Fístula arteriovenosa dural intracraneal y hemorragia subaracnoidea perimesencefálica. A propósito de un caso / Intracranial dural arteriovenous fistula and perimesencephalic subarachnoid haemorrhage. A case study

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Oclusión basilar pediátrica tratada mediante trombectomía con stents extractores / A paediatric case of basilar occlusion treated with mechanical thrombectomy using stent retrievers

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Recanalization and mortality rates of thrombectomy with stent-retrievers in octogenarian patients with acute ischemic stroke.

BACKGROUND: Our objective was to evaluate the effect of treatment with stent-retrievers in octogenarians suffering an acute ischemic stroke. METHODS: A total of 150 consecutive patients with acute stroke who were treated with stent-retrievers between April 2010 and June 2012 were retrospectively reviewed. Patients were divided into those <80 years old (n = 116) and those ≥80 (n = 34). Baseline characteristics, procedure data, and endpoints (postprocedural NIHSS, death, and mRS at 3 months) were compared. RESULTS: High blood pressure, atrial fibrillation, and anticoagulation were more frequent in octogenarians (p = 0.01, 0.003, and 0.04 respectively). There were no differences between both groups regarding previous intravenous thrombolysis (32.4 vs. 48.3 %, p = 0.1), preprocedural NIHSS (18.1 vs. 16.8, p = 0.3), procedure time (74.5 (40-114) min vs. 63 (38-92) min, p = 0.2), revascularization time (380.5 (298-526.3) min vs. 350 (296.3-452.8), p = 0.3), TICI ≥ 2B (88.2 vs. 93.9 %, p = 0.1), and symptomatic haemorrhage (5.9 vs. 2.6 %, p = 0.3). Discharge NIHSS was higher in octogenarians (9.7 vs. 6.5, p = 0.03). Death and 3-month mRS ≥3 were more frequent in octogenarians (35.3 vs. 17.2 %, p = 0.02 and 73.5 vs. 37.1 %, p = 0.02). ICA-involvement and prolonged revascularization involved higher mortality (66.7 vs. 27.6 %, p = 0.03) and worse mRS (50 vs. 24.4 %, p = 0.06) in octogenarians. CONCLUSIONS: In our series, treatment with stent-retrievers in octogenarians with acute ischemic stroke achieved good rates of recanalization but with a high mortality rate. ICA involvement and revascularization times beyond 6 hours associated to a worse prognosis. These data might be of value in the design of prospective studies evaluating the clinical efficacy of the endovascular treatments in octogenarians.

Comparison between proximal versus distal protection devices in 287 cases of carotid revascularization using angioplasty and stenting: periprocedure complications, morbidity, and mortality.

BACKGROUND: Embolic protection devices may decrease periprocedural thromboembolic complications during carotid angioplasty and stenting (CAS). When using proximal-protection devices (PPDs), protection starts before crossing the lesion. However, in the medical literature, its use is scarcely reported compared with that of distal-protection filters (DPDs). The objective of this study was to compare periprocedure complications, morbidity, and mortality among 287 consecutive cases of CAS performed with PPDs or DPDs. PATIENTS AND METHODS: This was a retrospective analysis of 287 patients treated with CAS at our hospital between January 2006 and March 2012. Periprocedure complications, morbidity, and mortality at 30 days, including ischemic stroke or transient ischemic attack, reperfusion syndrome, myocardial infarction (MI), and death, were globally registered, and the results in PPD and DPD groups were compared. RESULTS: Two hundred eight patients were treated with DPD and 79 with PPD; 80.8 % were symptomatic. CAS procedures performed with PPD presented a statistically significant greater grade of stenosis than those with DPD (82.5 vs. 74.5 %, p < 0.001). Death rates were 1.9 and 1.3 %; stroke rates were 4.3 and 3.8 %; MI rates were 1.4 and 1.3 %; and total morbidity and mortality rates were 6.2 and 5 % (DPD and PPD groups, respectively); all differences were nonstatistically significant. No statistical difference was found between symptomatic and asymptomatic patients. CONCLUSION: Carotid angioplasty and stenting is a safe procedure to treat carotid disease in our patients. PPDs are not always associated with a greater risk of periprocedure complications, morbidity, and mortality than DPDs despite the greater grade of carotid stenosis in the PPD group. This observation may be of interest in the design of future studies with CAS.

Manifestaciones neurológicas de los mixomas cardiacos. Experiencia en un centro de referencia / Neurological manifestations of cardiac myxoma: Experience in a referral hospital

Introducción: El mixoma cardiaco es una causa poco frecuente pero importante de infarto cerebral en pacientes jóvenes. Existen pocas series de pacientes que analicen la frecuencia de las manifestaciones neurológicas en pacientes con mixoma y su presentación clínica. Objetivo: Conocer las complicaciones neurológicas del mixoma cardiaco en nuestro hospital durante los últimos 28 años. Pacientes y métodos: Revisión retrospectiva de las manifestaciones neurológicas de 36 pacientes operados de mixoma cardiaco con confirmación patológica en nuestro centro desde diciembre de 1983 hasta marzo del 2012. Resultados: Ocho de los 36 pacientes con mixomas cardiacos (22%) intervenidos en nuestro centro presentaron clínica neurológica. El 50% eran mujeres y la edad media ± desviación estándar de 52,4 ± 11,6 años. El síntoma neurológico más frecuente fue la hemiparesia de aparición brusca (63%). El ictus isquémico establecido fue la manifestación clínica más frecuente (75%), seguido del accidente isquémico transitorio. El territorio más afectado fue el de la arteria cerebral media. En todos los casos se alcanzó el diagnóstico del tumor mediante ecocardiografía. El tamaño medio del mixoma fue de 4,12 cm. La mayoría (63%) presentaba una superficie polipoide. Todos los tumores fueron resecados quirúrgicamente con éxito. No hubo muertes hospitalarias. Conclusiones: Los mixomas cardíacos comienzan frecuentemente con manifestaciones neurológicas, en particular como eventos isquémicos (AIT o ictus establecidos) en pacientes jóvenes y sin factores de riesgo cardiovascular. El territorio anterior, en especial la arteria cerebral media, suele estar más frecuentemente afectado. La ecocardiografía puede facilitar el diagnóstico y permitir un tratamiento precoz de la lesión (AU)

Introduction: Cardiac myxoma is an important but uncommon cause of stroke in younger patients. Few published case series analyse the frequency and clinical presentation of neurological complications in patients with myxoma. Objective: To list all neurological complications from cardiac myxoma recorded in our hospital in the past 28 years. Patients and methods: We retrospectively reviewed the neurological manifestations of cardiac myxoma in patients treated in our hospital between December 1983 and March 2012. Results: Of the 36 patients with cardiac myxoma, 8 (22%) presented neurological manifestations. Half were women and mean age of patients was 52.4 ± 11.6 years. Sudden-onset hemiparesis was the most frequent neurological symptom (63%). Established ischaemic stroke was the most common clinical manifestation (75%), followed by transient ischemic attack. The most commonly affected territory corresponded to the middle cerebral artery. Myxoma was diagnosed by echocardiography in all cases. Mean myxoma size was 4.1 cm and most of the tumours (63%) had a polypoid surface. All tumours were successfully removed by surgery. There were no in-hospital deaths. Conclusions: Cardiac myxomas frequently present with neurological symptoms, especially ischaemic events (established stroke or transient ischaemic attack), in younger patients with no cardiovascular risk factors. The anterior circulation is more frequently affected, especially the middle cerebral artery. Echocardiography can facilitate prompt diagnosis and early treatment of the lesion (AU)

Neurological manifestations of cardiac myxoma: experience in a referral hospital.

INTRODUCTION: Cardiac myxoma is an important but uncommon cause of stroke in younger patients. Few published case series analyse the frequency and clinical presentation of neurological complications in patients with myxoma. OBJECTIVE: To list all neurological complications from cardiac myxoma recorded in our hospital in the past 28 years. PATIENTS AND METHODS: We retrospectively reviewed the neurological manifestations of cardiac myxoma in patients treated in our hospital between December 1983 and March 2012. RESULTS: Of the 36 patients with cardiac myxoma, 8 (22%) presented neurological manifestations. Half were women and mean age of patients was 52.4 ± 11.6 years. Sudden-onset hemiparesis was the most frequent neurological symptom (63%). Established ischaemic stroke was the most common clinical manifestation (75%), followed by transient ischemic attack. The most commonly affected territory corresponded to the middle cerebral artery. Myxoma was diagnosed by echocardiography in all cases. Mean myxoma size was 4.1cm and most of the tumours (63%) had a polypoid surface. All tumours were successfully removed by surgery. There were no in-hospital deaths. CONCLUSIONS: Cardiac myxomas frequently present with neurological symptoms, especially ischaemic events (established stroke or transient ischaemic attack), in younger patients with no cardiovascular risk factors. The anterior circulation is more frequently affected, especially the middle cerebral artery. Echocardiography can facilitate prompt diagnosis and early treatment of the lesion.

Treatment of acute vertebrobasilar occlusion using thrombectomy with stent retrievers: initial experience with 18 patients.

BACKGROUND AND PURPOSE: Acute vertebrobasilar occlusion is an ominous disease with few proved effective treatments. Experience with stent retrievers is scarce and limited to combined therapies (stent retrievers associated with previous intravenous fibrinolysis, intra-arterial thrombolysis, or other mechanical devices). We present our experience with 18 patients treated with direct thrombectomy by using stent retrievers. MATERIALS AND METHODS: Eighteen patients with vertebrobasilar occlusion were treated with direct thrombectomy by using stent retrievers at our hospital. The mean age was 67.5 years. Clinical presentation was sudden deterioration in consciousness level in 61.2% and progressive or fluctuating brain stem symptoms in 38.8%. Stroke subtype (TOAST) was atherothrombotic (33.3%), undetermined (33.3%), cardioembolic (27.7%), and of unusual etiology (5.5%). RESULTS: The occlusion site was the vertebral artery in 1 case, proximal basilar artery in 4, middle basilar artery in 6, distal basilar artery in 5, and unilateral posterior cerebral artery in 2 cases. SRs included the Solitaire AB in 8 cases, Solitaire FR in 5 cases, and Trevo Pro in 5 cases. An 8F Merci balloon guide catheter was used in 15 patients, and a Neuron 6F, in 3 patients. Post-clot retrieval definitive intracranial stents were used in 5 patients (27.7%). Postprocedural TICI ≥ 2b was achieved in 17 patients (94.4%). Clinically, 72.2% of patients experienced an improved NIHSS score at discharge, 22.2% died, and in 5.5% the NIHSS scores did not change. The mRS score at 3 months was 0-2 in 9 patients (50%) and 3-5 in 5 patients (27.7%). CONCLUSIONS: Thrombectomy with stent retrievers is feasible in the treatment of vertebrobasilar occlusion. These initial results must be confirmed by further prospective studies with a larger number of cases.

Hemorrhage/contrast staining areas after mechanical intra-arterial thrombectomy in acute ischemic stroke: imaging findings and clinical significance.

BACKGROUND AND PURPOSE: The aim of this study was to report the CT evolution and clinical significance of HCA after intra-arterial mechanical thrombectomy (revascularization by using retrievers and/or other mechanical devices without concomitant delivery of intra-arterial thrombolytics) in our patients. These lesions are common after intra-arterial thrombolysis, being considered a negative prognostic sign. Their significance after pure mechanical thrombectomy remains unknown. MATERIALS AND METHODS: Forty-eight patients were treated with mechanical thrombectomy by using retrievable stents between April 2010 and February 2011. All patients underwent initial (first 24 hours) and follow-up (48-72 hours) nonenhanced CT. We retrospectively analyzed the clinical and radiologic data of the patients with HCA and compared them with controls. RESULTS: Fifteen of 48 patients presented with HCA. The site of occlusion was the MCA in 7 patients, both the extra- and intracranial segments of the ICA in 6, and the intracranial ICA in 2. In 7 patients, previous intravenous thrombolysis was administered. Complete recanalization (TICI 3) was achieved in 12 patients, and incomplete recanalization (TICI 2b), in 3. The location of HCA was the subarachnoid space in 6 patients, the brain parenchyma in 4 patients, and both in 5 patients. The HCA were asymptomatic in all patients. There was no statistical difference in final NIHSS score reduction (NIHSS pretreatment-NIHSS at discharge) between patients and controls. CONCLUSIONS: In our series, HCA are common after mechanical thrombectomy but do not carry an increased risk of symptomatic hemorrhage or negative prognosis. These data might be related to the high rate of recanalization and the absence of intra-arterial thrombolytics.

Presurgical Identification of the Central Sulcus Using GE EPI Sequences in Combination with 3D Reconstruction is a Useful and Easy Technique for Functional Identification of the Sensorimotor Cortex.

Functional magnetic resonance imaging (fMRI) is a noninvasive neuroimaging technique that enables the visualization of vascular changes originating in the cortex on the execution of a simple motor task. We aimed to assess the usefulness of sensorimotor fMRI using echo-planar imaging (EPI) techniques and assess its clinical usefulness in the identification of the central sulcus. We studied 32 candidates for neurosurgery who had centrally located space-occupying lesions with fMRI using EPI images with blood oxygen level-dependent (BOLD) gradient-echo (GE) sequences acquired on a 1.5T scanner while patients repeatedly opened and closed their hands. Statistical activation images (t images) corresponding to the movements of the right and left hands were compared using cancellation analysis. Three-dimensional reconstruction of the cranium and brain of each patient showed the relative position of the expansive lesion and of non-damaged cortical tissue. Reproducible and selective functional sensorimotor activation was observed in 32 patients. Validation was carried out by intraoperative mapping in 19 patients. Based on intraoperative confirmation data we assumed that functional MR imaging (fMRI) is a valid method for identifying the motor cortex. Nevertheless, a limitation to our study is that not all the patients received invasive cortical stimulation. It is also relevant to indicate that fMRI and intraoperative procedures coincide in the sulcus identified as the sensorimotor cortex. Neurological examination did not reveal postoperative motor/sensitive deterioration in the remaining patients. fMRI using GE EPI sequences in combination with three-dimensional reconstruction is a useful and easy technique for functional identification of the sensorimotor cortex.

[Carotid revascularisation using angioplasty and stent in 134 consecutive cases in a reference hospital: a risky technique?]. / 134 casos consecutivos de revascularización carotídea mediante angioplastia y stent en un centro de referencia: ¿una técnica de riesgo?

INTRODUCTION: Carotid revascularisation (CR) using angioplasty and stent (ASC) is an effective procedure in the prevention of ischaemic stroke, but with a controversial morbidity and mortality in the different studies conducted in this field. METHODS: The results of the ASCs performed in the Virgen de la Arrixaca University Hospital (Murcia) between January 2006 and April 2009 were analysed (epidemiology, indication, grade of residual stenosis and procedure complications). All patients subjected to ASC were pre-selected and followed up by neurologists, and they followed a strict medical protocol for performing the procedure. All ASCs were performed by a team consisting of two surgeons, an anaesthetist and a nurse. RESULTS: A total of 134 ASC were performed. The mean age of our patients was 72.7 years, with the large majority (75%) being male. The most prevalent diseases were, high blood pressure (81%), smoking (66.4%), and diabetes (38.1%). The most common indications for CR were symptomatic carotid stenosis with a level of stenosis of 75-99%, either in the left (33.6%) or right (32.1%), followed by asymptomatic stenosis combined with risk factors (11.2% in the left side and 10.4% in the right side). A level of stenosis less than 30% was achieved in 132 of the 134 ASC (98.5%). performed. Five patients (3.7%) had complications associated with the procedure, of which four were different clinical presentations of a re-perfusion syndrome and one an asymptomatic thrombosis of the stent. CONCLUSIONS: ASC is a complex technique that must be performed by appropriately trained specialists. The performing a minimum number of procedures per year and an admission protocol controlled by Neurology are essential conditions for a low rate of complications. Under these conditions, the morbidity and mortality of the technique is no higher than that of endarterectomy.

134 casos consecutivos de revascularización carotídea mediante angioplastia y stent en un centro de referencia: ¿una técnica de riesgo? / Carotid revascularisation using angioplasty and stent in 134 consecutive cases in a reference hospital: A risky technique?

Introducción: La revascularización carotídea mediante angioplastia y stent (ASC) es un procedimiento eficaz en la prevención del ictus isquémico, pero con una morbimortalidad periprocedimiento muy discutida en los diferentes estudios realizados al respecto.Métodos: Se analizan los resultados (epidemiología, tipo de indicación, grado de estenosis residual y complicaciones periprocedimiento) de las ASC realizadas en el Hospital Universitario Virgen de la Arrixaca entre enero de 2006 y abril de 2009. Todos los pacientes sometidos a ASC fueron preseleccionados y seguidos por neurólogos, y siguieron un protocolo médico estricto para la realización del procedimiento. Todas las ASC fueron llevadas a cabo por un equipo formado por dos intervencionistas, un anestesista y un enfermero. Resultados: Se realizaron 134 ASC. La edad media de nuestros pacientes fue de 72,7 años, con predominio del sexo masculino (75%). Las patologías más prevalentes fueron la hipertensión arterial (81%), el tabaquismo (66,4%), y la diabetes (38,1%). La indicación de RC más frecuente fue la estenosis carotídea sintomática con grado de estenosis 75-99%, tanto izquierda (33,6%) como derecha (32,1%), seguida de las estenosis asintomáticas asociadas a factores de riesgo (11,2% en el lado izquierdo y 10,4% en el lado derecho). En 132 de las 134 ASC (98,5%) se consiguió un grado de estenosis residual menor al 30%. Cinco pacientes (3,7%) presentaron complicaciones relacionadas con el procedimiento, de las cuales cuatro correspondieron a diferentes presentaciones clínicas del síndrome de reperfusión y una, a una trombosis asintomática del stent.Conclusiones: La ASC es una técnica compleja que debe ser llevada a cabo por especialistas con una capacitación adecuada. La realización de un número mínimo de procedimientos al año, y la existencia de un protocolo de ingreso controlado por Neurología son condiciones imprescindibles para una tasa de complicaciones (AU)

Introduction: Carotid revascularisation (CR) using angioplasty and stent (ASC) is an effective procedure in the prevention of ischaemic stroke, but with a controversial morbidity and mortality in the different studies conducted in this field.Methods: The results of the ASCs performed in the Virgen de la Arrixaca University Hospital (Murcia) between January 2006 and April 2009 were analysed (epidemiology, indication, grade of residual stenosis and procedure complications). All patients subjected to ASC were pre-selected and followed up by neurologists, and they followed a strict medical protocol for performing the procedure. All ASCs were performed by a team consisting of two surgeons, an anaesthetist and a nurse. Results: A total of 134 ASC were performed. The mean age of our patients was 72.7 years, with the large majority (75%) being male. The most prevalent diseases were, high blood pressure (81%), smoking (66.4%), and diabetes (38.1%). The most common indications for CR were symptomatic carotid stenosis with a level of stenosis of 75-99%, either in the left (33.6%) or right (32.1%), followed by asymptomatic stenosis combined with risk factors (11.2% in the left side and 10.4% in the right side). A level of stenosis less than 30% was achieved in 132 of the 134 ASC (98.5%). performed. Five patients (3.7%) had complications associated with the procedure, of which four were different clinical presentations of a re-perfusion syndrome and one an asymptomatic thrombosis of the stent. Conclusions: ASC is a complex technique that must be performed by appropriately trained specialists. The performing a minimum number of procedures per year and an admission protocol controlled by Neurology are essential conditions for a low rate of complications. Under these conditions, the morbidity and mortality of the technique is no higher than that of endarterectomy (AU)

Prevalence of dementia and cognitive impairment in Southeastern Spain: the Ariadna study.

OBJECTIVES: To estimate the prevalence of amnestic mild cognitive impairment (aMCI), cognitive impairment, no dementia (CIND) and dementia in a general elderly population and to examine the associated socio-demographic factors. METHODS: The Ariadna study is a population-based cross-sectional study of cognitive function involving 1074 individuals aged 65-96 years from the Murcia Region of southeastern Spain. Prevalence, adjusted odds ratio (OR) and 95% confidence intervals (CI) were calculated. RESULTS: The overall prevalence was 8.7% (95% CI 7.1-10.5) for aMCI, 14.5% (95% CI 12.4-16.8) for CIND and 5.5% (95% CI 4.3-7.1) for dementia. Dementia was associated with age (OR 1.13 95% CI 1.09-1.18 for a 1-year increase in age). Illiterate subjects were more likely to present aMCI (OR 2.59; 95% CI 1.09-6.14) and dementia (OR 4.09; 95% CI 1.28-13.08) than subjects with secondary or higher education. Rural area residents (OR 2.13, 95% CI 1.07-4.24) and women (OR 1.53, 95% CI 1.06-2.22) were more likely to have CIND. CONCLUSION: The prevalence of dementia was low, despite a high prevalence of aMCI and CIND. Dementia was strongly associated with age and education. CIND was associated with living in a rural area and with female sex, while aMCI was associated with illiteracy.

Ictus carotídeo secundario a apoplejía hipofisaria. Respuesta favorable a trombosis intravenosa / No disponible

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Brain edema after carotid revascularization: benign syndrome or prelude to hemorrhage?

Brain edema (BE) post carotid revascularization (CR) is considered a benign presentation of the hyperperfusion syndrome. Its physiopathology has been related to production of vasogenic edema that tends to progressive spontaneous resolution. Its relation with post-CR hemorrhage remains unclear. Three cases of BE post-CR are described and compared to controls. Clinical evolution, medical management, and plain-CT and perfusion-CT (PCT) results are analysed. Two cases of BE had a benign course, with a progressive resolution of edema and disappearance of neurologic deficits. Effective blood pressure control was achieved in these patients. The third case suffered massive hemorrhage 24h after initial BE and died. This patient reached peak systolic levels of 220 mmHg before conversion to hemorrhage. Plain-CT and PCT findings were similar in the three patients with BE. CT showed signs of hemispheric brain swelling ipsilateral to CR. PCT showed low MTT and high CBF values on the hemisphere ipsilateral to CR compared to the contralateral hemisphere, with symmetric CBV values. Plain-CT and PCT in controls showed no abnormalities. BE post CR can be reversible but may also herald a hemorrhagic complication. A common physiopathology of post-CR BE and hemorrhage is suggested by PCT findings, related to failure of auto-regulation and secondary blood-brain-barrier dysfunction. Spontaneous resolution of BE post-CR should not be routinely expected in clinical practice. Conversion to hemorrhage might be related with deficient blood pressure control and secondary rupture of the already damaged vessel wall.

Magnetic resonance spectroscopy performance for detection of dementia, Alzheimer's disease and mild cognitive impairment in a community-based survey.

BACKGROUND/AIMS: To evaluate (1)H-labelled magnetic resonance spectroscopy (MRS) in patients with a low Mini Mental State Examination (MMSE) score identified during a dementia community-based survey. METHODS: A population sample of 1,500 individuals (>64 years old) was randomly selected. Two hundred and fifteen individuals (MMSE < or =24) were sorted into clinical groups: dementia, Alzheimer's disease, mild cognitive impairment (MCI), normal. Up to 56 of these individuals attended the MRS appointment. Two single-voxel sequences (TR 1,500, TE 35/144 ms) were carried out in the posterior cingulate gyrus of each individual, and the ratios N-acetylaspartate (NAA)/creatine (Cr), choline (Cho)/Cr, myo-inositol (mI)/Cr, NAA/mI and NAA/Cho were compared statistically. The ability of MRS to distinguish clinical groups was assessed by receiver-operating characteristics analysis. Cognition effects on metabolite ratios were estimated, with gender and cognition as categorical variables and age as a continuous covariate. RESULTS: NAA/Cr and NAA/Cho ratios were lower in dementia or Alzheimer's disease than in MCI and normal groups. The NAA/Cr ratio at TE 35 ms performed best when distinguishing dementia or Alzheimer's disease from non-demented subjects (cut-off point 1.40). MRS could not distinguish between MCI patients and normal subjects. Dementia was an independent predictor of metabolite values. CONCLUSION: In a population sample, conventional MRS still proved to be a useful tool for dementia discrimination, but it is potentially far less useful as a surrogate marker for MCI.

Liver transplantation in Wilson's disease: are its indications established?

UNLABELLED: The indications of progressive neurological deterioration despite no hepatic insufficiency, for liver transplant (OLT) in patients with Wilson's disease (WD) who do not improve with medical treatment is widely debated. The aim of this paper was to present our OLT experience in WD. PATIENTS AND METHODS: Fourteen patients were given a transplant after the diagnosis of WD for the following indications: in four patients, a steady neurological deterioration that failed to respond to chelation treatment (all with Child grade A liver function); in nine patients, Child grade C hepatic insufficiency, in whom medical treatment had failed (one of these patients also presented with severe neurological alterations); and in one patient, acute hepatic failure secondary to E. Coli infection of the ascitic fluid. RESULTS: Two patients died, one due to severe pancreatitis in the immediate postoperative period and the other, who was transplanted for neurological involvement, experienced an acute rejection episode treated with methylprednisolone in the first postoperative month and, in the 4th month, another episode of acute rejection, failed to respond to corticoids and required OKT-3 administration. She subsequently developed bilateral bronchopneumonia due to cytomegalovirus that led to her death. During the immediate postoperative period all of the cupremia, cupriuria, and ceruloplasmin levels returned to normal. The liver function in the 12 patients currently alive was totally normal after a follow-up of 8 years (range, 1-15 years) with actuarial 5-year survival of 85.7%. CONCLUSIONS: These cases demonstrated that OLT may mobilize copper sufficiently from the central nervous system to correct severe neurological deficits, a result that medical therapy alone cannot achieve. We suggest that OLT be considered for patients with WD who have crippling neurological and psychological diseases, even if liver function is stable.

[Nonconvulsive status epilepticus: experience in 33 patients]. / Status epiléptico no convulsivo: experiencia en 33 pacientes.

BACKGROUND: To review the nonconvulsive status epilepticus diagnosed in a general hospital in order to identify its frequency, electroclinical characteristics and response to medical treatment. PATIENTS ANTS AND METHODS: A retrospective study of 33 cases of nonconvulsive status epilepticus was undertaken. The diagnosis was based on clinical and EEG manifestations. Data regarding their clinical presentation, previous epilepsy, etiology of the status, its medical management and outcome were analysed. RESULTS: The 33 patients comprising the study included 20 men and 13 women. The medium age was 49.8 years. A previous history of epilepsy was present in 51.5% of them. Most of the patients presented impaired consciousness (39.4%) or confusional state (36%). The mean duration of the disorder did not exceed 24 hours (64.5%). There were five cases of absence status and 28 of complex partial status, two of them with secondary generalization. A precipitating factor was found in 80% of the patients and the cerebrovascular etiology was the most frequent. There was a good response to phenytoin (80%), although in the first month death was the final outcome for 25% of them. CONCLUSIONS: Nonconvulsive status epilepticus is an underdiagnosed medical emergency because of its different manifestations, similar to confusional or psyquiatric states. The precipitating factor determines its outcome. A high index of suspicion is needed in order to make a faster diagnosis and treatment.