Pablo Irimia

The cost of stroke.

The control of health expenditure has become one of the main axes of health policy. Cost studies are an indispensable tool for determining the economic impact of disease and for assigning the material and human resources required for the prevention, diagnosis, treatment, and follow-up of patients with different diseases. Cost studies in stroke are necessary due to the increasing incidence of this disease which represents a significant cause of death and invalidity in adults and produces important hospital and social spending, and for which patients must be treated in specialized units (stroke units). The principal cost-determining factors in most studies are those generated by hospital admission (principally hospital stay). Other cost-determining factors include severity, stroke subtype or the fate of patients on discharge. Future health policies aimed at optimizing economic resources must be directed towards reducing hospital stay and minimizing patient disability.

Carotid intima-media thickness changes with Mediterranean diet: A randomized trial (PREDIMED-Navarra) ☆

OBJECTIVE Observational studies have reported inverse associations between adherence to the Mediterranean diet (MedDiet) and atherosclerotic disease. We tested the effect of two types of MedDiet on progression of subclinical carotid atherosclerosis. METHODS We randomized 187 high-cardiovascular-risk asymptomatic subjects (51% women, mean age 67 years) to three treatment arms: MedDiet with supplemental virgin olive oil (VOO), n=66; MedDiet with supplemental nuts, n=59; and control diet, n=62. Participants received nutrition behavioral counseling in quarterly group and individual educational sessions. Free supplemental foods were provided to the MedDiet groups. Changes in mean intima-media thickness (IMT) were measured ultrasonographically in the far wall of bilateral common carotid arteries after 1 year. RESULTS Overall, no significant between-group differences in IMT progression were observed after 1-year. However, a significant interaction (p=0.03) between baseline IMT and treatment effect was apparent. Among participants with baseline IMT≥0.9 mm, 1-year IMT changes versus control showed significant differences of -0.079 mm (95% confidence interval, -0.145 to -0.012) for the MedDiet with VOO and -0.072 mm (-0.140 to -0.004) for the MedDiet with nuts. No IMT changes occurred in any intervention group among participants with lower baseline IMT values (<0.9 mm). CONCLUSIONS MedDiets enhanced with VOO or nuts were not effective in inducing ultrasonographic regression of carotid atherosclerosis after 1 year intervention. However, they were effective among subjects with elevated baseline IMT, suggesting that subclinical atherosclerosis may respond to dietary intervention within a relatively short time frame only among subjects with a high initial atherosclerotic burden.

Refractory migraine in a headache clinic population

BackgroundMany migraineurs who seek care in headache clinics are refractory to treatment, despite advances in headache therapies. Epidemiology is poorly characterized, because diagnostic criteria for refractory migraine were not available until recently. We aimed to determine the frequency of refractory migraine in patients attended in the Headache Unit in a tertiary care center, according to recently proposed criteria.MethodsThe study population consisted of a consecutive sample of 370 patients (60.8% females) with a mean age of 43 years (range 14-86) evaluated for the first time in our headache unit over a one-year period (between October 2008 and October 2009). We recorded information on clinical features, previous treatments, Migraine Disability Assessment Score (MIDAS), and final diagnosis.ResultsOverall migraine and tension-type headache were found in 46.4% and 20.5% of patients, respectively. Refractory migraine was found in 5.1% of patients. In refractory migraineurs, the mean MIDAS score was 96, and 36.8% were medication-overusers.ConclusionsRefractory migraine is a relatively common and very disabling condition between the patients attended in a headache unit. The proposed operational criteria may be useful in identifying those patients who require care in headache units, the selection of candidates for combinations of prophylactic drugs or invasive treatments such as neurostimulation, but also to facilitate clinical studies in this patient group.

Dietary fibre intake is inversely associated with carotid intima-media thickness: a cross-sectional assessment in the PREDIMED study

Objective:To assess the association between the intake of dietary fibre and carotid intima-media thickness (IMT) in a Mediterranean population at high cardiovascular risk.Methods:Baseline cross-sectional assessment of 457 men and women (average age 67 years) from two different Spanish centres of the PREDIMED trial. A previously validated food frequency questionnaire (137 food items) was administered by trained dieticians in a face-to-face interview. Mean common carotid IMT was measured using B-mode ultrasound imaging of the right and left carotid arteries by four certified sonographers who used a common protocol. Anthropometric and blood pressure measurements were performed and samples of fasting blood were obtained. Participants were categorized into four groups (roughly quartiles: ⩽21; >21 to ⩽25; >25 to ⩽31 and >31 g/day) of energy-adjusted intake of dietary fibre. Multiple linear regression models were used to adjust for age, sex, centre, smoking, body mass index, diabetes, blood pressure, lipid levels and statin use.Results:In the crude analyses, energy-adjusted fibre intake showed a significant inverse correlation with IMT (r=−0.27, P<0.001). In multivariate analyses, a modest, though statistically significant (P=0.03) inverse association between energy-adjusted fibre intake and IMT was also found. The multivariate-adjusted difference in average IMT was −0.051 mm (95% confidence interval: −0.094 to−0.009, P=0.02) for participants whose intake was >35 g/day, (n=47) when compared with those whose intake was <25 g/day (n=224).Conclusions:Our results suggest that high fibre intake is inversely associated with carotid atherosclerosis.

Guías de actuación clínica en la hemorragia intracerebral

Intracerebral haemorrhage accounts for 10%-15% of all strokes; however it has a poor prognosis with higher rates of morbidity and mortality. Neurological deterioration is often observed during the first hours after onset and determines poor prognosis. Intracerebral haemorrhage, therefore, is a neurological emergency which must be diagnosed and treated properly as soon as possible. In this guide we review the diagnostic procedures and factors that influence the prognosis of patients with intracerebral haemorrhage and we establish recommendations for the therapeutic strategy, systematic diagnosis, acute treatment and secondary prevention for this condition.

Independent Association of Fibrinogen with Carotid Intima-Media Thickness in Asymptomatic Subjects

Background: Fibrinogen has been found to be an independent risk factor for cardiovascular disease. Both genetic and environmental factors contribute to its variability in plasma. However, whether the relation between fibrinogen and carotid intima-media thickness (IMT) is independent of those factors has not been established. Therefore, the aim of this study was to investigate the relations of plasma fibrinogens and the –455 G/A Bβ-fibrinogen polymorphism with the carotid IMT in a series of asymptomatic subjects. Methods: Markers of inflammation, C-reactive protein (CRP) and leukocytes, and endothelial perturbation (von Willebrand factor, vWF) were measured in 135 subjects. All individuals underwent a complete clinical examination and lipid measurements (cholesterol and its fractions HDL and LDL and triglycerides). The carotid IMT was measured by B-mode ultrasound in the common carotid artery. Results: Patients in the highest fibrinogen tertile had a significantly higher BMI (p < 0.01), LDL-cholesterol (p < 0.01), leukocyte count, CRP and vWF (p < 0.001). In the univariate model a strong positive relationship was found between plasma fibrinogen and carotid IMT (p < 0.01). Fibrinogen also correlated positively with age, BMI, arterial systolic pressure, cholesterol, cholesterol-LDL, smoking, CRP and vWF (p < 0.01). In the multivariate analysis, the association of fibrinogen with carotid IMT remained significant (p < 0.01) after adjustment for all the parameters analyzed. Conclusion: In a population sample of adults without clinically overt atherosclerotic disease, elevated fibrinogen was related to carotid IMT independent of a wide range of important confounding variables.

Guía para el tratamiento preventivo del ictus isquémico y AIT (I). Actuación sobre los factores de riesgo y estilo de vida

OBJECTIVE To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and transient ischaemic attack (TIA). METHODS We reviewed available evidence on risk factors and means of modifying them to prevent ischaemic stroke and TIA. Levels of evidence and recommendation grades are based on the classification of the Centre for Evidence-Based Medicine. RESULTS This first section summarises the recommendations for action on the following factors: blood pressure, diabetes, lipids, tobacco and alcohol consumption, diet and physical activity, cardio-embolic diseases, asymptomatic carotid stenosis, hormone replacement therapy and contraceptives, hyperhomocysteinemia, prothrombotic states and sleep apnea syndrome. CONCLUSIONS Changes in lifestyle and pharmacological treatment for hypertension, diabetes mellitus and dyslipidemia, according to criteria of primary and secondary prevention, are recommended for preventing ischemic stroke.

Guía para el tratamiento preventivo del ictus isquémico y AIT (II). Recomendaciones según subtipo etiológico

BACKGROUND AND OBJECTIVE To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and Transient Ischaemic Attack (TIA). METHODS We reviewed the available evidence on ischaemic stroke and TIA prevention according to aetiological subtype. Levels of evidence and recommendation levels are based on the classification of the Centre for Evidence-Based Medicine. RESULTS In atherothrombotic IS, antiplatelet therapy and revascularization procedures in selected cases of ipsilateral carotid stenosis (70%-90%) reduce the risk of recurrences. In cardioembolic IS (atrial fibrillation, valvular diseases, prosthetic valves and myocardial infarction with mural thrombus) prevention is based on the use of oral anticoagulants. Preventive therapies for uncommon causes of IS will depend on the aetiology. In the case of cerebral venous thrombosis oral anticoagulation is effective. CONCLUSIONS We conclude with recommendations for clinical practice in prevention of IS according to the aetiological subtype presented by the patient.

Neurorrehabilitación tras el ictus

Resumen Introduccion La enfermedad cerebrovascular o ictus es uno de los motivos mas frecuentes de asistencia neurologica urgente, representa una de las primeras causas de muerte e invalidez en los adultos y supone un enorme coste tanto humano como economico. Los avances en el tratamiento del ictus tienen como ejes fundamentales la atencion neurologica precoz, el ingreso en las unidades de ictus, la aplicacion del tratamiento fibrinolitico en el infarto cerebral y el tratamiento rehabilitador. Entre los diferentes tratamientos, la neurorrehabilitacion presenta una ventana terapeutica mas amplia, puede aplicarse tanto en ictus isquemicos como hemorragicos y puede mejorar el pronostico funcional incluso meses despues del ictus. Desarrollo El neurologo, por sus conocimientos en neuroanatomia, fisiopatologia, neurofarmacologia y los procesos de plasticidad cerebral, esta en una posicion ideal para participar activamente en la neurorrehabilitacion. En el proceso de rehabilitacion hay una serie de factores que condicionan su eficacia; el tiempo hasta el inicio de la rehabilitacion, su duracion y la intensidad del tratamiento. Conclusiones La neurorrehabilitacion es una subespecialidad en que el neurologo puede formarse con el fin de participar en los equipos multidisciplinarios que dirigen el proceso de neurorrehabilitacion. El inicio precoz del tratamiento y su intensidad y duracion adecuadas conllevan mayor recuperacion funcional y menores mortalidad, tasa de institucionalizacion y estancia hospitalaria. Es imprescindible realizar un esfuerzo de planificacion para que los pacientes puedan beneficiarse de un tratamiento neurorrehabilitador especifico iniciado precozmente, con la intensidad necesaria y de forma continuada durante el ingreso y posteriormente de forma ambulatoria.

Challenges of neuroprotection and neurorestoration in ischemic stroke treatment.

Currently, the most important therapeutic approaches in the acute phase of ischemic stroke are focused on the restoration of regional cerebral blood flow, early admission to a stroke unit and the attempt to block, using neuroprotective drugs, the biochemical and metabolic changes involved in the ‘ischemic cascade’. Treatment with rt-PA in the acute phase, although very effective, is still limited to a small number of patients and positive preclinical results of neuroprotective treatment have not, as yet, been endorsed in clinical trials. The remarkable lack of concordance between the positive results in experimental models and the negative results obtained in clinical trials has led to a change in attitude in the conduct of preclinical studies as well as to a modification of the design of clinical trials, with special attention being paid to patient selection criteria and clinical evaluation. Some neuroprotective drugs, such as citicoline, have shown some efficacy in subgroups of patients with cerebral infarction, even with a therapeutic window of up to 24 h, which would suggest a possible neurorestorative effect. Different degrees of functional recovery, weeks or months after the ischemic event, are currently observed in clinical practice and have been related to endogenous self-repair mechanisms. The growing understanding of the mechanisms involved in the phenomena of brain plasticity and their modulation, together with the possibility of restoring functional deficits by encouraging endogenous neurogenesis or by cell therapy, open up new directions in the treatment of stroke patients.