Resultados quirúrgicos a largo plazo en pacientes con epilepsia fármaco-resistente del lóbulo temporal sin anormalidades histológicas

Introduction

Reports on surgical outcomes in patients with drug-resistant temporal lobe epilepsy without histological abnormalities are scarce.

Methods

Retrospective review of data from patients with drug-resistant temporal lobe epilepsy and no histopathological alterations who underwent anterior mesial temporal lobectomy. We analysed the following variables: age, sex, age at seizure onset, age at surgery, time elapsed between diagnosis and the date of the surgery, follow-up time, and classification according to the Engel rating scale.

Results

From a database of 256 temporal lobectomies, 21 were identified as meeting the inclusion criteria. The average age upon diagnosis of epilepsy was 8.3 years and average age at time of surgery was 28.6 years. The mean time elapsed between diagnosis and surgery was 20.2 years. After a mean follow-up of 6.5 years, 90.5% of the patients showed favourable outcomes (classes i and ii) and 42.9% were seizure-free (class IA). Comparative analysis of the variables revealed that average age at seizure onset was the only statistically significant difference between groups, with age at onset being lower in patients with favourable outcomes.

Conclusion

Although long-term surgical outcomes were favourable for a large majority of patients, the percentage of seizure-free patients is lower than in patients with lesional epilepsy and comparable to that previously reported in the literature.     

Estudio cuantitativo del flujo de líquido cefalorraquídeo mediante resonancia magnética en contraste de fase: método para identificar a los pacientes con hidrocefalia a presión normal

Objectives

The aim of this study is to evaluate the use of phase-contrast MR imaging to diagnose normal pressure hydrocephalus (NPH) and differentiate it from other neurological disorders with similar clinical symptoms.

Methods

The study included 108 subjects, of whom 61 were healthy controls and 47, patients; in the patient group, 19 had cerebrovascular disease (CVD) and 28 had NPH. All patients underwent a phase-contrast MRI study and several CSF flow and velocity parameters were measured at the aqueduct of Sylvius. Discriminant analyses were performed to evaluate the classification capacity of both individual parameters and the combination of different parameters.

Results

Maximum diastolic velocity, mean flow, and stroke volume showed statistically significant differences that could be used to distinguish between NPH and CVD patients (P<.001). Stroke volume and mean flow showed no false positive results and successful classification rates of 86% and 79%, respectively. No other parameters or combination produced better results.

Conclusions

Phase-contrast MR imaging is a useful tool for the early diagnosis of patients with NPH. CSF flow quantitative parameters, along with morphological features in a conventional MR study, enable us to differentiate between NPH and CVD patients.     

Análisis morfológico de la región del hipocampo asociado a una tarea conductual innata en el modelo de ratón transgénico (3xTg-AD) para la enfermedad de Alzheimer

Introduction

Different animal models for Alzheimer disease (AD) have been designed to support the hypothesis that the neurodegeneration (loss of neurons and synapses with reactive gliosis) associated with Aβ and tau deposition in these models is similar to that in the human brain. These alterations produce functional changes beginning with decreased ability to carry out daily and social life activities, memory loss, and neuropsychiatric disorders in general. Neuronal alteration plays an important role in early stages of the disease, especially in the CA1 area of hippocampus in both human and animal models.

Methods

Two groups (WT and 3xTg-AD) of 11-month-old female mice were used in a behavioural analysis (nest building) and a morphometric analysis of the CA1 region of the dorsal hippocampus.

Results

The 3xTg-AD mice showed a 50% reduction in nest quality associated with a significant increase in damaged neurons in the CA1 hippocampal area (26% ± 6%, P < .05) compared to the WT group.

Conclusions

The decreased ability to carry out activities of daily living (humans) or nest building (3xTg-AD mice) is related to the neuronal alterations observed in AD. These alterations are controlled by the hippocampus. Post-mortem analyses of the human hippocampus, and the CA1 region in 3xTg-AD mice, show that these areas are associated with alterations in the deposition of Aβ and tau proteins, which start accumulating in the early stages of AD.     

Manejo terapéutico con rivastigmina en pacientes con enfermedad de Alzheimer de leve a moderadamente grave en condiciones de práctica clínica habitual. Estudio ENTERPRISE

Introduction

Alzheimer disease (AD) causes progressive cognitive decline leading to loss of independence for activities of daily living; rivastigmine is one of the drugs used for symptomatic management.

Objective

To assess the therapeutic use of different pharmaceutical forms of rivastigmine in patients with AD in normal clinical practice.

Patients and methods

Cross-sectional, observational, multi-centre study conducted on patients with mild to moderate AD treated with rivastigmine in Spanish outpatient clinics specialising in Geriatrics, Psychiatry, and Neurology. Data regarding use of oral (OR) and transdermal (TDR) rivastigmine, compliance (degree of adherence), and caregiver satisfaction with treatment were evaluated.

Results

In total, 2252 patients with a mean age of 77.2 years were included; 60.2% were women. AD was moderate to moderately severe in 58.4%. Rivastigmine treatment was started orally in 54.4% of the patients and transdermally in 45.6%; 35.6% of those who started treatment by the OR route switched to TDR. A single dose adjustment was sufficient for 77.5% of patients on TDR treatment vs 11.8% of patients receiving OR treatment. More patients on TDR treatment (80.8% vs. 57.1% on OR treatment) reached the maximum therapeutic dose of rivastigmine and did so in a shorter period of time (51.6 vs 205.8 days). Compliance rates (60.5% vs 47.2%) and caregivers’ satisfaction with treatment (89.4% vs 81.9%) were also higher for TDR.

Conclusions

In normal clinical practice, using the TDR route of administration improves dose titration and drug compliance, allowing more patients to reach the maximum recommended dose of rivastigmine in a shorter time period.     

Alteraciones del sueño,un síndrome olvidado en los pacientes con malformación de Chiari tipo I

Introduction

Chiari type I malformation (CM-I) is characterised by caudal ectopia of the cerebellar tonsils through the foramen magnum. This is associated with brain stem, high spinal cord, and cranial nerve compression phenomena. The most frequent symptoms are occipital headaches and dizziness. Less well-known symptoms are sleep disorders and nocturnal respiratory abnormalities.

Sources

MEDLINE and information from patients evaluated at the Neurosurgery and Clinical Neurophysiology Departments at Hospital Universitario Vall d’Hebron.

Development

Review article based on data obtained from MEDLINE articles since 1966, using combinations of the following keywords: «Chiari malformation» or «Arnold-Chiari malformation» and «sleep apnea» or «sleep disorders».

Conclusions

CM-I patients show a higher prevalence of sleep disorders than that observed in the general population. Some studies report a 50% prevalence of sleep apnea-hypopnea syndrome (SAHS), probably associated with sudden death in some cases. These results support analysing sleep respiratory parameters in theses patients. Identifying SAHS symptoms may help optimise treatment, thereby improving quality of life and prognosis.     

Utilidad de la tomografía por emisión de fotón simple con Ioflupano en el diagnóstico del parkinsonismo relacionado con fármacos. Estudio prospectivo

Introduction

Drug-induced parkinsonism is a major type of parkinsonism in our setting. Symptoms usually disappear after discontinuation of the drug. However, they may persist in patients with a variant known as subclinical drug-exacerbated parkinsonism; early identification of this entity has important prognostic and therapeutic implications. The most widely used complementary test in this diagnosis is single-photon emission computed tomography with ioflupane (¹²³I), also known as ¹²³I-FP-CIT SPECT. The aim of our study is to verify its diagnostic accuracy.

Methods

We designed a prospective study of patients with drug-induced parkinsonism in which, after discontinuing the drug and undergoing a ¹²³I-FP-CIT SPECT scan, patients would be monitored for at least 6 months. Patients were categorised as having iatrogenic parkinsonism if symptoms disappeared, or as having subclinical drug-exacerbated parkinsonism if they persisted. Lastly, we verified concordance between the clinical diagnosis and results from the ¹²³I- FP-CIT SPECT scan.

Results

The sample included 19 patients. The most commonly prescribed drug class was neuroleptic agents. For the diagnosis of both subgroups, ¹²³I-FP-CIT SPECT showed a sensitivity of 66.7%, specificity and positive predictive value of 100%, a negative predictive value of 86.7%, and a negative likelihood ratio of 0.33.

Conclusions

Although the study needs to be repeated in a larger sample of patients, ¹²³I-FP-CIT SPECT is useful in the diagnosis of drug-induced parkinsonism since it is a very precise tool for identifying patients with that illness.     

Inducción del temblor mandibular por lesión electrolítica del estriado ventrolateral y por el tratamiento subcrónico con haloperidol en rata macho: un contraste electromiográfico

Introduction

Tremulous jaw movement (TJMs) in rats can be induced pharmacologically by striatal dopaminergic manipulation or electrolytic lesion of ventrolateral striatum (VLS). This tremor has neurochemical, anatomical and electromyographic (EMG) characteristics similar to those of tremor in Parkinson patients. However, the EMG characteristics of tremors generated by electrolytic lesion to the VLS have not yet been studied.

Method

This study used electromyography to describe tremulous jaw movement generated by bilateral electrolytic lesion in the VLS and compare it to tremors induced using subchronic IP treatment with haloperidol, a dopaminergic D2 receptor antagonist. The experimental groups contained rats with a lesion in the ventrolateral striatum and rats on subchronic haloperidol treatment; the control group received only the vehicle. The EMG signal from the temporal muscle was recorded at baseline and during TJMs in all groups.

Results

TMJ frequencies were heterogeneous among the groups. Rats with VLS lesion showed higher amplitude and frequency values than the haloperidol-treated rats. Amplitudes at baseline also differed among the groups.

Conclusions

We conclude that TMJs associated with electrolytic lesion to the VLS show a higher frequency and amplitude than tremors induced by haloperidol. This may be related to the way striatum neurons are affected.     

Medidas de calidad en la atención a pacientes con epilepsia en la consulta de neurología

Introduction

Epilepsy is one of the most frequently observed diseases in neurology outpatient care.

Methods

We analysed our hospital's implementation of the 8 epilepsy quality measures proposed by the American Academy of Neurology: documented seizure types and seizure frequency, aetiology of epilepsy or the epilepsy syndrome, review of EEG, MRI, or CT results, counselling about antiepileptic drug side effects, surgical therapy referral for intractable epilepsy, and counselling about epilepsy-specific safety issues and for women of childbearing age.

Results

In most cases, the first four quality measures were documented correctly. In 66% of the cases, doctors had asked about any adverse drug effects during every visit. Almost all patients with intractable epilepsy had been informed about surgical options or referred to a surgical centre of reference for an evaluation at some point, although referrals usually took place more than 3 years after the initial proposal. Safety issues had been explained to 37% of the patients and less than half of women of childbearing age with epilepsy had received counselling regarding contraception and pregnancy at least once a year.

Conclusions

The care we provide is appropriate according to many of the quality measures, but we must deliver more counselling and information necessary for the care of epileptic patients in different stages of life.     

Cefaleas en la persona mayor: características de una serie de 262 pacientes

Introduction

Although headache prevalence decreases in patients older than 65, headaches are a common complaint and their different clinical and therapeutic features must be understood. This article analyses the clinical characteristics of elderly patients treated in an outpatient headache unit.

Methods

We collected demographic and clinical data from patients treated in a tertiary hospital headache unit between January 2008 and May 2013. Headaches were codified according to the International Classification of Headache Disorders, 2nd edition (ICHD-2).

Results

Of a total of 1868 patients treated, 262 patients (14%, 189 women and 73 men) were older than 65 years. Ninety-nine (68 women, 31 men, 5.3% of the total) were over 75. Headaches began after the age of 65 in only 136 patients (51.9%). The 362 headaches were codified as follows: 23.8% as Group 1 (Migraine) and 28.7% as Group 2 (Tension-type headache). We diagnosed 58 (16%) secondary headaches; 26 (7.2%) were classified as Group 13 (Cranial neuralgias) and 23 (6.4%) in Group 14 (Other headaches). Symptomatic medication overuse was detected in 38 patients (14.5%). We also identified headaches considered typical in the elderly, including chronic migraine (41 cases), hypnic headache (6), occipital neuralgia (4), SUNCT (2), cervicogenic headache (1), primary cough headache (1), and giant cell arteritis (2).

Conclusions

Elderly patients were frequently treated in our outpatient headache unit. Tension-type headache was the most common diagnosis in this population. Geriatric headache syndromes such as hypnic headache or occipital neuralgia were also represented in our series.     

Pupilometría por infrarrojos. Descripción y fundamentos de la técnica y su aplicación en la monitorización no invasiva del paciente neurocrítico

Introduction

Pupil assessment is a fundamental part of the neurological examination. Size and reactivity to light of each pupil should be recorded periodically since changes in these parameters may represent the only detectable sign of neurological deterioration in some patients. However, there is great intraobserver and interobserver variability in pupil examination due to the influence of many factors, such as the difference in ambient lighting, the visual acuity and experience of the examiner, the intensity of the luminous stimulus, and the method used to direct this stimulus.In recent years, digital cameras have incorporated infrared devices allowing the development of user-friendly portable devices that permit repeated, non-invasive examinations of pupil size and its reactivity to light with an objective, accessible and inexpensive method.

Development

The purpose of this review is to describe the fundamentals of infrared pupillometry and discuss potential applications in the monitoring of neurocritical patients. We also present some recommendations in the routine assessment of pupils in neurocritical patients.

Conclusions

The possibility of evaluating the changes in pupil reactivity in an early, objective and almost continuous way provides a new non-invasive monitoring method. This method could improve the predictive factor of neurological deterioration and the bedside monitoring of the neurological state of the patient, avoiding unnecessary examinations and enabling early therapeutic intervention.