Elvira Munteis

Previous antiplatelet therapy is an independent predictor of 30-day mortality after spontaneous supratentorial intracerebral hemorrhage.

AbstractBackgroundIntracerebral hemorrhage (ICH) constitutes 10% to 15% of all strokes. Despite several existing outcome prediction models for ICH, there are some factors with equivocal value as well as others that still have not been evaluated.Patients and methodsAll patients with first ever supratentorial ICH presenting to our institution between December 1995 and December 2002 were prospectively enrolled into the study. Patients with historic modified Rankin Scale > 2 and those under anticoagulant treatment or with multiple ICH were excluded. The following parameters were analyzed in 194 consecutive patients: age, gender, past history of hypertension, diabetes mellitus, hypercholesterolemia, past history of ischemic stroke, presence of ischemic heart disease or cardioembolic disease, current antiplatelet treatment, current alcohol overuse, smoking, Glasgow Coma Scale score (GSS) at admission, volume and location (deep or lobar) of ICH, ventricular extension, glycemia and temperature at admission, and leukoaraiosis. We correlated these data with the 30–day mortality identifying the independent predictors by logistic regression analysis.ResultsFactors independently associated with 30–day mortality were: age, Glasgow Coma Scale score at admission, ICH volume, ventricular extension, glucose level at admission, and previous antiplatelet use.ConclusionsApart from the classical outcome predictors, the previous use of antiplatelet agents and the glucose value at admission are independent predictors of 30–day mortality in patients suffering a supratentorial ICH.

Early Arterial Study in the Prediction of Mortality After Acute Ischemic Stroke

Background and Purpose— The purpose of this study was to evaluate the value of the initial arterial study as a predictor of 90-day mortality in patients with acute ischemic stroke. Methods— A total of 1220 unselected patients assessed during the first 24 hours after stroke onset were prospectively studied. Initial stroke severity was evaluated by the National Institutes of Health Stroke Scale and dichotomized in mild (National Institutes of Health Stroke Scale ≤7) and severe (National Institutes of Health Stroke Scale >7). Severe arterial stenosis (≥70%) or arterial occlusion in the symptomatic territory was determined by a Doppler study and also by additional explorations (carotid duplex, MR or CT angiography) in the first 24 hours after admission. The following variables were also analyzed: age, gender, previous functional status, smoking, hypertension, hyperlipidemia, diabetes mellitus, peripheral arterial disease, ischemic heart disease, heart failure, atrial fibrillation, previous stroke, and prior use of antithrombotic or statins. Ninety-day mortality was the end point of the study. Results— Ninety-day mortality was 15.7%. A total of 25.5% of all deaths were in patients with mild stroke. In addition to well-known factors related to mortality (age, stroke severity, ischemic heart disease, heart failure, and previous disability), severe arterial stenosis/occlusion was the factor with the highest relationship with 90-day mortality (adjusted OR: stenosis 2.13, occlusion 4.42, both 3.36). Arterial stenosis/occlusion was a higher predictor of 90-day mortality in patients with mild (adjusted OR: 5.38) than severe stroke (adjusted OR: 3.05). Conclusions— Severe arterial stenosis/occlusion in the early arterial study was highly related with 90-day mortality in an unselected series of patients with stroke. These data achieve special relevance in patients with initial mild stroke.

Neuromyelitis optica spectrum disorders Comparison according to the phenotype and serostatus

Objective: To (1) determine the value of the recently proposed criteria of neuromyelitis optica (NMO) spectrum disorder (NMOSD) that unify patients with NMO and those with limited forms (NMO/LF) with aquaporin-4 immunoglobulin G (AQP4-IgG) antibodies; and (2) investigate the clinical significance of the serologic status in patients with NMO. Methods: This was a retrospective, multicenter study of 181 patients fulfilling the 2006 NMO criteria (n = 127) or NMO/LF criteria with AQP4-IgG (n = 54). AQP4-IgG and myelin oligodendrocyte glycoprotein immunoglobulin G (MOG-IgG) antibodies were tested using cell-based assays. Results: Patients were mainly white (86%) and female (ratio 6.5:1) with median age at onset 39 years (range 10–77). Compared to patients with NMO and AQP4-IgG (n = 94), those with NMO/LF presented more often with longitudinally extensive transverse myelitis (LETM) (p < 0.001), and had lower relapse rates (p = 0.015), but similar disability outcomes. Nonwhite ethnicity and optic neuritis presentation doubled the risk for developing NMO compared with white race (p = 0.008) or LETM presentation (p = 0.008). Nonwhite race (hazard ratio [HR] 4.3, 95% confidence interval [CI] 1.4–13.6) and older age at onset were associated with worse outcome (for every 10-year increase, HR 1.7, 95% CI 1.3–2.2). Patients with NMO and MOG-IgG (n = 9) had lower female:male ratio (0.8:1) and better disability outcome than AQP4-IgG-seropositive or double-seronegative patients (p < 0.001). Conclusions: In patients with AQP4-IgG, the similar outcomes regardless of the clinical phenotype support the unified term NMOSD; nonwhite ethnicity and older age at onset are associated with worse outcome. Double-seronegative and AQP4-IgG-seropositive NMO have a similar clinical outcome. The better prognosis of patients with MOG-IgG and NMO suggests that phenotypic and serologic classification is useful.

Steno-occlusive arterial disease and early neurological deterioration in acute ischemic stroke.

Aim: To evaluate the influence that steno-occlusive arterial disease may have on the development of early neurological deterioration (END) in a large series of patients with acute ischemic stroke. Methods: We studied a prospective cohort of 1,093 patients admitted to a single tertiary hospital with presence of neurological symptoms in the first 24 h after stroke onset. END was defined as any increase in the National Institutes of Health Stroke Scale score ≧4 points in the first 72 h. The arterial study assessed the presence of arterial occlusion or significative stenosis in the symptomatic territory. Additionally, age, initial stroke severity, blood pressure, glucose levels, vascular risk factors, lacunar stroke and prior use of antithrombotic treatment were also analyzed in a multivariable analysis. Results: END was detected in 179 patients (16.3%). Steno-occlusive disease (adjusted OR 3.60), initial blood pressure and abdominal obesity were independently associated with END. Both arterial stenosis (adjusted OR 2.33) or occlusions (adjusted OR 3.65) were associated with END. The higher adjusted OR (5.49) was obtained for steno-occlusive arterial disease in the vertebrobasilar system. Conclusions: An early arterial study may provide key data for the selection of patients with higher risk of END after acute ischemic stroke.

Serum lipid levels and in-hospital mortality in patients with intracerebral hemorrhage

Objective: To test the hypothesis that low serum cholesterol and low serum triglyceride levels at admission are related to an increase of in-hospital mortality in patients with first-ever supratentorial spontaneous intracerebral hemorrhage (ICH). Methods: The authors obtained the serum cholesterol and triglyceride levels during the first 48 hours after first-ever ICH in 184 patients. They analyzed the impact of serum cholesterol and triglyceride concentrations on the in-hospital mortality after adjustment for possible confounding variables according to the results of the univariate analysis (age, hemorrhage volume, intraventricular extension, glycemia, serum albumin, and Glasgow Coma Scale score at admission) using the Cox proportional hazards model. They also analyzed the survival curves according to the cholesterol and triglyceride quartiles. Results: Low serum cholesterol (p = 0.002; hazard ratio [HR] 0.988 [95% CI 0.979 to 0.997] mg/dL) and low serum triglyceride (p = 0.011; HR 0.986 [95% CI 0.976 to 0.997] mg/dL) concentrations were independently associated with increased in-hospital mortality after ICH. Analyzed by quartiles, the HR of in-hospital mortality was 3.136 (95% CI 0.833 to 11.087) for patients in the lowest cholesterol quartile (<166 mg/dL) and 3.484 (95% CI 1.088 to 11.155) for patients in the lowest triglyceride quartile (<74 mg/dL). Conclusions: Low serum cholesterol and triglyceride levels obtained during the first hours after intracerebral hemorrhage (ICH) are strong independent predictors of in-hospital mortality in patients with spontaneous supratentorial ICH.

Manometric correlations of anorectal dysfunction and biofeedback outcome in patients with multiple sclerosis

Objective To evaluate clinical and manometric characteristics of multiple sclerosis (MS) patients with anorectal dysfunction (ARD) and their influence on biofeedback outcome. Patients and methods Patients were clinically and manometrically studied and compared with controls. Patients were subsequently offered to initiate biofeedback manoeuvres to improve ARD. Results Fifty-two patients with ARD, 39 women, mean age 44.96 ± 9.26 years, mean Expanded Disability Status Scale 4.13 ± 1.72, were evaluated. Thirty-one patients had relapsing-remitting (RR), 16 secondary progressive and five primary progressive MS. ARD complaints were constipation (67.3%), double ARD (23.1%) and isolated incontinence (9.6%). The manometric study showed significant differences in patients compared with controls in maximal contraction pressures (98.1 ± 44.2 mm Hg versus 152.05 ± 66.9 mm Hg, P < 0.001) and anal inhibitory reflex threshold (92.9 ± 63.4 mL versus 40.45 ± 11.3 mL, P < 0.001). Maximal pressure was lower in progressive forms compared with RR forms (83.1 ± 36.2 mm Hg versus 108.2 ± 46.7 mm Hg, P < 0.05) in relation to higher disability. Patients with paradoxical contraction (PC) (35 patients, 67.3%) showed more manometric disturbances. From a total of 18 patients performing biofeedback, those reporting some improvement (six complete, two partial) had milder manometric abnormalities. Conclusions The most frequent manometric abnormalities in our MS patients with ARD were alterations of maximal pressures, anal inhibitory reflex and PC. Biofeedback could be more useful in patients with lower disability and manometric alterations. Multiple Sclerosis 2008; 14: 237—242. http://msj.sagepub.com

Unconventional therapy in multiple sclerosis

Background: The use of unconventional therapies is growing in western countries. Few studies on their frequency and rationale among multiple sclerosis (MS) patients have been carried out in Europe. Objective: To assess the frequency of use of unconventional therapies among MS patients and to explore associated clinical variables. Methods: Structured questionnaires were given to 380 consecutive patients seen at two hospital-based MS clinics in Barcelona. C linical and demographical data were recorded at the same time. The questionnaire inquired about demographical features, educatio n, income, use of unconventional therapies for MS and satisfaction with conventional medicine both in general and specifically in MS. Results: The response rate was 50.78%. Forty-one per cent of patients admitted using unconventional therapies during the previous year. Low levels of satisfaction with conventional medicine in general and for MS, and higher Expanded Disability Status Scale (EDSS) scores (EDSS mean: 4.43 in users versus 3.48 in nonusers) were significantly associated with use of unconventional therapies. Conclusion: Use of unconventional therapies is not rare among MS patients, and it is associated with high disability levels and dissatisfaction with conventional medicine.

Clustering of vascular risk factors and in-hospital death after acute ischemic stroke

Objectiveto evaluate the influence of clustering of vascular risk factors (VRF) on in-hospital mortality in patients with acute ischemic stroke (AIS) developing a risk score for mortality prediction.Methodsclinical data from 1527 patients admitted to hospital with a first-ever AIS were prospectively evaluated from 1997 to 2005 assessing the presence of six VRF: diabetes, hypertension, hyperlipidemia, ischemic heart disease, atrial fibrillation and peripheral arterial disease. A composite vascular risk score (VRS) was created using five risk factors.Hyperlipidemia was excluded from the score due to its protective impact on mortality. Two modified VRS models were created and assessed for their accuracy as predictors for in-hospital mortality based on the odds ratio for each VRF obtained in the univariate analysis.Results197 patients (12.9 %) died during the acute hospitalization period. Stroke severity increased with each additional VRF (p = 0.002). Cox proportional hazards model adjusted for confounders showed an association between the composite VRS and in-hospital mortality (p = 0.045). According to the clustering of VRS, the risk for in-hospital death increased from 1.951 (95 % CI 1.041–3.665) for patients having one VRS to 2.343 (95% CI 1.081–5.076) for those having a VRS ≥ 4. ROC curves showed that the modified VRS model based on a given value of one for each accumulated VRF, including the absence of hyperlipidemia, had the highest predictive capability for in-hospital mortality (p < 0.0001).Conclusionsthe presence of multiple VRF in patients with acute ischemic stroke increases the stroke severity and the risk of in-hospital death.

Periodic hyperthermia and abnormal circadian temperature rhythm in a patient with multiple sclerosis

Disturbances of the central thermoregulation in patients with multiple sclerosis (MS) are not often reported. We describe a 45-year old patient with a 13-year history of MS, who developed a clinical picture of recurrent hyperthermia. MRI showed a bilateral involvement of the hypothalamus in the setting of diffuse white matter disease. Serial body temperature measurement for five consecutive months disclosed an inversion of the circadian temperature rhythm. The clinical presentation and MRI findings suggested abnormalities of the central thermal control in relation to MS widespread involvement of the central nervous system (CNS).

Cannabis use in Spanish patients with multiple sclerosis: Fulfilment of patients' expectations?

OBJECTIVE Medicinal use of cannabis in chronic neurological diseases is a controversial topic of medical research and the subject of intense public debate. The aim of the study was to evaluate the prevalence of cannabis use, related factors, and degree of satisfaction in Spanish patients with multiple sclerosis (MS) prior to the establishment of medically supervised use. METHODS Cross-sectional, questionnaire-based survey provided during routine medical visits to consecutive patients in two university-based neurology clinics. RESULTS The questionnaire was returned by 175 MS patients (94.1% response rate). The prevalence of ever-use and medicinal cannabis use were 43% and 17.1%, respectively. At the time of the survey, cannabis was being used by 12.5% (5/45) of recreational and 56.7% (17/30) of medical users (p<0.001). First cannabis consumption was after MS onset in 15 (50%) medicinal users. Clinical improvement was reported by 14 (46.7%) medicinal users. Smoking use, awareness of cannabis potential benefits, pain, higher disability, and lower age were independently associated with the medicinal use of cannabis. Most patients would support a future legalisation of cannabis for the control of their symptoms and were willing to receive cannabis under medical control once legalised (83.4% of never-users, 94.5% of ever-users, p<0.05). CONCLUSION Almost half of our MS patients had tried cannabis at some time. However, medicinal use was low and clinical improvement after cannabis use was only reported by a subset of patients. Overall, MS patients were highly motivated for a future medically controlled use.