[Study of the prognostic implications in patients with a transient ischaemic attack before the implementation of an agreed process of treatment in the health region of Lleida]. / Estudio de las implicaciones pronósticas del paciente con ataque isquémico transitorio antes de la implantación de un proceso consensuado de tratamiento en la región sanitaria de Lleida.

AIM: The transient ischemic attack (TIA) is a medical emergency because of their high risk of early recurrence. We study the evolution and management of patients with a TIA in our hospital before establishing a process management and treatment of this condition. PATIENTS AND METHODS: We included 180 consecutive patients with suspected TIA attended in the emergency department of our hospital between January 2006 and March 2007. We collected clinical variables (risk factors, age, clinical symptoms, duration, ABCD2). Cases were reviewed by two neurologists to establish the correlation with the diagnosis. We established the risk of cerebral infarction after one year follow-up. RESULTS: 31% of patients were discharged home. There were differences between the two groups regarding age (82.9 Y 7.5 vs 70.53 Y 10.7 years); ABCD2 scale score (1.5 Y 5.32 vs 4.44 Y 1.37); and atrial fibrillation (27.5% vs 8.6%). There was much greater delay and lack of complementary explorations. During follow-up, 23% of patients not hospitalized had recurrent stroke versus 6.7% of hospitalized patients. Despite the fact that only age more than 80 years was identified as predictor of stroke recurrence (hazard ratio = 8,72; 95% CI = 2.4-31.74; p = 0.001) in regression multivariate model, the Kaplan-Meier model showed a higher risk of stroke recurrence among not admitted patients (p = 0.012). CONCLUSION: In our area, the management of TIA patients in the emergency room had high impact on the evolution of these patients. A process management should be performed in order to achieve improvement in clinical praxis.

Estudio de las implicaciones pronósticas del paciente con ataque isquémico transitorio antes de la implantación de un proceso consensuado de tratamiento en la región sanitaria de Lleida / Study of the prognostic implications in patients with a transient ischaemic attack before the implementation of an agreed process of treatment in the health region of Lleida

Objetivo. Conocer la realidad del manejo y evolución de los pacientes con un ataque isquémico transitorio (AIT) en nuestro centro antes de instaurar un proceso de tratamiento de esta patología. Pacientes y métodos. Estudiamos a 180 pacientes consecutivos que acudieron a urgencias de nuestro centro (entre enero de 2006 y marzo de 2007). Los casos fueron revisados por dos neurólogos para establecer la concordancia con el diagnóstico. Se estableció el riesgo de infarto cerebral tras un seguimiento de un año. Resultados. Hubo discordancia en el diagnóstico de AIT en 40 casos. Un 31% de los pacientes fue dado de alta a su domicilio desde urgencias. Al comparar éstos con los que ingresaron en el servicio de neurología, se observan diferencias en la edad (82,9 ± 7,5 frente a 70,53 ± 10,7 años), puntuación en la escala ABCD2 (5,32 ± 1,5 frente a 4,44 ± 1,37) y fibrilación auricular (27,5% frente a 8,6%). Asimismo, el tiempo para realizar el estudio etiológico fue mucho mayor y el número de exploraciones complementarias mucho menor. Al cabo de un año, el 23% de estos pacientes sufrió un infarto cerebral, por sólo el 6,7% de los hospitalizados en planta en neurología. Pese a que sólo la edad superior a 80 años se comportó como único predictor de recurrencia (razón de riesgo = 8,72; intervalo de confianza al 95% = 2,4-31,74; p = 0,001), el modelo de Kaplan-Meier demuestra la peor evolución del paciente no ingresado (p = 0,012). Conclusión. En nuestra zona, el alta domiciliaria desde urgencias tiene repercusión sobre el peor estudio etiológico y la evolución del enfermo. Se debe establecer un proceso de manejo del AIT consensuado para asegurar el diagnóstico y tratamiento adecuados (AU)

Aim. The transient ischemic attack (TIA) is a medical emergency because of their high risk of early recurrence. We study the evolution and management of patients with a TIA in our hospital before establishing a process management and treatment of this condition. Patients and methods. We included 180 consecutive patients with suspected TIA attended in the emergency department of our hospital between January 2006 and March 2007. We collected clinical variables (risk factors, age, clinical symptoms, duration, ABCD2). Cases were reviewed by two neurologists to establish the correlation with the diagnosis. We established the risk of cerebral infarction after one year follow-up. Results. 31% of patients were discharged home. There were differences between the two groups regarding age (82.9 ± 7.5 vs 70.53 ± 10.7 years); ABCD2 scale score (1.5 ± 5.32 vs 4.44 ± 1.37); and atrial fibrillation (27.5% vs 8.6%). There was much greater delay and lack of complementary explorations. During follow-up, 23% of patients not hospitalized had recurrent stroke versus 6.7% of hospitalized patients. Despite the fact that only age more than 80 years was identified as predictor of stroke recurrence (hazard ratio = 8,72; 95% CI = 2.4-31.74; p = 0.001) in regression multivariate model, the Kaplan-Meier model showed a higher risk of stroke recurrence among not admitted patients (p = 0.012). Conclusion. In our area, the management of TIA patients in the emergency room had high impact on the evolution of these patients. A process management should be performed in order to achieve improvement in clinical praxis (AU)

[The extent of knowledge about strokes among the population of a rural area in the province of Lleida]. / Grado de conocimiento del ictus entre poblacion de area rural en la provincia de Lleida.

INTRODUCTION: Although stroke continues to be a significant cause of morbidity and mortality, the knowledge of warning signs and risk factors among general population is still insufficient. AIM: To assess the current knowledge of stroke (terminology, signs and symptoms, risk factors and attitude) among rural population of Baix Segria in Lleida in order to the best target and message, prior to educational campaigns. SUBJECTS AND METHODS: A structured interview using closeended questions was conducted among 153 users of Primary Health Centers. RESULTS: In our cohort, 6.5% ignored the disease, while 48 (31,4%) had good knowledge of risk factors (more than three risk factors) and 62 (40,5%) identified more than three warnings signs correctly. Only 31,1% would correctly act if stroke occurred. Transient ischemic attack was not considered as emergency. Most participants, 78,5%, would contact to primary care. Surprisingly, knowledge of stroke symptoms and risk factors was not associated with an increased chance of calling 061 or going to the hospital. Older respondents were less likely to recognize symptoms and to consider stroke as an emergency, while the university education was associated with good knowledge and actuation. CONCLUSION: The level of knowledge of established stroke risk factors, warning signs, and treatment in rural population of Lleida is low. Our data suggested not only that a community-based education program to increase public knowledge of stroke among rural population is necessary, but also we need to inform the people stroke is treatable.

Grado de conocimiento del ictus entre población de área rural en la provincia de Lleida / The extent of knowledge about strokes among the population of a rural area inthe province of lleida

Introducción. Pese a que el ictus es la principal causa de discapacidad y una de las principales causas de muerte, el conocimiento de sus síntomas, sus causas y de la existencia del tratamiento fibrinolítico es escaso en la población general. Objetivo. Establecer el grado de conocimiento del ictus (terminología, factores de riesgo, síntomas y actitud) en el área rural de Lleida (Baix Segrià). Sujetos y métodos. Estudio de población mediante cuestionario cerrado realizado de forma aleatoria en tres centros de salud sobre un total de 153 sujetos. Resultados. Un 6,5% desconoce completamente la enfermedad. El término ‘ictus’ sólo lo reconoce el 26,7%, y el término ‘embolia’, el 86,9%. Veinte personas reconocen más de siete términos. Hay un buen conocimiento de los factores de riesgo (más de cuatro factores de riesgo y menos de dos distractores) en sólo 25 (16,3%) encuestados. El síntoma más reconocido es la alteración del habla (70,6%). El conocimiento de los síntomas es óptimo (más de cuatro síntomas y menos de dos distractores) en 32 (20,9%). El 68%, en caso de ictus, avisaría primero al médico de cabecera. Si se tratase de un ataque isquémico transitorio, el 84,5% acudiría primero al médico de cabecera; de ellos, el 27% no de forma urgente. Los encuestados con estudios universitarios son los que mejor conocen los factores de riesgo y los síntomas, y los que mejor actúan frente a un ictus (p < 0,05). Los mayores de 65 años son los que peor conocimiento tienen de la enfermedad. Conclusión. El conocimiento de la enfermedad es insatisfactorio en el área rural de Lleida. Son necesarias campañas de información a la población general para mejorar la implantación del Código Ictus en esta zona (AU)

Introduction. Although stroke continues to be a significant cause of morbidity and mortality, the knowledge of warning signs and risk factors among general population is still insufficient. Aim. To assess the current knowledge of stroke (terminology, signs and symptoms, risk factors and attitude) among rural population of Baix Segrià in Lleida in order to the best target and message, prior to educational campaigns. Subjects and methods. A structured interview using closeended questions was conducted among 153 users of Primary Health Centers. Results. In our cohort, 6.5% ignored the disease, while 48 (31,4%) had good knowledge of risk factors (more than three risk factors) and 62 (40,5%) identified more than three warnings signs correctly. Only 31,1% would correctly act if stroke occurred. Transient ischemic attack was not considered as emergency. Most participants, 78,5%, would contact to primary care. Surprisingly, knowledge of stroke symptoms and risk factors was not associated with an increased chance of calling 061 or going to the hospital. Older respondents were less likely o recognize symptoms and to consider stroke as an emergency, while the university education was associated with good knowledge and actuation. Conclusion. The level of knowledge of established stroke risk factors, warning signs, and treatment in rural population of Lleida is low. Our data suggested not only that a community-based education program to increase public knowledge of stroke among rural population is necessary, but also we need to inform the people stroke is treatable (AU)

Infartos cerebrales bihemisféricos agudos secundarios a aterosclerosis de grandes vasos / Bihemispheric acute stroke associated with large-artery atherosclerosis

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[Pseudo-ulnar palsy secondary to ischemic cerebral infarction]. / Parálisis seudocubital secundaria a un infarto isquémico cerebral.

INTRODUCTION: Paralysis of the fingers secondary to injury to the central nervous system or peripheral pseudoparalysis is an infrequent pathological condition. The most common form is the one affecting the ulnar area, although it has also been reported as affecting the radial area or even the index finger. CASE REPORT: We report a case of right-side pseudoparalysis of the ulnar with the fourth and fifth fingers in a bending posture in a 61-year-old male with risk factors for atherothrombosis. The definitive diagnosis was obtained by magnetic resonance (MR) imaging of the head, which revealed frontal cortical infarction on the left side. CONCLUSIONS: The paper includes a discussion on the affected anatomical regions that can trigger this condition, the most important of which is a specific segment of the precentral gyrus with a characteristic shape, that is, either an inverted omega or, less often, an epsilon shape lying horizontal in the axial plane. The literature, however, also includes reports of functional MR imaging or intracortical microstimulation being used to show models of spatial overlay in the cortical motor area of the hand. From a more clinical point of view, it becomes clear that the central nervous system must be evaluated for a stroke or even some other pathology as the causation of an isolated paresis of the fingers, especially if no sensory disorder exists.

Parálisis seudocubital secundaria a un infarto isquémico cerebral / Pseudo-ulnar palsy secondary to ischemic cerebral infarction

Introducción. La paresia de dedos de la mano secundaria a lesiones del sistema nervioso central o seudoparálisis periférica es una patología poco frecuente. La más común es la que afecta al área cubital, aunque también se ha descrito afectando al área radial o incluso al dedo índice. Caso clínico. Se comunica un caso de seudoparálisis cubital derecha con una postura en flexión del cuarto y quinto dedo en un varón de 61 años con factores de riesgo aterotrombótico. El diagnóstico definitivo se obtuvo a través de una resonancia magnética (RM) craneal que mostró un infarto cortical frontal izquierdo. Conclusiones. Se discuten las zonas anatómicas afectadas que pueden provocar esta clínica, y destaca como más importante un segmento específico de la circunvolución precentral, con una forma característica: omega invertida o, menos frecuente, épsilon horizontal en el plano axial. Sin embargo, en la literatura también se han demostrado modelos de superposición espacial del área motora cortical de la mano a través de imágenes de RM funcional o microestimulación intracortical. En el aspecto más clínico se pone de manifiesto la necesidad de valorar al sistema nervioso central en forma de ictus o incluso de otra patología como etiología de una paresia aislada de dedos de la mano, sobre todo si carece de afectación sensitiva (AU)

Introduction. Paralysis of the fingers secondary to injury to the central nervous system or peripheral pseudoparalysis is an infrequent pathological condition. The most common form is the one affecting the ulnar area, although it has also been reported as affecting the radial area or even the index finger. Case report. We report a case of right-side pseudoparalysis of the ulnar with the fourth and fifth fingers in a bending posture in a 61-year-old male with risk factors for atherothrombosis. The definitive diagnosis was obtained by magnetic resonance (MR) imaging of the head, which revealed frontal cortical infarction on the left side. Conclusions. The paper includes a discussion on the affected anatomical regions that can trigger this condition, the most important of which is a specific segment of the precentral gyrus with a characteristic shape, that is, either an inverted omega or, less often, an epsilon shape lying horizontal in the axial plane. The literature, however, also includes reports of functional MR imaging or intracortical microstimulation being used to show models of spatial overlay in the cortical motor area of the hand. From a more clinical point of view, it becomes clear that the central nervous system must be evaluated for a stroke or even some other pathology as the causation of an isolated paresis of the fingers, especially if no sensory disorder exists (AU)

[Cerebral venous thrombosis associated to subacute De Quervain's thyroiditis in a carrier for the G20210A mutation of the prothrombin gene]. / Trombosis venosa cerebral asociada a tiroiditis subaguda de De Quervain en una paciente con la mutación G20210A del gen de la protrombina.

INTRODUCTION: Recently, thyrotoxicosis has been described as a risk factor for cerebral venous thrombosis (CVT) in some reported cases. We present a case of CVT associated to a subacute De Quervain's thyroiditis in a young female who was an heterozygous carrier for the G20210A mutation of the prothrombin gene. CASE REPORT: A 42-year-old female with irrelevant past medical history developed a thrombosis of the superior sagital and right transverse sinus in the initial phase of a subacute thyroiditis. Diagnosis was made by thyroid radioactive iodine uptake, and cerebral computerized tomography scan, magnetic resonance imaging, and magnetic resonance angiography. Treatment with aspirin and corticosteroids was started until thyroid function was normalized. When CVT diagnosis was made, the patient was treated with anticoagulation. Two months later, magnetic resonance imaging showed resolution of the CVT. The patient was diagnosed as an heterozygous carrier for the G20210A mutation of the prothrombin gene by genetic studies. CONCLUSIONS: Subacute thyroiditis might act as a risk factor for CVT, increasing the thrombotic risk in the presence of other acquired or hereditary prothrombotic factors, such as the G20210A mutation of the prothrombin gene in our patient.

Trombosis venosa cerebral asociada a tiroiditis subaguda de De Quervain en una paciente con la mutación G20210A del gen de la protrombina / Cerebral venous thrombosis associated to subacute De Quervain's thyroiditis in a carrier for the g20210a mutation of the prothrombin gene

Introducción. Recientemente se ha descrito la tirotoxicosis como factor desencadenante de trombosis venosa cerebral (TVC) en diversos casos aislados. Se describe un caso de TVC asociada a tiroiditis subaguda de De Quervain en una mujer heterocigota para la mutación G20210A del gen de la protrombina. Caso clínico. Mujer de 42 años, sin antecedentes personales de interés, que durante la fase inicial de una tiroiditis subaguda desarrolló una trombosis del seno longitudinal superior y el seno transverso derecho. El diagnóstico por imagen se hizo mediante gammagrafía tiroidea, así como tomografía axial computarizada, resonancia magnética y angiorresonancia cerebral. Se inició el tratamiento con ácido acetilsalicílico y posteriormente esteroides orales, hasta normalizarse la función tiroidea. Una vez diagnosticada la TVC se instauró un tratamiento anticoagulante, con resolución de la TVC por resonancia magnética a los dos meses. El estudio genético demostró que era heterocigota para la mutación G20210A del gen de la protrombina. Conclusiones. La tiroiditis subaguda podría actuar como factor desencadenante de TVC, y aumentar el riesgo de TVC cuando se asocia a otros factores protrombóticos adquiridos o hereditarios, como, en nuestro caso, la mutación G20210A del gen de la protrombina (AU)

Introduction. Recently, thyrotoxicosis has been described as a risk factor for cerebral venous thrombosis (CVT) in some reported cases. We present a case of CVT associated to a subacute De Quervain’s thyroiditis in a young female who was an heterozygous carrier for the G20210A mutation of the prothrombin gene. Case report. A 42-year-old female with irrelevant past medical history developed a thrombosis of the superior sagital and right transverse sinus in the initial phase of a subacute thyroiditis. Diagnosis was made by thyroid radioactive iodine uptake, and cerebral computerized tomography scan, magnetic resonance imaging, and magnetic resonance angiography. Treatment with aspirin and corticosteroids was started until thyroid function was normalized. When CVT diagnosis was made, the patient was treated with anticoagulation. Two months later, magnetic resonance imaging showed resolution of the CVT. The patient was diagnosed as an heterozygous carrier for the G20210A mutation of the prothrombin gene by genetic studies. Conclusions. Subacute thyroiditis might act as a risk factor for CVT, increasing the thrombotic risk in the presence of other acquired or hereditary prothrombotic factors, such as the G20210A mutation of the prothrombin gene in our patient (AU)