Trastorno progresivo de la marcha y epilepsia secundarios a infarto venoso por fístula dural arteriovenosa tipo iii / Progressive gait disorder and epilepsy secondary to venous stroke due to dural arteriovenous fistula type iii

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Revisión del modelo del control de la mirada vertical / Review of the model of vertical gaze control

Introducción. Las principales estructuras implicadas en el control de la mirada vertical, tanto en las sacadas como en el seguimiento fino y los reflejos oculovestibulares, son el núcleo rostral intersticial del fascículo longitudinal medial, la comisura posterior, el núcleo intersticial de Cajal, el complejo oculomotor y el núcleo del IV par. Pese a conocer las funciones de estos núcleos, sus principales interconexiones, aferencias y eferencias, no existe un modelo definitivo contrastado del control de la mirada vertical en el ser humano. Objetivo. A través de tres casos clínicos y de lo descrito en la literatura científica, se pretende revisar los modelos descritos hasta la fecha. Desarrollo. El control de las sacadas verticales se genera en el núcleo rostral intersticial del fascículo longitudinal medial, proyectando hacia los núcleos de los oculomotores pertinentes de manera ipsilateral en la infraducción, y de manera bilateral en la supraducción. Conclusiones. La inervación doble y cruzada de los núcleos encargados de la mirada superior implica que lesiones unilaterales afectarán predominantemente a la mirada inferior (AU)

Introduction. The main structures involved in the control of vertical gaze, both saccades, smooth pursuit and oculovestibular reflexes, are the rostral interstitial nucleus of medial longitudinal fasciculus, posterior commissure, interstitial nucleus of Cajal, oculomotor complex and trochlear nerve nucleus. Despite knowing the functions of these nuclei, and their main interconnections, afferents and efferents, there is no definitive and contrasted model of vertical gaze control in humans. Aim. Through the description of three cases, and as described in scientific literature, our aim is to review the models described to date. Development. The control of vertical saccades generates in the rostral interstitial nucleus of medial longitudinal fasciculus, projecting to the pertinent oculomotor nuclei ipsilaterally for the inferior gaze, and bilaterally for the superior gaze. Conclusions. The double cross-innervation of the nuclei responsible for superior gaze, implies that unilateral lesions predominantly affect the inferior gaze (AU)

[Cerebral haemorrhage in patients treated with oral anticoagulation]. / Hemorragia cerebral en pacientes en tratamiento con anticoagulantes orales.

INTRODUCTION: Intracranial haemorrhage (ICH) during dicumarinic treatment is a complication related to anticoagulation intensity with a high level of mortality. The aim of our study is to analize etiology, location and outcome of intracerebral haemorrhages related with anticoagulant therapy. PATIENTS AND METHODS: Over 401 spontaneous intracranial haemorrhages consecutively admitted in the neurological ward, we analyzed the acenocumarol ICH by location, anticoagulation range and factors that conditioned the outcome. RESULTS: We identified 26 patients, 6.5% of total ICH. Mean age was 75.2 +/- 7.9 years-old, over the rest of ICH. International Normalized Ratio (INR) was less than 2 in 10 patients, between 2 and 3 in six and greater than 3 in ten patients. 8 patients (31%) died, three of them had multiple ICH, but none of them had a INR greater than 2. Dicumarinic haemorrhages were of lobar location in 14 cases (three of them multiples) and deep in 12 cases. CONCLUSIONS: In our study, dicumarinic ICH are responsible of 6.5% total intracranial haemorrhages and they are not in clear relation with excessive anticoagulation. Mortality is slightly greater than the other ICH. Relatively benignity of these patients, the age and lobar location suggest that the etiology of these haemorrhages can be related to a subjacent amyloid angiopathy.

Hemorragia cerebral en pacientes en tratamiento con anticoagulantes orales / Cerebral haemorrhage in patients treated with oral anticoagulation

Introducción. Se considera que la hemorragia cerebral (HIC) en pacientes en tratamiento con dicumarínicos (acenocumarol) es una complicación relacionada con el grado de anticoagulación y que comporta una alta mortalidad. El objetivo del estudio es analizar la etiopatogenia, topografía y pronóstico de las HIC por anticoagulantes orales. Pacientes y métodos. Sobre 401 HIC espontáneas ingresadas consecutivamente en nuestra unidad se han analizado las HIC en pacientes en tratamiento con acenocumarol en cuanto a localización, intervalo de anticoagulación y factores que condicionan el pronóstico. Resultados. Se han identificado 26 pacientes, un 6,5% del total de HIC. La edad media fue de 75,2 ± 7,9 años, superior al resto de HIC. El INR (International Normalized Ratio) fue inferior a 2 en 10 pacientes, entre 2-3 en seis y mayor de 3 en 10. Ocho pacientes (31%) fallecieron, tres presentaban HIC múltiples, pero ninguno tenía un INR superior a 2. Las HIC por dicumarínicos fueron lobares en 14 casos (en tres múltiples) y profundas en 12 casos. Conclusiones. En nuestro estudio las HIC por acenocumarol fueron responsables del 6,5% del total de HIC y no se relacionaron claramente con una anticoagulación excesiva. La mortalidad de las HIC por anticoagulantes orales es levemente superior al del resto de las HIC. La relativa benignidad de estos pacientes, junto con la edad y la localización lobar, sugieren que la etiología de estas hemorragias pueda estar relacionada con una angiopatía amiloide cerebral subyacente

Introduction. Intracranial haemorrhage (ICH) during dicumarinic treatment is a complication related to anticoagulation intensity with a high level of mortality. The aim of our study is to analize etiology, location and outcome of intracerebral haemorrhages related with anticoagulant therapy. Patients and methods. Over 401 spontaneous intracranial haemorrhages consecutively admitted in the neurological ward, we analyzed the acenocumarol ICH by location, anticoagulation range and factors that conditioned the outcome. Results. We identified 26 patients, 6.5% of total ICH. Mean age was 75.2 ±7.9 years-old, over the rest of ICH. International Normalized Ratio (INR) was less than 2 in 10 patients, between 2 and 3 in six and greater than 3 in ten patients. 8 patients (31%) died, three of them had multiple ICH, but none of them had a INR greater than 2. Dicumarinic haemorrhages were of lobar location in 14 cases (three of them multiples) and deep in 12 cases. Conclusions. In our study, dicumarinic ICH are responsible of 6.5% total intracranial haemorrhages and they are not in clear relation with excessive anticoagulation. Mortality is slightly greater than the other ICH. Relatively benignity of these patients, the age and lobar location suggest that the etiology of these haemorrhages can be related to a subjacent amyloid angiopathy

[Atrial fibrillation and stroke]. / Ictus y fibrilación auricular.

BACKGROUND: Atrial fibrillation (AF) is a known risk factor for stroke. Furthermore, it has been suggested that the severity of the stroke is increased in these patients. We studied the clinical characteristics, radiologic findings, in-hospital outcome and prognosis of stroke in patients with AF. METHODS: All patients who were admitted due to an stroke in our Hospital since March 1, 1995 from May 15, 1997 have been analysed. They were divided in two groups, according to the presence or not of AF and we analysed: vascular risk factors, clinical characteristics, radiologic findings, in-hospital outcome and Barthel index and Canadian score on admission and at discharge. RESULTS: 747 patients were analysed, 205 (27.4%) with AF and 542 without it. The mean age was higher in patients with AF (p < 0.001). The ischemic stroke/cerebral hemorrhage ratio was higher in patients with AF than in those without it (OR: 3.91). We found in 3/4 of patients with AF, clinical data supporting the embolic etiology. In the AF group, Barthel index on admission and at discharge and Canadian score on admission were significantly lower. Patients with AF had more complications, a higher mortality rate, longer hospital stays and lower discharge rate to their own home. CONCLUSIONS: AF is independently related with a greater severity and worse outcome in patients suffering acute stroke. These findings emphasize the importance of stroke prevention in patients with AF.

Ictus y fibrilación auricular / Atrial fibrillation and stroke

Fundamentos: La fibrilación auricular es un factor de riesgo conocido para el ictus y se ha sugerido que además es un factor de mal pronóstico al aumentar la gravedad del ictus. En este trabajo se evalúan las características clínicas, radiológicas, evolución intrahospitalaria y pronóstico del ictus, cuando acontece en los pacientes con fibrilación auricular. Sujetos y métodos: Se han analizado de forma consecutiva todos los pacientes que ingresaron en nuestro centro debido a un ictus entre el 1 de marzo de 1995 y el 15 de mayo de 1997. Fueron divididos en dos grupos, según la presencia o no de fibrilación auricular y se analizaron: antecedentes, clínica, neuroimagen, evolución intrahospitalaria y escalas funcionales de Barthel y canadiense, al ingreso y al alta. Resultados: Se analizaron 747 pacientes, 205 (27,4 por ciento) con fibrilación auricular y 542 sin ésta. La edad media fue mayor en los pacientes con fibrilación auricular (p < 0,001). La proporción de ictus isquémicos respecto las hemorragias fue mayor en los pacientes con fibrilación auricular (odds ratio, 3,91). En tres de cada 4 pacientes con fibrilación auricular observamos datos consistentes que apoyaban la naturaleza embólica del ictus. En este grupo, los índices de Barthel al ingreso y al alta fueron significativamente inferiores, así como la escala canadiense al ingreso. Se registraron también un mayor número de complicaciones intrahospitalarias, índice de mortalidad y días de estancia media, y menor porcentaje de altas al propio domicilio. Conclusiones: De forma independiente, la fibrilación auricular confiere mayor severidad y peor pronóstico al ictus, lo que hace especialmente importante la prevención de los ictus en estos pacientes. (AU)

[Acute posterior cord lesions in multiple sclerosis. An MRI study of the clinical course in 20 cases]. / Lésions cordonales postérieures aiguës dans la sclérose en plaques.Etude clinico-évolutive et par IRM de 20 cas.

Twenty patients with multiple sclerosis (MS), 19 women and 1 man, with acute proprioceptive sensory disturbances related to the presence of plaques on the posterior columns (posterior column syndrome) at the cervical or thoracic levels of the spinal cord, were selected among 138 new patients with MS assisted in our neurological unit over the past five years. In 17 of these patients, the acute posterior cordonal syndrome was responsible for the first clinical manifestations of the disease. The other 3 patients had a history suggestive of MS. These 20 patients were followed with a minute analysis of neurological function with repeated clinical evaluation combined with repeated MRI study of the spinal cord. Brain MRI (strongly suggestive of MS in 15 patients), evoked potentials (EP) and cerebrospinal fluid electrophoresis analysis (with oligoclonal bands present in all patients were it was performed) were also obtained at least once in each patient. Spinal cord MRI demonstrated more lesions in the cervical region (90 p.100) than in the thoracic regions (10 p.100). Eighty percent of the cervical lesions were located high, between C1 and C4. The most characteristic clinical expression was the deafferentation of one upper limb, preferentially the "useless hand" (Oppenheim) or even a pseudoathetosic or dystonic limb. Propioceptive ataxia or spontaneous cervical or brachial pain were other forms of clinical expression. No major motor deficit or sphincter disorders were noted at any time in the clinical course in any of the patients. There was a good correlation between localization and morphology of the plaques detected by spinal cord MRI and clinical signs. Intrinsic medullary lesions were seen as high intensity signals on T2-weighted images which were enlarged more than the same lesion visualized on T1-weighted images after injection of paramagnetic contrast agents. This reflected the presence of edema extending beyond the main inflammatory lesion. There was also a good correlation between improvement of clinical symptoms and total or, mor frequently, partial reduction of the plaques, analyzed morphologically by successive spinal cord MRI series. The diagnosis of MS was clinically definitive in 60 p.100 of cases and laboratory-supported definitive in 40 p.100. During the follow-up period (average 36 months), 15 patients (75 p.100) presented one or more exacerbations, all of them presenting a favorable course: at last follow-up, 9 patients were asymptomatic, EDSS was 1 in 6 patients, 1.5 in 4 patients and 2 in 1 patient. This study confirms the contribution of serial spinal cord MR studies to understanding the natural history and pathophysiology of medullary forms of MS presenting as a cordonal posterior syndrome. It also shows a good relationship between the clinical manifestations and course of this form of MS and the localization and variable morphology of plaques. Finally, our results suggest the predictive benign course for this medullary form of MS that seems to be almost exclusively restricted to the female gender.

[Bilateral intra-axial involvement of the common oculomotor nerve (III): 2 cases]. / Atteinte bilatérale intra-axiale du nerf moteur oculaire commun (III): deux cas.

Bilateral palsy of the common ocular motornerve (III) was observed in two patients with an intra-axial lesion due ti hemorrhage in one and ischemia in the other. The lesions involved the cerebral peduncle in the periaqueductal region and the nuclear complex of the III in the first case. Bilateral infarct of the thalamus was seen in the second. Clinical manifestations were transitory except for the oculomotor impairment. In the first patient, oculomotricity was dissociated as intrinsic mortricity was spared. These exceptional cases demonstrate a syndrome with unique oculomotor expression resulting from intra-axial oculomotor lesions. Prognosis varies and is related to the ischemic or hemorrhagic nature of the causal lesion and its localization.

[Amyotrophic lateral sclerosis syndrome and hyperthyroidism. Cure with antithyroid drugs]. / Syndrome de sclérose latérale amyotrophique et hyperthyroïdie. Guérison sous antithyroïdiens.

We report the case of a 62-year old man presenting with generalized muscular weakness, amyotrophy, dysarthria and dysphagia. Neurological examination showed bilateral pyramidal signs and lingual fasciculations. The clinical diagnosis was amyotrophic lateral sclerosis, since only shivers and weight loss pointed to hyperthyroidism. However, after several months the patient developed typical manifestations of hyperthyroidism. After treatment of hyperthyroidism, the neurological symptoms disappeared. Although this association is extremely rare, one must have in mind the possibility of thyroid dysfunction when studying patients with amyotrophic lateral sclerosis.

[Neuropathy of the chin associated with neoplasms. Presentation of 5 cases and a review of the literature]. / Neuropatía mentoniana asociada a neoplasia. Presentación de cinco casos y revisión de la literatura.

Mental neuropathy is a paraneoplastic syndrome characterized by hypoesthesia or anesthesia in the area of mental nerve inervation. Its ethyology is not well known, and in some cases would be secondary to metastasis in the mandible, meningeal carcinomatosis or infiltration of the ganglion of Gasser. We report five new cases; three of them we have studied the presence of circulating antibodies against nervous tissue of ganglion of Gasser, and it was negative in all of them. Likewise we have reviewed the literature.