Validez pronóstica de las amplitudes de presión,tiempo en alcanzar la meseta y la pendiente obtenidas en el test de infusión para el estudio de la hidrocefalia idiopática de presión normal

Background and objectiveTo study the prognostic value of the resistance to the cerebrospinal fluid outflow (Rout) obtained in the lumbar infusion test in idiopathic normal pressure hydrocephalus (iNPH), as well as the pulse pressure amplitudes in the different periods of the test and other new variables extracted by Neuropicture® software.Material and methodsPatients with ?probable iNPH? who underwent a lumbar infusion test were retrospectively revised. The positive predictive values (PPV) of the cutoff point of the best prognostic accuracy of the Rout, the basal pulse pressure amplitude (AMP0), the pulse pressure amplitude during the first 10 minutes (AMP_10min), the plateau pulse pressure amplitude (AMPmes), the Rout pulse pressure amplitude (AMP_Rout), the time to reach the plateau (T), and the slope until reaching the plateau were determined. Patients were categorized either as responders or non-responders.ResultsThe study included 64 responders patients and 16 non-responders patients. The PPV of Rout > 15 mmHg/ml/min was 91.7%; AMP0 > 2.34 mmHg: 91.3%; AMP10min > 4.34 mmHg: 83.3%; AMPmes > 12.44 mmHg: 84.6%; AMP_Rout > 6.34 mmHg: 85%; T < 634 seconds: 86.7%; P > 0.040 mmHg/sec: 96.3%.ConclusionsRout is a valid criterion to indicate a ventricular shunt. Pulse pressure amplitudes in the different periods of the lumbar infusion test, in addition to T and P, are other variables whose positivity is indicative of shunt response and should be considered in the diagnostic protocol of the iNPH.     

Evaluación del estado nutricional en la enfermedad de Alzheimer y su influencia en la progresión tras el diagnóstico

IntroductionNutritional deficiencies are frequent in Alzheimer disease (AD), even in early stages. Nutritional impairment (NI) may be associated with faster disease progression. The objective of this study was to describe the frequency of NI and the associated risk factors at the time of diagnosis and to analyse its influence on subsequent progression.MethodsWe performed a prospective, multicentre, observational study of patients recently diagnosed with prodromal AD (pAD) or dementia due to AD (ADd). Two clinical assessments were conducted over a period of 18 months. The Mini Nutritional Assessment test (MNA; score range, 0-30; cut-off point for NI, < 24) was used to estimate nutritional status. Progression was defined as an increase of ≥ 3 points on the Clinical Dementia Rating-sum of boxes test.ResultsThe sample included 50 patients with pAD (mean [standard deviation] age, 76.1 [5.3] years; 68% women), and 127 with ADd (80 [5.9] years; 72.4% women). A total of 141 (79.7%) completed both evaluations. The prevalence of NI was 28.2% (24% for pAD, 29.9% for ADd; P = .43), with the majority (92%) at risk of malnutrition. NI was associated with female sex (odds ratio [OR]: 4.2; 95% confidence interval [CI]: 1.7-10.5; P < .001) and greater behavioural involvement (OR: 5.8; 95% CI: 2.6-12.7; P < .001). A larger proportion of patients with progression was observed among those with NI than among those with normal nutritional status (50% vs 28.7%, P < .05; ADd: 53.6% vs 31.8%, P < .05; pAD: 41.7% vs 22.9%, P = .21). Greater cognitive impairment (OR: 2.1; 95% CI: 1.03-4.4; P < .05) and NI (OR: 2.4; 95% CI: 1.1-5.1; P < .05) were independent risk factors for disease progression.ConclusionsNI is highly prevalent in patients with AD. Assessing nutritional status at the time of diagnosis may enable identification of patients at greater risk of disease progression.     

La alteración de la mielina en la enfermedad de Alexander

Introduction

Alexander disease (AxD) is a type of leukodystrophy. Its pathological basis, along with myelin loss, is the appearance of Rosenthal bodies, which are cytoplasmic inclusions in astrocytes. Mutations in the gene coding for GFAP have been identified as a genetic basis for AxD. However, the mechanism by which these variants produce the disease is not understood.

Variabilidad en la exploración motora de la enfermedad de Parkinson entre el neurólogo experto en trastornos del movimiento y la enfermera especializada

Introduction and objectiveIn clinical practice, assessing patients with Parkinson's disease (PD) is a complex, time-consuming task. Our purpose is to provide a rigorous and objective evaluation of how motor function in PD patients is assessed by neurologists specialising in movement disorders, on the one hand, and by nurses specialising in PD management, on the other.MethodsWe conducted an observational, cross-sectional, single-centre study of 50 patients with PD (52% men; mean age: 64.7  ±  8.7 years) who were assessed between 5 January 2016 and 20 July 2016. A neurologist and a nurse evaluated motor function in the early morning hours using the Unified Parkinson's Disease Rating Scale (UPDRS) parts III and IV and Hoehn & Yahr (H&Y) scale. Tests were administered in the same PD periods (in 48 patients during the ‘off’ time and in 2 patients during the ‘on’ time). Inter-rater variability was estimated with the intraclass correlation coefficient (ICC).ResultsForty-nine patients (98%) were classified in the same H&Y stage by both raters. Assessment times were similar for both raters. ICC for UPDRS-IV and UPDRS-III total scores were 0.955 (P<.0001) and 0.954 (P<.0001), respectively. The greatest variability was found for UPDRS-III item 29 (gait; ICC = 0.746; P<.0001) and the lowest, for item 30 (postural stability; ICC = 0.918; P<.0001).ConclusionsMotor function assessment of PD patients by a trained nurse is equivalent to that made by an expert neurologist and takes the same time to complete.     

Evaluación de la incidencia y tendencia de la enfermedad cerebrovascular en la región sanitaria de Lleida (España) en el periodo 2010-2014

ObjectivesThis study aimed to determine the incidence and trends of cerebrovascular disease (CVD) in the healthcare district of Lleida.Material and methodsWe performed a population-based prospective cohort study including the entire population of the healthcare district of Lleida (440 000 people). Information was gathered from the minimum basic data set from the emergency department and hospital discharges for the period from January 2010 to December 2014. All types of stroke were included. We evaluated crude and age-standardised rates using the world population as a reference. Patients without neuroimaging confirmation of the diagnosis were excluded.ResultsWe identified 4397 patients: 1617 (36.8%) were aged 80 years or over; 3969 (90.3%) presented ischaemic stroke, and 1741 (39.6%) were women. The crude incidence rate ranged from 192 (95% confidence interval [CI], 179-205) to 211 (95% CI, 197-224) cases per 100 000 population, in 2012 and 2013, respectively. Age-standardised rates ranged from 93 (95% CI, 86-100) to 104 (95% CI, 96-111) cases per 100 000 population, in 2012 and 2013, respectively. For all years, incidence rates increased with age, and were significantly higher among men than among women.ConclusionThe impact of CVD in Lleida is comparable to that observed in other European regions. However, population ageing induces a high crude incidence rate, which remained stable over the five-year study period.     

Rehabilitación de la cognición social en el traumatismo craneoencefálico: una revisión sistemática

IntroductionMany studies have described the presence of difficulty processing and generating social behaviour in patients who have suffered a traumatic brain injury (TBI). These difficulties in social cognition (SC) deteriorate personal relationships in the family, at work, or in the community. However, therapeutic programmes aiming to improve SC continue to be an outstanding issue in clinical practice. We performed a systematic review of the existing literature on the recovery of SC in patients with TBI, assessing the methodological quality of the included studies and the therapeutic effectiveness of the rehabilitation strategies used.DevelopmentWe performed a bibliographic search of papers published before June 2018 in the Medline/PubMed, Google Scholar, PsycINFO, and ClinicalTrials.gov databases. Of the 198 potentially relevant articles, 10 met our eligibility criteria. Two of the authors independently and blindly assessed the methodological quality of these studies using the PEDro scale.ConclusionsThe articles included in this systematic review essentially studied the effect of different interventions aimed at the rehabilitation of SC in patients with chronic TBIs. The analysis showed adequate methodological quality and an acceptable level of evidence. Future research should analyse the effect of these interventions in patients with TBIs in the sub- and post-acute phases.     

Papel de la estimulación del nervio vago en el tratamiento de la epilepsia refractaria. Resultados clínicos e impacto en la calidad de vida

BackgroundVagus nerve stimulation (VNS) is used as a complementary therapy to pharmacological treatment in patients with refractory epilepsy. This study aims to evaluate the efficacy of VNS in reducing seizure frequency, severity, and duration; reducing the number of antiepileptic drugs administered; and improving patients’ quality of life.Material and methodsWe analysed the clinical progression of 70 patients with refractory epilepsy treated with VNS at Hospital Universitario de Alicante and Hospital Clínico de Valencia. Data were collected before and after the procedure. The difference in seizure frequency pre- and post-VNS was classified using the McHugh scale. Data were also collected on seizure duration and severity, the number of drugs administered, and quality of life.ResultsAccording to the McHugh classification, 12.86% of the patients were Class I, 44.29% were Class II, 40% were Class III, and the remaining 2.86% of patients were Class IV-V. A ≥ 50% reduction in seizure frequency was observed in 57.15% of patients. Improvements were observed in seizure duration in 88% of patients and in seizure severity in 68%; the number of drugs administered was reduced in 66% of patients, and 93% reported better quality of life.ConclusionsVNS is effective for reducing seizure frequency, duration, and severity and the number of antiepileptic drugs administered. It also enables an improvement in patients’ quality of life.     

Papel de la microbiota intestinal en el desarrollo de diferentes enfermedades neurológicas

IntroductionIn recent years, the scientific evidence supporting a relationship between the microbiota and various diseases has increased significantly; this trend has also been observed for neurological diseases. This has given rise to the concept of the gut-brain axis and the idea of a relationship between the gut microbiota and several neurological diseases whose aetiopathogenesis is yet to be clearly defined.DevelopmentWe review the role of the gut microbiota in the gut-brain axis and analyse those neurological diseases in which alterations in the gut microbiota have been described as a result of human studies: specifically, Parkinson's disease, Alzheimer disease, amyotrophic lateral sclerosis, neuromyelitis optica, and multiple sclerosis.ConclusionsThe body of evidence linking the gut microbiota to various neurological diseases has grown considerably. Several interesting studies show a relationship between the gut microbiota and Parkinson's disease, Alzheimer disease, neuromyelitis optica, and multiple sclerosis, whereas other controversial studies implicate it in amyotrophic lateral sclerosis. Many of these studies place considerable emphasis on modulation of inflammation, particularly by bacteria capable of producing short-chain fatty acids.Despite these encouraging results, many questions remain, and there is a need to demonstrate causality, determine the role of fungi or viruses, and research possible treatment through diet, probiotics, or faecal microbiota transplantation.     

Epilepsia y gestación. Factores asociados con la presencia de crisis en la gestación

IntroductionThe management of epilepsy during pregnancy requires optimal seizure control, avoiding the potential teratogenic effects of antiepileptic drugs.ObjectivesThis study aims to describe the clinical characteristics and perinatal outcomes of pregnant patients with epilepsy; to analyse the factors associated with seizures during pregnancy; to describe the most commonly used antiepileptic drugs in these patients; and to analyse changes in treatment regimens in 2 periods, 2000-2010 and 2011-2018.MethodsWe conducted a prospective observational study of patients with epilepsy who reported their pregnancy between 2000 and 2018. Patients were evaluated in the first and second trimesters of pregnancy, after delivery, and at one year. Data were collected on demographic variables, epilepsy, and perinatal and obstetric variables.ResultsA total of 101 pregnancies were included. Patients’ mean age was 32.6 years; 55.4% had focal epilepsy, 38.6% had generalised epilepsy, and 5.9% had undetermined epilepsy. We recorded 90 live births, 9 miscarriages, and 5 cases of congenital malformations, 4 of which were born to women who received valproate monotherapy. Forty patients (39.6%) presented seizures, with 16 (40%) presenting generalised tonic-clonic seizures. The variables associated with seizures during pregnancy were poor seizure control in the year prior to pregnancy (66.7% vs. 15.1%; P < .001), treatment with 2 or more antiepileptic drugs (30% vs. 14.8%; P < .001), and untreated epilepsy (25% vs. 0%; P < .001). The antiepileptic drugs most widely used in monotherapy were lamotrigine (n = 19; 27.1%), valproate (n = 17; 24.2%), and levetiracetam (n = 12; 17.1%). In the most recent period (2011-2018), we observed a greater proportion patients receiving monotherapy (81.5%, vs. 55.3%), as well as a decrease in the use of carbamazepine (2.3%, vs. 23.1%) and valproate (20.5%, vs. 30.8%); and a marked increase in the use of levetiracetam (27.3%, vs. 0%).ConclusionsThe factors associated with the presence of seizures during pregnancy were previous poor seizure control, treatment with 2 or more antiepileptic drugs, and lack of treatment during pregnancy. The most commonly used drugs were lamotrigine, valproate, and levetiracetam, with an increase in levetiracetam use and a decrease in valproate use being observed in the later period (2011-2018).     

Uso de la polipíldora cardiovascular en la prevención secundaria de la enfermedad cerebrovascular

IntroductionThere is little control of cardiovascular (CV) risk factors in secondary prevention after an ischaemic stroke, in part due to a lack of adherence to treatment. The CV polypill may contribute to proper treatment adherence, which is necessary for CV disease prevention. This study aimed to establish how and in what cases the CV polypill should be administered.MethodsA group of 8 neurologists drafted consensus recommendations using structured brainstorming and based on their experience and a literature review.ResultsThese recommendations are based on the opinion of the participating experts. The use of the CV polypill is beneficial for patients, healthcare professionals, and the health system. Its use is most appropriate for atherothrombotic stroke, lacunar stroke, stroke associated with cognitive impairment, cryptogenic stroke with CV risk factors, and silent cerebrovascular disease. It is the preferred treatment in cases of suspected poor adherence, polymedicated patients, elderly people, patients with polyvascular disease or severe atherothrombosis, young patients in active work, and patients who express a preference for the CV polypill. Administration options include switching from individual drugs to the CV polypill, starting treatment with the CV polypill in the acute phase in particular cases, use in patients receiving another statin or an angiotensin ii receptor antagonist, or de novo use if there is suspicion of poor adherence. Nevertheless, use of the CV polypill requires follow-up on the achievement of the therapeutic objectives to make dose adjustments.ConclusionsThis document is the first to establish recommendations for the use of the CV polypill in cerebrovascular disease, beyond its advantages in terms of treatment adherence.     

Ausencia de conflicto neurovascular durante la microdescompresión vascular en el manejo de la neuralgia trigeminal esencial: ¿qué hacer? Revisión sistemática de la literatura

Introduction

Neurovascular conflict is the most accepted hypothesis for the cause for trigeminal neuralgia. Microvascular decompression of the trigeminal nerve is the most common surgical treatment for these patients. However, despite advances in diagnostic techniques, neurovascular conflict is sometimes not detected during surgery. The aim of this paper is to systematically review all the options available to best manage this scenario.

Evidencias actuales sobre la estimulación magnética transcraneal y su utilidad potencial en la neurorrehabilitación postictus: Ampliando horizontes en el tratamiento de la enfermedad cerebrovascular

Introduction

Repetitive transcranial magnetic stimulation (rTMS) is a therapeutic reality in post-stroke rehabilitation. It has a neuroprotective effect on the modulation of neuroplasticity, improving the brain's capacity to retrain neural circuits and promoting restoration and acquisition of new compensatory skills.

Influencia de la estimulación cerebral profunda en la carga de cuidadores de pacientes con enfermedad de Parkinson

Introduction

Our aim is to assess the burden on caregivers of patients with Parkinson's disease treated with deep brain stimulation (DBS) compared to those caring for patients at advanced stages and undergoing other treatments. We have also assessed the variables associated with presence of caregiver overload.

¿Existen diferencias en el manejo neuroquirúrgico de las lesiones intracraneales en la paciente gestante? Resultados de nuestra experiencia y revisión de la literatura

ObjectiveThe main objective of our work is to revise our neurosurgical experience in pregnant patient and to carry out a revision of the related literature in order to optimize the neurosurgical handling of these kind of patients.MethodRetrospective study between august 1993 and June 2010. We included patients who were pregnant at the time and who presented any trace of cranial neurosurgical or spinal disease.ResultsThe research includes the cases of 12 patients aged between 17 and 37 years old with an average age of 28.8 years old. The average gestation period was of 24.17 weeks, finding 50% of the patients within their third three-month period of pregnancy at the moment of diagnosis, 25% in their second three-month period and the remaining 25% in their first three-month period. The mean follow-up duration for this series was 84 months. 4 of them presented brain vascular lesions, 5 presented brain tumor lesions, 1 of them presented Chiari malformation, one lumbar disc herniation and 1 patient suffered from traumatic intracraneal hemorrhage. 8 of the 12 patients were subjected to neurosurgical procedures under general anesthetic, 2 for aneurysm embolizations and 2 for conservative treatments. Between the neurosurgical procedures 6 craniotomies were done, of wich 4 were to resection of the tumor and 2 for aneurysm clippings. There were done a transesfenoidal approach and a lumbar microdiscectomy. 2 of the 6 patients given craniotomies required external ventricular drainage before the operation. 5 elective cesareans were done in the group of patients given the craniotomies whilst of the rest the pregnancy was allowed to bring to term for reasons of pulmonary maturity. In our patients there were no cases of therapeutic abortion. There was found no morbidity no mortality neither in the mother nor in the fetus related to surgery.ConclusionsIn our experience with pregnant patients who suffered from neurosurgical lesion and in the experience we got from the revision of the related literature, the surgery of intracranial lesions is well tolerated by the mothers and the fetus. It must though be considered, the possibility of labor through cesarean depending on the fetus’ lung maturity.