Reperfusion therapy in acute ischaemic stroke due to cervical and cerebral artery dissection: Results from a Spanish multicentre study.

INTRODUCTION: Ischaemic stroke (IS) due to cervical and cerebral artery dissection (CAD) is a rare entity, and few data are available on the use of such reperfusion therapies as intravenous fibrinolysis and mechanical thrombectomy in these patients. We analysed the use of these treatments in patients with IS due to CAD and compared them against patients receiving reperfusion treatment for IS of other aetiologies. METHODS: We conducted an observational, retrospective, multicentre study of patients with IS due to CAD recorded in the National Stroke Registry of the Spanish Society of Neurology during the period 2011-2019. Comparative analyses were performed between: a) patients with CAD treated and not treated with reperfusion therapies and b) patients treated with reperfusion for IS due to CAD and patients treated with reperfusion for IS due to other causes. Epidemiological data, stroke variables, and outcomes at discharge and at 3 months were included in the analysis. RESULTS: The study included 21,037 patients with IS: 223 (1%) had IS due to CAD, of whom 68 (30%) received reperfusion treatment. Reperfusion treatments were used less frequently in cases of vertebral artery dissection and more frequently in patients with carotid artery occlusion. Compared to patients with IS due to other causes, patients with CAD were younger, more frequently underwent mechanical thrombectomy, and less frequently received intravenous fibrinolysis. Rates of haemorrhagic complications, mortality, and independence at 3 months were similar in both groups. CONCLUSIONS: Reperfusion therapy is frequently used in patients with IS due to CAD. The outcomes of these patients demonstrate the efficacy and safety of reperfusion treatments, and are comparable to the outcomes of patients with IS due to other aetiologies.

Botulismo alimentario durante la pandemia por el SARS-CoV-2. Descripción de un caso y de un posible brote familiar en Barcelona / Food borne-botulism during SARS-CoV-2 pandemic time. A case and a possible familial outbreak in Barcelona

Introducción. El botulismo es un síndrome neuroparalítico hoy en día infrecuente, potencialmente fatal, causado por neurotoxinas de Clostridium botulinum. El origen es alimentario en el 25% de los casos. Caso clínico. Describimos el caso confirmado de botulismo alimentario en una paciente atendida en nuestro hospital en septiembre de 2020 y la sospecha de un segundo caso en un familiar de la paciente, no confirmado éste por las pruebas de laboratorio. La instauración en pocos días de una afectación bilateral de pares craneales, incluyendo disfagia, disnea y disartria, junto con midriasis y tetraparesia graves, precedida de diarrea, constituyó la presentación clínica en el primer caso; mientras que en su familiar cursó con síntomas inespecíficos y transitorios. Constatamos disautonomía consistente en hipotensión arterial en ambos casos. Teniendo en cuenta la situación pandémica en aquel momento, se descartó repetidamente la infección por SARS-CoV-2 antes de plantear alternativas diagnósticas. La neurotoxina B de C. botulinum fue detectada en las heces de la paciente, confirmando el diagnóstico de botulismo, que relacionamos con la ingesta de una conserva casera de alubias. Se completó el diagnóstico diferencial del cuadro descartando otras posibles etiologías. Conclusión. La sospecha clínica temprana, confirmada con los hallazgos de laboratorio y neurofisiológicos y que llevaron al manejo específico de la paciente, fueron cruciales para la evolución favorable. No fue necesario aplicar medidas de salud pública, a excepción de la notificación a sus allegados de la contaminación detectada. Conocer la existencia de esta patología puede contribuir a su pronóstico.(AU)

Introduction. Botulism is a potentially fatal neuroparalytic syndrome caused by Clostridium botulinum neurotoxin. The 25% are food-borne botulism cases. Case report. We describe a confirmed case of botulism attended in our hospital in September 2020, together with a second case in a patient’s relative, suspected but not confirmed by laboratory tests. Clinical presentation consisted on general weakness, bilateral cranial palsy, mydriasis, and rapidly progressive tetraparesis in case 1, involving respiratory and swallowing function so she required hospitalization and support treatment. Non specific and transient symptoms occurred in case 2. SARS-CoV-2 infection was initially suspected in both cases due to pandemic situation in our country, ruled out by negative PCR. When B neurotoxin was detected in stool sample of patient 1 we confirmed the diagnosis of food-borne botulism probably linked to home-made conserved beans. Conclusion. Early clinical suspicion, together with laboratory and electromyography findings, and support treatment provided at hospital were crucial for favourable outcome. Being aware of this rare syndrom might contribute to its better management.(AU)

Food borne-botulism during SARS-CoV-2 pandemic time. A case and a possible familial outbreak in Barcelona. / Botulismo alimentario durante la pandemia por el SARS-CoV-2. Descripción de un caso y de un posible brote familiar en Barcelona.

INTRODUCTION: Botulism is a potentially fatal neuroparalytic syndrome caused by Clostridium botulinum neurotoxin. The 25% are food-borne botulism cases. CASE REPORT: We describe a confirmed case of botulism attended in our hospital in September 2020, together with a second case in a patient's relative, suspected but not confirmed by laboratory tests. Clinical presentation consisted on general weakness, bilateral cranial palsy, mydriasis, and rapidly progressive tetraparesis in case 1, involving respiratory and swallowing function so she required hospitalization and support treatment. Non specific and transient symptoms occurred in case 2. SARS-CoV-2 infection was initially suspected in both cases due to pandemic situation in our country, ruled out by negative PCR. When B neurotoxin was detected in stool sample of patient 1 we confirmed the diagnosis of food-borne botulism probably linked to home-made conserved beans. CONCLUSION: Early clinical suspicion, together with laboratory and electromyography findings, and support treatment provided at hospital were crucial for favourable outcome. Being aware of this rare syndrom might contribute to its better management.

TITLE: Botulismo alimentario durante la pandemia por el SARS-CoV-2. Descripción de un caso y de un posible brote familiar en Barcelona.Introducción. El botulismo es un síndrome neuroparalítico hoy en día infrecuente, potencialmente fatal, causado por neurotoxinas de Clostridium botulinum. El origen es alimentario en el 25% de los casos. Caso clínico. Describimos el caso confirmado de botulismo alimentario en una paciente atendida en nuestro hospital en septiembre de 2020 y la sospecha de un segundo caso en un familiar de la paciente, no confirmado éste por las pruebas de laboratorio. La instauración en pocos días de una afectación bilateral de pares craneales, incluyendo disfagia, disnea y disartria, junto con midriasis y tetraparesia graves, precedida de diarrea, constituyó la presentación clínica en el primer caso; mientras que en su familiar cursó con síntomas inespecíficos y transitorios. Constatamos disautonomía consistente en hipotensión arterial en ambos casos. Teniendo en cuenta la situación pandémica en aquel momento, se descartó repetidamente la infección por SARS-CoV-2 antes de plantear alternativas diagnósticas. La neurotoxina B de C. botulinum fue detectada en las heces de la paciente, confirmando el diagnóstico de botulismo, que relacionamos con la ingesta de una conserva casera de alubias. Se completó el diagnóstico diferencial del cuadro descartando otras posibles etiologías. Conclusión. La sospecha clínica temprana, confirmada con los hallazgos de laboratorio y neurofisiológicos y que llevaron al manejo específico de la paciente, fueron cruciales para la evolución favorable. No fue necesario aplicar medidas de salud pública, a excepción de la notificación a sus allegados de la contaminación detectada. Conocer la existencia de esta patología puede contribuir a su pronóstico.

Reperfusion treatment in acute ischaemic stroke due to cervical and cerebral artery dissection: results of a Spanish national multicentre study. / Tratamiento de reperfusión en el ictus isquémico agudo por disección arterial cervicocerebral: descripción de los resultados de un estudio nacional multicéntrico.

INTRODUCTION: Ischaemic stroke (IS) due to cervical and cerebral artery dissection (CAD) is a rare entity, and few data are available on the use of such reperfusion therapies as intravenous fibrinolysis and mechanical thrombectomy in these patients. We analysed the use of these treatments in patients with IS due to CAD and compared them against patients receiving reperfusion treatment for IS of other aetiologies. METHOD: We conducted an observational, retrospective, multicentre study of patients with IS due to CAD recorded in the National Stroke Registry of the Spanish Society of Neurology during the period 2011-2019. Comparative analyses were performed between: a) patients with CAD treated and not treated with reperfusion therapies and b) patients treated with reperfusion for IS due to CAD and patients treated with reperfusion for IS due to other causes. Epidemiological data, stroke variables, and outcomes at discharge and at 3 months were included in the analysis. RESULTS: The study included 21,037 patients with IS: 223 (1%) had IS due to CAD, of whom 68 (30%) received reperfusion treatment. Reperfusion treatments were used less frequently in cases of vertebral artery dissection and more frequently in patients with carotid artery occlusion. Compared to patients with IS due to other causes, patients with CAD were younger, more frequently underwent mechanical thrombectomy, and less frequently received intravenous fibrinolysis. Rates of haemorrhagic complications, mortality, and independence at 3 months were similar in both groups. CONCLUSIONS: Reperfusion therapy is frequently used in patients with IS due to CAD. The outcomes of these patients demonstrate the efficacy and safety of reperfusion treatments, and are comparable to the outcomes of patients with IS due to other aetiologies.

[Anti-NMDA receptor encephalitis. Early diagnosis and treatment in patients with acute-subacute psychotic symptoms]. / Encefalitis antirreceptor de NMDA. Diagnostico y tratamiento precoz en pacientes con sintomatologia psicotica aguda-subaguda.

INTRODUCTION: Encephalitis due to anti-NMDA receptor antibodies is an acute and severe condition, which, if identified and treated quickly, can entail recovery without any sequelae. It is more prevalent in young females and is often associated with an underlying tumour. The initial symptoms are usually of a psychiatric nature, and in a matter of days or weeks take on a characteristic neurological profile. CASE REPORTS: We report the cases of three women, 17, 23 and 35 years of age, who were admitted to Psychiatry with acute psychotic clinical features. The poor response to antipsychotics, the fluctuations in the level of consciousness, dysautonomia and epileptic seizures were the symptoms that led to the clinical suspicion. The cerebrospinal fluid revealed slight pleocytosis and gave positive for anti-NMDA receptor antibodies in all cases. Only one patient displayed alterations in the magnetic resonance brain scan, and in two cases there was an extreme delta brush electroencephalographic pattern. All three women were diagnosed with an ovarian teratoma which was resectioned within a month. Two of the patients recovered without any sequelae, and the third presents cognitive sequelae six months after being discharged. CONCLUSIONS: The cases described began with an acute psychotic clinical picture. The atypical psychiatric progression and the neurological symptoms indicated the possible presence of encephalitis. Recognition of the disease and coordination among the different services is essential for early diagnosis and treatment. The systematic analysis of cerebrospinal fluid in patients with a first acute-subacute psychotic episode would help to reach a diagnosis sooner. In young women, a search must always be carried out for an ovarian teratoma or other associated tumour.

TITLE: Encefalitis antirreceptor de NMDA. Diagnostico y tratamiento precoz en pacientes con sintomatologia psicotica aguda-subaguda.Introduccion. La encefalitis por anticuerpos antirreceptor de NMDA es una entidad aguda y grave, cuya rapida identificacion y tratamiento puede comportar recuperaciones sin secuelas. Es mas prevalente en mujeres jovenes y a menudo esta asociada a un tumor subyacente. Los sintomas iniciales son habitualmente psiquiatricos y en dias o semanas adquieren el perfil neurologico caracteristico. Casos clinicos. Tres mujeres, de 17, 23 y 35 años, que ingresaron en el Servicio de Psiquiatria con clinica psicotica aguda. La mala respuesta a los antipsicoticos, las fluctuaciones del nivel de conciencia, la disautonomia y las crisis epilepticas fueron los sintomas que despertaron la sospecha clinica. El liquido cefalorraquideo mostro leve pleocitosis y positividad para los anticuerpos antirreceptor de NMDA en todas las pacientes. Solo una mostro alteraciones en la resonancia magnetica cerebral, y dos, el patron electroencefalografico extreme delta brush. En todas se diagnostico un teratoma ovarico, que fue resecado antes del mes. Dos se recuperaron sin secuelas y la tercera, a los seis meses del alta, presenta secuelas cognitivas. Conclusiones. Los casos descritos comenzaron con clinica psicotica aguda. La evolucion psiquiatrica atipica y la clinica neurologica alertaron de la posibilidad de una encefalitis. El reconocimiento de la enfermedad y la coordinacion entre servicios es fundamental para un diagnostico y tratamiento precoz. El analisis sistematico de liquido cefalorraquideo en pacientes con un primer episodio psicotico agudo-subagudo contribuiria a adelantar el diagnostico. En mujeres jovenes hay que buscar siempre un teratoma ovarico u otro tumor asociado.

Prevalence, risk factors and complications of oropharyngeal dysphagia in stroke patients: A cohort study.

BACKGROUND: Oropharyngeal dysphagia (OD) is a prevalent poststroke condition with severe complications and increased mortality. Poststroke OD prevalence varies among studies and there is little evidence of its related risk factors and associated complications. OBJECTIVE: to evaluate the prevalence of OD after stroke and the risk factors and associated complications. METHODS: We performed a prospective longitudinal study of stroke patients consecutively admitted to a general hospital. OD was diagnosed with the volume-viscosity swallow test (V-VST). Demographic, functional status and topographical and clinical variables of stroke were collected to assess risk factors for OD. We evaluated functional status, mortality, respiratory infections, and readmissions 3 and 12 months after stroke. A multivariate regression analysis determined associated risk factors for OD and for each outcome variable. KEY RESULTS: We included 395 stroke patients with a 45.06% prevalence of OD on admission. OD was independently associated with age (OR = 1.05; CI = 1.02-1.08), previous stroke (OR = 2.40; CI = 1.00-5.79), severity using the National Institute of Health Stroke Scale (OR = 3.52; CI = 1.57-7.87) and volume of the lesion (OR = 1.02; CI = 1.01-1.03). OD after stroke was an independent risk factor for prolonged hospital stay (P = .049; ß = 0.938) and institutionalization after discharge (OR = 0.47; CI = 0.24-0.92); OD was an independent risk factor for poorer functional capacity (OR = 3.00; CI = 1.58-5.68) and increased mortality (HR = 6.90; CI = 1.57-30.34) 3 months after stroke. CONCLUSIONS & INFERENCES: Poststroke OD is prevalent and associated with poor short and long term prognosis. Stroke severity and patient status before stroke were more relevant to OD than lesion location. Systematic screening programs and early OD management could significantly improve poststroke patient outcome.

Videofluoroscopic assessment of the pathophysiology of chronic poststroke oropharyngeal dysphagia.

BACKGROUND AND PURPOSE: Oropharyngeal dysphagia (OD) is a major complaint following stroke, associated with poor clinical outcome and high mortality rates. We aimed at characterizing the kinematics of swallow response associated with unsafe swallowing in chronic poststroke patients with OD. PATIENTS AND METHODS: Consecutive poststroke patients with a positive volume-viscosity swallow test for OD 3 months following stroke were studied by videofluoroscopy (VFS). Demographical and clinical factors and kinematics of swallow response were compared between those poststroke patients with safe swallow (penetration-aspiration scale, PAS≤2) and those with unsafe swallow (PAS≥3). Receiver operating characteristic (ROC) curves were drawn for laryngeal vestibule closure (LVC) time which predicts unsafe swallow. RESULTS: We studied 73 poststroke patients (76.7±9.3 years, 53.4% male) by VFS (60.4% with impaired safety, PAS=4.47±1.44, and 95.9% with impaired efficacy of swallow). Poststroke patients with unsafe swallow presented a poorer functional (Rankin 2.2±1.6 vs 1.2±1.0, P<.012) and nutritional status (MNA-sf≤11, 34.2% vs 7.4%, P<.05) than poststroke patients with safe swallow. Poststroke patients with unsafe swallow presented a significant delay in LVC time (406.4±99.5 ms vs 318.9±80.4 ms; P<.05) and weaker tongue bolus propulsion forces (0.771±0.450 mJ vs 1.638±3.212 mJ; P=.043). LVC time ≥340 ms predicts unsafe swallow in chronic poststroke patients with a diagnostic accuracy of 0.78. CONCLUSIONS: Impaired safety of swallow in chronic poststroke patients is caused by specific impairments in swallow response including delayed timing of airway protection mechanisms and weak tongue propulsion forces. Treatments aiming to restore swallowing function in poststroke patients with OD should be targeted to improve these critical biomechanical events.

Cough reflex attenuation and swallowing dysfunction in sub-acute post-stroke patients: prevalence, risk factors, and clinical outcome.

BACKGROUND: Cough and swallowing impairments in post-stroke patients (PSP) have been associated with increased risk for respiratory complications. AIMS: To assess the prevalence of alterations in protective cough responses in subacute PSP and its association with oropharyngeal dysphagia (OD), clinical, and neurotopographic stroke factors and clinical outcomes. METHODS: Three months after stroke, the cough reflex test (CRT) was performed by nebulizing incremental citric acid concentrations (7.8-1000 mmol L-1 ) to determine the concentration that elicited two and five coughs; OD was assessed by the volume-viscosity swallow test. Clinical and neurotopographic stroke risk factors and complications (readmissions, respiratory infections, institutionalization, and mortality) were recorded from 3 to 12 months post-stroke. RESULTS: We included 225 PSP. Prevalence of impaired CRT was 5.8%, that of OD was 40.4% (20.4% with impaired safety of swallow), and of both impairments was, 1.8%. No specific risk factors associated with impaired CRT were found; however, hemorrhagic, wide circulation infarction (TACI), and brainstem strokes delayed the cough response. OD was associated with age, TACI and poor functional and nutritional status. Outcome of PSPs was unaffected by impaired CRT but OD and impaired safety of swallow increased institutionalization, respiratory infections, and mortality with the poorest outcome for those with both impairments. CONCLUSIONS: Prevalence of subacute post-stroke OD and swallow safety impairments was much higher than CRT attenuation, and risk factors strongly differed suggesting that the swallow response receives a stronger cortical control than the cough reflex. OD has a greater impact on PSP clinical outcome than impaired cough, the poorest prognosis being for patients with both airway protective dysfunctions.

Emergency perception and other variables associated with extra-hospital delay in stroke patients in the Maresme region (Spain).

Delay in arrival to the emergency room (ER) may negatively influence outcome of stroke patients. We aim to analyze factors that influence extra-hospital delay in stroke patients. Two hundred and ninety-two consecutive stroke patients admitted in the ER were prospectively studied. Analysis was made to identify variables associated with <1- and <3 h delays from onset. About 18.8% of patients arrived before 1 h and 57.5% before 3 h. Factors independently associated with <3 h delay were decision to go immediately to ER (OR = 8.17; 95% IC = 4.47-18.8), ambulance transportation (OR = 2.35; 1.36-4.05) and total anterior circulation syndrome (TACS) (OR = 3.74; 1.51-9.24). History of >1 vascular risk factor was associated with a greater delay (OR = 0.47; 0.26-0.86). Factors associated with a <1 h delay were: (i) immediate decision to attend the ER (OR = 3.55; 1.85-6.81), (ii) stroke on Sunday (OR = 3.46; 1.56-7.66), (iii) aphasia (OR = 2.41; 1.23-4.74), (iv) absence of stairs at home (OR = 0.37; 0.17-0.81) and (v) absence of diabetes mellitus (OR = 0.42; 0.20-0.88). In our area, nearly 60% of stroke patients arrive to ER before 3 h from onset. Immediate decision to attend the ER has the strongest association with a short delay. Patients with TACS arrived mainly before 3 h and those with isolated aphasia arrived before 1 h. Patients with vascular risk factors attended the hospital later. Ambulance transportation is associated with <3 h delay, but not with <1 h.

Influence of the stroke code activation source on the outcome of acute ischemic stroke patients.

INTRODUCTION: In our metropolitan area, the Stroke Code (SC) system allows immediate transfer of patients with acute stroke to a stroke center. It may be activated by community hospitals (A), emergency medical services (EMS, B), or the emergency department of the stroke center (C). Our aim was to analyze whether the SC activation source influences the access to thrombolytic therapy and outcome of patients with ischemic stroke. METHODS: We prospectively registered patients with ischemic stroke admitted to the acute stroke unit who arrived through the SC system. The primary outcome variable was good outcome at discharge (Rankin Scale or=4 in National Institutes of Health Stroke Scale (NIHSS) score or NIHSS score 0 to 1 at 24 hours. RESULTS: A total of 262 consecutive patients with hyperacute ischemic stroke were studied; the SC source was A in 112, B in 57, and C in 92. Median time from onset to admission was longer in Group A and stroke severity higher in Groups B and C. Percentage of tPA administration was higher in patients from Groups B and C (27%, 54%, and 46% of patients; p = 0.001). With respect to Group A, Group B was associated with good outcome with an odds of 2.9 (1.2-6.6; p = 0.01), and Group C with an odds of 2.4 (1.1-4.9; p = 0.01) after adjustment for age and stroke severity at baseline. Patients coming via levels B and C were more likely to improve at 24 hours. CONCLUSIONS: Patients arriving directly to the stroke center via emergency medical services or on their own receive neurologic attention sooner, are more frequently treated with tPA, and have better clinical outcome than those patients who are first taken to a community hospital.

Anterior choroidal artery infarction: a clinical, etiologic and prognostic study.

OBJECTIVES: To analyze the clinical, etiologic and prognostic profile of anterior choroidal artery (AChA) infarcts. METHODS: 42 consecutive patients with AChA infarction were included. Symptoms, etiology and scores on neurological and functional scales were analyzed on admission, discharge and at 3-month follow-up. A comparative study was performed between deep (n = 23) and deep + superficial (n = 19) infarcts. RESULTS: Lacunar syndrome was present in 83.3% of patients. Etiology was large-vessel disease in 38.1% and cryptogenic in 38.1%. Ten patients had a National Institute of Health Stroke Scale score >7 on admission. At discharge, 45.3% had an modified Rankin Scale >2 (35.7% after 3 months). Infarcts involving superficial territory were more severe at admission (P = 0.034) and were associated with a worse functional status at discharge (P = 0.0008). CONCLUSION: AChA infarcts usually present with lacunar syndrome, although they are often not lacunar infarcts. At discharge, almost half of the patients are dependent in their activities of daily living, and most remain so at 3-month follow-up. Infarcts involving superficial territory are associated with worse prognosis.

Eficacia y tolerabilidad del levetiracetam en pacientes con temblor esencial: datos de un ensayo abierto de 11 semanas de seguimiento / Effectiveness and safety of levetiracetam in patients with essential tremor data from an open 11-week follow-up trial

Introducción. Es bien conocida la relativamente alta proporción de pacientes con temblor esencial refractarios a varios fármacos conocidos en la actualidad para su tratamiento. Objetivo. Evaluar la eficacia y la tolerabilidad del levetiracetam (LEV) en pacientes que hubieran mostrado respuesta escasa o nula o efectos secundarios intolerables en tratamiento con betabloqueadores o primidona, o presentasen contraindicaciones para el inicio de estos tratamientos. Pacientes y métodos. Llevamos a cabo un estudio piloto, abierto, de 11 semanas de duración en pacientes con las características descritas previamente. Las medidas principales de respuesta se basaron en la escala de temblor de Fahn, Tolosa y Marín (FTM), variables acelerométricas y efectos adversos. La dosis máxima de LEV fue de 3.000 mg, a la que llegaron los pacientes que no presentaron beneficio con dosis inferiores, tras una semana de tratamiento con 1.000 mg y cuatro semanas de tratamiento con 2.000 mg. Resultados. La muestra consistió en 14 pacientes con temblor esencial, con una media de edad de 70,08 (7,99) años y una mediana de 11,5 años de clínica. Aunque se observaron pequeños descensos en la escala de FTM y en la amplitud del temblor al final del estudio, ninguna de las diferencias observadas fue significativa. Seis pacientes abandonaron el estudio por falta de eficacia o efectos adversos. Conclusión. El LEV no produjo modificaciones estadísticamente significativas en ninguna de las variables controladas en este perfil de pacientes

Introduction. It is a well-known fact that a relatively high proportion of patients with essential tremor are resistant to a number of pharmaceuticals currently used to treat the condition. Aim. To assess the effectiveness and safety of levetiracetam (LEV) in patients who displayed little or no response or intolerable side effects under treatment with beta blockers or primidone, or who presented contraindications against beginning such treatments. Patients and methods. We conducted an open 11-week pilot study in patients with the characteristics described above. The main response measurements were based on the Fahn-Tolosa-Marín (FTM) tremor rating scale, accelerometric variables and side effects. The maximum dose of LEV was 3000 mg, which was reached by patients who did not benefit from lower doses, after one week’s treatment with 1000 mg and four weeks’ treatment with 2000 mg. Results. The sample consisted of 14 patients with essential tremor, with a mean age of 70.08 (7.99) years and an average clinical history of 11.5 years. Although by the end of the study small decreases were observed on the FTM rating scale and in the amplitude of the tremor, none of the differences were significant. Six patients dropped out of the study because of a lack of effectiveness or to side effects. Conclusion. LEV did not produce any statistically significant modifications in any of the variables that were monitored in this group of patients

[Effectiveness and safety of levetiracetam in patients with essential tremor: data from an open 11-week follow-up trial]. / Eficacia y tolerabilidad del levetiracetam en pacientes con temblor esencial: datos de un ensayo abierto de 11 semanas de seguimiento.

INTRODUCTION: It is a well-known fact that a relatively high proportion of patients with essential tremor are resistant to a number of pharmaceuticals currently used to treat the condition. AIM: To assess the effectiveness and safety of levetiracetam (LEV) in patients who displayed little or no response or intolerable side effects under treatment with beta blockers or primidone, or who presented contraindications against beginning such treatments. PATIENTS AND METHODS: We conducted an open 11-week pilot study in patients with the characteristics described above. The main response measurements were based on the Fahn-Tolosa-Marin (FTM) tremor rating scale, accelerometric variables and side effects. The maximum dose of LEV was 3000 mg, which was reached by patients who did not benefit from lower doses, after one week's treatment with 1000 mg and four weeks' treatment with 2000 mg. RESULTS. The sample consisted of 14 patients with essential tremor, with a mean age of 70.08 (7.99) years and an average clinical history of 11.5 years. Although by the end of the study small decreases were observed on the FTM rating scale and in the amplitude of the tremor, none of the differences were significant. Six patients dropped out of the study because of a lack of effectiveness or to side effects. CONCLUSION: LEV did not produce any statistically significant modifications in any of the variables that were monitored in this group of patients.

Aspirin or anticoagulants in stenosis of the middle cerebral artery: A randomized trial.

BACKGROUND: We report the results of an open, randomized, multicenter trial that compared the efficacy of aspirin to oral anticoagulants (OA) for the prevention of vascular events in patients with symptomatic stenosis of the middle cerebral artery (MCA). METHODS: Participants were randomly assigned to receive 300 mg/day of aspirin or a dose of OA (target INR 2-3). The MCA stenosis was demonstrated by conventional angiography or by at least two noninvasive examinations. Patients had either transient ischemic attack or cerebral infarct (CI) attributable to the MCA stenosis within 90 days before inclusion. The primary endpoint was: nonfatal CI, nonfatal acute myocardial infarct, vascular death and major hemorrhage. The patients were followed-up for a minimum of 1 year and a maximum of 3 years. RESULTS: The study included 28 patients (14 in each treatment group); the average age was 67 +/- 9.9 years. Men constituted 68% of the patients. After a mean follow-up of 23.1 +/- 10.9 months, there were no recurrences of CI in both groups. No endpoint was reported in the aspirin group, but 2 patients in the OA group (14.3%) exhibited vascular events: 1 acute myocardial infarct and 1 intracerebral hemorrhage). However, this difference was not statistically significant (p = 0.48). CONCLUSIONS: Our study suggests that aspirin is the treatment of choice for the prevention of vascular events in patients with symptomatic MCA stenosis.

[Clinical utility of outpatient videoelectroencephalogram monitoring]. / Utilidad clínica del videoelectroencefalograma en régimen ambulatorio.

OBJECTIVE: To analyze the utility of outpatient videoelectroencephalogram (VEEG) in a general neurology department to detect an ictal event. PATIENTS AND METHODS: One hundred and five patients with ictal phenomenology of unknown etiology, suspicion of pseudoseizures, refractory epilepsy with very frequent seizures, underwent outpatient VEEG monitoring from 30 minutes to five hours of duration, between June 1, 1999 and June 30, 2003. Patient medication was not modified to perform the recording. RESULTS: Among the 105 outpatient VEEG monitoring, 33 clinical pathologic events were identified; these comprised 14 epileptic seizures, 12 pseudoseizures, four syncopes, and three non epileptic abnormal movements. Outpatient VEEG monitoring duration was as follows: 30 minutes in 12 patients, between 30 minutes and two hours in another 12, and more than two hours in 9. In 19 patients, the VEEG recording allowed a definitive diagnosis; in one case, it changed the epileptic seizure type, and in 11 patients, it helped to better characterize the epileptic seizure type. CONCLUSION: Although the percentage of pathologic events during an outpatient VEEG monitoring of 30 minutes to five hours of duration is low, its clinical repercussion is very important and the added cost is low.

Utilidad clínica del videoelectroencefalograma en régimen ambulatorio / Clinical utility of outpatient videoelectroencephalogram monitoring

Objetivo. Analizar la utilidad de los registros por video-electroencefalograma (VEEG) en régimen ambulatorio realizados en un servicio de neurología general para la detección de un episodio crítico. Pacientes y métodos. Desde el 1 de junio de 1999 hasta el 1 de junio de 2003 realizamos 105 exploraciones por VEEG, de 30 minutos a 5 horas de duración, en pacientes con crisis de etiología no aclarada, ante la sospecha de pseudocrisis o en presencia de una epilepsia farmacorresistente y crisis muy frecuentes. No modificamos la medicación del paciente para realizar la exploración. Resultados. En 33 pacientes se registraron eventos clínicos patológicos; en 14 se trató de crisis epilépticas, en 12 de pseudos crisis, en 4 de síncopes y en 3 de movimientos anormales no epilépticos. La duración del registro fue de 30 minutos en 12, de entre 30 minutos y 2 horas en 12 y de más de 2 horas en 9 pacientes. En 18 pacientes el VEEG fue la exploración diagnóstica. En un caso cambió el diagnóstico del tipo de crisis epiléptica que sufría el paciente, y en 11 pacientes nos ayudó a caracterizar sus crisis epilépticas. Conclusión. Si bien el porcentaje de registro de eventos patológicos durante un estudio por VEEG ambulatorio de 30 minutos a 5 horas de duración es bajo, su repercusión clínica es muy alta y el coste añadido, escaso

Objective. To analyze the utility of outpatient videoelectroencephalogram (VEEG) in a general neurology department to detect an ictal event. Patients and methods. One hundred and five patients with ictal phenomenology of unknown etiology, suspicion of pseudoseizures, refractory epilepsy with very frequent seizures, underwent outpatient VEEG monitoring from 30 minutes to five hours of duration, between June 1, 1999 and June 30, 2003. Patient medication was not modified to perform the recording. Results. Among the 105 outpatient VEEG monitoring, 33 clinical pathologic events were identified; these comprised 14 epileptic seizures, 12 pseudoseizures, four syncopes, and three non epileptic abnormal movements. Outpatient VEEG monitoring duration was as follows: 30 minutes in 12 patients, between 30 minutes and two hours in another 12, and more than two hours in 9. In 19 patients, the VEEG recording allowed a definitive diagnosis; in one case, it changed the epileptic seizure type, and in 11 patients, it helped to better characterize the epileptic seizure type. Conclusion. Although the percentage of pathologic events during an outpatient VEEG monitoring of 30 minutes to five hours of duration is low, its clinical repercussion is very important and the added cost is low

[Validation of transcranial Doppler in Mataro, Barcelona]. / Validación del Doppler transcraneal en Mataró, Barcelona.

INTRODUCTION: Transcranial Doppler (TCD) is a new technique which is becoming increasingly used in neurology and is highly dependent on the user. OBJECTIVE: To evaluate the reliability of TCD in our hospital. PATIENTS AND METHODS: During a five month period, all patients who had a cerebral angiogram done, also had DTC within 24 hours. The TCD was reported on before the result of the angiogram was known. Subsequent analysis of the comparison of the results was done by a person who had not done the initial investigations. RESULTS: 49 persons were included in the study. The average time between the two investigations was 12.5 hours. In 5 patients the TCD was inconclusive due to a poor window. In 21 patients both tests were normal. Of the 14 patients in whom there were pathological findings on angiography, correct diagnosis was made on TCD in 12 cases, including those with stenosis of the anterior circulation. The two false negative findings of intracranial stenosis were in a vertebral artery and a posterior cerebral artery. The remaining seven cases were of patients in whom only one investigation showed signs of distal vasculopathy. CONCLUSION: The index of false positives of DTC showing intracranial stenosis was 0. All intracranial stenoses of the anterior circulation were correctly diagnosed.

[Partial benign crises in adolescence]. / Crisis parciales benignas en la adolescencia.

The aim of this paper is to present the case of teenage patient with partial seizures fulfilling the criteria of benign partial seizures of adolescence. A 16-year-old male patient had two seizures with a sensory-motor "march" that evolved into a secondarily generalized tonic-clonic seizure on the same day. Several weeks before this event he had had several simple partial sensory seizures. The patient had no previous history of seizures and there was no family history of epilepsy. The neurological examination, EEG and magnetic resonance imaging were normal. The patient was treated with antiepileptic monotherapy during two years. The treatment was gradually tapered and withdrawn over the following six months. He has had no recurrences during the five years of follow-up. The early diagnosis of this entity has the significant prognostic and therapeutic repercussions.

Crisis parciales benignas en la adolescencia / Partial benign crises in adolescence

El objetivo de este trabajo es aportar el caso de un varón de 16 años con crisis parciales que reúne los criterios del síndrome de la epilepsia parcial benigna de la adolescencia. Se trata de un paciente que presentó, en el mismo día, dos crisis parciales con una evolución sensitivomotora y generalización tónico-clónica secundaria. Había sufrido múltiples crisis parciales sensitivas en las semanas previas. No existían antecedentes personales ni familiares de epilepsia. La exploración neurológica, el electroencefalograma y la resonancia magnética cerebral fueron normales. Se realizó tratamiento en monoterapia durante dos años, que se suprimió de forma progresiva en 6 meses. Tras 5 años de evolución no se han producido recurrencias. El diagnóstico temprano de este síndrome tiene importantes repercusiones pronósticas y terapéuticas. (AU)