[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.

Evaluación rápida del ataque isquémico transitorio en un hospital sin guardias de neurología / Rapid assessment of transient ischaemic attack in a hospital with no on-call neurologist

Introducción: Los pacientes que presentan un ataque isquémico transitorio (AIT) tienen un alto riesgo de tener un ictus a corto plazo. Una atención urgente puede reducir dicho riesgo. El objetivo es describir y comprobar la eficacia de un protocolo de atención rápida a estos pacientes en un hospital sin guardias de neurología. Métodos: En febrero del 2007 se puso en marcha en nuestro hospital un protocolo de evaluación rápida del AIT, con el objetivo de priorizar la atención urgente y disminuir ingresos hospitalarios sin aumentar riesgo de recurrencias. Se analizan los resultados tras los primeros 5 años, incidiendo especialmente en los tiempos de valoración neurológica y neurovascular, motivos de ingreso y tasa de recurrencia a los 90 días. Resultados: Han sido evaluados 411 pacientes, de los cuales 282 (68,6%) fueron finalmente AIT. Entre los otros diagnósticos, los más frecuentes han sido el episodio vasovagal (5,6%) y el cuadro confusional (4,6%). La demora entre la llegada a Urgencias y la valoración del neurólogo fue < 24 h en el 82% de casos y < 48 h en el 93,9%. Tras la valoración neurológica, se decidió el ingreso en el 28,7% de pacientes (causas más frecuentes: hallazgos en el Doppler y AIT de repetición). A los 3 meses, 10 pacientes (3,55%) presentaron un ictus, 7 de ellos (70%) en la primera semana desde el episodio. Conclusiones: En un hospital sin guardias de neurología, es posible una evaluación rápida de los pacientes con AIT, de acuerdo con las recomendaciones de las guías, evitando la mayoría de ingresos y con un bajo índice de recurrencias

Background: Risk of stroke soon after a transient ischaemic attack (TIA) is high. Urgent care can reduce this risk. Our aim is to describe and evaluate the efficacy of rapid assessment of TIA patients in a hospital without a neurologist available 24 hours a day. Methods: In February 2007, we set up a protocol of rapid management of patients with symptoms consistent with acute TIA, with the aim of prioritising urgent care and reducing hospital admissions, without increasing risk of recurrences. We analyse our results since the protocol was implemented with particular focus on the analysis of delay in neurological and neurovascular assessment, percentage and reasons for hospitalisation, and stroke recurrence rates after 3 months. Results: Four hundred and eleven patients were studied, with a final diagnosis of TIA in 282 (68.6%). Among other diagnoses, the most frequent were a vasovagal reaction (5.6%) and confusional syndrome (4.6%). Delay between emergency arrival and neurovascular assessment was < 24 h in 82% of the cases, and <48 h in 93%. After neurological evaluation, 28.7% of the patients were immediately admitted to hospital (most common causes: severe stenosis of a large artery and crescendo TIA). The incidence of ischaemic stroke in TIA patients was 3.55% after 3 months and 70% of them suffered the recurrence within the first week after the initial TIA. Conclusions: In a hospital without a neurologist available 24 hours a day, early assessment and management of TIA patients can be carried out in accordance with the guidelines, and may avoid hospitalisation in most cases without increasing recurrence rates

Registro de Ictus del Hospital de Mataró: 10 años de registro en un hospital comarcal / The Mataró Stroke Registry: a 10-year registry in a community hospital

Introducción: Un registro prospectivo de ictus permite mejorar el conocimiento de la historia natural de la enfermedad. Presentamos los datos del Registro del Hospital de Mataró. Métodos: En febrero de 2002 se inició en nuestro hospital el registro prospectivo de pacientes ingresados con un ictus agudo. Se recogen variables sociodemográficas, antecedentes, clínicas, topográficas, etiológicas y pronósticas. Analizamos los resultados obtenidos después de los primeros 10 años de registro. Resultados: Se han registrado 2.165 pacientes, el 54,1% varones, con una edad media de 73 años. El factor de riesgo más frecuente es la hipertensión (65,4%). Mediana de la NIHSS al ingreso: 3 (rango intercuartílico, 1-8). Un 79,7% han sido infartos cerebrales, un 10,9% hemorragias y un 9,4% AIT. De los isquémicos, la etiología ha sido cardioembólica en el 26,5%, aterotrombótica en el 23,7% y lacunar en el 22,9%. La localización más frecuente de las hemorragias ha sido lobar (47,4%), y se han atribuido a hipertensión el 54,8%. La mediana de la estancia hospitalaria ha sido de 8 días. Al alta, un 60,7% pudieron volver directamente al domicilio y un 52,7% eran independientes para las actividades de la vida diaria. A los 3 meses, las cifras fueron 76,9 y 62,9% respectivamente. La mortalidad intrahospitalaria ha sido del 6,5% y a los 3 meses del 10,9%. Conclusiones: El perfil de los pacientes en nuestra área no difiere de las otras series, aunque la severidad de los ictus ha sido discretamente menor. Constatamos unas cifras óptimas de estancia hospitalaria y de discapacidad y mortalidad tanto a corto como a medio plazo

Introduction: A prospective stroke registry leads to improved knowledge of the disease. We present data on the Mataró Hospital Registry. Methods: In February-2002 a prospective stroke registry was initiated in our hospital. It includes sociodemographic data, previous diseases, clinical, topographic, etiological and prognostic data. We have analyzed the results of the first 10 years. Results: A total of 2,165 patients have been included, 54.1% male, mean age 73 years. The most frequent vascular risk factor was hypertension (65.4%). Median NIHSS on admission: 3 (interquartile range, 1-8). Stroke subtype: 79.7% ischemic strokes, 10.9% hemorrhagic, and 9.4% TIA. Among ischemic strokes, the etiology was cardioembolic in 26.5%, large-vessel disease in 23.7%, and small-vessel in 22.9%. The most frequent topography of hemorrhages was lobar (47.4%), and 54.8% were attributed to hypertension. The median hospital stay was 8 days. At discharge, 60.7% of patients were able to return directly to their own home, and 52.7% were independent for their daily life activities. After 3 months these percentages were 76.9% and 62.9%, respectively. Hospital mortality was 6.5%, and after 3 months 10.9%. Conclusions: Our patient's profile is similar to those of other series, although the severity of strokes was slightly lower. Length of hospital stay, short-term and medium term disability, and mortality rates are good, if we compare them with other serie

The Mataró Stroke Registry: a 10-year registry in a community hospital.

INTRODUCTION: A prospective stroke registry leads to improved knowledge of the disease. We present data on the Mataró Hospital Registry. METHODS: In February-2002 a prospective stroke registry was initiated in our hospital. It includes sociodemographic data, previous diseases, clinical, topographic, etiological and prognostic data. We have analyzed the results of the first 10 years. RESULTS: A total of 2,165 patients have been included, 54.1% male, mean age 73 years. The most frequent vascular risk factor was hypertension (65.4%). Median NIHSS on admission: 3 (interquartile range, 1-8). Stroke subtype: 79.7% ischemic strokes, 10.9% hemorrhagic, and 9.4% TIA. Among ischemic strokes, the etiology was cardioembolic in 26.5%, large-vessel disease in 23.7%, and small-vessel in 22.9%. The most frequent topography of hemorrhages was lobar (47.4%), and 54.8% were attributed to hypertension. The median hospital stay was 8 days. At discharge, 60.7% of patients were able to return directly to their own home, and 52.7% were independent for their daily life activities. After 3 months these percentages were 76.9% and 62.9%, respectively. Hospital mortality was 6.5%, and after 3 months 10.9%. CONCLUSIONS: Our patient's profile is similar to those of other series, although the severity of strokes was slightly lower. Length of hospital stay, short-term and medium term disability, and mortality rates are good, if we compare them with other series.

Rapid assessment of transient ischaemic attack in a hospital with no on-call neurologist.

BACKGROUND: Risk of stroke soon after a transient ischaemic attack (TIA) is high. Urgent care can reduce this risk. Our aim is to describe and evaluate the efficacy of rapid assessment of TIA patients in a hospital without a neurologist available 24 hours a day. METHODS: In February 2007, we set up a protocol of rapid management of patients with symptoms consistent with acute TIA, with the aim of prioritising urgent care and reducing hospital admissions, without increasing risk of recurrences. We analyse our results since the protocol was implemented with particular focus on the analysis of delay in neurological and neurovascular assessment, percentage and reasons for hospitalisation, and stroke recurrence rates after 3 months. RESULTS: Four hundred and eleven patients were studied, with a final diagnosis of TIA in 282 (68.6%). Among other diagnoses, the most frequent were a vasovagal reaction (5.6%) and confusional syndrome (4.6%). Delay between emergency arrival and neurovascular assessment was <24h in 82% of the cases, and <48 h in 93%. After neurological evaluation, 28.7% of the patients were immediately admitted to hospital (most common causes: severe stenosis of a large artery and crescendo TIA). The incidence of ischaemic stroke in TIA patients was 3.55% after 3 months and 70% of them suffered the recurrence within the first week after the initial TIA. CONCLUSIONS: In a hospital without a neurologist available 24 hours a day, early assessment and management of TIA patients can be carried out in accordance with the guidelines, and may avoid hospitalisation in most cases without increasing recurrence rates.

[Cryptogenic infarct. A follow-up period of 1 year study]. / Infartos criptogénicos. Estudio de 1 año de seguimiento.

OBJECTIVE: To analyze the outcome of patients with a cryptogenic infarct (CI) after a follow-up period of 1 year. METHODS: From our prospective registry of stroke, during a 4-year period, we've identified 121 consecutive patients with a CI (15.1% of all infarcts). They have been followed up for 1 year and we have registered stroke recurrence, cardiovascular events and other incidences. RESULTS: Mean age 70.6 years-old, 53% male. Middle cerebral artery (MCA) was the most often involved territory (52 cases), 70% of them with cortical involvement. No patient died during admission, 95.8% received antiplatelet therapy and 4.1% oral anticoagulant. Fourteen patients were lost of follow-up. During 1-year period, atrial fibrillation (AF) was detected in 7 patients (6.54%), their mean age was 75 years-old, in 5 of them the CI was in MCA territory (4 with cortical involvement, 1 only deep infarct). Three patients (2.76%) suffered a recurrent ischemic stroke, in weeks 15, 16 and 44 after the CI. In all 3 cases the infarct was considered cryptogenic again. Two patients suffered a myocardial infarction and 4 died during follow-up period. CONCLUSION: In our series rate of stroke recurrence and cardiovascular events after a CI was low. An 11% of patients with a CI involving cortical MCA territory developed FA during the following year.

Infartos criptogénicos. Estudio de 1 año de seguimiento / Cryptogenic infarct. A follow-up period of 1 year study

Objetivo. Analizar la evolución de los pacientes con un infartocriptogénico (IC) tras 1 año de seguimiento.Método. De nuestro registro prospectivo de ictus, durante unperíodo de 4 años, identificamos 121 pacientes consecutivos con unIC (15,1% del total de infartos). Se recogen datos de recurrencia delictus, eventos cardiovasculares y otras incidencias tras 1 año de seguimiento.Resultados. Edad media: 70,6 años, 53,7% de varones. La arteriacerebral media (ACM) fue el territorio más afectado (52 casos), el70% de ellos con afectación cortical. Ningún paciente falleció duranteel ingreso, un 95,8% recibió tratamiento antiagregante y un4,1% anticoagulante. En 14 pacientes no se pudo completar el añode seguimiento por diferentes motivos.Durante el período de seguimiento se detectó fibrilación auricular(FA) a 7 pacientes (6,54%), su edad media fue 75 años y en 5 deellos el IC había sido en el territorio de la ACM (4 superficial y 1 profundo).Tres pacientes (2,76%) sufrieron una recurrencia de ictus isquémicoen las semanas 15, 16 y 44 después del IC. En los 3 casos elictus fue considerado de nuevo criptogénico. Dos pacientes sufrieronun infarto agudo de miocardio y 4 fallecieron (infarto de miocardio,neoplasia de esófago, neumonía y muerte súbita).Conclusión. En nuestra serie, la tasa de recurrencia y de episodioscardiovasculares en el primer año tras un IC es baja. Un 11% depacientes con un IC en el territorio cortical de la ACM desarrollaronuna FA en el año siguiente (AU)

Objective. To analyze the outcome of patients with a cryptogenicinfarct (CI) after a follow-up period of 1 year.Methods. From our prospective registry of stroke, during a4-year period, we’ve identified 121 consecutive patients with a CI(15.1% of all infarcts). They have been followed up for 1 year andwe have registered stroke recurrence, cardiovascular eventsand other incidences.Results. Mean age 70.6 years-old, 53 % male. Middle cerebralartery (MCA) was the most often involved territory (52 cases),70% of them with cortical involvement. No patient died duringadmission, 95.8% received antiplatelet therapy and 4.1% oralanticoagulant. Fourteen patients were lost of follow-up.During 1-year period, atrial fibrillation (AF) was detected in7 patients (6.54%), their mean age was 75 years-old, in 5 of themthe CI was in MCA territory (4 with cortical involvement, 1 onlydeep infarct). Three patients (2.76 %) suffered a recurrent ischemicstroke, in weeks 15, 16 and 44 after the CI. In all 3 cases theinfarct was considered cryptogenic again. Two patients suffereda myocardial infarction and 4 died during follow-up period.Conclusion. In our series rate of stroke recurrence and cardiovascularevents after a CI was low. An 11 % of patients with aCI involving cortical MCA territory developed FA during the followingyear (AU)

Reconocimiento de los síntomas del ictus y respuesta frente a ellos en la población / Knowledge about stroke symptoms and attitude towards them in the population

Introducción. Conocer el significado de los síntomas de un ictus y tener percepción de urgencia ante ellos es un factor decisivo para reducir la demora extrahospitalaria. El objetivo es analizar el grado de reconocimiento de sus síntomas en los pacientes con un ictus, su actitud ante ellos y los factores que influyen en el conocimiento de la enfermedad. Métodos. Se estudian prospectivamente 292 pacientes consecutivos diagnosticados de ictus mediante un protocolo de recogida de datos que incluye 76 variables. Se realiza análisis univariante y multivariante para identificar las variables que se asocian independientemente con una mejor interpretación de sus síntomas y percepción de urgencia. Resultados. Sólo un 34% de pacientes reconoció saber que estaba sufriendo un ictus. El antecedente de ictus previo (OR: 3,97), vivir en una residencia (odds ratio [OR]: 3,20), tener síntomas motores (OR: 1,92) y un ictus más grave (OR: 1,05) se asociaron de forma independiente a un mejor reconocimiento de los síntomas. Sólo un 31,8 % de pacientes (41% de los que reconocieron los síntomas del ictus) decidió acudir inmediatamente al hospital o llamó a una ambulancia. La etiología cardioembólica del infarto (OR: 2,62), no tener hipertensión (OR: 0,48) y reconocer correctamente sus síntomas (OR: 0,62) son factores asociados de forma independiente a una mayor percepción de urgencia. Conclusión. Sólo un 14 % de los pacientes tienen un buen conocimiento del ictus y actúan correctamente cuando éste ocurre. Es necesario desarrollar programas de formación de la población en los que se resalte la urgencia ante la presencia de síntomas sugestivos de ictus (AU)

Introduction. To know the meaning of stroke symptoms and to perceive them as an emergency is a decisive factor to reduce hospital admission delay. The aim of the study is to analyze the degree of recognition of stroke symptoms by the patients, their attitude towards them, and which factors contribute to a better knowledge on cerebrovascular diseases. Methods. A total of 292 patients diagnosed of stroke were studied prospectively, following a protocol designed for data collection that included 76 variables. Univariate and multivariate analyses were conducted to identify which variables were independently associated with a better interpretation of stroke symptoms and emergency perception. Results. Only 34% of all patients recognized they were suffering a stroke. The background that was independently associated with a better interpretation of symptoms included previous stroke (odds ratio [OR]: 3.97), institutionalized subjects (old people's home) (OR: 3.20), motor symptoms (OR: 1.92) and more serious stroke (OR: 1.05). Only 31% of all patients, 41% of whom had recognized stroke symptoms, decided to go immediately to hospital or call for an ambulance. Variables that were independently associated with a better perception of emergency included cardioembolic stroke (OR: 2.62), not having hypertension (OR: 0.48) and a correct interpretation of stroke symptoms (OR: 0.62). Conclusion. Only 14% of all patients have a good knowledge about stroke and correctly act when it occurs. It is necessary to develop education programs aimed at the population that emphasize the emergency when symptoms suggesting stroke appear (AU)

[Knowledge about stroke symptoms and attitude towards them in the population]. / Reconocimiento de los síntomas del ictus y respuesta frente a ellos en la población.

INTRODUCTION: To know the meaning of stroke symptoms and to perceive them as an emergency is a decisive factor to reduce hospital admission delay. The aim of the study is to analyze the degree of recognition of stroke symptoms by the patients, their attitude towards them, and which factors contribute to a better knowledge on cerebrovascular diseases. METHODS: A total of 292 patients diagnosed of stroke were studied prospectively, following a protocol designed for data collection that included 76 variables. Univariate and multivariate analyses were conducted to identify which variables were independently associated with a better interpretation of stroke symptoms and emergency perception. RESULTS: Only 34% of all patients recognized they were suffering a stroke. The background that was independently associated with a better interpretation of symptoms included previous stroke (odds ratio [OR]: 3.97), institutionalized subjects (old people's home) (OR: 3.20), motor symptoms (OR: 1.92) and more serious stroke (OR: 1.05). Only 31% of all patients, 41% of whom had recognized stroke symptoms, decided to go immediately to hospital or call for an ambulance. Variables that were independently associated with a better perception of emergency included cardioembolic stroke (OR: 2.62), not having hypertension (OR: 0.48) and a correct interpretation of stroke symptoms (OR: 0.62). CONCLUSION: Only 14% of all patients have a good knowledge about stroke and correctly act when it occurs. It is necessary to develop education programs aimed at the population that emphasize the emergency when symptoms suggesting stroke appear.

[Intracranial stenosis. Study and follow-up of 38 patients]. / Estenosis intracraneales. Estudio y seguimiento de 38 pacientes.

INTRODUCTION: To describe vascular risk factors of patients harboring intracranial arterial stenosis (IAS) as well their final outcome. METHODS: We reviewed clinical reports of all patients admitted to our Institution from April 1, 1999 to November 30, 2001 with the diagnosis of IAS. Diagnosis was made by means of magnetic resonance angiography (MRA) or four-vessels digital subtraction angiography. Thirty-eight patients harboring 56 IAS were identified. Mean follow-up was 18 months. Two control groups were selected: one was a group of 44 patients with stroke and embolic cardiopathy (EC) and the other was a group of 67 patients with stroke and extracranial stenosis without IAS. RESULTS: Mean age was 69.7 years, with male preponderance (76.3 %). Seventeen cases (44.7 %) had associated extracranial carotid stenosis greater than 50 %. Multiple IAS were found in 12 patients. Diabetes mellitus was significantly more frequent in the IAS group than in both control groups. On the other hand, cigarette smoking was more common in the IAS group with respect to the EC group. IAS was symptomatic in 25 cases, whereas in 13 patients IAS was found in the work-up for cerebral ischemia in another territory. From the group of symptomatic patients, 22 (88 %) had a Rankin scale 2 or lower on discharge and, in the long term follow-up, their incidence rate of recurrent ischemic stroke was 15 per 100 patients/year. CONCLUSIONS: Diabetes mellitus was the most specific risk factor for IAS. IAS was multiple in 32% of patients and in extracranial stenosis from moderate to severe degree was found in 44.7% of the cases. Stroke secondary to IAS caused a low dependency level at discharge. Incidence rate of recurrent ischemic stroke was 15 % patients/ year.