Impacto de la pandemia de COVID-19 en la organización asistencial del ictus. Plan Ictus Madrid Pandemia COVID-19. Impacto en la asistencia del ictus. Plan Ictus Madrid / Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan

INTRODUCCIÓN: La sobrecarga asistencial y los cambios organizativos frente a la pandemia de COVID-19 podrían estar repercutiendo en la atención al ictus agudo en la Comunidad de Madrid. MÉTODOS: Encuesta estructurada en bloques: características del hospital, cambios en infraestructura y recursos, circuitos de código ictus, pruebas diagnósticas, rehabilitación y atención ambulatoria. Análisis descriptivo según el nivel de complejidad en la atención del ictus (disponibilidad o no de unidad de ictus y de trombectomía mecánica). RESULTADOS: De los 26 hospitales del SERMAS que atienden urgencias en adultos, 22 cumplimentaron la encuesta entre el 16 y 27 de abril. El 95% han cedido neurólogos para atender a pacientes afectados por la COVID-19. Se han reducido camas de neurología en el 89,4%, modificado los circuitos en urgencias para ictus en el 81%, con circuitos específicos para sospecha de infección por SARS-CoV2 en el 50%, y en el 42% de los hospitales los pacientes con ictus agudo positivos para SARS-CoV2 no ingresan en camas de neurología. Ha mejorado el acceso al tratamiento, con trombectomía mecánica las 24 h en el propio hospital en 10 hospitales, y se han reducido los traslados interhospitalarios secundarios. Se ha evitado el ingreso de pacientes con ataque isquémico transitorio o ictus leve (45%) y se han incorporado consultas telefónicas para seguimiento en el 100%. CONCLUSIONES: Los cambios organizativos de los hospitales de la Comunidad de Madrid frente a la pandemia por SARS-Co2 han modificado la dedicación de recursos humanos e infraestructuras de las unidades de neurología y los circuitos de atención del ictus, realización de pruebas diagnósticas, ingreso de los pacientes y seguimiento

INTRODUCTION: The overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. METHODS: We conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). RESULTS: The survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. CONCLUSIONS: The organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up

Contraindications to intravenous thrombolysis in prehospital triage of thrombectomy candidates.

BACKGROUND AND PURPOSE: The existence of contraindications to intravenous thrombolysis (IVT) is considered a criterion for direct transfer of patients with suspected acute stroke to thrombectomy-capable centers in the prehospital setting. Our aim was to assess the utility of this criterion in a setting where routing protocols are defined by the Madrid - Direct Referral to Endovascular Center (M-DIRECT) prehospital scale. METHODS: This was a post hoc analysis of the M-DIRECT study. Reported contraindications to IVT were retrospectively collected from emergency medical services reports and categorized into late window, anticoagulant treatment and other contraindications. Final diagnosis and treatment rates were compared between patients with and without reported IVT contraindications and according to anticoagulant treatment or late window categories. RESULTS: The M-DIRECT study included 541 patients. Reported IVT contraindications were present in 227 (42.0%) patients. Regarding final diagnosis no significant differences were found between patients with or without reported IVT contraindications: ischaemic stroke (any) 65.6% vs. 62.1%, ischaemic stroke with large vessel occlusion (LVO) 32.2% vs. 28.3%, hemorrhagic stroke 15.4% vs. 15.6%, stroke mimic 18.9% vs. 22.3% respectively. Amongst patients with LVO, endovascular thrombectomy (EVT) was performed less often in the presence of IVT contraindications (56.2% vs. 74.2%). M-DIRECT-positive patients had higher rates of LVO and EVT compared with M-DIRECT-negative patients independent of reported IVT contraindications. CONCLUSIONS: Reported IVT contraindications alone do not increase EVT likelihood and should not be considered to determine routing in urban stroke networks.

Impact of the COVID-19 pandemic on the organisation of stroke care. Madrid Stroke Care Plan. / Impacto de la pandemia de COVID-19 en la organización asistencial del ictus. Plan Ictus Madrid.

INTRODUCTION: The overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. METHODS: We conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). RESULTS: The survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. CONCLUSIONS: The organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up.

Acute stroke care during the COVID-19 pandemic. Ictus Madrid Program recommendations. / Atención al ictus agudo durante la pandemia por COVID-19. Recomendaciones Plan Ictus Madrid.

INTRODUCTION: The COVID-19 pandemic has resulted in complete saturation of healthcare capacities, making it necessary to reorganise healthcare systems. In this context, we must guarantee the provision of acute stroke care and optimise code stroke protocols to reduce the risk of SARS-CoV-2 infection and rationalise the use of hospital resources. The Madrid Stroke multidisciplinary group presents a series of recommendations to achieve these goals. METHODS: We conducted a non-systematic literature search using the keywords "stroke" and "COVID-19" or "coronavirus" or "SARS-CoV-2." Our literature review also included other relevant studies known to the authors. Based on this literature review, a series of consensus recommendations were established by the Madrid Stroke multidisciplinary group and its neurology committee. RESULTS: These recommendations address 5 main objectives: 1) coordination of action protocols to ensure access to hospital care for stroke patients; 2) recognition of potentially COVID-19-positive stroke patients; 3) organisation of patient management to prevent SARS-CoV-2 infection among healthcare professionals; 4) avoidance of unnecessary neuroimaging studies and other procedures that may increase the risk of infection; and 5) safe, early discharge and follow-up to ensure bed availability. This management protocol has been called CORONA (Coordinate, Recognise, Organise, Neuroimaging, At home). CONCLUSIONS: The recommendations presented here may assist in the organisation of acute stroke care and the optimisation of healthcare resources, while ensuring the safety of healthcare professionals.

The Direct Referral to Endovascular Center criteria: a proposal for pre-hospital evaluation of acute stroke in the Madrid Stroke Network.

BACKGROUND AND PURPOSE: For patients with acute ischaemic stroke due to large-vessel occlusion, it has recently been shown that mechanical thrombectomy (MT) with stent retrievers is better than medical treatment alone. However, few hospitals can provide MT 24 h/day 365 days/year, and it remains unclear whether selected patients with acute stroke should be directly transferred to the nearest MT-providing hospital to prevent treatment delays. Clinical scales such as Rapid Arterial Occlusion Evaluation (RACE) have been developed to predict large-vessel occlusion at a pre-hospital level, but their predictive value for MT is low. We propose new criteria to identify patients eligible for MT, with higher accuracy. METHODS: The Direct Referral to Endovascular Center criteria were defined based on a retrospective cohort of 317 patients admitted to a stroke center. The association of age, sex, RACE scale score and blood pressure with the likelihood of receiving MT were analyzed. Cut-off points with the highest association were thereafter evaluated in a prospective cohort of 153 patients from nine stroke units comprising the Madrid Stroke Network. RESULTS: Patients with a RACE scale score ≥ 5, systolic blood pressure <190 mmHg and age <81 years showed a significantly higher probability of undergoing MT (odds ratio, 33.38; 95% confidence interval, 12-92.9). This outcome was confirmed in the prospective cohort, with 68% sensitivity, 84% specificity, 42% positive and 94% negative predictive values for MT, ruling out 83% of hemorrhagic strokes. CONCLUSIONS: The Direct Referral to Endovascular Center criteria could be useful for identifying patients suitable for MT.

[Incidence of strokes in Spain: the Iberictus study. Data from the pilot study]. / Incidencia de ictus en España: estudio Iberictus. Datos del estudio piloto.

INTRODUCTION: In a population-based study of the incidence of stroke conducted on a broad denominator, it is wise first to carry out a pilot study. AIM: To present the results of the pilot phase of the study on stroke incidence in Spain, entitled Iberictus. PATIENTS AND METHODS: Population of the study: all cases involving the first episode of acute cerebrovascular disease (stroke or transient ischaemic attack) diagnosed among residents over 17 years of age with their habitual place of abode registered in the areas of study between 15th and 31st October 2005 (total denominator: 1,440,997 inhabitants). SOURCE OF DATA: prospective, hospital records (basic minimum data set, discharge abstracts) and casualty department registers. Standardised definitions: diagnostic categorisation and pathological, topographical and aetiological classification. Inter-observer agreement analysis among researchers (kappa). RESULTS: A total of 128 cases were identified. Age range, 37-103 years; mean age, 75.7 +/- 13.4 years; 54% were females. In all, 71.1% of the cases were collected by means of a basic minimum data set. There were 91 ischaemic events (29.7% atherothrombotic and 29.7% cardioembolic). Of the 15 haemorrhagic strokes, 40% due to arterial hypertension, six were lobar hemispheric, six were deep basal ganglia, and there were three cerebellar haemorrhages. The incidence of stroke was seen to increase exponentially with age. Inter-observer agreement was good for the classifications that were employed (range of kappa indices, 0.57-0.78). Several problems were detected and corrected in the fieldwork. CONCLUSIONS: The Iberictus pilot study yielded data that were consistent with the literature and provided us with the opportunity to detect and correct issues that would hinder us from conducting the main study.

[Incidence of strokes in Spain. Methodological foundations of the Iberictus study]. / Incidencia de ictus en España. Bases metodológicas del estudio Iberictus.

INTRODUCTION: Epidemiological data on the incidence of cerebrovascular diseases in our country are scarce. A representative population-based study with a large denominator is required. AIM: To present the design of the study on stroke incidence in Spain, entitled Iberictus. SUBJECTS AND METHODS: We conducted a prospective, population-based study on the incidence of strokes and transient ischemic attacks, in which it is possible to distinguish: 1) population with a steady risk, which was well defined and had a broad denominator. We included all the cases in which the first episode of acute cerebrovascular disease was diagnosed among those over the age of 17 years (with no upper age limit) with their habitual residence in the areas of study between the 1st January and 31st December 2006: Lugo, Segovia, Talavera de la Reina, Mallorca and Almeria (total denominator, 1,440,997 inhabitants; minimum denominator per area, 100,000 inhabitants); 2) source of multiple and complementary data: hospital records (minimum basic data set, discharge abstracts), emergency and primary care records for the area with diagnostic codes 430-39 and 674.0 (International Classification of Diseases-9), population-based mortality records; 3) standardised definitions: diagnostic categorisation (MONICA-World Health Organisation, 1987), pathological classification (ischaemia, haemorrhagic), topography and aetiology; 4) presentation of data in suitable age groups, by sex and overall; 5) pilot study and analysis of inter-observer agreement among researchers. CONCLUSIONS: With this design, the Iberictus study satisfies the methodological criteria as an 'ideal' study of the incidence of acute cerebrovascular diseases proposed by Malgrem, Sudlow and Warlow, and represents a unique opportunity to further our knowledge of the epidemiology of strokes in our country.

[The psychometric properties of the Spanish version of the stroke-adapted 30-item Sickness Impact Profile (SIP30-AI)]. / Propiedades métricas de la versión española del perfil de las consecuencias de la enfermedad de 30 ítems adaptado al ictus (SIP30-AI).

AIM: To assess the psychometric attributes of the stroke-adapted 30-item version of the Sickness Impact Profile, Spanish version (SA-SIP30), in stroke survivors. PATIENTS AND METHODS: 79 patients were evaluated (mean age: 68.1 years) by means of the modified Rankin Scale (m-RS), Scandinavian Stroke Scale (SSS), Barthel Index (BI), and the modified 23-item Beck-Hamilton's Depression Rating Scale (HDRS). Health-related quality of life was evaluated using the MOS-Short Form 36 (SF-36) and the SA-SIP30. RESULTS: SA-SIP30 mean score was 36.8. SA-SIP30 floor and ceiling effects were 3.8% and 0%. Regarding SA-SIP30 categories, floor effect ranged from 15.2% (social interaction) to 49.4% (alertness behavior), whereas ceiling effect ranged from 2.5% (social interaction) to 26.6% (household management). A floor effect was observed in seven SA-SIP30 categories. The internal consistency of SA-SIP30 (Cronbach's alpha = 0.87), physical (Cronbach's alpha = 0.89) and psychosocial (Cronbach's alpha = 0.75) dimensions were satisfactory. Standard error of measurement (SEM) values for each SA-SIP30 category ranged from 15.9 (household management) to 26.3 (ambulation). SEM values for overall SA-SIP30, physical and psychosocial dimensions were 8, 10 and 17.3, respectively. Corrected item-category correlations ranged from 0.17 (item 28) to 0.83 (item 23). A significant correlation (Spearman's correlation coefficient; p < 0.0001) between SA-SIP30 scores and BI (-0.71), m-RS (0.68), SSS (-0.67), HDRS (0.52), SF-36 physical (-0.67) and mental components (-0.51) was found. SA-SIP30 mean score significantly increased as m-RS increased (discriminative validity; Kruskal-Wallis, p < 0.0001). CONCLUSION: The Spanish-version of the SA-SIP30 has satisfactory internal consistency, convergent validity and discriminative validity in stroke patients.

Propiedades métricas de la versión española del perfil de las consecuencias de la enfermedad de 30 ítems adaptado al ictus (SIP30-AI) / The metric properties of the Spanish version of the stroke-adapted 30-item sickness impact profile (SIP30-AI)

Evaluar los atributos métricos de la versión española del perfil de las consecuencias de la enfermedad de30 ítems adaptado al ictus (SIP30-AI). Pacientes y métodos. Se evaluó a 79 pacientes (edad media: 68,1 años) con la escala escandinava de ictus, el índice de Barthel (IB), la escala de Rankin modificada, la escala de depresión de Hamilton, el cuestionariode salud SF-36 y el SIP30-AI. Resultados. La puntuación media del SIP30-AI fue de 36,8. Los efectos suelo y techofueron 3,8 y 0%, respectivamente. El efecto suelo se observó en siete categorías del SIP30-AI, y osciló entre 15,2% (relaciones sociales) y 49,4% (actividad intelectual); el efecto techo varió de 2,5% (relaciones sociales) a 26,6% (tareas domésticas).La consistencia interna del SIP30-AI (alfa de Cronbach = 0,87) y de sus dimensiones física (alfa de Cronbach = 0,89) y psicosocial (alfa de Cronbach = 0,75) fue satisfactoria. Los valores del error estándar de la medida (EEM) para el SIP30-AI y sus dimensiones física y psicosocial fueron 8, 10 y 17,3, respectivamente. El EEM de las categorías osciló entre 15,9 (tareasdomésticas) y 26,3 (desplazamiento). Las asunciones escalares (correlación ítem-categoría corregida: 0,17-0,83) fueron adecuadas. El SIP30-AI se correlacionó significativamente (coeficiente de Spearman; p < 0,0001) con el IB (–0,71), Rankin (0,68), escalas escandinava (–0,67) y de Hamilton (0,52), e índices físico (–0,67) y mental (–0,51) de la SF-36. Los valores delSIP30-AI se incrementaron conforme empeoraba la situación funcional en la escala de Rankin (Kruskal-Wallis; p < 0,0001).Conclusión. La versión española del SIP30-AI tiene una consistencia interna, una validez convergente y una validez discriminativa adecuadas

To assess the psychometric attributes of the stroke-adapted 30-item version of the Sickness Impact Profile,Spanish version (SA-SIP30), in stroke survivors. Patients and methods. 79 patients were evaluated (mean age: 68.1 years) by means of the modified Rankin Scale (m-RS), Scandinavian Stroke Scale (SSS), Barthel Index (BI), and the modified 23-item Beck-Hamilton’s Depression Rating Scale (HDRS). Health-related quality of life was evaluated using the MOS-Short Form 36(SF-36) and the SA-SIP30. Results. SA-SIP30 mean score was 36.8. SA-SIP30 floor and ceiling effects were 3.8% and 0%. Regarding SA-SIP30 categories, floor effect ranged from 15.2% (social interaction) to 49.4% (alertness behavior), whereas ceiling effect ranged from 2.5% (social interaction) to 26.6% (household management). A floor effect was observed in sevenSA-SIP30 categories. The internal consistency of SA-SIP30 (Cronbach’s alpha = 0.87), physical (Cronbach’s alpha = 0.89) and psychosocial (Cronbach’s alpha = 0.75) dimensions were satisfactory. Standard error of measurement (SEM) values for each SA-SIP30 category ranged from 15.9 (household management) to 26.3 (ambulation). SEM values for overall SA-SIP30,physical and psychosocial dimensions were 8, 10 and 17.3, respectively. Corrected item-category correlations ranged from 0.17 (item 28) to 0.83 (item 23). A significant correlation (Spearman’s correlation coefficient; p < 0.0001) between SA-SIP30scores and BI (–0.71), m-RS (0.68), SSS (–0.67), HDRS (0.52), SF-36 physical (–0.67) and mental components (–0.51) was found. SA-SIP30 mean score significantly increased as m-RS increased (discriminative validity; Kruskal-Wallis, p < 0.0001). Conclusion. The Spanish-version of the SA-SIP30 has satisfactory internal consistency, convergent validity and discriminative validity in stroke patients

[Transient ischemic attack: the only presenting syndrome of dural sinus thrombosis]. / Ataque isquémico transitorio como expresión de trombosis de senos venosos durales.

INTRODUCTION: Intracranial hypertension (ICHT) is the most frequent presenting syndrome of dural vein sinus thrombosis (CVT). A transient ischemic attack as an acute mode of onset is exceptional. CASE REPORT: A right handed, forty years old man with a medical history of recurrent headaches, microcephalia and calcifications in his brain, presenting to the emergency department with left paresis that lasted a few minutes and with a complete recovery. The cerebral and neck magnetic resonance (MR) including MR angiography showed superior sagittal sinus, both transverse sinuses and right sigmoid sinus thrombosis with an increase in size of superficial cerebral venous that drained to the left sigmoid sinus. There was no evidence of intracranial dural malformations. The cerebral MR did not show any abnormal parenchymal enhancement (edema, arterial or venous infarctions, hemorrhage) including diffusion-weighted IMR. The digital subtraction angiography (ADC) confirmed the same findings as the MR angiography. The diagnosis was a chronic CVT. We studied stroke in a young adult and we did not find other irregularities. The neurological examination was normal when the patient left the hospital with an antiplatelet drug. CONCLUSIONS: Focal neurological deficit is an exceptional event of a chronic vein sinus thrombosis during follow-up. Isolated cases regarding an acute time course have been described. The interest of this case lies in the fact that venous sinus thrombosis rarely has transitory focal deficit in its course and we found no such description as onset symptoms.

Ataque isquémico transitorio como expresión de trombosis de senos venosos durales / Transient ischemic attack: the only presenting syndrome of dural sinus thrombosis

Introducción. La forma más frecuente de expresión de la trombosis de senos venosos (TSV) durales es la hipertensión intracraneal (HTIC). Excepcionalmente puede manifestarse clínicamentre como déficit neurológico focal. Caso clínico. Paciente varón de 40 años, con antecedentes personales de cefaleas recurrentes, microcefalia y calcificaciones cerebrales que consultó por dos episodios de hemiparesia izquierda de minutos de duración con recuperación completa. La resonancia magnética (RM) craneal y cervical, incluyendo secuencias de angio-RM most´ró trombosis del seno sagital superior, ambos senos transversos y seno sigmoide derecho con marcado aumento del tamaño de venas cerebrales superficiales que drenaban en el seno sigmoide izquierdo, sin existencia de malformaciones durales intracraneales. No presentó alteración del parénquima cerebral en forma de edema, infartos, hemorragia ni infartos venosos en ninguna de las secuencias (incluida la difusión). La angiografía por sustracción digital (ADC) confirmó los hallazgos de angio-RM. Se interpretó como TSV de curso crónico, procediendo al estudio de ictus en paciente joven, no encontrando otras alteraciones significativas. La exploración neurológica a alta fue normal, pautándose tratamiento antiagregante. Conclusiones. La sintomatología focal transitoria como manifestación clínica de una TSV de curso crónico es excepcional. Se han descrito casos aislados con referencia a un curso temporal agudo. El interés del caso reside en que la trombosis de senos venosos rara vez presenta clínica focal transitoria deficitaria en su evolución y no hemos encontrado tal descripción como sintomatología de inicio

Introduction. Intracranial hypertension (ICHT) is the most frequent presentig syndrome of dural vein sinus thrombosis (CVT). A transient ischemic attack as an acute mode of onset is exceptional. Case report. A right handed, forty years old man with a medical history of recurrent headaches, microcephalia and calcifications in his brain, presenting to the emergency department with left paresis that lasted a few minutes and with a complete recovery. The cerebral and neck magnetic resonance (MR) including MR angiography showed superior sagital sinus, both transverse sinuses and right sigmoid sinus thrombosis with and increase in size of superficial cerebral venous that drained to the left sigmoid sinus. There was no evidence of intracranial dural malformations. the cerebral MR did not show any abnormal parenchymal enhancement (edema, arterial or venous infarctions, hemorrhage) including diffusion-weighted IMR. The digital subtration angiography (ADC) confirmed the same findings as the MR angiography. the diagnosis was a chronic CVT. We studied stroke in a young adult and we did not find other irregularities . the neurological examination was normal when the patients left the hospìtal with and antiplatelet drug. conclusions. focal neurological deficit is an exception event of a chronic vein sinus thrombosis during follow-up. Isolated cases regarding an acute time course have been described. The interest of this case lies in the fact that venous sinus thrombosis rarely has transitory focal deficit in its course and we found no such description as onset symptoms

[Hashimoto's encephalopathy associated with scleromyxedema: coincidental or the overlapping of two syndromes with a possible autoimmune origin?]. / Asociación de encefalopatía de Hashimoto y escleromixedema: coincidencia o solapamiento de dos síndromes de posible origen autoinmune?

INTRODUCTION: The encephalopathies that may accompany Hashimoto's thyroiditis and scleromyxedema, both of which are diseases that probably have an autoimmune origin, are clinically similar. The presence of both Hashimoto's thyroiditis and scleromyxedema in a patient with encephalopathy led us to compare the clinical symptoms and the different possible mechanisms accounting for the pathology. CASE REPORT: We describe the case of a 54-year-old male who was admitted to hospital because of several occurrences of transient neurological focus that finally developed into a clinical picture of aphasia, acalculia and right homonymous hemianopsia. The patient had previously been diagnosed as suffering from scleromyxedema, which responded poorly to treatment, as well as IgG kappa paraproteinemia and, six months before admission to hospital, Hashimoto's thyroiditis. No abnormalities were found in the complementary tests, except for slightly high protein levels in the cerebrospinal fluid, a diffuse slowing of brain waves in the electroencephalogram and alterations due to thyroiditis and paraproteinemia. Neurological symptoms improved after a few days of corticoid therapy. CONCLUSIONS: The presentation of encephalopathy as a stroke and its excellent response to treatment with corticoids pointed to a case of Hashimoto's encephalopathy, although we cannot completely rule out the possibility of it being a dermato-neuro syndrome, which is associated to scleromyxedema. In this paper we review the different pathological mechanisms proposed for the two clinical entities, as well as the clinical features that are similar in both syndromes and which could be an indication of some common mechanism shared by them.

[Post stroke depression: predictive factors at one year follow up]. / Depresión postictus: factores predictivos al año de seguimiento.

INTRODUCTION: The presence of depression constitutes one of the treatable complications in stroke survivors. Its long term prevalence and the triggering factors are unknown in our community. Moreover, its presence can interfere in the process of rehabilitating the patient and in family dynamics. PATIENTS AND METHODS: A sample of 118 patients from the Stroke Unit at the Hospital Universitario San Carlos in Madrid were studied. After one year follow up, 90 survivors (41 females and 49 males; average age: 68 years) were evaluated, with their informed consent, with the Hamilton depression and Beck s melancholia scale, the Barthel index, the Rankin scale, Psychosocial Dimension of Sickness Impact Profile and the Scandinavian neurological scale. A factorial ANOVA model was used to conduct the statistical analysis. RESULTS: On discharge, a third of the patients presented symptoms of depression, while a year after the stroke the figure had risen to 67%. The average score on the Hamilton scale at one year follow up was 13.1 and was rated as mild depression. The variables related with depression one year after the stroke were of a socio demographic nature (female, women working in the home, long lasting occupational disability; p< 0.0001), whereas biological variables (cortical/subcortical distribution, laterality, aetiology and subtype of the stroke) were not statistically significant. Subjects suffering from serious disabilities that affected the performance of their daily activities (Barthel< 60) scored significantly worse (p= 0.005). Motor deficit, according to the Scandinavian scale, was of no use as a predictor of depression one year after the stroke (p= 0.0617). CONCLUSIONS: Post stroke depression is highly prevalent in our community and, late on in the follow up, is associated with socio demographic variables and with the degree of disability.

Depresión postictus:factores predictivos al año de seguimiento / Post-stroke depression: predictive factors at one year follow-up

Introducción. La presencia de depresión constituye una de las complicaciones tratables en los supervivientes de un ictus. Su prevalencia a largo plazo y los factores desencadenantes se desconocen en nuestra comunidad. Su presencia puede interferir, además, con el proceso de rehabilitación del paciente y con la dinámica familiar. Pacientes y métodos. Se incluyeron en el estudio 118 pacientes consecutivos procedentes de la Unidad de Patología Cerebrovascular del Hospital Universitario San Carlos de Madrid. Tras un año de seguimiento, 90 supervivientes (41 mujeres y 49 varones; edad media: 68 años) se evaluaron, previo consentimiento informado, con la escala de depresión de Hamilton ampliada con melancolía de Bech, el índice de Barthel, la escala de Rankin, la dimensión psicosocial del perfil de las consecuencias de la enfermedad y la escala neurológica escandinava. Se empleó en el análisis estadístico un modelo de ANOVA factorial. Resultados. En el momento del alta, un tercio de los pacientes presentaban síntomas depresivos, mientras que al año del ictus eran un 67 por ciento. El valor medio de la escala de Hamilton al año fue 13,1 y se situaba en el intervalo de la depresión menor. Las variables relacionadas con la presencia de depresión al año del ictus fueron de carácter sociodemográfico (sexo mujer, ser ama de casa, persistir en incapacidad laboral; p< 0,0001), mientras que las variables biológicas (distribución cortical/subcortical, lateralidad, etiología y subtipo del ictus) no fueron estadísticamente significativas. Los sujetos afectos de discapacidad grave para las actividades de la vida diaria (Barthel< 60) puntuaban significativamente peor (p= 0,005); el déficit motor según la escala escandinava no tuvo valor predictivo de depresión al año del ictus (p= 0,0617). Conclusiones. La presencia de depresión postictus tiene una alta prevalencia en nuestro medio y se asocia, tardíamente en el seguimiento, con variables de carácter sociodemográfico y con el grado de discapacidad (AU)

[Are statins indicated in the prevention of cerebral infarct?]. / Están indicadas las estatinas en la prevención del infarto cerebral?

INTRODUCTION: Some studies of ischemic cardiopathy have shown that when pravastatin is used for the prevention of strokes, these are reduced. Whilst we await suitable clinical trials, we discuss the possible role played by these drugs in this subgroup of patients. DEVELOPMENT: A panel of experts from different specialties assess the data published on dislipemias in the epidemiology of strokes, the possible effect of statins in the prevention of cerebral infarcts in patients with atheromatous stenosis of the carotid artery and their mode of action. CONCLUSIONS: Pravastatin is indicated in all patients with ictus of atheromatous origin as primary prevention of ischemic cardiopathy, in patients with strokes and hypercholesterolemia, and in patients with symptomatic or asymptomatic carotid stenosis while we wait for more specific clinical trials.

[Comparative clinico-radiological study of lacunar infarcts of the cerebral hemispheres and brain stem in 110 cases]. / Estudio clinicorradiológico comparativo entre infartos lacunares hemisféricos y de tronco cerebral en 110 casos.

INTRODUCTION: Lacunar infarcts (LI) are small deep infarcts due to occlusion of perforating branches. OBJECTIVE: Our objective was to outline the clinical and epidemiological characteristics which differentiate hemispherical lacunar infarcts (HLI) from those of the brain stem (SLI). PATIENTS AND METHODS: We present 110 cases of LI (80 HLI, 30 SLI) analysing risk factors, clinical syndromes, findings on neurological examination (dysarthria, gravity, distribution and proportional paresia), form of clinical presentation, evolution whilst in hospital, site and results of carotid duplex. Diagnosis was made in 72 patients using magnetic resonance (MR) and in 38 patients using computerized axial tomography (CT). RESULTS: The commonest characteristics of SLI, as compared with HLI, with statistical significance (p < 0.05) was the appearance of supranuclear facial paresia (OR = 2.68), severe motor involvement (OR = 4.23), form of presentation with previous TIA (OR = 6.33), fluctuating evolution of the symptoms (OR = 5.78) and progression of the paresia (OR = 6.41). Also, in the pontine LI there was significant correlation between site and gravity: the lower the site of the lesion, the more serious was the paresia. Patients with multiple LI presented with no previous risk factors significantly more frequently than those with a single LI. CONCLUSION: The different clinical profiles may help to establish the subgroups of IL, according to where they occur.

[Transient paradoxical embolism. Importance of early ultrasonography diagnosis]. / Embolia paradójica en tránsito. Importancia del diagnóstico ecocardiográfico precoz.

The paradoxical embolism or the crossing of an embolism through a permeable foramen ovale is considered to be a rare mechanism of cerebral embolism although its real frequency is unknown. Reports demonstrating the embolism during its crossing through cardiac cavities are scarce. Two cases of moving paradoxical embolism are presented. In the first, an infarction of the superior branch of the left middle cerebral artery was produced during the course of deep vein thrombosis and pulmonary thromboembolism with transesophageal echocardiography demonstrating the crossing of the embolism through the foramen ovale. Surgery performed 12 days later did not discover the auricular thrombus. In the second case, a mass was discovered in the right auricle with a permeable foramen ovale during the course of a left middle cerebral artery infarction and a large auricular thrombus was demonstrated in surgery. The diagnostic usefulness of early transsesophageal echocardiography in the diagnosis of moving paradoxal embolism is discussed.