Lucas Martín Romano

Benign multiple sclerosis: a new definition of this entity is needed

Background: To study a cohort of benign multiple sclerosis (BMS) patients beyond physical disability, including the evaluation of cognitive and social function, as well as fatigue, pain and MRI studies. Methods: A cohort of 342 patients was prospectively followed for 10.9 ± 0.71 years. Forty-three patients (12.5%) met the BMS diagnosis criteria [Expanded Disability Status Scale (EDSS) < 3 after at least 10 years’ disease duration], undergoing full neurological examination every 6 months. Neuropsychological status, pain, fatigue, social functioning and work-related disability, as well as brain MRIs, were assessed yearly. Results: By the end of follow-up, 20 of 43 BMS patients (47%) had suffered cognitive impairment and 23 (53.3%) referred depression. Furthermore, 21 (48.8%) reported significant changes in pain intensity, with fatigue and environmental severity scores significantly increasing over time in 33–35% of patients. Finally, 32 BMS patients (74%) showed significant increase in the number of new or enlarging T2 lesions, gadolinium-enhanced lesions, and persistent black holes, without changes in EDSS. Thirty-five of 43 patients (81%) fulfilling the BMS diagnostic criteria showed significant worsening of cognitive function, fatigue, pain or depression during the 10-year follow-up. Conclusions: Currently accepted criteria for BMS diagnosis may cause overestimation of true prevalence, underscoring the need for routine monitoring of non-motor symptoms and imaging studies, to help physicians improve diagnostic accuracy as well as therapeutic decision-making in this subgroup of MS patients.

Ischemic stroke related to anabolic abuse.

Anabolic-androgenic steroid (AAS) abuse increased in recent years, and it is associated with numerous adverse effects. Few reports on ischemic stroke related to anabolic steroid abuse have been published. We report a case of a 26-year-old male amateur athlete who suffered a posterior territory ischemic stroke. No abnormalities were found in angiography and echocardiography studies, neither in hemostatic profile. His only significant risk factor was nonmedical use of stanozolol, an anabolic steroid. Anabolic steroids are capable of increasing vascular tone, arterial tension, and platelet aggregation; therefore, they are prone to produce atherothrombotic phenomena. Because of young peoples widespread use of anabolic steroids, physicians should be aware of this kind of complication.

Outcome of newly-diagnosed epilepsy in older patients

INTRODUCTION The annual incidence of seizure disorders rises sharply after the age of 60. Treatment is complicated by the normal physiological changes of aging, comorbid diseases, and polypharmacy. Despite this, approximately 80% of the patients become seizure-free. OBJECTIVES The objectives of this study were to (1) analyze the outcome of a cohort of patients with newly-diagnosed epilepsy over the age of 65, (2) describe epilepsy etiology and seizure type, and (3) classify the outcome according to the latest ILAE classification proposal for drug-resistant epilepsy (2010). METHODS All patients with newly-diagnosed epilepsy over the age of 65 who were evaluated in two different institutions were included. Seizures and epilepsy syndromes were classified according to the International League Against Epilepsy proposal (2010). Epilepsy outcomes were also analyzed according to the proposal of the ILAE Commission on Therapeutic Strategies (2010). RESULTS One hundred and twenty-two patients were included with a median follow-up time of 15 months. Median age of diagnosis was 78 years. Seventy-seven patients (55%) had epilepsy of unknown cause, and 55 (45%) had structural-metabolic epilepsy. The proportions of seizure-free patients at 6, 12, 18, and 24 months were 90%, 77%, 74%, and 67%, respectively. Thirty percent of patients experienced adverse effects (AEs). We found a statistically significant trend toward a higher frequency of AEs as the number of concomitant medications rose and in younger patients. According to the 2010 ILAE classification proposal for drug-resistant epilepsy criteria, 55.8% of the patients were seizure-free, 12.3% had treatment failure, and 32% had undetermined seizure outcome. CONCLUSION Patients with newly-diagnosed epilepsy after the age of 65 have very good chances of achieving seizure control with AED treatment. It seems that fulfilling the ILAE classification proposal for drug-resistant epilepsy (2010) criteria for seizure freedom was more difficult in our cohort. Older patients also seem to be more prone to suffering from AEs.

Tratamiento mínimamente invasivo del hematoma subdural crónico del adulto. Resultados en 116 pacientes

INTRODUCTION Chronic subdural hematoma in adults (CSDH) has a global crude incidence of 14.1/100,000 per year in our institution captive population. There is no single treatment protocol. In our hospital we choose a minimal invasive technique (trans-marrow puncture) without general anaesthesia due to the age of the population. A descriptive study of patients with CSDH and treatment results, including a laterality analysis, is presented. MATERIAL AND METHODS We retrospectively searched patients with (CSDH) between January 1998 and May 2009. The diagnosis was made by neuroimaging techniques in all patients. The preferred treatment was trans-marrow puncture; exceptionally some patients were treated by burr holes or craniotomy. RESULTS We found 127 patients. Age, gender, midline displacement, hospitalisation days, and number of procedures, were not a predictive factor of mortality in the first month. A slight majority (55%) of CSDH were on the left side, with no statistically significant difference. There were 6 (4.7%) deaths during hospitalisation. In our series cumulative mortality at six months was 11.8%. Markwalder scale at admission was not a predictive factor of statistically significant mortality. An 80% of the patients received trans-marrow puncture as single procedure was performed on 80% of the patients. CONCLUSIONS The results of our study suggest that trans-marrow puncture is an acceptable procedure, with low mortality, and less hospitalisation days and complications. Mortality, associated mechanisms, age, gender, midline displacement are no different than in others previous publications. We found a higher frequency of hematomas to the left, as in other series. Meta-analysis studied need to be performed to determine more accurately the frequency of this dominance.

Incidencia de demencia de inicio precoz en Mar de Plata

INTRODUCTION Early-onset dementia (EOD) is defined as dementia with onset before the age of 65 years. EOD is increasingly recognised as an important clinical and social problem with devastating consequences for patients and caregivers. OBJECTIVE Determine the annual crude incidence rate and the specific incidence rates by sex and age in patients with EOD, and the standardised rate using the last national census of the population of Argentina (NCPA), from 2010. MATERIALS AND METHODS Hospital Privado de Comunidad, Mar del Plata, Argentina, attends a closed population and is the sole healthcare provider for 17 614 people. Using the database pertaining to the Geriatric Care department, we identified all patients diagnosed with EOD between 1 January, 2005 and 31 December, 2011. EOD was defined as dementia diagnosed in patients younger than 65. RESULTS The study period yielded 14 patients diagnosed with EOD out of a total of 287 patients evaluated for memory concerns. The crude annual incidence of EOD was 11 per 100 000/year (CI 95%: 6.25-19.1): 17 per 100 000 (CI 95%: 7.2-33.1) in men and 8 per 100 000 (CI 95%: 3.4-17.2) in women. We observed a statistically significant increase when comparing incidence rates between patients aged 21 to <55 years and ≥ 55 to <65 years (3 vs 22 per 100 000, P=.0014). The rate adjusted by NCPA census data was 5.8 cases of EOD habitants/year. CONCLUSION This study, conducted in a closed population, yielded an EOD incidence rate of 11 per 100 000 inhabitants/year. To the best of our knowledge, this is the first prospective epidemiological study in Argentina and in Latin America.

Es el cociente normalizado internacional un factor pronóstico de mortalidad en hemorragias intracerebrales

BACKGROUND Oral anticoagulant therapy (ACO) is considered an independent predictor of mortality in patients with intracerebral haemorrhage (ICH), with the role of the international normalised ratio (INR) being unclear. The aim of this work is to evaluate the relationship between ACO and the INR value and the ICH volume, and to determine the relationship between both variables and mortality. PATIENTS AND METHODS Patients were retrospectively analysed using the Private Community Cerebrovascular Hospital Register (Registro Cerebrovascular del Hospital Privado de Comunidad), between December 2003 and May 2009. Volumes of the haematomas (dependent variable) were calculated from the first image performed, using the abc/2 method. Independent variables were age, gender, vascular risk factors, site of bleeding, intraventricular dump, clinical severity (Glasgow scale), time to image, antiplatelet drugs, and INR value on admission. An analysis of the relationship between all these variables and mortality was also performed. RESULTS A total of 327 patients with HIC were identified (35 with ACO). Median volume was higher in the anticoagulated patients (55ml vs 24ml P<.05), with no statistically significant relationship between volume and the other variables. In the multivariate analysis, a statistically significant higher mortality associated to volume was observed, but not with anticoagulation. CONCLUSIONS Oral anticoagulation was associated with a higher initial volume of the haematoma, with no correlation between the INR value and volume. The HIC volume was directly related to mortality, however, like the volume, the INR was not associated with increased mortality.

Teaching Video NeuroImages: Recurrent oculomotor neuropathy with isolated ptosis vs ophthalmoplegic migraine

A 13-year-old girl presented with left-sided periorbital headache and homolateral ptosis with normal ocular motility and pupillary response (video segment 1 on the Neurology ® Web site at www.neurology.org). She had a similar …

Topiramate-induced acute myopia with MRI contrast enhancement

Topiramate is a sulfamate-substituted monosaccharide mainly used to treat epilepsy in children and adults and prophylaxis of migraine. This article describes a case of topiramate-induced acute transient myopia. The underlying mechanism and management is discussed. A 13-year-old female complained of sudden onset of blurred vision; 7 days prior to this she had commenced topiramate therapy for migraine prophylaxis. Visual acuity was reduced in both eyes. Examination revealed myopic refractive changes which resolved quickly following discontinuation of the drug. An MRI showed uveoscleral and subcutaneous cellular tissue abnormalities in the T1 contrasted images.

Variables predictivas de letalidad y rendimiento de la escala ReC-HPC en hemorragia intracerebral primaria en pacientes anticoagulados*

Resumen Introduccion Existen diversas escalas pronosticas para hemorragia intracerebral (HIC) primaria. Entre ellas, la escala ReC-HPC ha sido recientemente validada para predecir la mortalidad. Sin embargo, ninguno de los scores disponibles discrimina pacientes anticoagulados con HIC (HIC-ACO). Objetivos Analizar variables y comparar el rendimiento de la escala ReC-HPC para predecir letalidad al dia 30 en HIC-ACO y sin anticoagulacion (HIC-noACO). Materiales y metodos Se analizaron, en forma retrospectiva, todos los pacientes con HIC incluidos consecutivamente en el Registro Cerebrovascular del Hospital Privado de Comunidad, entre diciembre de 2003 y mayo de 2009 inclusive. El desenlace analizado fue la letalidad a los 30 dias del evento. Resultados Se registraron 292 pacientes con HIC-noACO y 35 HIC-ACO. Edad: mediana, 76 anos (cuartiles: 71-83). Sexo: 49% masculino. Las caracteristicas basales de ambos grupos fueron similares. Al examinar diferentes valores de corte de la escala ReC-HPC en el grupo HIC-ACO, con valores ≥2 se obtuvo un marcado descenso de la sensibilidad (76% vs 96%) y la especificidad (72% vs 88%) con respecto al grupo HIC-noACO. La certeza pronostica y el area bajo la curva fueron del 74% y 0,8 vs 88% y 0,9 en pacientes anticoagulados y no anticoagulados. En el analisis univariado, el volcado intraventricular, el volumen de hematoma, la escala de Glasgow, la localizacion y el tabaquismo actual fueron estadisticamente significativos, pero no asi en el analisis multivariado. Conclusiones La escala ReC-HPC tiene un menor rendimiento para predecir mortalidad en HIC-ACO que en HIC-noACO.

El test del reloj: reproducibilidad, consistencia interna y variables predictivas de la prueba del reloj utilizando el método de puntuación de Cacho. Análisis de 985 relojes

Resumen Introduccion La prueba del reloj (PR) es una prueba de evaluacion de cribado para deterioro cognitivo ampliamente difundida en la practica clinica. Existen varios metodos de puntuacion. En nuestro medio utilizamos el desarrollado por Cacho et al en 1999. El objetivo del trabajo es evaluar la reproducibilidad interevaluadores y la consistencia interna de la PR a la orden de pacientes que son derivados para evaluacion de deterioro cognitivo utilizando el metodo de puntuacion de Cacho, y analizar variables predictivas del resultado. Material y metodos Dos evaluadores entrenados ciegos entre si y de otras evaluaciones y diagnosticos efectuados, valoraron los dibujos de reloj de 985 pacientes mediante el metodo de Cacho. Con los resultados y los datos de las historias clinicas se confecciono una base de datos. Se utilizo el coeficiente kappa ponderado para evaluar la reproducibilidad interevaluadores y alfa de Cronbach para la consistencia interna. Se analizo la relacion entre la puntuacion del reloj con el sexo, la edad y los anos de educacion. Resultados La mediana del resultado de la PR de ambos evaluadores fue de 7. Se obtuvo un coeficiente kappa ponderado elevado (0,87 [95% IC 0,80-0,93]). La consistencia interna resulto regular en las pruebas realizadas por ambos observadores. La edad y la educacion tendrian una correlacion estadisticamente significativa pero de regular y escasa magnitud, negativa y positiva respectivamente. Conclusiones La reproducibilidad interevaluador fue similar a la de otros metodos de puntuacion de la PR. La consistencia interna es menor que la observada por el autor original. La edad y los anos de educacion se correlacionan con los resultados de la prueba.