsed between the CAT scan and starting treatment. We have examined the existence of an inappropriate correlation between delays that should be independent of one another. RESULTS: The mean age of the 17 patients treated was 68 years and they had a stroke severity score of 17 points on the NIHSS. The mean time of delay until arrival, arrival-CAT, and CAT-treatment were slightly under 1 hour each, and onset-treatment delay was 165 minutes, which is very close to the limit of the therapeutic window period. We found a strong inverse linear association between the time elapsed between onset and the CAT scan, and from the latter to the beginning of treatment (Spearman's r: -0.664, p = 0.004). CONCLUSIONS: Findings indicate that in our hospital, as in other centres in the initial phases of implementation, the therapeutic time window for intravenous thrombolysis in ischaemic stroke tends to run out. It must be highlighted that the resolve of the physician who indicates the treatment exerts a decisive effect on the delay.

[Malignant middle cerebral artery infarction: medical or surgical treatment?]. / Infarto maligno de la arteria cerebral media: tratamiento médico o quirúrgico?

INTRODUCTION: Post-ischemic brain edema occurs in 10-20% of cases of infarction of the middle cerebral artery and is the main cause of early death following a completed stroke. This complication, which is known as malignant middle cerebral artery infarction (MMCI), has a mortality rate of 78% when treated medically and thus requires a different management, such as a decompressive craniectomy. The main aim of this study is to review this procedure. DEVELOPMENT: We conducted a search in the literature published over the last 20 years on this subject. Most of the studies are series of clinical cases with very favourable surgical outcomes. In non-random case-control studies the mortality rate was seen to decrease in the surgical group, and more so if the intervention was carried out early, as compared to the group that underwent medical treatment. Another study that compared decompressive craniectomy with hypothermia showed a higher survival rate in the surgical group. The post-surgery morbidity rate has not been determined, although it seems to be lower in infarction of the non-dominant hemisphere and in younger patients. CONCLUSIONS: The low degree of conclusiveness of the studies published to date only enables us to offer one practical opinion concerning this issue: decompressive craniectomy should be evaluated on an individual basis in patients with MMCI who do not respond to medical treatment. The final decision and the most appropriate moment to operate on the patient following the stroke must be based on the family's opinion and on the clinical features of the patient.

[Natural evolution of radiculopathies and myelopathies caused by cervical arthrosis]. / Evolución natural de las radiculopatías y mielopatías por cervicoartrosis.

AIMS: From the data available in the literature, to analyse the natural history of acute or chronic radiculopathies and myelopathies linked with degenerative disease of the cervical spine. DEVELOPMENT: By means of different electronic and manual search methods, we located original pieces of work dealing with recent objectives and reviews on the subject. We have attempted to take into account any data that might be relevant, regardless of the characteristics or quality of the work in which it was published. The high prevalence of degenerative changes in the cervical region in the general population, the fact that the development of the concept of cervical radiculopathies and myelopathies has gone parallel to the development of their surgical treatment, and that there are few series with a control group and independent evaluation and no trials with random assignation do not allow a systematic approach. The anatomical and radiological aspects of cervical arthrosis are well known, but there is little information available on the causal relation between both processes and their clinical translation or their natural evolution. CONCLUSIONS: In the present state of knowledge, it is not possible to establish unmistakable relations between cervical disc disease and the radiculopathies and myelopathies it is attributed with. The natural evolution of these neurological syndromes is not known and therefore neither is it known how this could be modified by conservative or surgical treatment. From critical points of view, there is a unanimous claim for clinical trials to be performed with random assignation, which would provide us with an understanding of the natural history of these entities and the role of the different surgical or conservative treatments available

[Clinical iconographic dissociation in a case of monophasic demyelinating disease]. / Disociación clinicoiconográfica en un caso de enfermedad desmielinizante monofásica.

We report a patient with monophasic inflammatory demyelinizing disease whose initial symptoms and imaging studies led to the undertaking of a cerebral biopsy for suspicion of an expansive process. The evolution of the both the CT and MR imaging studies with contrast and overall the surprising size of the lesions in MR when the patient was clinically asymptomatic support the hypothesis of residual dysfunction in the hemato-encephalic barrier as a cause of the persistence of MR images. This explanation appears more acceptable than its attribution to a gliosis secondary to previous inflammation.