Recanalización arterial en el ictus agudo mediante el empleo de un stent autoexpandible / Arterial recanalisation in acute stroke by means of a self-expanding stent

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[Locked-in syndrome due to a vertebral dissection and therapeutic options with intraarterial fibrinolysis in acute phase]. / Disección vertebral como causa del síndrome de enclaustramiento y opciones terapéuticas con fibrinólisis intraarterial durante la fase aguda.

INTRODUCTION: Dissection of vertebral artery is an unusual pathology but sometimes is the cause of stroke in young patients. Since last years, and with the rise of some chiropractic technics, some authors have related these ones with the dissection of vertebral artery. CASE REPORT: We show a case of a 37 years old woman that after a chiropractic session began symptoms of posterior circulation dysfunction as decrease level of sense, tetraparesis and alteration of cranial nerves. The arteriography confirmed the existence of a vertebral dissection of V2 portion and thrombosis of basilar and contralateral vertebral arteries. Intraarterial fibrinolysis was performed with complete recanalization of the artery. Although this, the patient had parenchimal lesions in pons, cerebellum and territory of posterior cerebral artery that produced a locked-in syndrome. All the complementary exams were normal. DISCUSSION: We discuss the relationship between cervical manipulation as an aetiology of vertebral dissection, locked-in syndrome and therapeutic options in these patients

Disección vertebral como causa del síndrome de enclaustramiento y opciones terapéuticas con fibrinólisis intraarterial durante la fase aguda / Locked-in syndrome due to a vertebral dissection and therapeutic options with intraarterial fibrinolysis in acute phase

Introducción. La disección de la arteria vertebral es una patología poco frecuente, pero que en ocasiones se ha implicado en la etiología del ictus en pacientes jóvenes. Desde hace algunos años, se han relacionado determinadas técnicas quiroprácticas, que poseen un elevado grado de aceptación, con la aparición de este fenómeno. Caso clínico. Presentamos el caso de una paciente de 37 años que, después de una sesión de masaje cervical, presentó una clínica progresiva de disminución del nivel de conciencia, tetraparesia y alteración de los pares craneales compatible con trastornos de la circulación posterior. Una arteriografía confirmó la sospecha de la existencia de una disección de la arteria vertebral izquierda, segmento V2, con una trombosis basilar y vertebral contralateral secundarias. Se realizó una fibrinólisis intrarterial y se consiguió la lisis del trombo y la recanalización arterial. A pesar de ello, la paciente presentó múltiples lesiones parenquimatosas en el tronco, el cerebelo y el territorio de la arteria cerebral posterior, que configuraron un síndrome clínico de enclaustramiento. El estudio etiológico mostró una absoluta normalidad de todas las exploraciones practicadas. Discusión. Se discuten las posibles relaciones de la manipulación cervical como causa de disección vertebral, su implicación etiológica con el síndrome de enclaustramiento y las opciones terapéuticas en estos pacientes (AU)

Introduction. Dissection of vertebral artery is an unusual pathology but sometimes is the cause of stroke in young patients. Since last years, and with the rise of some chiropractic technics, some authors have related these ones with the dissection of vertebral artery. Case report. We show a case of a 37 years old woman that after a chiropractic session began symptoms of posterior circulation dysfunction as decrease level of sense, tetraparesis and alteration of cranial nerves. The arteriography confirmed the existence of a vertebral dissection of V2 portion and thrombosis of basilar and contralateral vertebral arteries. Intraarterial fibrinolysis was performed with complete recanalization of the artery. Although this, the patient had parenchimal lesions in pons, cerebellum and territory of posterior cerebral artery that produced a locked-in syndrome. All the complementary exams were normal. Discussion. We discuse the relationship between cervical manipulation as an aetiology of vertebral dissection, locked-in syndrome and therapeutic options in these patients (AU)

[Angioplasty and stenting in severe stenosis of basilar artery refractory to pharmacotherapy]. / Angioplastia y stent en la estenosis severa de arteria basilar refractaria al tratamiento farmacológico.

Stenoses in the posterior cerebral circulation often have a bad prognosis. There may be a high rate of morbi-mortality and recurrences of ischemic events in this territory. Currently we have no evidence or consensus about what the best pharmacological option is for these patients. We report a case of a 75 year old woman with sever stenosis of the proximal part of the basilar artery with recurrent transient ischemic events unresponsive to different combinations of antiagregant and anticoagulant treatments. A percutaneous transluminal angioplasty with the addition of a stent in the basilar artery was performed successfully. At present, there are few studies and a low number of patients treated by this technique. The results obtained are promising, with a low rate of morbi-mortality, the most frequent complications being embolization of the atherosclerotic lesion, dissection, rupture or restenosis.

[Analysis of cost minimization of monotherapy antiepileptic treatment in patients with recent diagnosed epilepsy : the situation in Spain]. / Análisis de coste-minimización del tratamiento antiepiléptico en monoterapia en pacientes con epilepsia de reciente diagnóstico: situación en España.

OBJECTIVE: To analyze the cost of monotherapeutic treatment of patients with newly diagnosed epilepsy. PATIENTS AND METHODS: We analysed the cost of treatment with lamotrigine (LTG), carbamazepine (CBZ), phenytoin (PHT) and valproic acid (VPA) using published data regarding the efficacy and tolerability of comparative clinical trials of monotherapy. We established a model of treatment for newly diagnosed patients during the first 12 months after diagnosis. A panel of doctors reached a consensus on the use of resources, costs and model of treatment in Spain. We made a cost minimization analysis for economic assessment of the data based on the fact that randomized trials indicated that CBZ, LTG, PHT and VPA ware of similar efficacy. Analysis was done as 'intention to treat'. Only direct medical costs were considered. RESULTS: In Spain treatment with LTG is twice or three times as expensive as treatment with the other drugs. Sensitivity analysis showed that variations in the interval of use of resources and of costs (defined by the panel of doctors) did not significantly alter the results. CONCLUSIONS: Treatment with LTG is more expensive than treatment with the classical drugs. In view of the methodological limitations of this study, further analysis is necessary, particularly of the methodology of cost-benefit, to evaluate the economic impact of the new antiepileptic drugs and determine whether their use is justified as drugs of first choice.

Análisis de coste-minimización del tratamiento antiepilépticoen monoterapia en pacientes con epilepsia de reciente diagnóstico:situación en España / Cost minimization analysis of monotherapy for antiepileptic treatment in patients with newly diagnosed epilepsy: the position in Spain

Objetivo. Analizar el coste del tratamiento en monoterapia de los pacientes con epilepsia de reciente comienzo. Pacientes y métodos. Se analizó el coste del tratamiento con lamotrigina (LTG), carbamacepina (CBZ), fenitoína (PHT) y ácido valproico (VPA) utilizando datos publicados sobre eficacia y tolerabilidad de los ensayos clínicos comparativos en monoterapia. Se estableció un modelo de tratamiento de pacientes con epilepsia de reciente comienzo durante los primeros 12 meses tras su diagnóstico. Un panel de médicos consensuó el uso de recursos, costes y el modelo de tratamiento en nuestro país. Se llevó a cabo un análisis de coste-minimización para evaluar económicamente los datos, basado en que los ensayos aleatorizados indicaban que CBZ, LTG, PHT y VPA eran de eficacia similar. El análisis se realizó como `intención de tratar'. Únicamente se consideraron los costes médicos directos. Resultados. En nuestro país, el tratamiento con LTG es entre dos y tres veces más costoso que con las otras medicaciones. Un análisis de sensibilidad demostró que variaciones en el intervalo de uso de recursos y de costes (definido por el panel de médicos) no alteraban de forma significativa los resultados. Conclusiones. El tratamiento con LTG es más costoso que el tratamiento con fármacos clásicos. Dadas las limitaciones metodológicas del actual estudio, se precisan nuevos análisis, especialmente con metodología de coste-beneficio, para valorar el impacto económico de los nuevos antiepilépticos y determinar si está justificada su utilización como fármaco de primera elección (AU)

A prospective study of atrial fibrillation and stroke.

In a prospective study of 72 patients with stroke and atrial fibrillation, we classified strokes as cardioembolic or noncardioembolic based on arterial assessment using Doppler sonography and angiography. We analyzed and cross-tabulated 18 clinical characteristics and found four to be significantly associated with a cardioembolic mechanism: stroke with onset during activity and peak deficit at onset (p less than 0.008), previous infarct in a different vascular territory (p less than 0.01), previous transient ischemic attack in a different vascular territory (p less than 0.01), and transient ischemic attack lasting greater than 1 hour (p less than 0.02). Starting with these four characteristics, we used a step-down procedure to select variables for a logistic regression model. Only previous infarct in a different vascular territory (odds ratio = 7.38) and transient ischemic attack lasting greater than 1 hour (odds ratio = 7.89) were selected by the model. Using M-mode and two-dimensional echocardiography, we compared left atrial size in 46 patients with that in 78 controls who had atrial fibrillation without stroke. Left atrial size in patients and controls with mitral valvulopathy was significantly larger than that in patients and controls without mitral valve disease. There was, however, no difference in left atrial size between patients with nonvalvular atrial fibrillation and cardioembolic stroke and controls or patients with nonvalvular atrial fibrillation and noncardioembolic stroke. We concluded that some clinical characteristics are closely related to cardioembolic stroke and that left atrial enlargement reflects underlying cardiopathy rather than atrial emboli-forming capability.

[Neurosyphilis in patients infected with the human immunodeficiency virus]. / Neurosífilis en los pacientes infectados por el virus de la inmunodeficiencia humana.

Nervous central system involvement is observed in two out of three patients infected with human immunodeficiency virus and probably, the true prevalence is even higher than that clinically detected. The coexistence of neurosyphilis in this group of patients has been poorly studied and the possibility that some alterations in the natural history of syphilis related to its rapid course with respect to time in which neurologic involvement would occur would have reasonable immunologic basis. We report two patients aged 26 and 22 who presented antibodies against human immunodeficiency virus together with meningo-vascular syphilis with spinal involvement and secondary brain infarction, respectively. In both patients, neurosyphilis was the first manifestation of human immunodeficiency virus infection and none of them referred a history of previous primary or secondary syphilis.

[Hemifacial spasm disclosing neurinoma of the hypoglossal nerve]. / Spasme hémifacial révélateur d'un neurinome du nerf hypoglosse.

A hemifacial spasm was symptomatic of a neurinoma of the hypoglossal nerve in a 50 year-old woman. It disappeared after the surgical cure of the tumor. Hemifacial spasm is not mentioned among the 19 cases of neurinoma of the hypoglossal nerve which have been reported up to now. The spasm could have been due to the compression of the 7th nerve by the anterior inferior cerebellar artery, displaced by the tumor.

[Hemangioblastoma of the spinal cord. A case with a probably single lesion (author's transl)]. / Hémangioblastome intra-médullaire. Un cas sporadique avec une localisation apparemment unique.

A 43 year-old woman was admitted after 2 years of progressive disturbances of deep sensation mainly in her lower limbs. Examination led to the diagnosis of a tumor of the cervical spinal cord. The tumor--partially cystic--was attached to the posterior third of the spinal cord. At its level several varicosities of the pia were present accounting for the myelographic picture as well as for the albumino-cytologic dissociation in the CSF. Pathological examination showed a hemangioblastoma. After a review of the literature, this case of hemangioblastoma of the spinal cord appears to have special features because of its likely single location in the spinal cord in a patient without any familial history of phacomatosis or of von Hippel-Lindau's disease. No other lesion could be clinically suspected in the spinal cord. The post-operative evolution was satisfactory.